Training primary care colleagues

Two patterns of training are evident in the literature. First, training may be targeted at primary care professionals who intend to continue providing an entirely generalist service. Bernard et al (1999) developed a teaching package for GP registrars designed to improve abilities in detection, assessment and management of mental health problems in adolescents. In a London study of 61 GP registrars, there was evidence for positive changes in self-perceived competence, increased knowledge and increased recognition of adolescent psychiatric disorder.

Second, training may be aimed at primary care professionals who plan to devote a specific proportion of their time to non-specialist CAMH work. In a London study, health visitors and clinical medical officers were trained in parent counselling, parenting and child behaviour management (Reference Davis, Spurr and CoxDavis, et al, 1997). These staff then provided a local clinical service under the supervision of Tier 2 child mental health specialists. In a controlled study, child and family outcome measures were promising, although the authors stress the need for replication (Reference Davis and SpurrDavis & Spurr, 1998).

Turning to educational settings, there is evidence that training teachers in effective classroom management can reduce rates of school-based aggressive behaviour (Reference Hawkins, von Cleve and CatalanoHawkins et al, 1991).

In practice, during the early stages of comprehensive CAMHS development, it can be difficult to negotiate release of primary care colleagues for training and development work. Strategic planning agreement at primary care group trust and local authority chief executive level is essential before expecting primary care colleagues to make difficult choices between the many different demands on their time.

Providing consultation to primary care

Skills may also be disseminated via consultation. In the context of community-based mental health services, the term ‘consultation’ has a specific meaning, which derives originally from the work of Gerald Caplan (Reference CaplanCaplan, 1970). Consultation may be defined as collaborative problem solving between a mental health specialist (the consultant) and one or more persons (the consultees) who are responsible for providing some form of psychological assistance to another (the client or patient). Consultation may take a range of forms, as outlined in Box 4. There is a considerable literature on primary care consultation, in both health and educational settings, although some of it lacks systematic research (Reference Medway and UpdykeMedway & Updyke, 1985; Reference Meyers, Brent, Faherty and ErchulMeyers et al, 1993; Reference Garralda, Rutter, Taylor and HersovGarralda, 1994).

Clearly, the purpose of consultation is to go beyond traditional teaching modes of communication, by engaging primary care colleagues in a sustained and interactive learning programme, usually involving a mutual commitment from both Tier 2 and Tier 1 professionals. Experienced consultants emphasise the considerable time investment involved in the early stages of setting up consultation links with schools or health care settings, as well as the importance of respecting status hierarchies in the ‘host’ organisation. For instance, consultation links with a school always require careful negotiation with the head teacher (and local education authority) before permission is granted for direct access to the front-line teaching staff. If a consultation is provided between agencies (e.g. psychiatrist to school), explicit work on stereotypes and differences of language may be of crucial significance in creating a working relationship. This may, of course, also be true for working within agencies.

Consultation about an individual child or family may result in a referral to Tier 2 when it is agreed that needs cannot be met at Tier 1. Some referrals will be dealt with at Tier 2, whereas others may require referral for multi-disciplinary assessment and treatment.

Tier 2 interventions

Most interventions at Tier 2 involve active collaboration between Tier 2 and primary care. As we have seen, a Tier 2 service is usually provided in a context of training and consultation, with filtering and gate-keeping. Clinical referrals to Tier 2 provide an opportunity for a dialogue with Tier 1 about individual case management.

Clinical interventions provided for families seeking help constitute one category of service intervention. As CAMHS begin to take on a public health function, other categories of intervention will be adopted as evidence accrues for effectiveness. Reference Offord, Kraemer and KazdinOfford et al (1998) outline three types of intervention, each contributing to a lowering of the burden of child psychiatric suffering in the population (see Box 5). In contrast to clinical interventions, which are provided for families seeking help, targeted interventions are aimed at children deemed to be at high risk of developing a disorder (e.g. children of drug-misusing parents), and universal interventions are aimed at all children in a geographical area or setting (e.g. a school). Targeted and universal interventions are provided without reference to individual help-seeking behaviour. A detailed analysis of trade-offs among each of these approaches is provided by Reference Offord, Kraemer and KazdinOfford et al (1998).

Gate-keeping access to Tiers 3 and 4

The fourth function of Tier 2 is to ensure that children with complex or severe disorders are referred to Tiers 3 or 4 for multi-disciplinary investigation and treatment. There will be a need to develop protocols to ensure that appropriate referrals are made, but it is also recognised that, in the presence of long waiting times for specialist work, Tier 2 services may have to ‘hold’ complex cases, providing a brief intervention and ensuring that inter-agency support resources are maximised for the family (see also Davis et al, 1997). There is the risk that if this process is not well managed, Tier 3 waiting times will be replicated at Tier 2, with consequent erosion of training, consultation and preventive intervention functions.

Organisation and development of Tier 2 functions

In this journal, Gask & Croft (2000) have drawn attention to the importance of identifying manageable steps in the development of primary-secondary mental health services. The authors highlight the need for identifying the evidence base, for bringing together the key players at local level, for a local needs assessment, and for the involvement of service users. Earlier in this paper, the importance of strategic agreements at inter-agency chief executive level was emphasised. A case example of Tier 2 CAMHS development is provided in Box 7.

In general, CAMHS have found it impossible to begin substantive Tier 2 work without the creation of new primary child mental health specialist posts. Leadership and clinical supervision for colleagues in these posts then becomes crucial for planned organisation and development. To meet this requirement, some areas have invested in a consultant-level Tier 2 CAMH specialist post, sometimes working in equal partnership with a local authority (or voluntary agency) senior manager (ideally with extensive specialist educational or children's social care experience).

Access to CAMHS for children from ethnic minority groups

Equal access to CAMHS for children from ethnic minority groups is essential (Reference Cooper, Smaje and ArberCooper et al, 1998). During the needs assessment stage of Tier 2 service, there is an early opportunity to seek guidance from ethnic minority community leaders on appropriate service structures and processes, including membership of stakeholder groups.

Training and supervision

Existing literature rightly emphasises the training needs of Tier 1. However, there is an equally important need for accredited continuing professional development (CPD) training for CAMH professionals taking on Tier 2 duties. Working in community settings requires new skills. Supervision is also important, and in small services may be difficult to access. Creative inter-agency linkages, and sharing of supervision resources across geographical areas may address this problem during early stages of service development.

Geographical planning

There has been little discussion in the literature on the appropriate nature and size of geographical unit for Tier 2 services. At least two issues arise. First, whether or not socially disadvantaged areas should be ‘targeted’. Benefits of this approach include increased access for a high-risk population, and increased support for primary care colleagues working in high-need areas. A disadvantage is the stigma that may accrue to an area when new services are seen to target it. One option is to choose an area that includes a wide spectrum of level of need (Reference Appleton and Hammond-RowleyAppleton & Hammond-Rowley, 2000).

A second issue is the size of the geographical area chosen for provision. Three approaches seem to be evident in the literature. The first approach is to provide services to a large area (total population exceeding 40 000), beginning with a subset of Tier 1 services that are either ‘organisationally ready’ or show particularly high need (see Reference Day, Davis and HindDay et al, 1998). The second is to choose a small area (total population 10 000-20 000) and provide comprehensive Tier 2 services to all inter-agency primary care facilities (Reference Appleton and Hammond-RowleyAppleton & Hammond-Rowley, 2000). A third method is to begin with one or two general practices (Reference Coverley, Garralda and BowmanCoverley et al, 1995). Choice of approach will depend on the purposes of the planned service and the resources available.

Children with severe and complex psychiatric disorder

As Box 1 indicates, longitudinal and coordinating responsibility for children and families with severe and complex problems resides with primary care. Schools are responsible for managing children with severe difficulties in the classroom. Primary care health services are responsible for continuing to care for children after Tiers 3 or 4 have completed clinical interventions. In emphasising the early identification role of Tier 1, the current tiered model does not fully address the role of primary care in long-term care and education of children with complex difficulties. More often than not, both a parent and a child in such families may be experiencing psychiatric disorder. Currently, new Tier 2 services are asked to help with complex cases, sometimes before and sometimes after Tier 3 or 4 involvement, but inevitably the intensive nature of this clinical and consultancy work will erode the wider functions of Tier 2. Strategic inter-agency plans will need to identify specific resources for multi-tier training and support for work with children with severe and complex disorder, concentrating on the front-line demands on Tier 1 staff. Gask & Croft (2000) draw attention to the potential of shared care plans in GP management of complex cases. In CAMHS, there is also a need to focus shared care plans on the partnership between the school and family.

Child protection

Schools and primary care health services are at the front line in identification of risk of child abuse and neglect (Department of Health, Home Office & Department for Education and Employment, 1999: paras 3.10-3.14, 3.28-3.38). Often, emotional and behavioural difficulties are the first clues that a child may be at risk of, or experiencing, abuse or neglect. It is important, therefore, that new Tier 2 services recognise the implications of possible increased early recognition of risk of abuse and neglect, as primary care professionals improve in their detection of CAMH problems.

Children with a long-term physical illness or disability

Most children with a chronic illness cope well but as a group they are at higher risk of psychiatric disorder than physically well children, especially if there is neurological involvement. It is important that the mental health needs of these children are met in community and school settings, where social inclusion can be promoted. A link is important between inter-agency child disability services and Tier 2 CAMHS, to ensure that mental health needs can be addressed in the community.

Inter-agency collaboration

The two ground-breaking CAMH strategy documents published in 1995 (Department of Health/Home Office/Department for Education and Employment, 1995; NHS/HAS, 1995) were explicitly multi-agency in their orientation. Since the election of a new UK Government in 1997, that theme has continued, with, for instance, joint circulars requiring agencies to submit jointly agreed CAMH strategies. However, considering Box 1, if the primary care tier of CAMHS is to develop in a ‘seamless’ fashion, the notions of first contact access, longitudinal care, comprehensive access, individual coordination of care and education, and family and community-centred service will need to be approached from an inter-agency perspective. Tier 2 services are in a strong position to promote such an approach if they themselves are funded and managed on an inter-agency basis.