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).


The recommendations are structured into four sections: further research, meeting the needs of children, young people and their families, practical changes to the existing system, and improving data collection.

This research has identified a strong indication of a gap in provision for children and young people whose needs do not fit the CAMHS Tier 3 and 4 eligibility criteria. The first set of recommendations focus on work to further explore this gap, while the second make recommendations for changing CAMHS to better meet the needs of these children and young people. Other work is also being undertaken by Audit Scotland, Health Improvement Scotland and the Youth Commission, and these projects may also provide helpful data.

There is also evidence that CAMHS is not well understood by those referring into it or those who are referred to it, and that it can be a difficult, confusing and distressing system to navigate. The third set of recommendations therefore focus on changes that can be made to the current system, to create a service that is not only more appropriate for children, young people and their families but also more efficient. However, these recommendations will only improve processes, when this research suggests the system may be in need of fundamental reform. As such they should be seen as a set of short-term measures, pending further research and more substantial reform.

The first three sections are informed by the qualitative element of this research. The final set of recommendations are drawn from the quantitative element of this research, and relate to improving data collection.

Recommendations section 1: further research

This report dealt with a subset of those children, young people and their families who are referred to CAMHS but not accepted, so it is not possible to draw conclusions about the entire CAMHS system. However, there are indications that there may be serious problems. The following recommendations suggest work to explore the CAMHS system as a whole.

Recommendation 1

The Scottish Government should explore the views and experiences of staff working in CAMHS regarding the system’s fitness for purpose, current good practice and innovation, and opportunities for improvement in processes as well as the system overall.

The Scottish Government should also explore the views of children, young people and parents who do access CAMHS to explore their experiences of the referral system and processes.

Recommendation 2

The Scottish Government should request that ISD explore how data can be gathered about Tiers 1 and 2 of CAMHS, so that a full picture of the service being provided to children, young people and their families can be gained.

Recommendations section 2: meeting the needs of children, young people and their families

Notwithstanding the efforts of many CAMHS professionals and the recent increase in workforce and investment, it is clear that many children, young people and their families who are rejected from CAMHS do have genuine and in some cases urgent need of help. From speaking to individuals who took part in this research, this help does not appear to be available. Time and time again we heard that there is a gap in provision for whom CAMHS is not the most appropriate service.

Recommendation 3

The Scottish Government should consider whether the tiered model of CAMHS continues to be fit for purpose. In the short term it should change the language used to describe services: references to specific tiers are confusing and unhelpful to children, young people and their families.

Recommendation 4

The Scottish Government should review and if necessary restructure the current system so appropriate services are easily accessible to children and young people with behavioural and emotional problems, alongside a mental health problem not severe enough to fit the eligibility criteria for CAMHS. The Scottish Government should consider whether achieving this aim requires nationwide provision of schools-based services.

Recommendation 5

In carrying out Recommendation 4, the Scottish Government, Health Boards and Integration Joint Boards ( IJBs) and local government should ensure services are funded at an appropriate level, available consistently nationwide and measure both waiting times, outcomes and patient satisfaction.

Recommendation 6

In creating the system suggested at Recommendation 4, the Scottish Government should develop a multi-agency assessment system, with a focus on quickly referring young people to the appropriate service and eliminating the inefficiency of multiple referrals. This should build upon areas of existing good practice.

Recommendation 7

In creating the system suggested at Recommendation 4, all CAMHS teams should publish information on the circumstances in which they will conduct a paper-based assessment. There should be an expectation that face to face assessments will take place in almost every circumstance.

Recommendation 8

In a well-functioning system, there should be no need for rejected referrals. However, if they do occur, the Scottish Government should require personalised and meaningful signposting to be mandatory

Recommendations section 3: making immediate changes to CAMHS

Making and receiving a referral

Recommendation 9

Where this does not already happen, all CAMHS teams should establish regular sessions when a member of staff is available by telephone to discuss potential referrals with referrers, to reduce the number of inappropriate referrals received.

Assessing a referral

Recommendation 10

All CAMHS teams should review their assessment procedures to ensure they offer appropriate opportunities for young people to speak to professionals without parents being present, and for parents to speak to professionals without children being present, with regard to issues of capacity and consent.

Recommendation 11

All CAMHS teams should train those conducting assessments to introduce themselves, explain their role and clearly set out what will happen during the assessment and the possible outcomes, this should also be included in the appointment letter.

Rejecting a referral

Recommendation 12

All CAMHS teams should send notification of rejected referrals to both the referrer and the child or young person, or where appropriate their parent or guardian. Notifications should be written in clear, non-medical language and should clearly identify the team who has made the decision to reject the referral.

Recommendation 13

Notifications of rejected referrals should wherever possible and appropriate include a direct re-referral to a more appropriate service, without requiring the child, young person or their family to start the process again.

Support for referrers

Recommendation 14

All CAMHS teams should publish information on what support is available in a crisis, and where children, young people and their families should be referred in a mental health crisis, including out of hours services.

Recommendation 15

The Scottish Government should work with Royal Colleges and appropriate NHS bodies to create training and/or targeted and regularly refreshed resources for GPs to ensure they understand when a referral to CAMHS is appropriate and what other services are available, building on current examples of good practice and taking into consideration the local context .

Recommendation 16

CAMHS teams should ensure all those who can refer into them have child-centred and developmentally appropriate information which they can provide to children, young people and their families at the point of referral, setting out what will happen next and signposting to sources of information.

Recommendation 17

Normal practice should include a conversation between the referrer and CAMHS teams before rejecting all but the most clearly inappropriate referrals, to establish whether any other information is available. Good practice should be that child or young person planning meeting minutes are included.

Recommendation 18

All bodies responsible for children’s services should intensify efforts to ensure GPs have sufficient information about non- CAMHS services in their area and are aware of resources such as the ALISS database.

Availability of services

Recommendation 19

The relevant and responsible bodies should review their CAMHS and adult mental health services to ensure all those aged up to 18 can receive a service, regardless of educational status. For those who are approaching the age of 18 are either helped within CAMHS or quickly routed into adult services.

Recommendation 20

The relevant and responsible bodies should encourage and support the establishment of peer support groups for parents caring for children with emotional, behavioural as well as mental health issues.

Recommendation 21

The relevant and responsible bodies should review their mental health services to ensure they are available for children and young people who have Autistic Spectrum Disorder, or a learning disability alongside a mental, emotional or behavioural problem.

Recommendation 22

The relevant and responsible bodies should review their mental health services to ensure provision exists for children, young people and their families where the child is no longer attending school but has emotional, behavioural and mental health difficulties.

Recommendations section 4: data collection

Recommendation 23

ISD should agree with Scottish Government and NHS Boards ongoing data needs around rejected referrals to improve the experience and outcome for children and young people.

Recommendation 24

ISD should work with third sector organisations to understand the services they provide to children and young people and explore sharing data between these organisation and statutory services to ensure full pathway information is available and used for improving services and experience.

Recommendation 25

The Scottish Government should request ISD to begin enhanced data collection and publication of rejected referral information on a routine basis. This would allow for further analysis in such areas as SIMD, geographical areas and service delivery differences. In particular, the Scottish Government should request research comparing the demographic profiles of those who are rejected from CAMHS with those who are not, to establish whether particular groups are being especially disadvantaged.

Recommendation 26

The Scottish Government should request ISD to undertake further work to understand what happens next to the children and young people e.g. usage of other services. This could be achieved through linkage of records included in the audit to other services.

Recommendation 27

ISD and Scottish Government should work with NHS Boards to standardise the definitions of all data items relating to CAMHS including ‘Referral Source’, ‘Reason for Referral’ and ‘Rejected Referral Reason’. These should be adopted and implemented by all Health Boards to ensure consistency and comparability. This would include less use of ‘Other’ categories.

Recommendation 28

The term ‘rejected’ is emotive and distressing. However, the qualitative element of this research indicates a lack of evidence that referrals are genuinely being ‘redirected’, which is the preferred alternative term. The Scottish Government should act on the recommendations in this report to create a system that minimises inappropriate referrals and ensures that those which do occur are demonstrably redirected. Only at this point should a change in language be considered.

Recommendation 29

NHS Boards should have clear referral protocols available to all referrers, including GPs and teachers, which clearly define the process of referrals and what services the NHS Board provides through:

  • Enhancement of existing referral pathways and development of standard referral pathways which are clearly written, freely available and easily understood by all referrers
  • The development and use of a standard referral form, clearly indicating which information is essential before a referral can be considered. This form should include space for input from GPs, schools, parents and the child, so that as much information as possible can be provided. It should also include space to indicate what services and approaches have already been tried, to avoid unhelpful signposting in case of rejection.
  • Considering the development of standard referral criteria which applies to all services across Scotland.


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