The National CAMHS review
A response from the Royal College of Psychiatrists Child and Adolescent
Faculty
We are grateful for this opportunity to contribute to the review and hope our
comments will contribute to a constructive outcome for children and families
We have aimed for brevity here, further information or detail is available if required
in relation to each point.
The Faculty has welcomed the increased investment and commitment to CAMHS in
recent years, which has brought about positive change in many parts of the country.
However we believe there are still a number of deficits in service provision which
require attention:
Out-standing issues, future directions
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The capacity of services remains severely constrained by resource limitations.
Currently 1-1.5% of the child and adolescent population is seen in specialist
CAMHS per annum. Using best estimates available from epidemiological
studies we estimate around 3-4 % should be seen per year (ONS; care
pathways data from UK and internationally).
Norway, parts of Australia and New Zealand are commissioning specialist
CAMHS services to treat 3-4% of the children’s population per annum
Reasons for the gap between demand (3-4%) and supply (1-1.5%) include;
low levels of resource at specialist service levels; low rates of detection in
generic and targeted services, average 15% detection rates across all disorders;
stigma and lack of knowledge about services in the wider community;
accessibility.
Merely reorganising and re-engineering services cannot bridge this gap, one
cannot envisage a 3 fold increase in efficiency being possible while retaining
effectiveness;
We believe the basic problem is a lack of investment in that the underlying
spend per child on CAMHS across all tiers remains too low, by any
international comparison.
A major limiting factor is weakness in the commissioning of CAMHS.
Certain parts of CAMHS lack investment and services are under developed.
An example is the mental health of children in hospital.
Scarce CAMHS time is wasted trying to ensure safe commissioning with
constantly changing commissioning landscapes; currently tier 4 children’s
services are a casualty, 5 units of 13 nationally have been closed, increasing
pressures on tiers 2-3
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A reprioritisation of children and CAMHS in commissioning could change
this, ring-fencing funds, consistent organisations not constant change
It is not feasible that simply investing more in tier 1 or 2 services will solve
this problem. Tier 1 and 2 need capacity, knowledge and skills investment, for
sure as they need to see milder to moderate cases/disorders (probably 6-7% of
the child population) alongside those who don’t yet have a disorder, probably
another 10% and then select and refer the 3-4% who require specialist
treatment in tiers 3-4
More staff with more skills in generic and targeted services will detect more
cases and pick up complexity and severity sooner. Increased detection at Tiers
1 and 2 place demand on Tiers 3 and 4 for training, consultation and
supervision, not simply increasing case referrals.
A focus on efficiency i.e. spreading resources more thinly, will result in a loss
of effectiveness of interventions and result in higher over all costs to other
parts of the economy. There is evidence to support this assertion, and
user/carer demands and NICE guidelines press in the opposite direction.
Year on year growth in investment over a 10 to 20 year period could redress
the shortfall; for example aiming for real terms growth in capacity of 7-10%
per annum.
We are concerned that a focus on early intervention not be at the expense of
investment in specialised services with academic links whose role is to
facilitate development and dissemination of the treatments CAMHS delivers
(for example, the Newcastle Autism service which has been decommissioned
as ‘no longer necessary’ because these services are now available at Tiers 2
and 3, which fails to recognise the centre that developed them).
While of course argument can be ranged against such a growth in specialist
services we would see it as part of a comprehensive rethink on children’s
wellbeing and point the review once more to our very poor international
comparative ratings for both investment and outcomes in kids,
UNICEF/drugs/pregnancy/violence
Pressure points
 In the last 10 years the UK population has increased by 10%-15%
 The prevalence of child & adolescent mental disorder in the UK has increased
by between 70-100% in the last 25 years (Maughan et al 2005) along with
increased severity, complexity and risk of presentations.
 Many more children with complex difficulties remain in their communities.
Social care beds and residential schools used to take children with complex
difficulties.
 Children remaining with their families is a good thing but it means that the
level of provision needs to increase in line with this policy direction.
 The policy of inclusion of children in difficulty in mainstream education
settings needs the resource to support it including early effective recognition
and management; this is often missing and leaves other children adversely
effected in their learning and development, an adverse ‘ripple effect’ of
trauma, hurt, disruption and loss
 We are near the bottom of UNICEF league tables on children’s mental
wellbeing, teenage drug use and pregnancy rates
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Unfortunately, more recently there is evidence of a standstill or indeed
decreases in the CAMHS workforce. Up to 75% of services in a college
survey report no change or a decrease in workforce and funding for tiers 2-4
since 2006; losses to Cost Reduction Efficiency Savings/CIPs around the
country have been particularly noted.
Appendix 1:
Action on the determinants of children’s and family’s mental health and
wellbeing
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Continued step changes in mental health services (tiers 1-4) would be
welcome and necessary but they will not be sufficient to stem the current
negative flux of children and adolescents mental wellbeing.
We can help those with disorders and achieve successes in primary prevention
e.g. in infant mental health services (these also require access to a high level of
expertise from tier 2-4), changes in schools and so forth and we can prove our
effectiveness and efficacy for many conditions
The emotional wellbeing of children is "everybody's business". Core CAMHS
is one quite small part of this but we have daily experience and some empirical
data to support the importance of attending to policy and legislation in the way
proposed herein.
So, taking a really broad national perspective we would like to propose a step
change in the priority given to thinking about children, adolescents and family
wellbeing……
We recommend a reprioritisation of children& families at a national policy level
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This could be achieved by creating a requirement that all legislation and
policy must consider its impact on the well being of infants, children,
adolescents and families before being enacted.
The fiscal cost of negative impacts should be considered including long term
costs accruing of mental ill health in young people
This could be achieved by a ‘National Children’s Advocacy Council and
expert group which would advise legislative and policy makers, using
evidence, to influence change
If there is doubt that this is possible then Finland provides an example of just
such a process (personal communication with Professor in Helsinki)
Some examples of what is meant here: cycle paths in all new housing
development and road building; much more stringent control of foods,
additives, labelling and advertising direct to children, open spaces and sporting
facilities in all communities; public transport policy, to encourage more social
interaction and environmentally friendly; more consideration of the
developmental and social impact of parents being actively encouraged by
fiscal and other legislation to leave their children from early in life; the
collapse of NHS dentistry further marginalises the children of the poor, and so
forth, many other examples are possible
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What is good for young peoples development will be good for the population
as a whole, all ages, by both fiscal and health measures
Appendix 2:
National Survey of Consultant Child & Adolescent Psychiatrists: Tiers 2-4
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Attached are the results of a National Survey of Consultant Child &
Adolescent Psychiatrists conducted by the Faculty Executive of the Royal
College of Psychiatrists
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Aim: To provide a ‘direct from the coal face snapshot’, evidence of current
service circumstances across England in CAMHS
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Sampling time frame: 5 weeks from 3rd week of May to 26th June 2008
Survey Results (see attachment folder called ‘National Survey Results’)
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The whole survey (n = 147)
Tiers for England only (n = 116 for tier 2-4) as the review refers to England,
We could provide the same also for responses from the other nations ( n = 31)
There are 3 PDFs Summaries of responses to the survey (%)
1 is the overall summary of responses (n = 147)
1 is for tier 4 England only (n = 27)
1 is for tier 2/3 England only (n = 89)
Then 2 word files, containing all the free text comments made separately listed
but anonymous
1 is for Tier 4 England ( n = 17)
1 is for Tier 2/3 England ( n= 65)
Representativeness of the samples
An estimate is that each tier ‘2/3 response’ should represent around 4 consultants
taking an average tier 2/3 service as having 4 consultants.
So we could say 89 x 4 = 356
That we have here about 356 consultants represented in England tier 2/3.
If there are in total around 570 consultants in England tier 2-4
And if we estimate around 60 are in tier 4 then 510 in tier 2-3
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Then we have 356/510 x 100 = 69.8 % of the English tier 2/3 consultant body
represented by this survey.
Appendix 3:
Cross National European Comparisons of Child and Adolescent Psychiatrists
per head of Population of children and adolescents
Cross national workforce comparison from the European Society of Child And
Adolescent Psychiatry courtesy of Dr. Thomas von Salis (Switzerland).
Link
http://www.escapnet.org/web/index.php?option=com_content&task=view&id=60&Itemid=143
This table refers to medical workforce only at consultant level but this can be taken as
an indicator or marker of overall investment in multidisciplinary CAMHS.
In Conclusion
We hope this response will be useful in the considerations of the review.
We are happy to discuss further.
Thank you for you consideration of this submission,
Dr Greg Richardson
Chair of Faculty of Child and Adolescent Psychiatry
Royal College Of Psychiatrists
17 Belgrave Square
London SW1 8PG
Dr Raphael Kelvin
Elected Representative to the Faculty Executive
Consultant in Child and Adolescent Psychiatry and Associate Lecturer,
Cambridgeshire and Peterborough NHS Foundation Trust & University of Cambridge
Professor Simon Gowers
Elected Representative to the Faculty Executive
Professor of Adolescent Psychiatry, University of Liverpool
04.07.08
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