Statham, June

Storey, Pamela

English

Storey, P

Statham, J

UCL Discovery

BackgroundThis report presents the findings from a two-stage studyundertaken between April and December 2006 by theThomas Coram Research Unit for the Department ofHealth. It examines the issues raised for providers andcommissioners of child and adolescent mental healthservices (CAMHS) by the national target to provide on-call and 24-hour specialist cover by December 2006. Thereport includes the results of an electronic survey ofCAMHS providers in late autumn 2006, which investigated the quality and configuration of on-callservices in place by the target date.MethodsThe study draws on information from:initial consultation with key experts in the National CAMHS Support Service and elsewhere; a focused review of literature on the effectiveness of different models of 24-hour CAMHS cover and on the views of young people using this provision; telephone interviews with 18 commissioners andproviders from 14 CAMHS in England;an electronic survey of CAMHS providers to determine the cover provided for emergency presentations, to gather data on audits of out of hours presentations and the costs of providing emergency cover.   Literature reviewThere are few robust evaluations relating to the emergency management of children and young peoplepresenting with a mental health crisis out of workinghours.  Intensive home-based interventions may reducethe need for out-of-hours crisis admissions, although theevidence is not conclusive. Young people with experienceof mental health crises emphasise the importance of theway they are treated when accessing services in anemergency. To be treated by staff who are approachable,non-judgemental, empathetic and able to make thingshappen appears to be of greater value to them than theparticular organisational arrangements or the professionof the person they see. Young people also value community-based services which offer 24-hour access toa drop-in or telephone service providing advice and reassurance, which may help them to avoid hospitaladmission. The extent of 24-hour coverAlthough the majority of CAMHS providers reportedbeing able to provide an on-call service by CAMHS professionals by the target date, and most of the restcould offer a next-day emergency response by CAMHSstaff, it remains difficult to accurately assess the currentextent of provision.  The survey conducted by this studysuggests that 9% of services are unable to provide anon-call CAMHS response to provide emergency Meeting the target: providing on-call and 24-hourspecialist cover in Child and Adolescent MentalHealth ServicesFinal report summaryPamela Storey and June Statham, March 2007assessment at any time, and around 30% have noCAMHS staff on call to undertake assessments at weekends. The study found evidence that the data provided for the national mapping exercise and for localdelivery plans are based on different interpretations byproviders of the 24/7 PSA target, and indeed of whatconstitutes an ‘emergency’. The situation is further complicated as some out-of-hours cover arrangementsdo not depend on formal protocols or agreements butinstead rely on informal systems of goodwill which maydisappear if particular members of staff are unavailableor may apply only in specific locations of a service area.Additionally, some 24-hour cover remains under reviewdue to limited resources, restructuring or fixed periodfunding. Types of provisionThe main models of 24-hour CAMHS cover reported in this study are:a consultant child psychiatrist on call round the clock, with various arrangements for first- and second-level on-call before reaching the consultant;the same model, but with the consultant providing telephone-only advice;informal shared arrangements for on-call with adult mental health services; andpartnerships with other agencies to offer a multi-agency response. Where services provide 24-hour access to a CAMHS consultant psychiatrist there appears to be a reluctanceto consider alternatives, even when difficulties in maintaining this level of cover are experienced. Amongthe shared arrangements that had been considered oradopted, often by smaller providers, combining with aneighbouring CAMHS to provide a bigger pool of stafffor an on-call rota had generally been the least successful due to the variety of contractual and servicedelivery arrangements. Purchasing consultant psychiatristcover from a neighbouring area appears a more successful and cost effective solution, but not one thatthat is available to all. Partnerships and multi-agencycollaboration with adult mental health or social careservices have proved effective solutions, but have frequently required considerable tenacity from commissioners to steer and sustain the interest and commitment of partners through protracted negotiations.BarriersThe main barriers to developing 24-hour on-call CAMHSare perceived to be resources, lack of staff (especially forsmaller providers or where there has been a history ofunder-investment in CAMHS) and the frequently reportedreluctance of existing staff – from nurses to consultants– to contracting to provide 24-hour cover.  At the sametime, an underlying ethos of patient care means thatmost services report a culture of responding when a situation is perceived to be a real emergency which theformalising, through contractual on-call arrangements,may undermine.  There is some evidence, however, thatwhen staff are provided with a realistic picture of thedemands of on-call work, through audits or pilotschemes, they are more willing to participate in formalrotas. ConclusionsThe 24/7 target has encouraged CAMHS and other services to critically review the wider issues concerningyoung people experiencing a mental health crisis, and toconsider the services that need to be in place bothbefore and after the point of accessing an emergencyassessment. There is a growing interest in the role ofCAMHS in supporting staff in other services such as A&Eto undertake assessments, and in developing closer linkswith a range of agencies to offer better pathways of carefor children and young people who present as a mentalhealth emergency.  Setting up and providing specialistcover out of hours has in some cases diverted resourcesfrom other aspects of the service and may be unsustain-able in the longer term.  Whilst the great majority ofCAMHS providers report 24/7 services in place to meetthe proxy target at the end of 2006, it is likely that further changes in out-of-hours provision may develop aspressure on CAMHS resources focuses on other aspectsof  providing a comprehensive service.This work was undertaken by the Thomas Coram Research Unit which receives funding from the Department of Health.  The views expressedin the publication are those of the authors and not necessarily those of the Department of Health.For further information please contact the Thomas Coram Research Unit, Institute of Education, 27-28 Woburn Square, London WC1H 0AA,tel: 020 7612 6957, email: tcru@ioe.ac.uk, web: www.ioe.ac.uk/tcru

Meeting the target: providing on-call and 24-hour specialist cover in Child and Adolescent Mental Health Services: Final report.

Institute of Education EPrints

Background
This report presents the findings from a two-stage study
undertaken between April and December 2006 by the
Thomas Coram Research Unit for the Department of
Health. It examines the issues raised for providers and
commissioners of child and adolescent mental health
services (CAMHS) by the national target to provide on-
call and 24-hour specialist cover by December 2006. The
report includes the results of an electronic survey of
CAMHS providers in late autumn 2006, which 
investigated the quality and configuration of on-call
services in place by the target date.
Methods
The study draws on information from:
initial consultation with key experts in the 
National CAMHS Support Service and elsewhere; 
a focused review of literature on the 
effectiveness of different models of 24-hour 
CAMHS cover and on the views of young people 
using this provision; 
telephone interviews with 18 commissioners and
providers from 14 CAMHS in England;
an electronic survey of CAMHS providers to 
determine the cover provided for emergency 
presentations, to gather data on audits of out of 
hours presentations and the costs of providing 
emergency cover.   
Literature review
There are few robust evaluations relating to the 
emergency management of children and young people
presenting with a mental health crisis out of working
hours.  Intensive home-based interventions may reduce
the need for out-of-hours crisis admissions, although the
evidence is not conclusive. Young people with experience
of mental health crises emphasise the importance of the
way they are treated when accessing services in an
emergency. To be treated by staff who are approachable,
non-judgemental, empathetic and able to make things
happen appears to be of greater value to them than the
particular organisational arrangements or the profession
of the person they see. Young people also value 
community-based services which offer 24-hour access to
a drop-in or telephone service providing advice and 
reassurance, which may help them to avoid hospital
admission. 
The extent of 24-hour cover
Although the majority of CAMHS providers reported
being able to provide an on-call service by CAMHS 
professionals by the target date, and most of the rest
could offer a next-day emergency response by CAMHS
staff, it remains difficult to accurately assess the current
extent of provision.  The survey conducted by this study
suggests that 9% of services are unable to provide an
on-call CAMHS response to provide emergency 
Meeting the target: providing on-call and 24-hour
specialist cover in Child and Adolescent Mental
Health Services
Final report summary
Pamela Storey and June Statham, March 2007
assessment at any time, and around 30% have no
CAMHS staff on call to undertake assessments at 
weekends. The study found evidence that the data 
provided for the national mapping exercise and for local
delivery plans are based on different interpretations by
providers of the 24/7 PSA target, and indeed of what
constitutes an ‘emergency’. The situation is further 
complicated as some out-of-hours cover arrangements
do not depend on formal protocols or agreements but
instead rely on informal systems of goodwill which may
disappear if particular members of staff are unavailable
or may apply only in specific locations of a service area.
Additionally, some 24-hour cover remains under review
due to limited resources, restructuring or fixed period
funding. 
Types of provision
The main models of 24-hour CAMHS cover 
reported in this study are:
a consultant child psychiatrist on call round the 
clock, with various arrangements for first- and 
second-level on-call before reaching the 
consultant;
the same model, but with the consultant 
providing telephone-only advice;
informal shared arrangements for on-call with 
adult mental health services; and
partnerships with other agencies to offer a multi-
agency response. 
Where services provide 24-hour access to a CAMHS 
consultant psychiatrist there appears to be a reluctance
to consider alternatives, even when difficulties in 
maintaining this level of cover are experienced. Among
the shared arrangements that had been considered or
adopted, often by smaller providers, combining with a
neighbouring CAMHS to provide a bigger pool of staff
for an on-call rota had generally been the least 
successful due to the variety of contractual and service
delivery arrangements. Purchasing consultant psychiatrist
cover from a neighbouring area appears a more 
successful and cost effective solution, but not one that
that is available to all. Partnerships and multi-agency
collaboration with adult mental health or social care
services have proved effective solutions, but have 
frequently required considerable tenacity from 
commissioners to steer and sustain the interest and 
commitment of partners through protracted negotiations.
Barriers
The main barriers to developing 24-hour on-call CAMHS
are perceived to be resources, lack of staff (especially for
smaller providers or where there has been a history of
under-investment in CAMHS) and the frequently reported
reluctance of existing staff – from nurses to consultants
– to contracting to provide 24-hour cover.  At the same
time, an underlying ethos of patient care means that
most services report a culture of responding when a 
situation is perceived to be a real emergency which the
formalising, through contractual on-call arrangements,
may undermine.  There is some evidence, however, that
when staff are provided with a realistic picture of the
demands of on-call work, through audits or pilot
schemes, they are more willing to participate in formal
rotas. 
Conclusions
The 24/7 target has encouraged CAMHS and other 
services to critically review the wider issues concerning
young people experiencing a mental health crisis, and to
consider the services that need to be in place both
before and after the point of accessing an emergency
assessment. There is a growing interest in the role of
CAMHS in supporting staff in other services such as A&E
to undertake assessments, and in developing closer links
with a range of agencies to offer better pathways of care
for children and young people who present as a mental
health emergency.  Setting up and providing specialist
cover out of hours has in some cases diverted resources
from other aspects of the service and may be unsustain-
able in the longer term.  Whilst the great majority of
CAMHS providers report 24/7 services in place to meet
the proxy target at the end of 2006, it is likely that 
further changes in out-of-hours provision may develop as
pressure on CAMHS resources focuses on other aspects
of  providing a comprehensive service.
This work was undertaken by the Thomas Coram Research Unit which receives funding from the Department of Health.  The views expressed
in the publication are those of the authors and not necessarily those of the Department of Health.
For further information please contact the Thomas Coram Research Unit, Institute of Education, 27-28 Woburn Square, London WC1H 0AA,
tel: 020 7612 6957, email: tcru@ioe.ac.uk, web: www.ioe.ac.uk/tcru


http://eprints.ioe.ac.uk/663/1/24hour_CAMHS.PDF

Meeting the target: providing on-call and 24-hour specialist cover in Child and Adolescent Mental Health Services: Final report.

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