EN-CAMHS 2: Enhancing CAMHS Referrals

BACKGROUND Children and young people's mental health is a national priority for the Department of Health and Social Care [1] and all major national funders. This research addresses critical problems in the referral processes to Child and Adolescent Mental Health Services (CAMHS) that the project team identified during the project team's qualitative research program during the project team's NIHR HS&DR-funded EN-CAMHS 1 project.

1. CAMHS cannot cope with the growing numbers of referrals. Nearly 500,000 children and young people (CYP) were referred to CAMHS in 2021/2022 [2], and this number has risen steadily since 1999 [3,4]. CAMHS providers are overwhelmed by the number of referrals [5,6].
2. Rising demand is coupled with high levels of rejection. Almost a quarter of the referrals made into CAMHS are unsuccessful because they are deemed inappropriate or do not reach the threshold for treatment [2]. This results in longer delays for children who need the specialist care, which is exacerbating mental health difficulties [7].
3. The experience of the referral process is poor [8,9]. The high rate of inappropriate referrals causes unnecessary distress to children, their families and to referrers, who can wait many weeks if not months for a decision [10]. The family upset is compounded by a lack of communication throughout the long process [11]. When a referral is rejected, it typically goes to the 'back of the queue', resulting in further delays for children and families.
4. The quality of CAMHS referrals is poor and CAMHS is often seen as the gold standard by families or the only alternative by referrers struggling to know what else is available in primary care [7,10].
5. Clear information about what CAMHS can and cannot provide is not readily available and suitable alternative sources of mental health support are often not explained to children and their families at the point of referral rejection [12,13].
6. Non-CAMHS support is poorly understood [14] and not widely valued as a helpful source of support. People who could be helped better by non-CAMHS support are not signposted elsewhere early enough in the process, except in a minority of places.
7. Rejected referrals incur a significant cost for CAMHS who must triage often incomplete and/or inaccurate, referral documentation. Receiving a rejection is also frustrating and costly to referrers (GPs, school staff) who spend valuable time preparing referral documentation [15,16].

The NIHR funded EN-CAMHS project ("EN-CAMHS 1", NIHR131379) consulted with 110 CAMHS stakeholders (CYP, parents/carers, GPs, mental health school staff and CAMHS professionals) [17]. EN-CAMHS 1 confirmed and extended previous research: stakeholders reported widespread confusion about the kinds of support CAMHS can and cannot provide. Referrers reported poor support during the referral process, lack of transparency about the process and a lack of knowledge and low confidence in other sources of support. Services reported poor quality of referrals such that many were 'rejected'. Families described using 'workarounds' to get to CAMHS (e.g. going to A&E). This is concerning not least because it highlights families' difficulties, but also because it disrupts the goals of referral and triage: i.e. to provide timely, appropriate care and to prioritise those in most need. The project team identified overwhelming problems with the current referral processes resulting in high levels of unnecessary additional cost to services; and widespread despair for referrers and for children and families.

RATIONALE Direct changes to CAMHS resourcing and staffing are the domain of DHSC and not something the project team can change. However, by improving referrals, the work can relieve additional pressure on services, make the process work better and create greater satisfaction for users. The project team can also increase understanding of what CAMHS is and does; and create confidence in CAMHS alternatives. The research has demonstrated an urgent health and care need to provide a straightforward referral process to ensure that children most in need are prioritised for treatment, and that all children are signposted to appropriate help in a timely manner. Such a process needs to be scalable, low cost, widely accessible and sustainable over time.

110 CAMHS stakeholders in EN-CAMHS 1 [18] repeatedly expressed a clear preference for a digital solution that could simplify and improve the CAMHS referral process. Stakeholders unanimously advised that the project team should create a national, standardised referral process which could also be tailored to local CAMHS' configurations. To date, there has been no national collaboration to improve the referral process; rather, piecemeal attempts across CAMHS providers have adopted different approaches. The project team's audit of such approaches unfortunately suggests referrals do not meet the requirements of CAMHS stakeholders identified in EN-CAMHS 1. For example, none has been rigorously co-developed with stakeholders; none provides a mechanism for people to track 'where they are' in the referral journey once a referral is submitted. From a technical perspective, the digital tools currently developed are not interoperable with core NHS infrastructure (e.g. NHS app; NHS website). There is patchy sharing of digital referrals in geographically-aligned providers, but it is fragmented and again lacks most of the recommendations the project team brings from EN-CAMHS 1 stakeholders for what the digital referral should 'look like'.