Could specialist regional centres solve CAMHS access problems?

A year after the government published the Future in Mind five-year strategy for children’s mental health services, evidence suggests more must be done for young people across the country to have equal access to specialist care.

CentreForum’s State of the Nation report, published earlier this month, concludes that current child and adolescent mental health services (CAMHS) provision and funding is “patchy and highly variable”. It found huge variations in spending across the country, from £41 per child in the East Midlands, to £83 in the north of England.

The think-tank also found evidence that CAMHS are turning away nearly a quarter of children referred, and that clinical commissioning groups, which commission community services at tiers two and three [see box], were too often neglecting spending on mental health.

In the foreword to the report, former health minister Norman Lamb says more needs to be done to find a “lasting solution” to the inequality of access to care.

One idea gaining momentum is for therapeutic services for specific groups of young people to be delivered at a regional level. The issue has arisen in meetings between the Department for Education and Department of Health over how to better meet the mental health and support needs of adopted children.

It is recognition that “the needs of those vulnerable children might be better met through centres of excellence”, says Hugh Thornbery, chief executive of Adoption UK.

Thornbery says regional centres of excellence for adopted children would be comparable in terms of size and scale to regional adoption agencies, which are networks of council and voluntary adoption agencies working together to speed up the adoption process.

Potential benefits

For many years, some areas have struggled to find sufficient adopters, particularly for older children and sibling groups, and the government believes one of the potential benefits of regional agencies is the improved access to “specialisation, innovation and investment” it could offer.

The problems in CAMHS are not dissimilar. The Commons’ health select committee reported in 2014/15 that there are “serious and deeply ingrained problems with the commissioning and provision” of CAMHS.

Evidence to the committee highlighted the difficulties children with particular conditions, or from “especially vulnerable” groups of society, faced in accessing CAMHS.

These included children with Attention Deficit Hyperactivity Disorder and eating disorders, as well as young asylum seekers, lesbian, gay, bisexual and transgender young people, and looked-after children.

Thornbery says taking a wider geographic approach means it will be more likely that adopted children and others with specific issues or conditions will be treated by professionals with the right range of skills and knowledge.

“I don’t believe the Department for Education or Department of Health want to talk about ‘regional’ [services], but they do understand that CAMHS are of varying sizes, knowledge and skills base, and struggle consistently to meet the need of this group of children,” he says.

“What the majority of CAMHS are trying to do is to deliver against a whole range of varying needs.

“And the academics involved [in government meetings] talked about how if you’re going to deliver a good service for adopted children, you need to not just be a clinical expert and understand how to assess and what interventions are best, you also need to understand the adoption context.

“We take a different approach at the moment in CAMHS, where we often expect very small teams to be experts in everything.”

Professional ignorance

Thornbery says this means that children are often faced with a professional who does not recognise or understand their situation and needs.

Instead, he says the NHS generally should be organised so that children with complex needs can get the best care at a regional centre. “You’ve got your primary health services, which you should access from time to time, then if treatment can’t be delivered at the local level you should get referred to a hospital. Then if you have a particularly complex need, you might be referred to the regional expertise.

“A centre of excellence or more regional approach will have the potential to address those issues in a way they will never be addressed currently because there is never going to be enough money if one continues to do this at a local level.”

Emily Frith, director of mental health and rehabilitation at CentreForum and author of its recent report, says that the idea of CAMHS acting on a regional basis is an “interesting” one.

“In-patient mental health care is better co-ordinated on a regional basis, so it is definitely worth exploring whether community services could be more aligned to that,” she says.

 “One of the things we recommended in our report was for more standardisation, but we also felt that there was the need for better data collection and understanding of what’s going on,” she says, adding that this means areas can share best practice and benchmark how they are performing.

However, Bruce Clark, clinical director of CAMHS and a child and adolescent psychiatrist at South London and Maudsley NHS Trust, says one barrier to establishing centres of excellence is a lack of expertise in the sector.

Clark works at the Michael Rutter Centre, which has 22 specialist teams for different mental health conditions to whom young people from across the country can be referred.

“Teams have developed over many years, and organically,” says Clark.

“You can’t just ‘cookie-cutter’ them in. There is sometimes an assumption that if you want to be a professor of obsessive compulsive disorder (OCD) that can happen overnight. Why is it less complex than other areas of physical health?”

While Clark says it would be good to have more academics and specialist centres, some conditions are still better treated at a local level.

“I’m certain that if you have OCD and come to my team, we’ll get you better quicker and in a shorter timeframe, and with less money involved than if you’re seen locally,” he says.

“Where there’s a very clear treatment package – and if you do it well – people almost always get better.

“There are other disorders, such as young people who repeatedly self-harm, where I believe the causes are much more complex than it is with OCD. It can be trickier to deal with those things when you are at a distance.”

Duncan Law, clinical lead for the children and young people’s Improving Access to Psychological Therapies programme in London and the South East Learning Collaborative at the Anna Freud Centre, also says having fewer, but more specialist, teams could have some advantages.  

However, he says there would be issues about how the idea is applied, particularly in rural areas.

“It’s fine to have specialist models in urban areas – it would work well in London – but in rural areas, how do you deploy those specialist teams?

“It would add another layer to a tiered system. Anything that adds another specialist layer is arguably adding in another tier [of service].”

Better integration

He says the focus should be on how existing services can be better integrated to work together, and how services can be led by the needs of the child.

“It may be there is still a need for regional hubs that might mean that families travel,” he says. “But if those hubs could be integrated across health and social care, then it will make them worth travelling to.”  

Sue Bailey, chair of the Children and Young People’s Mental Health Coalition, also believes the idea of specialist regional CAMHS has potential to support the mental health of all looked-after children.  

“I’d look at it more like a hub and spoke, where there’s a regional hub, and where there’s particular expertise in this area, but where you’d still be working with a local specialist CAMHS, because on the ground is where problems rise. You need local CAMHS involved,” she says.

She adds that CAMHS could deal with issues such as attachment problems, but that a regional hub could deal with a child’s more specific problems.

“This is a journey, with risks and benefits, and surely those working in adoption would see benefits.”


Guide to the four tiers of child and adolescent mental health services