The NHS Plan: making it work for CAMHS
Stella Charman asks what child and adolescent mental health professionals can expect of the NHS Plan and suggests that, however jaded and sceptical professionals may feel, it is those clinicians and managers who are most prepared to engage with its broad agenda who stand to gain the most for their services. June 2001
It is now nine months since publication of the NHS Plan, but has it yet changed anything for clinical staff trying to meet the mental health needs of the children they encounter in local schools, clinics and hospitals? And now that the early flurry of excitement has died down, what is it that the NHS Plan can realistically be expected to achieve for those children in the future?
Over the coming weeks, the NHS Executive will be considering these questions as they look at the joint CAMHS Development Strategies which must be submitted this month by all health authorities and their partner local councils. But many hard-pressed staff remain sceptical about whether the gulf between rhetoric and reality will ever be bridged, and doubt very much that the promises of additional staff and resources will be realised in their own localities.
In this article, it is not my intention to try and persuade you otherwise. Past experience teaches us that some services consistently lose out, while others succeed in their bids for increased investment, leading to wide variations in the level of resources available in different parts of the country.1,2 The reason for this, however, is not different needs among their respective child populations, but the extent to which local CAMHS clinicians and managers have the sympathy of their colleagues and the effectiveness with which they are able to exploit the opportunities available to them.
Even allowing for the extensive performance assessment framework attached to the implementation of the NHS Plan, it is unlikely that the development of child and adolescent mental health services (CAMHS) across the country will now proceed in an equitable and consistent manner. Instead, progress will depend on how well CAMHS teams can stimulate their organisations and the wider service system to get the best deal out of what is on offer locally.
It is as if some ‘grit’ needs to be injected into the ‘oyster’ of the NHS Plan before it will produce the ‘pearl’ of better mental health services for children. This article offers some practical suggestions about how to put that grit into the oyster.
Understand the broad policy agenda
The first problem to be overcome is that CAMHS does not appear as a single, coherent section of the NHS Plan, but instead is implicated in a number of the Plan’s commitments, alongside other services. For example, the recruitment of 1,000 new graduate primary care mental health workers trained in brief therapy techniques is intended to tackle common mental health problems in all age groups, including children (NHS Plan, page 119, section 14.29).
And among a variety of other developments, the 50 new early intervention teams to provide treatment in the community to young people with psychosis and their families (p119, s14.30), the expansion of Sure Start projects (p108, s13.16) and improvements in prison mental health services - including those for young offenders - (p121, s14.36), will all have an impact upon aspects of child and adolescent mental health services provision.
Implementation of the children’s aspect of the NHS Plan will be taken forward by a Children’s Taskforce, mirrored by local taskforces for generic children’s services. Furthermore, the full agenda for children cannot be understood by studying the NHS Plan in isolation from other Government plans and initiatives, such as Quality Protects.
So CAMHS professionals need to appreciate a range of policy aspirations in order to become influential and effective advocates for children’s mental health, to make sense of the implications of the full agenda on their services and to exploit the opportunities presented.
They should secure representation on local children’s taskforces when they are set up and engage in active dialogue with colleagues in paediatrics and adult mental health services, as well as those employed by other agencies, to prepare joint plans and proposals that meet the needs of priority groups of children as identified in the NHS Plan. The priority groups are looked-after children, those with severe disabilities, young carers, those excluded from school, young people with substance misuse problems and adolescents on the borderline between children’s and adult services.
Until recently, many of the children and young people in these priority groups would not have been regarded as appropriate users of specialist child and adolescent mental health services, but the NHS Plan demands that their needs are now attended to in an imaginative and co-ordinated way across service boundaries. Specialist CAMHS teams must now choose whether to become active players in the game of developing these new services, or else remain on the sidelines.
Identify and influence those with access to resources
It is clear that at a national level, considerable resources are available to meet the targets set by the National Plan. How these will be distributed to local services, and via what routes, is less clear. However, those services that are redesigned to focus on the key target areas and priority groups are more likely to attract funding than those which continue to function along traditional lines.
Furthermore, CAMHS professionals need to identify and influence those who are in a position to access resources, and need to play an active and supportive role in preparing the necessary strategies to underpin proposals. Indeed, it would be interesting to know just how many are now engaged in putting together the required joint Development Strategies which should guide future investment into CAMHS.
The NHS Plan Implementation Programme states that its objectives will only be achieved through the work of the clinicians and other staff who are in direct contact with patients and users. Yet professionals working in child and adolescent mental health services are very often ‘disconnected’ from the processes of decision-making for the allocation of resources, and the activity of preparing bids for service re-design or development.
Moreover, sources of additional funding are not always to be found in the most obvious places and time and energy are required to root them out. Applications to voluntary organisations and charities are sometimes required, or to ‘last-minute’ schemes for NHS Modernisation Fund money.
The NHS Plan includes the inevitable targets for reducing waiting times for outpatient appointments - in theory, this should attract funds into CAMHS as much as into the acute specialities, but probably not without a fight! One of the most powerful findings of the Audit Commission’s survey in 19992 was that what distinguished the services of effective, ‘high-scoring’ trusts was ‘clear, informed, imaginative and understanding management’ for CAMHS.
In short, strong and mutually supportive relationships between clinicians and general managers are the key to accessing new resources for local services and reaping the potential benefits of the NHS Plan.
Turn structural change to your advantage
It is sad to say, however, that structural change within the NHS is currently having a bigger practical impact on child and adolescent mental health services than is the NHS Plan. Bruce Irvine and Dinah Morley3 have outlined the challenges facing local services as a consequence of the creation of primary care trusts and specialist mental health trusts, and have advocated the development of ‘living partnerships’ across agencies.
But while structural change does threaten the stability of those clinical relationships and management arrangements that are already working well, it also presents opportunities. When organisations are newly-formed and still in the process of developing their infrastructures, there is an opportunity to negotiate management arrangements, establish clinical governance arrangements and overhaul information systems so that they bring greater benefits for CAMHS.
Where the creation of a large specialist mental health trust pulls a number of separate CAMHS teams under the umbrella of a single organisation, then functional specialisation, the provision of 24-hour cover and collaborative working between adult and child mental health professionals can be promoted more effectively.
The Audit Commission2 cast doubt on the ability of CAMHS teams of less than 11 whole time equivalent staff to function effectively. So specialist mental health trusts may provide a vehicle for teams to build up the necessary critical mass of staff with which to develop services. Every team knows how vital it is to be able to attract new staff, and the NHS Plan acknowledges that achieving its workforce objectives is one of its toughest challenges.
On the other hand, some CAMHS teams are moving into primary care trusts and this may enable a different set of relationships to be forged, encouraging local responsiveness and a more committed response to children’s mental health issues from GPs and other primary care professionals. This will enable other aspects of the NHS Plan’s aspirations to be achieved. Each CAMHS team must decide how it sees itself developing in the future and be clear about how to get the best out of the organisational structure in which it ultimately resides.
Allow children and families to influence how services develop
A key target of the Implementation Programme is ‘to give patients’ views greater prominence in shaping NHS services in line with NHS Plan commitments’. Thus, it is expected that in future there will be increased involvement of children and their families in the way CAMHS are designed and operate.
However, it is proving hard for many services to translate this expectation into reality, especially when the children and families most in need are also those who are the hardest to engage. We know from research (for example, the Mental Health Foundation’s report Hear Me4) that for many young people, health professionals represent authority and are perceived more as a cause of their problems than a gateway to solutions. They are feared rather than sought out for help.
New service models which work closely with the voluntary sector and which reach children and young people on their territory, rather than that of the health professionals, are therefore being advocated. But the first step is simply to begin the process of listening to what young people and communities are saying about services, and to set up opportunities which allow this to happen.
Here again, NHS trusts and primary care trusts should be supporting clinicians in this process by establishing systematic mechanisms to collect feedback from users, and setting up Patient Advocacy and Liaison Services (PALS) and Patient Forums. It is important for CAMHS professionals to understand and influence these arrangements in their local trusts so that children and families are given appropriate opportunities to participate and that the structures established are ‘child-friendly’.
A strong child focus for PALS and Patients Forums will benefit services by raising their profile within the host trust, as well as stimulating investment in service developments.
Conclusion
The NHS Plan offers child and adolescent mental health services no guarantees regarding future investment, but it does offer courageous clinicians and managers plenty of opportunities to explore and exploit. The overall agenda is huge and bewildering - and over time, ‘headline-hitting’ political priorities will emerge which may engulf those which are less sensational or create less tension within the system.
CAMHS professionals must now generate creative tension within the NHS Plan’s Implementation Programme to ensure that services begin to develop to match the growing need and corresponding expectations. In other words, you must get the grit inside the oyster which is needed to grow a CAMHS ‘pearl’ out of the NHS Plan.
Stella Charman is an Associate Director of the Centre for Mental Health Services Development, leading its management consultancy programme on CAMHS and working in collaboration with YoungMinds.
The NHS Plan: a plan for investment, a plan for reform costs £15 from The Stationery Office on 0845 7 023474.
References
1 Kurtz, Z., Thornes, R., Wolkind, S. (1994). Services for the Mental Health of Children and Young People in England: A National Review. London: Department of Public Health, South Thames (West) RHA
2 Audit Commission (1999). Children in Mind: child and adolescent mental health services. London: Audit Commission Publications
3 Irvine, B., Morley, D. (2001). Children’s mental health: creating comprehensive services in a climate of change. YoungMinds Magazine 51, pp20-21.
4 Laws, S. (1998). Hear Me. Mental Health Foundation.
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