Surely the problem of transition from child to adult services should be shared between commissioners and providers. You can’t leave these decisions to clinicians on the ground, because when that does happen
a) people complain about provider-led decision making/commissioning
b) practitioners make the best decisions they can, which often means unofficially keeping young people in a CAMH service way past their 18th birthday (the oldest “CAMHS” client we heard of was 22).
What about commissioners who have grasped these tensions and chosen to interpret the spirit rather than the letter of policy. We met a group of commissioners and providers who had sanctioned what we called “boundary stretching”, because it was in the best interests of the young person. Basically if a young person needed continuing service after 18, but was unable for whatever reason (developmental stage, or type of mental health problem – see also posting on Taxonomy of need) to access adult provision, they would be retained by CAMHS – with the commissioner’s approval. The CAMHS and AMHS commissioner reached an agreement whereby CAMHS would be compensated indirectly for this extra work, which in any case was not high in volume.
Another key finding in relation to commissioning was around multiple providers. When a new Early Intervention in Psychosis Service (EIS) was planned, the commissioners put it out to tender, with the result that a voluntary organisation was awarded the contract. There were all sorts of advantages to tapping into the voluntary sector ethos (see also posting on Valuing the voluntary sector) and to us it seemed we had found a reality in the “plurality of provision” rhetoric.
It seemed difficult in many places to get both CAMHS and AMHS, commissioners and providers, to sit round the table. Inevitably it was often CAMHS driving the process, because in a way the problem is theirs – if a transition to adult services does not happen, they still feel honour bound to provide something for that young person.
