Rejected referrals to child and adolescent mental health services: audit

Referrers’ views

General Practitioners’ ( GPs’) Views

The main issues that GPs raised were:

• High number of rejections
• Lack of time with the child, young person or parent
• Lack of clarity on CAMHS criteria
• A feeling of being professionally disrespected when referrals are rejected
• Lack of alternative services
• Generic and unhelpful signposting

GPs’ suggested improvements in the following areas:

• Provision of community and early intervention services
• Clearer guidelines on the referral and assessment process
• Full assessments in all cases
• More multidisciplinary referrals
• Mandatory and relevant signposting

As part of the qualitative audit, interviews were conducted with nine GPs. GPs are approached to submit referrals by parents, schools and young people themselves. The referral process itself is considered fairly straightforward and similar to other types of referrals: the GP dictates a letter which is submitted via a gateway system.

GPs tend to submit their referral within a few days of seeing the person and agreeing to refer. Five of the nine GPs interviewed suggested they were making fewer referrals nowadays due to the volume of rejections received. Two GPs said CAMHS is the largest rejecter of referrals of any department, and a further two referred to it being very difficult to refer into CAMHS.

“The number of rejections is highest in CAMHS for any service. Adult Mental Health Service might change your ‘urgent’ to a ‘routine’ but they will still see the patient”

GPs: concerns about referrals

GPs do not always believe they are best placed to make referrals, particularly in instances where the initial recommendation to refer has come from school. Some would prefer a multidisciplinary approach to making referrals. However, the necessary interface for co-ordination between schools, GPs and others involved is not necessarily established or perceived as easy to set up.

GPs are not always clear on the pathways in the system: for example, in cases where the school nurse is also the primary mental health worker in the area.

One mentioned a perception that referrals from a secondary service are more likely to be accepted, therefore their practice is to refer to other services, rather than CAMHS direct.

“I think schools often don’t feel that they’re in a position to make that referral, even though they probably hold the key information, quite often the key information”

“We find that CAMHS is a very difficult service to refer in to…and our perception is the easiest way to get a CAMHS referral is to refer to a second service, who are more likely to be able to get a positive response from them [ CAMHS], so it’s either the school service or community paediatric service”

“Sometimes we feel like we’re piggy in the middle almost; that the school has concerns but the parent comes to us to get the referral”

• Time pressures

GPs reported concern that a standard 10 minute appointment is insufficient to gain a full enough history and background to write a detailed referral.

“Often the reason the referral is not accepted is because there’s not enough information, and the reason there’s not enough information is because we’ve had 10 minutes, whereas this individual, this child, this adolescent, whatever, has been in the school 300 days of the year, eight hours a day, and the school has a file as thick as you can imagine”

“Usually it’s [referral request] driven by the parents who are usually at the end of their tether and so it’s usually quite a pressurised consultation and it usually has a pressure effect on the rest of that consulting afternoon”

• Lack of transparency over criteria for acceptance by CAMHS

GPs reported that the referral form is essentially a ‘blank sheet’ and some report multiple instances of referrals being returned for more and or specific information. They would welcome more detail on the form about the information CAMHS require.

• Negative perceptions exist about the CAMHS service in general

Some GPs reported feeling that CAMHS do not have the same pressured workload as GPs. Some raised a sense that CAMHS is generally difficult to deal with and expressed frustration about the perceived extremely narrow definition of situations in which they will provide support and or treatment.

GPs: rejections

GPs do not feel they refer to CAMHS lightly: they state that referrals are made where they have exhausted other avenues and have no other options.

“It’s only the very, very pinnacle of patients that I would refer because my expectation of the referral being accepted for anything lower is so low”

“We’re referring to CAMHS because we’re stuck. If there was something else we could be doing, that would or will have been done, it’s not that we’re just testing the water with CAMHS”

“I feel that I am an experienced GP who sees a lot of distressed young people and I don’t refer lightly. If I make a referral it’s because it’s outwith my scope or my timescales and I just find it rude to have it rejected”

Rejection causes anger and disappointment for GPs, and a feeling of lack of respect for their professional opinion.

“Obviously, I expect if I’m making a professional decision to refer someone, that the vast majority would be accepted. I’m an experienced GP. I’ve got experience in mental health issues and I do believe my job is to manage referrals into the service, to manage people as best we can in primary care, but if we can’t manage them in primary care I do expect the services in secondary care to take that on; it does seem that there’s significant barriers to achieving that”

There is a strong feeling that children and young people should at least be seen, assessed before being rejected.

“I personally would expect at least some level of assessment to be made, especially when you’ve got four or five separate professionals all agreeing that a specialist service is required”

GPs are often left to explain to the young person or parent that the referral has not been accepted, which can put them in a difficult situation. They often cannot explain why the referral has been rejected and have limited alternatives for providing support to the young person. The responsibility for care remains theirs, often in a worsening situation.

“Then the onus is on you, so it’s more time that we didn’t have in the first place, to try and address a problem that we don’t have the skills or resource to address”

“The difficulty for us is then trying to explain to parents that I don’t know what else to do”

This can have a longer term detrimental impact on the relationship, as the child, young person or family feels the GP has let them down. Several GPs mentioned that adult mental health services have a better managed system / process for referrals and treatment.

“It does destroy trust…because basically they’d come to see me for help and I’d not managed to secure that for them; why would you come and see that doctor again?”

Rejection letters from CAMHS often do not give what GPs feel are satisfactory or detailed reasons for rejection, or provide a clear route for GPs to follow up for more information. GPs criticised the language and lack of clarity of rejection letters, particularly where these are copied to parents or young people.

“You just get a, what I find a very disrespectful reply back saying ‘your patient doesn’t meet the criteria’ and there’s no discussion with me…and they don’t speak to the patient directly”

Signposting from CAMHS is not always included in rejection letters. Where it is included GPs feel it is often fairly generic and that children, young people and their families have often already accessed available third sector and or other support.

“Often there will be a suggestion of using other local services, most of which we would have already considered and considered not adequate for the needs and that’s why we’re referring to them [ CAMHS]”

In some areas, particularly rural, there is no local alternative service provision. Ultimately the lack of available service provision for those not accepted by CAMHS is the major problem for GPs.

“I’d probably find it less difficult to not be able to get people into CAMHS if there were other alternatives”

GPs: recommendations for change

GP s would like to see:

• The development of alternative service provision for those who don’t meet CAMHS Tier 3 and 4 criteria
• More structured guidelines for referral letters
  “Because they do want quite specific information it perhaps would be more useful if they did have a much more specific form to fill out almost, so that we could give them specific information that they do need”
• Schools empowered to make more referrals directly
• Greater clarity around assessment decision processes, such as criteria for accepting referral, information on who makes decisions and how they are made, a named contact for follow-up and details of an appeals process
• Greater respect for the opinion of primary healthcare professionals
• Full assessments to be carried out for all cases
• Clear reasons for rejection provided
• Universal and relevant signposting where referrals are rejected

Teachers’ Views

Twenty-four teachers responded to our survey, all had an experience of rejected referrals.

The main issues that teachers raised were:

• Waiting times
• Lack of support after a referral is rejected
• Lack of information, both during the referral process and after the referral had been rejected

Teachers suggested improvements in the following areas:

• Improved interagency working and communication
• Standardised referral form with space for the views of the young person, parent and other agencies involved
• Improved other tiers of support

Teachers: concerns about referrals

The most common reasons teachers reported making referrals were for anger or physical violence, issues at home and self-harm.

Only two teachers said that an assessment was carried out by CAMHS. Seven said that an assessment wasn’t carried out and nine were unsure. Of these two cases where an assessment was carried out, one teacher said they were given no information during / after the assessment. The other indicated they were told to continue with the strategies they were working on at school and there was to be no further CAMHS input at this stage as it was not deemed severe enough.

The most common way teachers heard the referral had not been accepted was by a CAMHS letter (eight teachers).

Five of the referrals discussed were rejected as they were not considered to be an appropriate referral. Three were not considered severe enough. One was rejected because not enough information was provided.

Teachers were asked about what happened after a referral was rejected.

Common themes included:

• A lack of follow up by CAMHS
• The school trying to support the child without the support of CAMHS
  - one teacher noted that the school were now ‘funding regular counselling for a pupil’.
  - Another mentioned that the referral had been resubmitted.

• One teacher told of how the Additional Support Needs ( ASN) Manager and school head teacher “both wrote to CAMHS to request fuller assessment and review of decision. This was refused.”
• Contacting other agencies such as the educational psychologist, GP, play therapy or paediatrician.
• Continued decline in the mental health and educational performance of the child:

“Child had to be moved to another class and taught by member of Senior Management Team.”

“The child has now had to be put onto a reduced timetable as unable to cope on p5 setting for full days. Little academic work being completed. A very upset, vulnerable little boy.”

Teachers were asked about the impact of rejected referrals. A common theme was a negative effect on the mental health of the young person concerned.

“The pupil in question continues to struggle with mental health issues, without specialist support.”

“Distress and behaviour continued to deteriorate until eventual crisis.”

“He feels he is stupid and it”s another person who “isn”t interested” in helping him.”

“They said it proved that no one cared.”

Teachers also spoke of trust with agencies being broken:

“Left feeling helpless “The young person felt helpless - like no one out there could help her. It also made it very difficult for them to trust support - what”s the point as they won”t do anything/ the advice I am given is pointless etc.”

“He asked me why I didn”t get someone for him to talk to about his ‘big feelings.’ Because of his Nana’s issues I had said I would attend appointments with him in school and I had a letter from Nana witnessed by SW (social worker) to do this. I think he felt like no one cared about him. It was another agency not to bother. Very limited SW intervention too.”

Thinking about the overall CAMHS process, teachers commonly raised their focus on the most severe cases:

“They seem to take very little on. Only seem to want to deal with severe cases that can be medicated / level 4 service but in our authority there is no Tier 3 service for children with attachment difficulties which are now having a significant impact on their day to day lives. Sometimes cases are too severe for homelink and educational psychology and no impact by their actions so all channels exhausted. Agreement then made to refer to CAMHS who then decline and the child/family is left with nothing.”

Teachers also spoke about a lack of assessments and a feeling that the system was not fit for purpose.

“Completely inadequate assessment as no contact was made with school whatsoever to request information. Process was perfunctory at best.”

“I genuinely feel that the process is pointless as CAMHS have not engaged with any young person that I have referred.”

“Not fit for purpose, too long and reliant on a medical jargon to justify acceptable or non-accepted referrals. No emphasis on early intervention as we understand in education as being crucial for inclusion and engagement”

“Terrible expect better.”

Another common issue raised by teachers was the impact on their own emotional and mental health.

“There was no discussion with the school before a decision was made. I am extremely upset and angry with the way this child was treated however it seems many young children I have referred have been rejected.”

“Frustrated and helpless. We are told to encourage pupils and parents to seek help from professionals yet they are turned down or we are given ridiculous and unrealistic advice.”

“Had a very unpleasant training session from CAMHS recently, felt they were asking us to stop referring and do more ourselves. We are already doing as much as we can.”

Teachers’ suggested improvements

• Improved communication

“A one to one chat with the referring adult to pick apart the concerns. If someone had spoken to me about the use of strategies I could have explained all the things we had done with little or no impact.”

“Improve the communication by providing updates. Employ more staff as it is a service which is very much needed but can”t cope with demands.”

“Consultation between CAMHS staff and educators.”

“Include requests for information in the initial referral to avoid duplicating work.”

“Better communication/information sharing with school as partners in promoting wellbeing of the child.”

“ CAMHS teams must work much closer with schools to see how engagement can be achieved well with vulnerable children! Children with mental health issues are not going to slip to a strange place to see a stranger once a month and expect to engage well with the process.”

• Shorter waiting times

“Length of waiting time (18 weeks is simply too long).”

“Improved waiting times (if not able - which I understand - maybe some practical advice based on the referral of what we can be doing in the meantime with the young person to support them), streamlined forms.”

• Support for children and young people who are not considered severe enough for CAMHS

“There almost needs to be something in the middle between education and CAMHS. I understand that resources are stretched but to just pass pupils back to education who are not the professionals puts pressure both on schools to deliver and also the pupils themselves. I also strongly believe that CAMHS need to seek advice and info from schools before making decisions about a pupil”s needs based only on a referral from a GP or from the info given by pupils and family.”

• Other comments for improvements included:

“A huge shake up of the CAMHS service. Has been failing children and families for too long. Don”t feel as if they play an active part in the ‘inter-agency team’.”

“That CAMHS appreciate that schools do not refer children willy-nilly; there is always a good reason for the referral.”

“For me it was brick wall after brick wall after brick wall and lack of continuity, no communication, no accountability, no action, nothing. It was just a process that isn’t fit for purpose.” (young person, group)