Articles and Briefings

Summary of a Review of the Social Work Contribution to CAMHS in a London Borough – Spring 2006

RICHARD SWANN, BA (Hons), MSW, CQSW, PGCert, MA, AASW
Independent Consultant and Trainer

STELLA CHARMAN, MA, MSc, DipHSM
Director

1. Introduction

1.1 As part of the wider development of a multi-agency commissioning strategy for child and adolescent mental health services (CAMHS), CAMHS Consultants Ltd was recently commissioned to review the social work posts located within a specialist CAMHS team working within a London Borough. These posts were funded by the Borough Council and represented a significant commitment to the team.

1.2 It was accepted that concern about the role and functions of social workers within CAMHS teams is not new, nor unique to this Borough, and has been addressed in different ways by different Local Authorities. In preparation for this Review, a request for information was circulated and a particularly helpful discussion paper received from Surrey County Council which has a County Specialist for the CAMHS Social Work Service. The paper received reflected many of the same issues as those identified by this Review, and reinforces the fact that they should not be regarded as particular to services in any individual Local Authority area nor attributable to individuals.

1.3 The Review process itself consisted of a series of face-to-face interviews with the social workers themselves, the wider CAMHS team and the Borough Social Services Manager. In addition documentation was made available for the review, including job descriptions, Awayday notes, referral leaflets etc.

2. Context

2.1 The Government has set a challenging agenda for the development of comprehensive CAMHS in every area by the end of 2006. Local Partnerships are expected to establish CAMHS as ‘everybody’s business’ and to ensure that services contribute fully to achieving the ‘Every Child Matters’ outcomes as well as reaching the standards contained in the National Service Framework for Children, Young People and Maternity Services.

2.2 The National Service Framework (NSF)¹ provides the following vision for CAMHS and issues a clear expectation that a comprehensive CAMHS will be available in all areas by 2006.

Standard 9: The Mental Health and Psychological Well-being of Children and Young People

All children and young people, from birth to their eighteenth birthday, who have mental health problems and disorders have access to timely, integrated, high quality multidisciplinary mental health services to ensure effective assessment, treatment and support, for them, and their families.

2.3 Currently, there are four key areas in which Government is monitoring progress on the development of comprehensive CAMHS and the implementation of the NSF, and these have to be central to any CAMHS Commissioning Strategy. They are:

• 24 hours, 7 days a week cover with emergency response
• Services for children & young people with learning disabilities
• Services for 16 & 17 year olds
• Interagency arrangements for children with complex needs

2.4 The NSF establishes 10 indicators of good practice to be achieved over a 10-year period. One of these is that:

“Arrangements are in place to ensure that specialist multi-disciplinary teams are of sufficient size and have an appropriate skill-mix, training and support to function effectively”.

2.4 An essential requirement of effective multi-disciplinary team-working is clarity regarding different professional roles, tasks and responsibilities. Although other professional disciplines within CAMHS have been traditionally seen has having distinctive roles and contributions and influential professional bodies, it may be argued that social work has struggled historically to define a core knowledge, value and skills base. It should be noted that it was only from April 2005 that the term ‘social worker’ became a legally protected title, which now requires individuals to meet certain professional standards and competencies to be awarded registration with the UK’s General Social Care Council².

2.5 Defining the contribution of social workers within CAMHS, and the role played by professionals from different agency backgrounds, is an issue being addressed in many areas. It is agreed that social workers are essential to the development of comprehensive CAMHS:

“Social Workers are positioned at the interface between the economic, social and psychological and therefore ideally placed to work with children and young people suffering with or at risk of developing mental health problems” (Steven Walker, 2003³)

2.6 The 1995 HAS Report ‘Together We Stand’⁴, which set out the blueprint for comprehensive CAMHS, suggested that regardless of which tier of service is involved with a child or young person there are some basic attributes which all members of multidisciplinary teams should possess:

• Empathetic interviewing and counselling,
• Working knowledge of child development,
• Up-to-date working knowledge of child and family problems,
• Understanding of the impact of major life events on children’s lives,
• Awareness of how professional’s own life experiences informs their approaches to others,
• Familiarity with manifestations of serious psychiatric disorders.

2.6 The above attributes are consistent with the psychosocial model of social work, but may not all be reflected in other professional training and education. Similarly social work has traditionally championed professional interventions that are characteristically anti-oppressive and actively promote social inclusion. Indeed social workers are currently the only mental health workers with social science training. Therefore this combined knowledge together with their core statutory responsibilities should help to shape effective multi-disciplinary working and organisational development (Gilbert, 2003⁵).

2.7 Gilbert’s view has been recently reinforced in a Care Services Improvement partnership (CSIP) discussion paper entitled: ‘The social work contribution to mental health services: the future direction’⁶. This paper concludes that the contribution of social work knowledge, skills and values are integral to the reform and future of mental health services and that the new language and concepts contained in recent policy documents contain the unacknowledged influences of social work. For example, work on social exclusion and mental distress published by the Office of the Deputy Prime Minister⁷ emphasises the need to embrace the social model of mental distress and values based practice that characterises social work.

2.8 However, because it is primarily concerned with adult mental health, the CSIP paper pays little attention to social work responsibilities in relation to child protection. Under section 11 of the Children Act 2004, Local Authorities have a duty to safeguard and promote the welfare of children and to set up Safeguarding Boards as the statutory successors to Area Child Protection Committees. Partner agencies must now fully co-operate with local Safeguarding arrangements and share statutory responsibilities with Local Authorities. This is an area in which historically many CAMHS teams have been weak, especially those managed by NHS Trusts which have adult services as the main focus of their business. It is now expected that active participation and regular training will be undertaken by all professionals working with children, and that this will not be the sole responsibility of social workers. However, professional social work input to CAMHS teams remains the vehicle for highlighting this necessary dimension of their activity, which might otherwise be overlooked.

2.9 Central Council for Education and Training in Social Work (CCETSW) has identified the skills and competencies required for mental health social workers⁸. It should be noted that the minimum list includes knowledge of mental health legislation, and further post-qualification training can lead to full exercise of the duties, powers and responsibilities of approved social worker (ASW) under the terms of the Mental Health Act 1983. This is an area of knowledge and expertise in which many specialist CAMHS have been deficient in the past, but is becoming increasingly important as services are expected by the NSF to extend the age range of young people treated to the 18th birthday and beyond to ensure effective transition to adult services.

2.10 The CSIP Discussion Paper highlights the importance of effective team leadership in ensuring that the contribution of all professionals are integrated into the work of multiagency teams such as those found in CAMHS. However, recently published research on new forms of professional knowledge in the multi-agency delivery of services for children undertaken by the University of Leeds⁹ has demonstrated how easily the beliefs of minority professional groups, and especially part-time team members, can be subjugated to dominant team beliefs. The Report concludes that high quality leadership is required to ‘insist that diversity within teams is celebrated and the knowledge and skills of all members given equal value’. Positive strategies for resolving potential conflict and reconciling diverse perspectives included respecting specialist expertise, maintaining good personal relationships, working towards a shared language in team activities and service delivery and setting aside team time for developing shared values, exchanging skills and knowledge and developing common protocols and documentation.

3. Findings of the initial review of the Social Work Team within specialist CAMHS

3.1 The Review concluded that there was a critical role for social work within a CAMHS Tier 3 multi-disciplinary and multi-agency setting. However, it found that the development of such a role had been adversely affected by a lack of direction for the team, lack of understanding of its contribution by wider team members, and a lack of strategic thinking in the wider CAMHS system about how to integrate the contributions of all professionals to create a coherent whole. It concluded that for some time members of the Social Work Team had acted as if they were family therapists, filling an acknowledged skills gap, but without all the requisite supervision, clinical training or experience required.

3.2 The Review proposed the retention of a social work presence and ethos, but the reconfiguration of the service to support a more integrated multi-agency approach. It suggested the creation of a Senior CAMHS Specialist Social Work post for Tier 3, as well as developing CAMHS specialist posts separately within Tier 2.

3.3 It was suggested that the function and tasks of the Senior CAMHS Specialist Social Work post/s should include:

Consultation and advice to CAMHS colleagues concerning:

• Psychosocial explanations of mental health
• Child protection thresholds and ACPC Procedures, including advising the team on new arrangements under the Children Act and linking with the Borough’s Safeguarding Board
• Needs of Looked After Children and children on Child Protection Register
• Coordination of work across complex systems and networks,
• Development of services accessible to marginalised groups
• Mental health legislation and use of the Mental Health Act 1983

Clinical Practice:

• Contribution to mental health assessments and provision of therapeutic interventions
• Supervision of social workers employed elsewhere with specialist CAMHS roles

Interface with the Borough's children’s services:

• Developing and enabling effective links between CAMHS and the Borough's children's services
• Provision of consultation, advice and training to social care staff regarding mental health issues

Provision of Social Work perspective:

• Promotion of client’s own strengths, interests and rights
• Mental health difficulties placed within wider social context
• Oppressive and discriminatory processes actively challenged

3.4 However, although the Review maintained that there were good reasons to retain a social work presence within specialist CAMHS, that the CAMHS Partnership may wish to consider reinvesting some of these resources in family therapists posts, in order to strengthen its therapeutic skill-mix. Some social workers had already undertaken the necessary training to be UKCP registered, and those who had done so in the past had left the service. The Review proposed that it is now a good time to formally recognise the skills, experience and contribution of family therapists more explicitly, and to integrate such posts into the team. It added that it would be helpful if this were to take place as part of a wider skill-mix review of specialist CAMHS and examination of team processes and leadership informed by the findings of the MATCh project (see 2.10).

Back to top