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Keywords:

  • Tiered health care;
  • service provision;
  • access

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

UK government initiatives have proposed changes in the provision of child and adolescent mental health services (CAMHS) within the NHS. In response to this, tier 2 services have been created to provide early assessment and intervention and improved access. This study investigated whether these services met the aims compared to traditional generic tier 3 services, using data from a national mapping exercise. The results were consistent with the tier 2 services providing early assessment and intervention and enhanced accessibility of the services compared to tier 3. The implications of these results in relation to service development are discussed.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

In recent years, a number of government initiatives and reports in the UK have proposed changes in the provision of child and adolescent mental health services (CAMHS) within the NHS (e.g. Audit Commission, 1999; Health Advisory Service, 1995; National Health Service, 2004; HM Treasury, 2003). In 1995, the UK NHS Health Advisory Service proposed a tiered service framework for child and adolescent mental health services. Tier 1 consists of professionals (such as health visitors or General Practitioners) who are not necessarily employed for the purpose of providing mental health care for children but are likely to be the first point of contact between a child and health agencies. Tier 2 professionals are child mental health specialists who both offer direct clinical services to children and provide specialist support to tier 1 staff. Tier 3 and 4 services are aimed at managing problems of a greater degree of severity or complexity, within multidisciplinary, single site services.

More recent government reports have highlighted the importance of early assessment and intervention and improved access to CAMH services associated with mental health services (HM Treasury, 2003; National Health Service, 2004). The importance of provision of mental health care in community settings has also been emphasised by the recent Layard report (Bell et al., 2006) and many of the national treatment guidelines for mental illnesses (e.g. National Institute of Clinical Excellence, 2004a, b). These targets are particularly pertinent to tier 2 CAMH services, which aim to provide early assessment and intervention in a more accessible service.

Despite these national guidelines, the nature of tier 2 services varies nationally. Some trusts have set up a unidisciplinary service, as originally suggested by the tiered service model (Audit Commission, 1999; Health Advisory Service, 1995). Others have created a more multidisciplinary team, which interfaces between primary care and more specialist tier 3 services. Tier 2 services may be solely based in one or several primary care settings (e.g. GP surgeries or schools) (Abrahams & Udwin, 2002; Appleton & Hammond-Rowley, 2000). Others are based at an independent site, or within a tier 3 site, but in contrast to standard tier 3 services restrict their referral criteria by the complexity or risk level of a case (e.g. Day & Davis, 1999).

The nature of the direct clinical work in tier 2 teams also may vary, from clinical interventions for families who seek help or targeted interventions for families who are at high risk of developing a disorder (such as initiatives based in a restricted deprived local area focusing on children under 5 years, e.g. Sure Start local programmes) (see NESS Research Team, 2004) to universal interventions (such as initiatives based in schools) (see Offord et al., 1998).

The characteristics of tier 2 services have not been widely investigated (MacDonald & Bower, 2000; Wiener & Rodwell, 2006), with many services still in the early stages of development (Appleton & Hammond-Rowley, 2000). Although differences between GP based and independent site tier 2 services have been investigated (e.g. Abrahams & Udwin, 2002), to date there have been no comparisons between tier 2 teams and generic tier 3 CAMH services. Such information is key to monitoring and evaluating the success of these changes in service provision.

Since 2002, all CAMH services in the UK have taken part in CAMHS mapping - an annual government initiative designed to obtain a service and team overview of all CAMH services across the NHS. This exercise has several aims including supporting local and national performance management and improvement, as well as characterising the capacity and capabilities of CAMHS. Each year, all out-patient based CAMH services are asked to provide a summary of their caseload for the month of November. The CAMHS mapping data therefore provide a snapshot of service provision, referral patterns and case load characteristics.

The CAMHS mapping data can be used to investigate whether tier 2 services are meeting their key targets. Early assessment and intervention should result in the client population being younger and presenting with less well defined symptoms (as they are seen earlier in the development of any disorder) (Appleyard et al., 2005). Improved ease of access to tier 2 services should mean less delay between referral and assessment and intervention (i.e. shorter waiting times) and direct referral from tier 1 (primary care and education) staff (Appleton, 2000; Health Advisory Service, 1995). Furthermore, to ensure such waiting times are sustainable, duration of treatment must be short (Appleton, 2000).

This study investigated these topics using the 2005 CAMHS mapping data for the Child and Adolescent Directorate of the South London and Maudsley NHS trust. In order to validate the findings, additional analyses were carried out using the 2004 and 2003 CAMHS mapping data.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

This study received approval from the Clinical Governance Committee of South London and Maudsley Trust.

Sample

The CAMHS mapping data for the Child and Adolescent Directorate of the South London and Maudsley NHS Trust (SLAM) were used in this study. SLAM provides mental health services to a deprived area of inner London in which physical, psychological, educational and social needs are high (Davis et al., 2000). The Child and Adolescent Directorate is divided into four boroughs: Lambeth, Lewisham, Croydon and Southwark. The characteristics of each team that submitted a return to the CAMHS mapping exercise were examined to determine eligibility for inclusion in the study. Information regarding the teams was taken from the Clinical Services Directory of SLAM NHS trust and checked with the Business Manager. The following inclusion and exclusion criteria were used:

Tier 2 inclusion criteria

  • Teams accepting referrals from tier 1 professionals (such as GPs, health visitors, educational staff) and/or self referrals, or offering targeted or universal interventions
  • The nature of any direct clinical work focused on assessment and intervention for children at an early stage in the developmental pathway of a disorder.

Description of the tier 2 teams

Consistent with the aims of tier 2 as described by the Health Advisory Service (1995), many of the tier 2 teams offered both direct clinical work and consultation to professionals working in tier 1. The nature of the clinical work included assessment and early intervention for children with a range of relationship, emotional, behavioural and mental health difficulties. Several services also offered or supported targeted interventions (such as Sure Start local programmes and parenting courses). However, contrary to the suggestion of the Health Advisory Service (1995), many of the teams were multidisciplinary, including nurses, doctors, clinical psychologists, family therapists and social workers (see Appendix 1).

The organisation of the services varied between boroughs, not only in terms of the number of tier 2 teams in the each borough (see Appendix 1) but also the catchment population. Some services accepted referrals for any child living within the geographic area of the borough, whilst others were only available to clients registered with particular GPs, living in particular restricted geographic areas, or attending particular schools. Although some teams focused on a particular age group of clients (such as under 5s, or secondary school age), in each borough at least one team catered for children aged 0–18. The location of any direct clinical work also varied from community settings (such as schools, GP surgeries) or the child's home to designated clinical environments.

A more detailed description of the tier 2 services is beyond the scope of this study. However, the work of one of the tier 2 Southwark teams has been described by Day and Davis (1999).

Tier 3 team inclusion criteria

  • Team with no specific disorder focus (e.g. special needs, neurodevelopmental, youth offending)
  • Team offering both assessment and intervention for children and/or adolescents in the community
  • Team accepting referrals for young people with severe/unusual mental health difficulties

Tier 3 team exclusion criteria

  • Teams solely focusing on looked after children
  • National specialist services

In each borough, there were two tier 3 teams, which were either split by age (e.g. child: 0–13 and adolescent: 14–18) or by geographic location (e.g. East and West). Tier 3 teams with a specific disorder focus were not included in order to restrict the comparison to generic tier 3 services. This was done to minimise the possibility that any differences found between the tier 2 and tier 3 services were artefacts of the team definition (since all tier 2 services were generic). The teams included in the study are detailed in Appendix 1.

Measures

All measures included appointments with clients who did not attend or cancelled. Clients who were seen more than once in November were recorded only once on each measure.

Client age/ethnicity. The age and ethnicity of each case were recorded when first seen in November. Age categories were 0–4, 5–9, 10–14, 15–18, 19–25. Ethnicity categories were white, mixed, Asian or Asian British, Black or Black British and other.

Primary presenting problem. The closest main primary presenting problem of each case was recorded, categorised according to hyperkinetic disorders, emotional disorders, conduct disorders, developmental disorders, other or not possible to define.

Waiting list: new cases. Defined as the number of new cases seen in the month of November by duration of wait (from when referral received to date of first appointment offered).

Waiting list. Defined as the number of cases still on waiting list at the end of November, by duration of wait (from when referral received).

Duration of treatment. The duration of treatment of caseload, to the end of November.

Referral source. The referral sources of the caseload when first seen in November, categorised according to primary health care, education, social services, child health or other.

Statistical analysis

Statistical analysis was carried out using SPSS 13.0 for Windows (© SPSS Inc.). Non-parametric Chi-square tests were carried out to determine whether there were significant differences between the tier 2 services and the tier 3 services. Adjusted standard residual (Z scores) were used to determine which categories were significantly different (with correction for multiple comparisons). The expected proportion of children seen in tier 2 was calculated by dividing the number of children seen by tier 2 by the total number of children seen by either tier 3 or tier 2.

The CAMHS mapping exercise only captures the activity of the services of one month in a year. Such a limited sample of the annual workload, particularly in smaller services, might lead to undue sensitivity to events such as post vacancies, annual leave or sick leave. In order to determine the stability of these results, the analyses were repeated with the 2003 and 2004 CAMHS mapping data.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

Client age

There was a significant difference in age between the two service provisions (χ2 = 367.3, df = 4, p < .001). The tier 2 services saw a significantly higher proportion of children aged 0–4 and a significantly smaller proportion of children aged 10–18, (see Table 1 and Figure 1a).

Table 1.   Statistical analyses (* indicates significant at corrected p < .05)
 Tier 2Tier 3
ObservedExpectedAdjusted standard residualsObservedExpected
Age |Z| > 2.58
 0–419265.918.9*84210.1
 5–9168181.5−1.4592578.5
 10–14148205.2−5.7*712654.6
 15–1891146.9−6.1*524468.1
 19–2543.30.41010.7
PDD |Z| > 2.64
 Hyperkinetic1658.3−6.7*228185.7
 Emotional215235.0−1.9769749.0
 Conduct7768.31.3209217.7
 Dev disorders4462.1−2.8*216197.9
 Other167131.64.0*384419.4
 Not possible to define8447.86.3*116152.2
New cases (waiting list) |Z| > 2.50
 <4 weeks2621.01.56772.0
 4–13 weeks3128.10.99395.9
 13–26 weeks512.4−2.7*5042.6
 >26 weeks00.5−0.821.5
Waiting list |Z| > 2.50
 <4 weeks9780.42.9*180196.6
 4–13 weeks8388.0−0.8220215.0
 13–26 weeks1526.4−2.8*7664.6
 >26 weeks11.2−0.232.8
Duration of treatment |Z| > 2.58
 < 4 weeks192160.03.4 *480512.0
 4–13 weeks202163.84.0 *468524.2
 13–26 weeks107124.3−2.0415397.7
 26–52 weeks6375.9−1.8256243.1
 >52 weeks3979.0−5.5 *293253.0
Referral source |Z| > 2.58
 Primary304228.87.2 *657732.2
 Education161115.55.4 *324369.5
 Social Services1498.6−10.7 *400315.4
 Child Health4347.6−0.8157152.4
 Other81112.6−3.8 *392360.4
image

Figure 1.  Proportion of children seen in tier 2 (line represents expected proportion; * indicates significant at corrected p < .05; Error bars represent 95% confidence intervals) a) by age group; b) by primary presenting disorder (PPD); c) by new cases (waiting list); d) by waiting list; e) Duration of treatment; f) Referral source

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Primary Presenting Disorder (PPD)

There was a significant difference in PPD between the two service provisions (χ2 = 99.540, df = 5, p < 0.001). Tier 3 saw a higher proportion of individuals with hyperkinetic disorder and children with developmental disorders, whilst the tier 2 services saw a significantly higher proportion of children classified as ‘Other’ or ‘Not possible to define’, (see Table 1 and Figure 1b).

Waiting list: new cases

There was a significant difference in length of waiting times in new cases between the two service provisions (χ2 = 8.249, df = 3, p = .041). A significantly higher proportion of new cases waited between 13–26 weeks in the tier 3 services compared to the tier 2 services, (see Table 1 and Figure 1c).

Waiting list

There was a significant difference in length of waiting times between the two service provisions (χ2 = 12.198, df = 3, p = .007). The proportion of clients on the waiting list for between 13–26 weeks was significantly higher in the tier 3 services, whilst the proportion of clients on the waiting list for less than 4 weeks was significantly higher in the tier 2 services, (see Table 1 and Figure 1d).

Duration of treatment

There was a significant difference in duration of treatment between the two service provisions (χ2 = 52.776, df = 4, p < .001). The tier 2 services had a significantly higher proportion of clients seen for less than 13 weeks and tier 3 services had a significantly higher proportion of clients seen for over 52 weeks (see Table 1 and Figure 1e).

Referral source

There was a significant difference in referral sources between the two service provisions (χ2 = 163.378, df = 4, p < .001). Tier 2 services received a significantly higher proportion of referrals from primary and education services, whilst tier 3 received significantly more of their referrals from social services or ‘other’ sources (see Table 1 and Figure 1f).

Longitudinal analyses

The pattern described above was replicated using both 2003 and 2004 data samples. The only minor variation was no significant difference between the length of time new cases had waited prior to being seen in the tier 2 and tier 3 services in 2003 (see Table 2).

Table 2.   Statistical analysis from 2004 and 2003 CAMHS data
Category2004 CAMHS data2003 CAMHS data
χ2dfpχ2dfp
Age297.9834<.001266.0314<.001
PPD494.3075<.001149.7434<.001
New cases: WL11.7973.0083.9913.262
Waiting list36.7683<.00119.2803<.001
Duration of treatment62.4974<.00129.1623<.001
Referral source124.1094<.001142.0084<.001

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

This is the first study to characterise the CAMHS tier 2 services delivered within a trust and to compare the differences in the direct clinical work carried out between tier 2 and tier 3 services. Tier 2 services have been set up to provide early assessment and intervention in a more accessible service. The results from this study reveal that tier 2 services in the child and adolescent directorate of the South London and Maudsley NHS trust are meeting many of these aims.

Early assessment and intervention

Tier 2 services saw a younger population of clients. This suggests that the tier 2 services provided assessment and intervention early in development. This is also consistent with (although not necessarily equivalent to) assessment and intervention early in the development of psychological difficulties. Further evidence that might indicate the clients of the tier 2 services were seen early in the development of their psychological difficulties comes from the primary presenting disorders analysis. Early presentations of psychological difficulties are less likely to meet clinical criteria of primary presenting disorders such as emotional, hyperkinetic disorders etc (Appleyard et al., 2005). Consistent with this, increased rates of ‘other’ and ‘not possible to define’ primary presenting disorders were found in the tier 2 services. Examples of children in these categories include those adjusting to parental divorce or with sleep disorders.

Although the results suggest that the tier 2 services are working with children early in the development of their psychological difficulties, it is not possible to determine whether the services are targeting a genuinely different population of children or whether the tier 2 children go on to be seen by tier 3, either immediately or at a later date. Future studies should investigate both the referral rate of tier 2 services onto tier 3 and the evolution of the children's difficulties post discharge from tier 2 services.

Ease of access: waiting times and referral source

A key aim of the tier 2 services is for the time between referral and first appointment to be as brief as possible. Consistent with this, new cases taken on during the mapping exercise had waited for less time in the tier 2 services compared to the tier 3 services. Further, children remaining on the tier 2 waiting list at the end of the mapping exercise had waited less time than the children on the tier 3 waiting list.

It has been highlighted that as there are a limited number of appointment slots in a service, a key factor in maintaining short waiting times is the length of treatment (Appleton, 2000). In particular, shorter treatment lengths mean that the rate of discharge (and consequently the rate of new cases being taken on) is higher. The data from the duration of treatment analysis reveal that the tier 2 services saw clients for significantly shorter durations compared with the tier 3 services. This suggests that the short waiting times for the tier 2 services are likely to be sustainable.

A final factor to consider in terms of determining ease of access to the services is how many professionals the family had to see before receiving a referral to tier 2 or tier 3. Significantly more of the referrals to the tier 2 services were received from tier 1 services (education and primary care (e.g. GPs and health visitors)) compared to tier 3. This suggests that tier 2 services are easily accessible with referrals being made by the family's first point of contact.

It should be noted that the CAMHS mapping exercise does not provide any information regarding non-attended or cancelled appointments. Such information might provide further insight into the comparative ease of access of the tier 2 services compared to the tier 3 services (see Attride-Stirling et al., 2004).

Limitations

One limitation of the CAMHS mapping data is the questionable validity of some of the choices of categories. For example, the primary presenting disorder descriptions do not follow standard diagnostic criteria, such as American Psychiatric Association (2000) or World Health Organisation (1992). It is unclear whether the PPD of a child working through the grief process should be classified as ‘emotional disorder’ (due to the nature of the difficulty) or if ‘other’ or ‘not possible to define’ categories would be more appropriate. In light of such uncertainties, it is likely that classification may be inconsistent both within and between different clinicians. Similarly, the data on the duration of treatment do not reflect length of completed treatment, but provide a snapshot of the length of time the current case load has been seen. Further research is required to confirm that completed length of treatment follows a similar pattern.

CAMHS mapping data only reflect direct individual client work. As such, this study is likely to be an incomplete characterisation of tier 2 roles, which not only include group interventions but also consultation, training and liaison with tier 1 colleagues (Appleton, 2000; Gask, Sibbald, & Creed, 1997). Future studies should characterise these aspects of tier 2 services. In addition, the mapping exercise does not permit comparisons of the nature of interventions or relative efficacy of interventions in tier 2 and tier 3. Such direct comparisons are now warranted to further validate the service model.

Finally, the restriction of some of the tier 2 schemes to certain localities means that some children were referred to tier 3 due to a lack of tier 2 service provision. Further, some of the tier 3 teams include posts specifically designed to target tier 2 work (such as educational behavioural support workers). However, interpretation of the findings of this study is not limited by these issues, as they would tend to minimise any differences between tier 3 and tier 2 services. The differences found are therefore likely to be robust.

Implications for future service development

This study reveals that tier 2 services may be highly diverse in nature, even within a single NHS trust. This is consistent with the diversity documented in reports of other tier 2 CAMH services (e.g. Appleton & Hammond-Rowley, 2000; Wiener & Rodwell, 2006), and with the considerable regional variation in the service provision and structure revealed by the national CAMHS mapping exercise itself (Barnes et al., 2006). Whilst it might be argued that it would be preferable to develop uniform services across boroughs and trusts (to provide equitable care for all), such diversity in tier 2 might be expected, and possibly essential, given the breadth of the service remit and limited evidence base (see Offord et al., 1998). For example, in meeting the needs of the local community, tier 2 services need to be adapted to enhance strengths and address difficulties in the local tier 1 and 3 services. Indeed, perhaps the evolving nature of services in this study during the 3 years of data collection was a key factor in ensuring that the targets continued to be met over a 3-year period.

The results from this study suggest that the tier 2 services in the CAMH service of South London and Maudsley are fulfilling an important role in CAMHS provision. Such evidence supports the expansion of these services both nationally and locally. From a local perspective, the results suggest that teams that currently offer services to a subset of the local population (such as those registered with a particular GP) should be expanded to provide a more universal service. In support of this, the results for Lambeth (a borough with restricted tier 2 services) did show some minor differences from the overall trust pattern (such as no differences in referral sources between tier 3 and EI) (data not shown), reflecting the reduced efficacy of the service.

Whilst the data also support expansion of tier 2 services on a national scale, it is important to consider limitations to the generalisability of these findings to other trusts. The NHS trust investigated in this study is based in an area of significant deprivation (Davis et al., 2000) and as such does not represent an average UK NHS trust. For example, the higher prevalence of psychiatric disorder in inner city areas (Offord et al., 1987; Rutter et al., 1975) may affect waiting list lengths. In light of this, comparisons of tier 2 and tier 3 services in other trusts are warranted.

The results from this and other studies (Appleton & Hammond-Rowley, 2000; Wiener & Rodwell, 2006) reveal that many tier 2 services are not unidisciplinary. This was commonly held to be the distinction between tier 2 and tier 3 services, as suggested by the Health Advisory Service (1995). It is therefore pertinent to consider the key distinction between tier 2 and tier 3 services. We would suggest that the focus on early intervention differentiates the two tiers. The term early intervention can be defined in a number of ways (see Davis et al., 2002) and is often associated with disorder-specific programmes targeting individuals at risk or with early symptoms (see Kuipers et al., 2004). However, increasingly in UK policy documents (e.g. HM Treasury, 2003; National Health Service, 2004; National Institute of Clinical Excellence 2004a, b), as well as internationally (e.g. NSW Health Department, 2001), early intervention is used to refer to therapeutic input offered shortly after symptom onset. The aims of such input (such as reduced distress, brief treatment) dovetail with those of tier 2 services. The introduction of this terminology within service provisions may enhance professional and public understanding and utilisation of the service.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

The data from the CAMHS mapping exercise were consistent with the tier 2 services providing early assessment and intervention to young people. Compared to the more traditional tier 3 services, the client population of tier 2 services was younger and had less well defined psychological difficulties. Waiting times and duration of treatment in the tier 2 services were shorter and significantly more referrals came from tier 1 workers, consistent with enhanced accessibility of the tier 2 services compared to tier 3. These findings have important implications for both local and national service development.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

The authors would like to thank Simon Cook (CAMHS business manager, SLAM), Daniel Stahl (for statistical advice) and Dr Paula Corredor Lopez and Amita Jassi.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix
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Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
  10. Appendix

Appendix 1.

Characteristics of teams included in 2005 analysis. Figures give whole time equivalent (including unfilled posts). Clinical psychologists include trainees, Other includes administrative support, non-clinical staff and other unqualified staff. C&A = Child and Adolescent