Child Care in Practice

ISSN: 1357-5279 (Print) 1476-489X (Online) Journal homepage: https://www.tandfonline.com/loi/cccp20

Personal Reflections on the Development of

an Integrated Service Delivery for Child and
Adolescent Mental Health Services

Sam Allison , David Gilliland , Kathy Mayhew & Richard Wilson

To cite this article: Sam Allison , David Gilliland , Kathy Mayhew & Richard Wilson
(2007) Personal Reflections on the Development of an Integrated Service Delivery for
Child and Adolescent Mental Health Services, Child Care in Practice, 13:1, 67-74, DOI:
10.1080/13575270601103564

To link to this article: https://doi.org/10.1080/13575270601103564

Published online: 11 Jan 2007.

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Child Care in Practice
Vol. 13, No. 1, January 2007, pp. 67
74

Personal Reflections on the

Development of an Integrated Service
Delivery for Child and Adolescent
Mental Health Services
Sam Allison, David Gilliland, Kathy Mayhew &
Richard Wilson

This paper explores the issue of how to develop a greater level of integration across the
continuum services to young people with mental health difficulties. Reference is made to
the strategic guidance offered by key documents and a pilot project is described, which
attempted to link services across providers including a specialist Child and Adolescent
Mental Health Teams, Paediatricians, a Family Centre, a schools counselling service, the
voluntary sector and the Youth Justice agency. The achievements of the pilot are noted, as
are some of the difficulties encountered. The potential for further development is also
considered.

In Northern Ireland, Health and Social Services are provided through four Boards,
which combine health and social care at a commissioning level. Within the Northern
Board there are two Community Trusts (Homefirst Trust and Causeway Trust) and
an Acute Trust (United Hospitals Trust). The Community Trusts provide, through a
unified structure, the complete range of Health and Social Services provision.
In common with many providers of mental health services for young people, the
Northern Board and its constituent Trusts have aspired to operationalise the
four-tiered model as outlined by the Health Advisory Service Report (1995) Together
We Stand.
The main functions of the four tiers have been summarised by the Audit
Commission Report (1999) Children in Mind.

Mr Sam Allison is the Team Leader, Newton Abbey Family Centre. Mr David Gilliland is the Assistant Director
in Child and Adolescent Mental Health Services, Homefirst Trust. Mrs Kathy Mayhew is a link social worker. Dr
Richard Wilson is a consultant child and adolescent psychiatrist. Correspondence to: David Gilliland, Homefirst
Community Trust, PineWood offices, 101 Fry’s Road, Ballymena BT43 7EN, UK. Email: julie.
[email protected]

ISSN 1357-5279 print/1476-489X online/07/010067-08 # 2007 The Child Care in Practice Group
DOI: 10.1080/13575270601103564
68 S. Allison et al.
Tier 1 is a primary level service, which includes interventions by general
practitioners, health visitors, juvenile justice workers, school nurses and teachers.
These staff:
. identify mental health problems early in their development;
. offer general advice and, in certain cases, treatment for less severe mental health
problems; and
. pursue opportunities for promoting mental health and preventing mental health
problems.

Tier 2 is a level of service provided by professionals working on their own who

relate to others through a network rather than within a team, and can include:
. clinical child psychologists;
. educational psychologists;
. paediatricians;
. community child psychiatric nurses or nurse specialists; and
. child psychiatrists.

This service offers:

. training and consultation to other professionals (who might be within Tier 1);
. consultation for professionals and families;
. outreach to identify severe or complex needs where children or families are
unwilling to use specialist services; and
. assessment, which may trigger treatment at this level or in a different tier.

Tier 3 is a specialist service for the more severe, complex and persistent disorders.
Contributors could include:
. social workers;
. clinical psychologists;
. community psychiatric nurses;
. child and adolescent psychiatrists;
. art, music and drama therapists;
. child psychotherapists; and
. occupational therapists

This is usually a multi-disciplinary team or service working in a community child

mental health clinic and offering:
. assessment and treatment of child mental health disorders;
. assessment for referrals to Tier 4;
. contributions to the services, consultation and training at tiers 1 and 2; and
. participation in research and development projects.
 Child Care in Practice 69
Tier 4 is described as ‘‘infrequently used but essential tertiary services such as day
units, highly specialised out-patient teams and inpatient units for older children and
adolescents who are severely mentally ill or at suicidal risk’’ (Audit Commission,
1999, p. 7).
One of the great inspirational messages of the 1995 Health Advisory Service report
Together We Stand concerned the development of Tier 2 Child and Adolescent Mental
Health Services (CAMHS), a community-based capacity able to support front-line
staff through consultation, liaison, training and joint working. In many areas, the
enhancement of this capacity has coincided with increasing integration of the work of
the many different services involved in the complex task of meeting the mental health
needs of the population of children and young people. Progress towards this vision of
a seamless, multi-faceted CAMHS, which would be able to respond to need in an
appropriate and flexible way, has not always been easy. CAMHS within Homefirst
Trust has adopted one way of responding to the issue.
Following a review of child mental health services across the Northern Board area
in 1999, undertaken by the YoungMinds Consultancy Service, the Homefirst Trust
decided to implement a number of recommendations, including the enhancement of
provision at tier 2.
The review had identified the significance of the Family Centres, which at that time
were providing support and assessment for families identified as being highly
vulnerable. Referrals were primarily made by social workers and the staff had
considerable expertise in working with troubled families, including those involved
with the Child Protection system and engaged in Child Care Assessments. At the
same time the Tier 3 teams were struggling with long waiting lists and limited
capacity, unable to respond to the need to develop new ways of working within the
community. Recruitment and retention of those with specialist CAMHS expertise was
then, and still remains, a challenge. The YoungMinds report suggested that:

Family Centres should be considered as a potential resource for bringing together

the CAMHS services at tier 1 and tier 2 and to act as a filter for tier 3 . . . work to
support local community and voluntary sector groups in increasing their capacity
to support young people.

Along with a number of other important initiatives, it was agreed to develop a pilot
project to evaluate whether this would be helpful. The first step was to set up a Tier 2
Support Group, drawing together senior representatives from health, education,
Family Centres, youth justice and the voluntary sector, reflecting the diversity in tier 2
provision already established, and also drawing on the expertise and knowledge of
staff from the Family Centres and the Tier 3 CAMHS. The Assistant Director for
CAMHS, who worked alongside the lead clinician in CAMHS to develop the overall
service, also supported the group. Through the work of this group, communication
between the various services was greatly enhanced and a referral protocol was
produced and disseminated, to enable users of the services to develop an overview of
what was available and how to access appropriate help.
70 S. Allison et al.
In 2002, one of the four Family Centres was identified for the pilot project and one
of the social workers there became a CAMHS link worker, spending two days a week
within the Tier 3 CAMHS team. This experience greatly enhanced the expertise of the
link worker, particularly in the assessment of children and young people with
complex mental health difficulties, but it also facilitated much greater mutual
understanding between the two teams. The Family Centre staff gained a much clearer
picture of the sort of work being undertaken by the tier 3 team, while the CAMHS
staff were able to appreciate more fully both the skill of their Family Centre colleagues
and the challenging work in which they were engaged. As this understanding grew,
the teams began to feel much more confident about transferring cases from one team
to the other, where it was clear that this would be helpful for the family or young
person. An audit of referrals to the CAMHS team showed that while many referrals
were appropriate, about 15% of their new referrals were ones that could also be dealt
with by the Family Centre. For a team with a very long waiting list, this represented a
significant benefit.
During this period, one of the consultant child and adolescent psychiatrists
provided regular, monthly consultation sessions within the Family Centre, open to
staff working within the tier 2 services. Initially, mainly Family Centre staff attended
the sessions, but attendance from other services is now growing.
When the pilot project started there were a number of groups engaged in
behavioural work and parenting. Integration and coordination of the services
provided by the Family Centre and the Community Paediatric Service has been of
great benefit to families and professionals in terms of referral processes, waiting time
and collaborative approaches. There has also been greater coordination with the
voluntary sector (Barnardos and Parents’ Advice Centre), which has provided
parenting groups for families on the waiting list for behavioural support. These
groups have been very well received by families, many of whom decided they no
longer needed individual help after having attended the group.
Training has been provided by YoungMinds through a short course, comprising of
eight one-day modules, covering a wide range of topics relevant to meeting the
mental health needs of children and young people*divorce, bereavement, attach-
ment issues, and so on. This course has been greatly valued by the 30 participants
from the first course, and a third course is now running this year. Those who
attended this course included:
. Family Centre social workers;
. paediatricians;
. educational psychologists;
. education welfare officers;
. youth justice agency staff;
. school counselling staff;
. residential social workers;
. social work staff from fostering support teams; and
. colleagues from counselling agencies from the voluntary sector.
 Child Care in Practice 71
Members of the tier 2 support group are aware of the contribution this course has
had in raising awareness and skill levels across a number of tier 2 services.
Involvement in the pilot project linking the Family Centre with the specialist
CAMHS team has had positive outcomes for the Family Centre on a number of
different levels. The link worker has enhanced her skills and knowledge in the area of
child and adolescent mental health and has become a significant resource not only for
Family Centre colleagues, but also for other childcare professionals with whom they
have contact. The development of the link worker’s clinical skills, particularly in the
area of initial assessment, has led to a more productive use of time and ensures that
planning takes account of the range of factors relevant in identifying and undertaking
interventions. This has enabled staff to be clearer regarding what is an appropriate
referral to the specialist tier 3 team.
Family Centre practice has been enhanced by the development of a deeper
understanding of the CAMHS specialist team. A firm grasp of the multidisciplinary
aspects (what they do and how they do it) has created a much clearer view of their
area of expertise and of how and when that expertise may be useful to the Family
Centre, either through requesting consultation or making direct referrals. Being clear
about the expertise of the specialist Tier 3 services has also underlined and reinforced
a sense of their area of expertise and created an added sense of confidence in the
service provided. One might think that such clarity regarding the differences and the
different roles might lead to a sense of separation between the two services. However,
the opposite seems to be the case, with an emphasis on how the two services might
collaborate and best compliment each other.
The glue that holds these developments together are the relationships that have
developed between members of both services. In some ways this seems to have been
the most significant development. Working together at all levels through developing a
strategy, recruiting a suitable link worker, co-working, sharing joint training or
participating in consultation has created a set of relationships that allows work to be
diverted, advice to be accessed, difficulties shared and expertise to be acknowledged
in a very constructive manner. Having a common manager who provided the
direction and support has been seen as helpful in allowing these relationships to
develop in such a positive way.
However, not all of the impacts on the Family Centre have been so positive. The
diversion of referrals from tier 3 has led to an increase in the Family Centre waiting
list. While it might seem that this simply involves a shift from one waiting list to
another, the fact is that the waiting lists of both services now contain referrals that are
most appropriate to the list that they are on and the case of additional resources can
be made on the basis of where the need is.
Above all else, the pilot project has reinforced for Family Centre staff the notion
that child and adolescent mental health is the business of everyone. No matter what
labels are constructed for staff, such as ‘‘child in need’’, ‘‘child protection’’, or ‘‘looked
after’’, it has become increasingly recognised that the mental health needs of children
should be at the heart of thinking.
72 S. Allison et al.
The tier 2/3 pilot project has produced a number of benefits for the CAMHS
system in the catchment area, including greater awareness and skills in working with
Child and Adolescent Mental Health problems at tier 2. Notably, the tier 2 workers at
the Family Centre feel more supported by having ready consultation with
professionals at tier 3 or via the link worker.
There have also been bonuses for the tier 3 team in its own right. As the pressure of
referral has fallen (by diversion to tier 2 through a managed referral protocol
network), time has been freed up and is being used creatively in a number of ways:
1. Greater planning and thought is available for complex cases.
2. Time for consultation and co-working with other agencies is now readily
available.
3. Time for audit and evaluation of outcomes is being used to assess the efficacy of
interventions.
4. Tier 3 professionals are now in a position to contribute directly to clinical case
and planning meetings, network meetings and service development ventures,
which was not possible before.
5. The emphasis has been on developing sound reciprocal working practices
between partner agencies.

In 2004, YoungMinds returned to review the Family Centre pilot project and
the overall development of tier 2 provision, providing an opportunity to look to
future developments. Through consultation with many of those directly involved
with the pilot project as well as those involved with planning and managing
provision, it was clear that the pilot project had been a great success and had
achieved many of the hoped for outcomes, including developing the Family
Centre to be able to bring together CAMHS and tiers 1 and 2 and act as a filter
for tier 3. It was also successful in the area of supporting local voluntary sector
groups in increasing their capacity to support young people. This has led to a
decision to extend the pilot to the other Family Centres within the Homefirst
Trust area, and through this to continue with the mapping of need across the
whole area.
A primary mental health worker has taken up post, and this will allow the pilot to
extend support to colleagues working in primary care.
The growing understanding of the flow of referrals to a range of services and the
success in working more collaboratively in this area provides the impetus and
confidence to look at developing a more integrated referral process. This clearly needs
to be explored with care, responding to the views and concerns of professionals across
a range of agencies and ensuring that families are offered choice and flexibility in
deciding what sort of help is most appropriate for their child’s particular
circumstances.
The potential to develop and extend links within and between services has not yet
been fully explored, and there is now interest in working much more closely with, for
example, educational welfare and community paediatricians.
 Child Care in Practice 73
One area that has proved more difficult to develop in the way that might have been
anticipated was the capacity to divert work across various contributors to tier 2.
There has been a tendency to effectively transfer work between Tier 3 CAMHS and
the Family Centre (helped undoubtedly by the resource of the link worker), but there
has been less success in diverting work around other components of Tier 2. As the
system has evolved in other parts of the Northern Board area there have been
attempts to develop a common referral form across tier 2, and that may assist in
better targeting of referrals. Clearly such a form will have to be piloted to establish
whether this is in fact the case. If resources permitted, there could also be
considerable benefit in having a single point of entry to the tier 2/3 system operated
on a sessional basis*this would potentially be very attractive to referring agents as it
would avoid the difficulty of deciding to which agency send referrals to.
Although extending the role of the Family Centre has been widely welcomed, the
traditional work undertaken in Family Centres remains important, and must not be
overlooked. Further thought needs to be given in order to support professionals
working with highly vulnerable families and in linking this work with that
traditionally undertaken by the CAMH services. The Family Centre staff are likely
to play a pivotal role in facilitating this process, drawing on their knowledge and
understanding of the challenge facing their colleagues in social services and their
appreciation of how issues relevant to mental health can influence family functioning.
The development may have added significance given the recent emphasis in The
Review of Mental Health and Learning Disability (2006) on Managed Clinical
Networks. This review points out that the concept was first set out in the report of the
Acute Services Review. It was followed in February 1999 by the Management
Executive Letter, which defined managed clinical networks as ‘‘linked groups of health
professionals and organisations from primary, secondary and tertiary care, working
in a co-ordinated manner, unconstrained by existing professional and Health Board
boundaries, to ensure equitable provision of high quality clinically effective services’’
(Management Executive Letter, 1999, p. 2).
The review further suggests that the key ideas behind managed clinical networks
are as follows:
. Emphasis on connection and partnership.
. Distribution of resources rather than centralisation.
. Maximising the benefits for all patients.
. Erosion of barriers between secondary and primary care.
. Emphasis on the term ‘‘managed’’ in ‘‘managed clinical network’’ to underscore
the importance of accountability and professional responsibility with a lead
clinician having central importance.
. Networks are consistent with a renewed emphasis on the role of primary care in
acute health care.
74 S. Allison et al.
The review further points out that:

Managed Networks cross-institutional and other organisational boundaries.

Consequently they challenge existing planning and budgetary processes, which
are based around facilities or geographical areas. They rest on top of, or weave their
way through static components of the overall service. They demand high levels of
partnership between all those within the system as well as shared professional rotas
and common clinical protocols. Clinical life needs to flow evenly across the
network. (2006, p. 29)

References
Audit Commission Report. (1999). Children in mind .
A vision of Comprehensive Child and Adolescent Mental Health Service. (2006).
Health Advisory Service. (1995). Together we stand . London.
Management Executive Letter. (1999). Edinburgh: Scottish Executive Department of Health.