Rejected referrals to child and adolescent mental health services: audit

A qualitative and quantitative audit of rejected referrals to Child and Adolescent Mental Health Services (CAMHS).


Rejected Referral - can be described as ‘when the request to a healthcare professional or to an organisation to provide appropriate healthcare to a patient is deemed as not appropriate’.

Tier 1

Child and adolescent mental health services at Tier 1 are provided by practitioners working in universal services who are not mental health specialists. This includes:

  • GPs
  • health visitors
  • school nurses
  • teachers
  • social workers, and
  • youth justice workers and voluntary agencies

Tier 1 practitioners are able to offer general advice and treatment for less severe problems. They contribute towards mental health promotion, identify problems early in the child or young person’s development and refer to more specialist services.

Tier 2

Mental health practitioners at Tier 2 level tend to be CAMH specialists working in teams in the community and primary care settings (although many will also work as part of Tier 3 services). They can include, for example:

  • mental health professionals employed to deliver primary mental health work, and
  • psychologists and counsellers working in GP practices, paediatric clinics, schools and youth services

Tier 2 practitioners offer consultation to families and other practitioners. They identify severe or complex needs requiring more specialist intervention, assessment (which may lead to treatment at a different tier), and training to practitioners at Tier 1 level.

Tier 3

Tier 3 services are usually multidisciplinary teams or services working in a community mental health setting or a child and adolescent psychiatry outpatient service, providing a service for children and young people with more severe, complex and persistent disorders. Team members are likely to include:

  • child and adolescent psychiatrists
  • social workers
  • clinical psychologists
  • community psychiatric nurses
  • child psychotherapists
  • occupational therapists, and
  • art, music and drama therapists

Tier 4

Tier 4 encompasses essential tertiary level services such as intensive community treatment services, day units and inpatient units. These are generally services for the small number of children and young people who are deemed to be at greatest risk (of rapidly declining mental health or serious self-harm) and/or who require a period of intensive input for the purposes of assessment and/or treatment. Team members will come from the same professional groups as listed for Tier 3. A consultant child and adolescent psychiatrist or clinical psychologist is likely to have the clinical responsibility for overseeing the assessment, treatment and care for each Tier 4 patient.

Source of Tier Information -

Unsuitable - A referral can be deemed unsuitable if:

  • The information provided does not meet the health board provider referral criteria
  • Early stage mental health illness/disorder - no other services involved
  • Mild mental health illness/disorder - no impact on life
  • No mental health illness/disorder
  • Out with Board catchment


An easy-read version is available on request from

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