Written Submission from Thornby Hall for Health Select Committee for Inquiry re Children’s and Adolescent Mental Health and CAMHS.

The author is clinical lead at Thornby Hall therapeutic community. Thornby Hall is a part of a charity called Childhood First that offers long term specialist residential therapeutic care, education, and treatment to children suffering severe emotional and behavioural disturbance as the result of early life trauma.

Thornby works with a group of around twenty high acuity adolescents. Over the last five years more than 60% of admissions have had direct experience of CAMHS and more than 50% come direct from either NHS or private tier 4 adolescent psychiatric provision. These are young people who have become “marooned” in psychiatric settings. This often reflects complex and intractable circumstances within their families that have generated the chronic problematic behaviours leading to CAMHS involvement.

Crucially the setting provides a context in which these young people are children looked after under the Children Act rather than patients under the Mental Health Act. This provides the opportunity to receive care and treatment that creates conditions supporting access to an educational pathway leading to a position from which they can become net contributors to society rather than consumers of services. This structure also enables them to be supported in, and rewarded for, further educational achievement as independent young adults under the Children Leaving Care Act. This is in striking contrast to other routes available for young adults to access support which require them to evidence vulnerability or an inability to cope, and then to consume services from health or social care.

This submission is based on engagement with twenty five different authorities over the last five years to provide individual placements for highly complex young people. Circumstances have also evolved in which young people with equivalent complex presentation referred by other authorities have not been placed because their CAMHS services have judged they do not have mental health needs.

The young people from Thornby Hall are aware of this inquiry. We have discussed it in our community meeting. A group of residents have prepared their own submission which they have sent alongside this one. What has impressed me through this process is their preparedness to reflect on their own experience with CAMHS and their wish to represent it in a way that might mean other young people could benefit from their

experience in the future. I am aware that they have asked for the chance to talk directly with you about these things. They are articulate and would be able to take the opportunity to describe their experiences and views in greater detail if that would help the progress of the inquiry.

I have laid out my own responses to the terms of reference below:

The current state of CAMHS, including service provision across all four tiers; access and availability; funding and commissioning; and quality

1. There is enormous variation of resource and skill between authorities.

2. There seem to be clear occasions when CAMHS agencies describe young people as not meeting criteria for diagnosis either to avoid responsibility for risk management or through limited resource. – This observation is based in anecdotal experience in which young people with equivalent difficulties have access to widely varying services depending on the area in which they live.

3. Our predominant experience is of tier 4 provision and based in the records provided and the accounts professionals and young people give us of their experience as service users. This suggests a huge variation in quality based in part on available skills and resources, but also on the constitution of the group of young people being treated at any moment.

4. It is extremely rare for tier 4 provision to provide a coherent well prepared analysis of the composition and function of a young person’s family. In our view this often means key elements in the aetiology of their presentation are not addressed. It would also be important to notice that this often reflects enduring and intractable complexities in family function that would be best addressed through effective inter-agency working.

5. There are some authorities in which there appears to be a growing gulf between psychiatrists and commissioners which can impede decision-making and action.

Trends in children’s and adolescent mental health, including the impact of bullying and of digital culture

1. A proportion of young people who, in our judgement, would previously have presented as complex cases within the social care sector are now presenting through tier 4 psychiatric services. This reflects a reduction in the availability and coherence of social care in some authorities.

2. 100% of the young people we have admitted over the last five years are reported to have had difficulties in the area of bullying predominantly as victim but also as perpetrator

3. 66% of the young people we have admitted over the last five years are reported to have had difficulties that have arisen through the internet and mobile phones.

Data and information on children’s and adolescent mental health and CAMHS

1. Childhood First are participant members of the Camhs Outcomes Research Consortium. The data gathering and processing this facilitates is helpful both in the assessment of individual progress and to benchmark quality across the sector.

2. It would be helpful to find a way in which young people’s histories and family function could be recorded in greater detail to support targeted clinical work.

Preventative action and public mental health, including multi-agency working

1. Our consistent experience is that a pathway plan leading from “patient” to “student” makes sense to young people, professionals, and families and motivates progress.

2. Multiagency working is pivotal in constructing a robust framework that enables admission, treatment, and discharge processes that can properly assess, intervene, consolidate, and sustain improvement for young people.

3. The best conditions for an effective intervention are achieved when it proves possible to attain a united view between health, care, and education professionals, and their respective commissioners. This is a complex task that requires expertise, focus, and energy. Often this seems only achievable when the young person has generated a crisis that “concentrates the mind” of the network. The first task in a referral and admission process is to proactively engage with the professional network to achieve these conditions.

4. The promotion and maintenance of an effective multiagency network to support placement requires regular network meetings, for the most part we achieve this by synchronising education and health review processes to run in parallel with the LAC review framework.

5. Education Health and Care plans as proposed in the Children and Families Bill (2013) could potentially provide a structure to further develop these processes. Thus far only one referring authority has referenced their implementation.

Concerns relating to specific areas of CAMHS provision, including perinatal and infant mental health; urgent and out-of-hours care; the use of S136 detention for under 18s; suicide prevention strategies; and the transition to adult mental health services

1. We regularly look after young people past their eighteenth birthday. We have been impressed with the number of CAMHS services who have found creative ways to ensure that psychiatrists who have had consistent relationships with clients over years can continue to maintain these into early adulthood.

Mark Waddington Deputy Director