Transition from child and adolescent mental health services to adult mental health services

We investigate how young people are supported in the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) when they turn 18 years old.  

Investigation summary

It’s estimated that more than 25,000 young people transition from CAMHS to AMHS each year. Many young people don’t have a positive experience of transition. As a result they may disengage from services and put their health and wellbeing at risk.  

In this investigation we share the story of a young person who died by suicide shortly after transitioning from CAMHS to AMHS. 

The investigation identifies a number of factors that contributed to this event, which the report describes both in relation to this young person and in the context of the wider healthcare system.

As part of the investigation we held a focus group involving young people who had either transitioned from CAMHS to AMHS or were in the process of transitioning. They provide the investigation with a lived experience of the issues and concerns for young people when services don’t meet their needs.

Safety recommendations

We've made safety recommendations to NHS England (NHSE), NHS Improvement (NHSI) and the Care Quality Commission (CQC) as a result of this investigation. 

NHS England (NHSE) and NHS Improvement (NHSI)

Recommendation 2018/006

That NHS England, within the ‘Long-Term Plan’, works with partners to identify and meet the needs of young adults who have mental health problems that require support but do not meet the current criteria for access to adult mental health services.

Response

Response received 1 October 2018 and updated 12 March 2019:

  • NHSE gathered views on identifying and meeting the needs of young adults through the stakeholder engagement which informed the development of the Long Term Plan (LTP); stakeholder engagement will continue throughout the process of implementing the LTP. 

Timescale: completed December 2018.

  • The LTP was published in January 2019; it recognises the need to ensure appropriate support for young adults and commits to implementing a new approach to young adult mental health services. This will include a comprehensive offer for 0-25 year olds which reaches across mental health services for children, young people and adults. 

Timescale: completed January 2019.

  • In addition, the Long Term Plan sets out our ambition to improve transition for all young people whether they are receiving care for their mental or physical health needs. By 2028 we aim to move towards service models across all chronic conditions for young people that offer person- centred and age appropriate care for mental and physical health needs, rather than an arbitrary transition to adult services based on age not need. Our aim is to achieve a safe transition, maintain engagement, improve outcomes and support young people to be fully involved in their own care.
  • On 11 March 2019 we published the Clinically-led Review of NHS Access Standards interim report by the NHS National Medical Director, Professor Stephen Powis which sets out our plans to test access to timely, evidence based mental health interventions for people of all ages. 
  • Following the publication of the NHS Long Term Plan (LTP), the National Implementation Framework, to be published in the Spring, will provide further information on how the LTP will be implemented. Additional details, based on local health system 5 year plans, will be brought together in a detailed national implementation plan in the Autumn. 

Timescale: Spring 2019.

Recommendation 2018/007

That NHS England requires Clinical Commissioning Groups to demonstrate that the budget identified for current children and young people’s services – those delivering care up until the age of 18 – is spent only on this group.

Response

Response received 1 October 2018 and updated 12 March 2019:

  • Funding for Children and Young People’s Mental Health Services will form part of the £2.3bn ringfenced funding identified for Mental Health within the NHS Long Term Plan, and the NHS has made a commitment that funding for CYPMHS will grow faster than both overall NHS funding and total mental health spending.
  • NHS England continues to require all CCGs to meet the Mental Health Investment Standard. As part of the 18/19 planning process, CCGs were told that allocations must be spent on the purposes for which they were originally intended and cannot be used to cross-subsidise other services or supplant existing spend. To support this, an indicative estimate of CCG level allocations for the Children and Young People’s Mental Health transformation funding, including CYP eating disorder services, was made available. CCG plans were scrutinised as part of the 18/19 financial planning process to ensure they planned to increase spending in line with transformation funding increases and this is being monitored and scrutinised as part of in-year financial reporting.
  • NHS England and NHS improvement are working together to increase transparency and the reporting requirements for both commissioner spend and for provider income. There will be increased focus on provider income analysis as part of the 2019/20 planning round and 2019/20 reporting processes.

Timescale: already underway.

Recommendation 2018/008

That NHS England and NHS Improvement ensure that transition guidance, pathways or performance measures require structured conversations to take place with the young person transitioning to assess their readiness, develop their understanding of their condition and empower them to ask questions. NHS England and NHS Improvement must then ensure that the effectiveness of this is robustly evaluated.

Response

Response received 1 October 2018 and updated 12 March 2019:

  • NHS England will work jointly with NHS Improvement to promote a co-ordinated approach to transitions across agencies and to develop existing and new tools, protocols and resources for transition processes. This will primarily be taken forward through NHS Improvement’s Transitions Collaborative which will work with trusts to improve transitions in both physical and mental health services.
  • The Transitions Collaborative will promote the implementation of Transitions Champions in trusts, particularly in Adult Mental Health Services, with support from NHS England.
  • NHS England will use existing adult and CYP clinical networks to support improvements in local delivery of transition processes.

Timescale: already underway.

Recommendation 2018/009

That NHS England, within the ‘Long-Term Plan’, requires services to move from aged-based transition criteria towards more flexible criteria based on an individual’s needs.

Response

Response received 1 October 2018 and updated 12 March 2019:

  • As above, NHS England has committed to improving access to appropriate mental health services for young adults, including those with co morbid autistic spectrum disorder and mental health problems, in the NHS Long Term Plan.

Timescale: completed January 2019.

  • The comprehensive offer for 0-25 year olds will deliver an integrated approach across health, social care, education and the voluntary sector. This will include potential expansion of existing needs-based approaches such as the iThrive model.
  • NHSE has commissioned the National Collaborating Centre for Mental Health (NCCMH) to consider and review approaches to improve mental health support for young adults; this includes consideration of existing needs-based approaches to transition.

Timescale: completed January 2019.

Recommendation 2018/010

That NHS England and NHS Improvement work with commissioners and providers of mental health services to ensure that the care of a young person before, during and after transition is shared in line with best practice, including joint agency working.

Response

Response received 1 October 2018 and updated 12 March 2019:

  • NHS England will ensure local areas demonstrate planned improvements for transition in their Local Transformation Plans for Children and Young People’s Mental Health, to be assured by regional teams.

Timescale: completed January 2019.

  • Through the establishment and delivery of the Transitions Collaborative, NHS England will work jointly with NHS Improvement to consider how to drive forward improvements in transition processes nationally.

Timescale: already underway.

  • The NHS Long Term Plan promotes the role of Adult Mental Health Services in transition to ensure young adults are supported across the mental health system.

Timescale: already underway.

Care Quality Commission

Recommendation 2018/011

That the Care Quality Commission (CQC) extends the remit of its inspections to ensure that the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.

Response

Response received 1 October 2018: 

Our current approach to inspection is determined by the Health and Social Care Act 2008. We inspect registered providers or locations and do not normally inspect local systems. To commit to doing otherwise, would be to change the nature of how we inspect – which is based on risk, ratings and core services.

We have just piloted local system reviews in 20 areas looking specifically at how older people move through the health and care system. These reviews were undertaken with specific permission under section 48 of the Health and Social Care Act. To do this routinely would require a change in legislation. What CQC can commit to is ensuring that when we inspect CAMHS, we will review the arrangements they have to manage the pathway for patients into adult services. Likewise, when we inspect adult mental health services, we can enquire about their interface with CAMHS. Guidance is available to help our inspectors consider these issues.

Safety observations

This investigation makes the following safety observations:

  1. It would be beneficial for both CAMHS and AMHS clinicians to be trained in safe and effective transitions from CAMHS to AMHS.
  2. It would be beneficial for NHS England to consider developing a method to identify where Clinical Commissioning Groups spend on CAMHS per capita is lower than reasonably expected.

Safety observations are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention.