Children and young people's mental health services

Welcome to the ZSA Facts for Action series

This page provides key information to explain what children and young peoples mental health services are and will help build your understanding of the role this service has in suicide prevention.

Contents:

1. What are children and young peoples mental health services (CYPMHS)?

2. Use of CYPMHS

3. Why are these services important in the context of suicide prevention?

4. ZSA Suicide Prevention Resource Map - key takeaways

5. National guidelines for practice

6. Impact of COVID-19

7. Recommendations for action

8. ZSA Suicide Prevention Resource Map - related indicators

9. References

What are children and young people’s mental health services (CYPMHS)?

Specialist care for children and young people experiencing mental health problems is provided across the UK by child and young peoples mental health services (CYPMHS) providers, previously known CAMHS (child and adolecent) mental health services. In many cases CYPMHS services are delivered by the same local provider as adult mental health services, but in some areas this care is provided by private healthcare organisations or by children’s hospital services. CYPMHS services operate across the range of needs, from primary care mental health through to crisis provision and inpatient care.

CAMHS services offer a different level of service from adult mental health services, with key differences being around the use of diagnoses, the pastoral and wrap around support, and the integration with education and wider young people services within a community. There is significant variation in service models seen across the country with provision by the NHS, local authorities, schools and voluntary sector organisations.[1]

Use of CYPMHS

NHS Digital publishes an annual bulletin which reports on the use of mental health services based on the mental health data set (MHDS) submissions by providers. For reporting purposes children and young people are described as those aged under 18 in the publications.

The latest publication[2] shows:

• There were 566,762 children and young people in contact (once in the year) with NHS funded secondary mental health, learning disabilities and autism services in 2019/20. 420,579 of these have had two or more contacts in the year. This indicates that 26% of the children and young people in England who access these services have only one clinical contact. Rates at clinical commissioning group (CCG) level vary significantly from 11% to 51%.
• There are slightly more females (51%) than females (47%) in contact with CYPMHS (in 2% of cases, gender was recorded as unknown).
• The majority of users are aged 11 to 15 (48%) and 64% of service users are of a white ethnic group. It should be noted that the data completeness for ethnicity is poor with only 78% of those with one or more contacts during the year having a valid ethnicity reported, so we have also looked at ethnicity proportions based on the number of users with valid ethnicity recorded. 
• The percentage of children from children and young people from black and minority ethnic groups in contact with services (at least one contact where valid ethnicity is recorded) is 14%. This is 7% lower than the percentage of the general population in these groups (21%).[3] This suggests that children and young people from black and minority ethnic groups are less likely to access mental health services than their white peers and may therefore be more at risk of not receiving appropriate support if they experience mental health problems.

The NHS mental health dashboard for quarter 1 2020/21[4] references a national target that 35% of children with a diagnosable mental health condition would access support by NHS funded community services in 2020/21. This target was achieved at 72% at an England level.

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Why are these services important in the context of suicide prevention?

The Care Quality Commission (CQC) phase one report into children and young people’s mental health services (2017)[5] describes childhood and adolescence as “a period of physical, emotional, social and psychological development”. It is well recognised that our experiences in childhood have a significant influence on our lifelong mental health as described in our facts for action relating to risk factors for children and young people. 

It is estimated that half of mental health conditions in adult life start by the age of 14.[6] Suicide is one of the leading causes of death in young people in the UK. Data published in 2022 showed that there were 2,041 suicides and probable suicides by people aged 10-19 in England and Wales from 2010 to 2022 (Office for National Statistics, 2022).[7]

It is vital that children and young people have timely access to high-quality care that is person-centred and tailored to meet the unique needs of each child and young person at the different stages of development. Improving children and young people’s mental health services is, therefore, a priority across health, education and social care.

Transitioning from CYPMHS services to adult services can be particularly challenging for young people and the disruption of care than can occur during this period is known to adversely affect the health, well-being and potential of this group.[8] It is critical that there are robust pathways and processes in place to support children and young people during this time.

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ZSA Suicide Prevention Resource Map data - key takeaways

Our ZSA Suicide Prevention Resource map developed with the NHS Benchmarking Network includes a number of metrics which provide a picture of the overall situation for CYPMHS services across England and shows wide variation in the number of people referred to and accessing these services and the amount of clinical contacts received by individuals. The data below relates to 2019-21 and is sourced from the NHS Benchmarking Project for CYPMHS unless stated otherwise:

• The number of people in contact with mental health services aged under 18 per 100,000 population  varies from 2,610 (NHS Ealing CCG) to 11,646 (NHS South Tyneside CCG) with a median average of 5,569.
• The median number of referrals received per 100,000 population varies between 99 and 8,399 with a median average of 3,372 up from 3,582 in 2019/20.
• The median number of referrals accepted per 100,000 population varies between 87 and 8,050 with a median average of 2,666 down from 2,730 in 2019/20.
• Referral acceptance rates vary from 51% to 100% with a median average of 82%, up from 78% in 2019/20.
• The average waiting time from referral to first appointment is 6.4 weeks (down from 6.7 weeks in 2019/20) with waits varying from 1 week to 22 weeks. Note that data completeness for this indicator is low.
• Waiting times from referral to second appointment average at 12 weeks (down from 13.3 weeks in 2019/20) and vary from 1 week to 36.8 weeks. The lengthy and variable waiting times reported in the map suggest that the long term plan ambition of a four week waiting time would prove challenging to the majority of provider organisations. Note that data completeness for this indicator is low.
• More than one appointment: The provider data included in the map indicates that 69% of people who have a first appointment go on to have a second one, up from 66% in 2018/19. The 2019/20 data is slightly lower than the national data reported by NHS digital for the same period which shows 71% of those in contact with services have two or more contacts. Rates vary from 39% to 95%. Note that data completeness for this indicator is low.
• Caseload sizes also vary significantly between providers with the lowest caseload per 100,000 population at 49 and the highest at 6,340  The median average caseload is 1,641 per 100,000 population, down from 1,419 in 2019/20.
• The median average clinical contacts per 100,000 population is 26,584 (up from 22,781 in 2019/20) and activity rates vary from 1,671 to 95,522. When we examine the clinical contacts in relation to caseload size, we see that the average number of clinical contacts in a year is 17 per person on the caseload, up from 16 in 2019/20. The lowest number of contacts per person was 4 and the highest 338.

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National guidelines for practice

NHS Long Term Plan

The expansion of Children and Young People’s Mental Health Services (CYPMHS) is one of the priority areas of the NHS Long Term Plan (2019).[9] It aims to widen access to services closer to home, reduce unnecessary delays and deliver specialist mental health care which is based on a clear understanding of the young person’s needs and provided in a way that works for them. This will be provided through the development of integrated services with clear pathways from early intervention to crisis and inpatient care. The NHS Mental Health Implementation Plan (2019)[10]  translates the Long Term Plan ambitions into measurable goals including:

• 345,000 additional children and young people aged zero to 25 accessing NHS funded services and school or college based mental health support teams by 2023/2024
• 100% coverage of 24/7 crisis care provision for children and young people which combines crisis assessment, brief response and intensive home treatment functions accessing aged zero to 25 by 2023/2024
• Exploration of the establishment of a four week waiting time target for access to services.

Care Quality Commission

In 2018, the Care Quality Commission published its phase two report reviewing the system of services that support children and young people’s mental health.[11]  This report looked at three main aspects of the mental health system for children and young people:

• People’s experience of and involvement in care
• How partners plan and deliver services that offer high quality care that can be assessed in a timely fashion
• How partners in the local area identify mental health needs and what they do to start the process of getting the right support for children and young people

The review found that many children and young people experiencing mental health problems do not get the care they deserve and the system is complicated with no easy or clear way to get help and support. The report made a number of recommendations for action including:

• Joint action across government to make children and young people’s mental health a national priority involving health, social care, education, housing and local government
• Local organisations working together to deliver a clear ‘local offer’ of the care and support available
• Everyone who works, volunteers or cares for children and young people are trained to encourage good mental health and offer basic mental health support
• School inspections to look at what support children and  young people get around their mental health

In 2020, the Care Quality Commission reported on local actions in response to these recommendations[12] based on self assessments completed by health and wellbeing boards. This showed that local recommendations were being implemented to varying degrees across the country and that continued improvements are required. A summary of the findings is provided below:

• Joint commissioning – There was strong prevalence of joint commissioning, although not in relation to transitions (including to adult care)
• Referral pathways – Pathways and eligibility criteria were not always clear and comprehensive
• Care co-ordination – Only 15% of respondents reported that there was always single members of staff to co-ordinate care
• Listening to people who use services – 57% of commissioners and providers always used feedback about people’s experience to monitor the quality of care they provide
• Working together day-to-day – 27% of services always had prompt and easy access to other agency information
• Keeping children, young people, their parents, families and carers informed and involving them in their care – 34% of areas were always in touch with children and young people (and relevant others) while on waiting lists. In relation to transition to other services, 39% of areas were always in touch with the person and relevant others
• Harnessing technology – 91% of areas were exploring how technology could improve access to mental health support at least some of the time
• Embedding mental wellbeing in school life and valuing the importance of education – 25% of areas felt that schools always supported pupils with this. The report recommends that schools and Ofsted should continue to strengthen their assessment of how schools respond to pupil’s mental health needs
• Supporting and valuing staff – 52% of areas said that there was always training for staff working with children and young people to identify and support mental health needs. It is worth noting that Health Education England has now commissioned training programmes to support the implementation of the actions proposed in the children and young people’s mental health green paper (Department for Education and Department of Health & Social Care, 2018).[13] This includes a new role of education wellbeing practitioner for school-based mental health support teams.

The THRIVE framework

Supporting the Long Term plan ambitions summarised above, the UK is undergoing a shift in the delivery of child and adolescent mental health services (CAMHS) from the historic four tier model (Figure 1) towards a more integrated service model structured around the needs of children and young people such as the THRIVE framework (Wolpert et al., 2019)[14] (Figure 2).

Figure 1 – The four tier model of CAMHS

Figure 2 – The THRIVE Framework

The THRIVE Framework conceptualises the mental health and wellbeing needs of children, young people and families into five need based groupings; from thriving through to getting risk support. The key difference offered by the THRIVE model, in comparison with the four tier model, is that children and young people can move more flexibly between the groupings based on their presenting needs as part of a shared care pathway rather than led by diagnosis or severity.

The implementation of THRIVE as guided by their eight framework principles offers numerous benefits including:

• Improved functioning and future life chances
• Greater empowerment to manage own mental health
• Greater involvement and transparency in decision making processes
• More positive experiences of working with care professionals
• Mental health needs can be identified and responded to earlier
• Improving access to appropriate mental health support and services
• Improved partnership working across multiple agencies, sharing understanding and vision through a common language

There are 99 local areas that are now working towards implementing the THRIVE Framework local and sharing learning through the National i-THRIVE Community of Practice, accounting for 62% of children and young people in England (Wolpert et al., 2019).[14] For more information on implementation sites of i-THRIVE, visit the Implementing Thrive website.

NICE guidance

All service delivery for children and young people experiencing mental health problems should be underpinned by relevant evidence based clinical guidance and quality standards.  NICE recommends that the easiest way to find all guidance related to children and young people’s mental health is to use NICE pathways.[15]

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Impact of COVID-19

It has been forecast that up to ten million people, the equivalent of nearly 20% of the total population, will need new or addition support for their mental health needs as a result of the COVID-19 pandemic, with 1.5 million of these being children and young people (Centre of Mental Health, 2020).[16]

In response to the pandemic, a number of bodies have undertaken work to predict the potential increase in demand for mental health services.

One example of this is the work undertaken by The Strategy Unit[17] which predicts that there may be 1.8 million new presentations, recurrences or exacerbations of mental ill health across England in the next three years as a direct or indirect result of the pandemic with the next 18 months being particularly challenging for services. 

The Strategy Unit’s work suggests that there could be a 33% increase in overall demand in the next three years (to 2022/23) and their modelling app[18] estimates that CYPMHS in England could receive an additional 32,834 referrals in the next three years. Local systems can use the app to model the potential surge in demand for their area and impact on specific services and use this to support planning.

The Centre for Mental Health, in collaboration with NHS Trusts and NHS England, has also worked on developing a modelling toolkit for forecasting additional demand for mental health services resulting from the pandemic.[19] This takes the results of various studies and enables the user to input the information they have about their local population into the model to generate an estimate of the amount of additional demand for mental health services in that area.   

Not only has the COVID-19 pandemic has increased the number of people predicted to need mental health support (Centre for Mental Health, 2020) [16] it has also significantly impacted access to services, with 24% of adults, and 28% of young people reporting not being able to access mental health support (Mind, 2020).[20] A 30 to 40% drop in referrals to children and young people’s services has been reported (Health and Social Care Committee, 2020).[21]

In light of social distancing measures put in place to control the spread of the virus, mental health care services have had to adapt and adopt remote means of patient care, including the dispensing of medications and use of videoconferencing for routine consultations and therapy sessions. Engaging in mental healthcare through new methods does come with some challenges, for example a report by Young Minds engaging with young people found concerns over lack of privacy in the home and fear of family members overhearing sessions with mental health professionals (Young Minds, 2020).[22]

Data shared at the NHS Benchmarking Network’s children and young people’s shared learning event in January 2021 showed the change in how services have been provided during the COVID-19 pandemic and included information on the method of contact with children and young people:

• In 2019/2020, 74% of clinical contacts by CAMHS were face to face with 26% non-face to face (mainly telephone and video-consultations).
• In April 2020, the amount of face to face work reduced to just 18% with 82% being delivered by telephone or video and by October 2020, the position had recovered somewhat with 35% of work now being completed face to face and 65% using non-face to face methods.
• Digital technologies such as video consultation are being used to greater extent in children and young people’s mental health services when compared with adult services.  In October 2020 20% of clinical contacts used these methods, suggesting that they were becoming embedded within services and may remain an important part of service delivery in the longer term.

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Recommendations for action

Action for NHS Commissioners and NHS Providers (Mental Health):

• Routinely review access to CYPMHS against estimated prevalence of diagnosable mental health problems in children and young people for the population services
• Routinely review waiting times data against the proposed four week standard outlined in the NHS Long Term Plan
• Routinely review progress against the extent to which the recommendations from the Care Quality Commission’s review of mental health services for children and young people have been implemented
• Undertake a local assessment of potential increase in demand for mental health services as a result of the COVID-19 pandemic and routinely monitor referral trends against this
• Capitalise on the opportunities afforded by the COVID-19 pandemic to embed the use of digital technologies in the provision of mental health services for children and young people taking into account some of the potential challenges of such an approach
• Ensure that robust pathways and processes are in place to support the transition of children and young people into adult services.

For a summary of all recommendations from the Facts for Action series, visit the Actions by Sector page.

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ZSA Suicide Prevention Resource Map - related indicators

Direct

Referrals

• Referrals into CAMHS per 100,000 registered population (0-18)
• Referrals accepted into CAMHS per 100,000 registered population (0-18)
• CAMHS referral acceptance rate

Waiting times

• Mean waiting time from referral to 1st routine CAMHS appointment
• Mean waiting time from referral to 2nd routine CAMHS appointment

Caseload

• Number of children and young people on CAMHS caseload per 100,000 registered population (0-18)

Contacts

• Total CAMHS contacts per 100,000 registered population (0-18)
• Conversion rate - percentage of people who had a first CAMHS appointment who had a second appointment
• Average annual number of contacts per person on the caseload of CAMHS

Indirect indicators

• Total CCG spend on mental health (all ages) per 100,000 registered population (£)
• CCG spend on mental health (all ages) as a percentage of CCG base allocations
• Percentage of school pupils with social, emotional and mental health needs
• Hospital admissions as a result of self-harm per 100,000 population (aged 10-24)
• Admissions due to alcohol for under 18 year olds per 100,000 population

* All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being received from provider organisations to have their data included in the map. The information reported reflects the data available as at 10/03/2021.

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References

[1] NHS. Children and young people’s mental health services (CYPMHS). Available at: https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/children-and-young-peoples-mental-health-services-cypmhs/ 

[2]NHS Digital (2021). Mental Health Bulletin 2020-21 Reference Tables v2. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-bulletin/2020-21-annual-report 

[3] Office for National Statistics. DC2101EW – Ethnic Group by sex by age. Available at: https://www.nomisweb.co.uk/census/2011/DC2101EW/view/2092957699?rows=c_ethpuk11&cols=c_age 

[4] NHS England and Improvement (December 2020). NHS Mental Health Dashboard Quarter 1 2020/21. Available at: https://www.england.nhs.uk/publication/nhs-mental-health-dashboard/ 

[5] Care Quality Commission (2017). Review of children and young people’s mental health services. Phase one report. Available at: https://www.cqc.org.uk/publications/major-report/review-children-young-peoples-mental-health-services-phase-one-report 

[6] Children and Young People’s Mental Health Task Force, Department of Health and Social Care (2015). Future in mind: promoting, protecting and improving our children and young people’s mental health and wellbeing. Available at: https://www.gov.uk/government/publications/improving-mental-health-services-for-young-people 

[7] The Office for National Statistics. (2022). Suicides in England and Wales. Available at: https://www.ons.gov.uk/file?uri=/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/suicidesintheunitedkingdomreferencetables/current/mainaccessible.xlsx  

 [8] Singh, S., Paul, M., Ford, T., Kramer, T., Weaver, T., McLaren, S., Hovish, K., Islam, Z., Belling, R., White, S. (2010). Process, outcome and experience of transition from child to adult mental healthcare: Multiperspective study. British Journal of Psychiatry, 197(4), 305-312. doi:10.1192/bjp.bp.109.075135. Available at: https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/process-outcome-and-experience-of-transition-from-child-to-adult-mental-healthcare-multiperspective-study/7E7201DFDB1C81F467B9C679080870A5 

[9] NHS (2019). The NHS Long Term Plan. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf 

[10] NHS (2019). NHS Mental Health Implementation Plan 2019/20 – 2023/24. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf 

[11] Care Quality Commission (2018). Are we listening? A review of children and young people’s mental health services. Available at: https://www.cqc.org.uk/publications/themed-work/are-we-listening-review-children-young-peoples-mental-health-services 

[12] Care Quality Commission (2020). Children and young people mental health review: Update on local actions. Available at: https://www.cqc.org.uk/publications/themed-work/children-young-people-mental-health-review-update-local-actions 

[13] Department of Education and Department of Health & Social Care (2018). Transforming children and young people’s mental health provision. Available at: https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper 

[14]Wolpert, M., Harris, R., Hodges, S., Fuggle, P., James, R., Wiener, A., McKenna, C., Law, D., York, A., Jones, M., Fonagy, P., Fleming, I., Munk, S. (2019). THRIVE Framework for system change. London: CAMHS Press. Available at: http://implementingthrive.org/wp-content/uploads/2019/03/THRIVE-Framework-for-system-change-2019.pdf 

[15] National Institute for Health and Care Exellence. Children and young people’s mental health. How NICE resources can support local priorities. Available at: https://stpsupport.nice.org.uk/cyp-mental-health/index.html 

[16] Centre for Mental Health (2020).  Covid-19 and the nation’s mental health: October 2020. Available at: https://www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-october-2020 

[17] The Strategy Unit (2020). Estimating the impacts of COVID-19 on mental health services in England. Available at: http://www.strategyunitwm.nhs.uk/sites/default/files/2020-11/Modelling%20covid-19%20%20MH%20services%20in%20England_20201109_v2.pdf 

[18] The Strategy Unit (2020). Mental Health Surge Modelling app. Available at: https://strategyunit.shinyapps.io/MH_Surge_Modelling/ 

[19] Centre for Mental Health (2020). Forecast Modelling Toolkit. Available at: https://www.centreformentalhealth.org.uk/forecast-modelling-toolkit 

[20] Mind (2020). The mental health emergency: How has the coronavirus pandemic impacted our mental health? Available at: https://www.mind.org.uk/media-a/5929/the-mental-health-emergency_a4_final.pdf 

[21] Health and Social Care Committee (2020). Oral evidence: Delivering Core NHS and Care Services during the Pandemic and Beyond, HC 320. Available at: https://committees.parliament.uk/oralevidence/331/pdf/ 

[22] Young Minds (2020). Coronavirus: Impact on young people with mental health needs. Available at: https://www.headstartkernow.org.uk/HSK%20uploads/COVID19/YM%20coronavirus-report_march2020.pdf

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Content reviewed and updated 13/09/22