NHS England takes action to improve access to specialised mental health services for children and young people

NHS England is taking urgent action to improve access to specialised inpatient mental health services for children and young people after publishing a “frank and honest” report on current provision.

For England as a whole, the report says “it is impossible to conclude definitively whether the current level of bed provision is sufficient to meet the need.”

The report found that the number of NHS-funded child and adolescent mental health services (CAMHS) tier four beds increased from 844 in 1999 to 1128 in 2006, rising further to 1264 in January 2014.

But NHS England also found relative shortages in the South West and areas such as Yorkshire and Humber, resulting in patients being admitted to services a long way from home.

Alongside undersupply of beds in some areas, there was also evidence of patients being inappropriately admitted to specialised units. This was caused by a variety of reasons including gaps in CAMHS tier three services and other local health and social services provision, as well as weaknesses in commissioning and case management; Tier 4 is reliant upon the arrangements for Tiers 1, 2 and 3 which are organised at a local level.

For example, intensive outreach teams can almost halve the average length of inpatient stay, yet many areas lack them.

In response to the findings, NHS England will urgently:

  • Increase general CAMHS specialised beds for young patients – there will be up to 50 new beds around the country with further beds moved according to need;
  • Recruit 10 to 20 new case managers working  across the country responsible for ensuring that young people receive appropriate levels of care;
  • Improve the way people move in and out of specialised care; with consistent criteria for admission and discharge, based on best practice

In addition, a longer-term, strategic review of CAMHS services, will be carried out as part of NHS England’s wider work on specialised services; this will include further work with patients and their families and in partnership with other organisations.

NHS England took on commissioning responsibility for tier four CAMHS services in April 2013.  Previously they were commissioned by separate commissioning organisations.

In response to concerns about people travelling long distances for care and to bring transparency to these services, NHS England carried out a mapping exercise.

NHS England’s report describes the outcome of the exercise – the first time these specialised services have been looked at nationally by one commissioner.

Dr Martin McShane, NHS England’s director for people with long term conditions, said: “Too many children and young people have had to travel some distance from their homes to access specialised inpatient beds.

“We are committed to both addressing the more immediate problems, by increasing capacity, and to improving these services longer-term, together with our national partners. We want to ensure that we can provide sustainable, high quality care as near to patients’ homes as possible.”

CAMHS Tier 4 are specialised services that provide assessment and treatment for children and young people with emotional, behavioural or mental health difficulties.

There are four tiers of care.  Tiers one to three are community or outpatient-based and commissioned by clinical commissioning groups and local authorities. Tier four services treat patients with more complex needs usually requiring inpatient treatment.

Information collated during the mapping exercise will now be used to inform the longer-term review.


  1. Jacqui Mann says:

    After listening to the commons select committee discussions I was horrified for a table of UK’s top people to admit that mental health care for youngsters was so fragmented and patchy.
    I know to my own familiy’s cost how bad it is having a daughter with an eating disorder. We suffered not only poor generic CAMHS but suffrered from a lack of eating disorder service resulting eventually in a tier 4 admission to London from Devon for 6 months. I cannot convey how awful an experience it was.
    It’s not necessarily a good thing to have taken tier 4 nationally unless the issue of there being provision of a robust community service (T2/3) in every area is addressed otherwise there is not the ability to continue the in-patient efforts to recovery and consolodate the work done. As well of course community services being able to intervene early to avoid admission which is also proven to work.
    So provision of T4 needs to think about an element of sub- sprecialities within it or to consider a specialist service T4 provision for ED as a sub set. Also the geographic spread of T4 services need to be considered. From Devon if we have to travel, Birmingham is easier than London, somewhere SW would be even better if it is appropriately specialist.
    How will the quality loop be ensured to ensure how the provider is working back with the community and surely CAMHS budgets generally have to be improved to make best use of T4.
    I have spent a career in NHS Childrens, Young Peoples services and am so sad that so little improvement has been made in CAMHS, its appalling. I have reference material back as far back as 1996/7 when a house of commons select committee looked at CAMHS and said they should collect better data, services had been neglected, children and families suffered dreadfully, morbidity and mortality were poor. Having drawn attention to the failings something needed to be done.
    Then in 2004 came the national service framework for children mental health and psychological well-being and Every Child Matters,standards which are still only an aspiration 10 years later!!
    My daughter suffered the consequences of your inadequacies whatever your excuses pre18, the system failed her. She did make a short recovery but its still failing her as an adult when the ED returned on transition to university, where she spent her 1st year struggling, deteriorating on a waiting list. It makes me weep.
    Instead I try to support other families locally in Devon, help them cope to look after their youngsters with continued inadequate CAMHS and ED services.
    Here in 2014 the house of commons panel sat and said how poor data was, integrating services had made commissioning fragmented, CAMHS remain under resourced, patchy!!!! Its outrageous! NHS England has not had the pain of watching a beautiful young daughter overwhelmed by mental illness. If she’d had Leukemia at least she would have had a service, the family received support, and if you look at survival rates she would also have stood a better chance of ‘cure’.
    We are not talking investing in expensive ,’long-shot’ treatment to give a child a few more months, we are talking proven treatments/therapies with clear cost benefits to ensure healthy adults and reduce complications without the suffering would be saved. What’s not to agree with!!!
    I thought Sarah Woolaston was too kind!! Someone has to be accountable for making it better.

  2. Glenys Marriott says:

    Please read my report published yesterday for Tim Farron MP ‘Born in South Lakeland, developing emotional resilience’

    I have spent 8 months interviewing over 200 people in Cumbria and their comments are included in the report, together with recommendations for NHS England, CCG and providers.

    I would welcome further discussion with Dr McShane.

    Glenys Marriott
    Public representative Greater Manchester, Lancs and South Cumbria NHS Senate neurological conditions

  3. mike still says:

    The raw figures disgusie the fact of the amount of private provission use. The increase in NHS funded beds in 2000 to 2010 was primarily due to a desire to cut ECR referrals.
    The danger of focussing on the teir 4 clients is we take our eyes off the preventive work.
    we are now seeing the effect of goverment cuts to service from 2008 to current at tier 1, 2and 3. in addtion Goverment policy on education and changes focussing away from whole life education, to accademic achievement, with the accadamy programme have also a massive knock on effect.
    We need National guidance, enforced, for the provision of teir 1 2 and 3 services, to address the real issue which is not the provission and management of young people at teir 4 but how did services fail to such an extent that they became teir 4 in the first place.

  4. Peter Morris says:

    When reviewing services, it would in my opinion, be helpful to identify care pathways between Tier 3 and 4 making clear what work and what level of risk is appropriate. Ideally the refering and receiving teams should be familiar to each other and used to their ways of working. As family therapy will be part of most packages of care in Tier 4 arrangements for this should be shared between Tier 3, 4 and the families including frequency of visits and travel arrangements.

  5. dr mike blows says:

    When undertaking the review of CAMHS it may be helpful to look at the effects of reorganisation of services in Suffolk as an example.
    The model follows a discussion paper from Gloucestershire (which wasn’t implemented by Glos.). The majority of the fears by clinicians that the new arrangement would lead to reducing the efficiency of the tier three service, and resulted in an increase (doubling) of admissions to adolescent beds has been realised after 1 year. There are likely systemic management issues- such as no CAMHS trained person in a strategic management position within the trust, but there are predictable issues, such as those cited in the tier 4 review that have likely decreased the efficiency of the service.
    The abandonment of the tiered model (HAS) with loss of specialist services, the dislocation of the MDT including breaking Youth (14-25 years) from Child (under 14’s) has contributed, as has getting rid of the intensive outreach team for under 18’s.

  6. Philippa Boulter says:

    I have worked in CAMHS for 18 years and I am concerned at the number of children and young people (CYP) who are being admitted to Tier 4 services. I do not see any increase in actual mental health problems than there was at the time I started in CAMHS. What I do see is an inability of clinicians across the range of professions to manage, contain and understand the meaning behind children and young people’s increased cry of suicide, increasingly risk adverse cultures in CAMHS, schools, school nursing and peadiatrics and less and less containment and support for CAMHS staff when trying to manage children who are not suicidal but who are saying they are. This week I visited a school about a child who I did not feel was suicidal and was treated with complete distain when I said this and advised them to remove her from ‘suicide’ watch. Their words not mine. The way they are responding to this child makes my job in making sense of why she acting in the way she is increasingly impossible. I have seen CAMHS move from a place where children’s behaviour is thought about and understood, thus making sense of why they are making threats to one of risk assessment and diagnosis, inexperienced staff, lower grades etc. This clearly may reduce costs in one part of the system, Tiers 2 and 3 but escalates them in Tier4 which is serving only a small handful of the child population. It also means there is less expertise available further down the Tiers which means increasing numbers of children are not able to access to a good service. I have watched the CAMHS service in which I work haemorrhage experienced staff replacing them with people who panic, make split second decisions, have little experience and ability with working therapeutically to create change and therefore are unable to tolerate risk. In my view it is very shortsighted.
    Philippa Boulter
    Consultant Child and Adolescent Psychotherapist