Authors' objectives: The mental health of children/young people is a growing concern internationally. Numerous reports and reviews have consistently described United Kingdom children’s mental health services as fragmented, variable, inaccessible and lacking an evidence base. Little is known about the effectiveness of, and implementation complexities associated with, service models for children/young people experiencing ‘common’ mental health problems like anxiety, depression, attention deficit hyperactivity disorder and self-harm. This study is a response to a National Institute for Health and Care Research (NIHR) commissioning call on research to improve services for children and young people (CYP) with common mental health problems (CMHPs). The mental health of CYP has been a growing public health concern both nationally and internationally. Estimates from 2021, covering the height of the coronavirus disease 2019 (COVID-19) pandemic, suggest that around one in six CYP in England may be experiencing significant mental health difficulties, including the likes of anxiety, depression, self-harm and behavioural difficulties. The tiers model has dominated UK service provision for at least two decades. However, it has become increasingly clear that this model has not met the needs of most CYP experiencing mental health problems. Numerous reports and reviews have consistently described UK children’s mental health services as fragmented, unco-ordinated, variable, inaccessible and lacking an evidence base. While there have been recent attempts to transform services using initiatives such as Choice and Partnership Approach (CAPA), Children and Young People-Improving Access to Psychological Therapies (CYP-IAPT) (a CYP’s version of adult IAPT) and THRIVE, little is known about the effectiveness of these initiatives nor the effectiveness of children’s mental health service models in general. Moreover, the disparate factors associated with accessing and navigating services for CYP experiencing CMHPs have not been synthesised into a coherent model of effective and acceptable service provision.

Authors' results and conclusions: A service model typology was derived from the scoping review. The integrative review found effectiveness evidence for collaborative care, outreach approaches, brief intervention services and the ‘availability, responsiveness and continuity’ framework. There was cost-effectiveness evidence only for collaborative care. No service model appeared to be more acceptable than others. The service map identified 154 English and Welsh services. Three themes emerged from the case study data: ‘pathways to support’; ‘service engagement’; and ‘learning and understanding’. The integrative review and case study data were synthesised into a coproduced model of high-quality service provision for children/young people experiencing common mental health problems. There was no strong evidence to suggest any existing service model was better than another. Instead, we developed a coproduced, evidence-based model that incorporates the fundamental components necessary for high-quality children’s mental health services and which has utility for policy, practice and research. Work Stream 1 (literature reviews) Overall, 310 documents met the inclusion criteria for the scoping or integrative review. Two hundred and ninety-six documents were included in the scoping review, 98 in the integrative review. To simplify the complexities associated with fragmented, variable and often unco-ordinated services, the 342 service descriptions in the 296 scoping review documents were mapped to produce a descriptive service model typology containing seven broad service model groupings. Across the international literature, the service models most described in the scoping review documents were outreach models, followed by community-embedded specialist CAMHS models. Service transformation frameworks were also relatively common. The integrative review found effectiveness evidence only for collaborative care, outreach approaches, brief intervention services and ‘availability, responsiveness and continuity (ARC)’, a service transformation framework from the USA. The strongest effectiveness evidence was for collaborative care. Cost-effectiveness evidence was very limited (just three papers met the inclusion criteria), with the only robust evidence also being for collaborative care. Since most of the collaborative care evidence was from the USA, its applicability to UK health systems is questionable. No service model appeared to be more acceptable than others. Integrative review findings suggest that effective and acceptable services tend to be underpinned by few barriers to access, interagency working, the use of consultation-liaison and consideration of the service’s culture. Brief intervention approaches may be helpful in managing waiting lists; their brief nature may also facilitate the acquisition of self-management skills. In a robust and transparent way, we have developed a comprehensible, evidence-based model of high-quality service design for CYP experiencing CMHPs that is transferable across services, sectors and geography. Our model has utility for policy, practice and research. Not only does it support previous research and reports about children’s mental health services, but it also adds significant depth to core issues surrounding mental health service provision for CYP. In terms of implications for policy, practice and education, our research suggests that: Using our model components to support the design and delivery of services – rather than the ‘top–down’ imposition of specific local or national models – could improve the consistency of services for CYP experiencing CMHPs. Our model still allows for tailoring to the local context. We also note that: Aftercare arrangements are often neglected (especially for those aged 16–17 years), not just in terms of transitions to adult services but also in terms of exiting and re-entering a service, longer-term ad hoc support and continuity of care. A learning culture strongly implies services need more than mere staff training. Workforce development requires strategies that incorporate reflexive learning opportunities, clinical supervision, reflective practice, freedom to innovate in practice and leadership. CYP and families need to be the arbiters of what compassion and competence in staff mean. Lived experience in service provision is valuable, but it may work better when delivered alongside professional support. More information about what services are available locally, how services might be accessed, what support is offered and what happens once the CYP leaves the service should be provided. CYP and their families want to be able to choose, ideally from a range of services, those best tailored to their needs. In terms of future research, there should be: research focusing on how to implement into practice the components in our model research determining whether using our model to design, deliver or audit services impacts on outcomes research exploring the advantages and disadvantages of digital/remote platforms in delivering services research around what the statutory sector could learn from the non-statutory sector regarding choice, personalisation and flexibility research with those who refuse and/or disengage from services and others whose voices are seldom heard further research on the cost effectiveness of different approaches in CYP’s mental health research to establish one or more standardised measures of health benefit in children’s mental health services.

Authors' methods: Evidence syntheses with primary research, using a sequential, mixed-methods design. Inter-related scoping and integrative reviews were conducted alongside a map of relevant services across England and Wales, followed by a collective case study of English and Welsh services. Global (systematic reviews); England and Wales (service map; case study). Literature reviews: relevant bibliographic databases and grey literature. Service map: online survey and offline desk research. Case study: 108 participants (41 children/young people, 26 parents, 41 staff) across nine case study sites. A single literature search informed both reviews. The service map was obtained from an online survey and internet searches. Case study sites were sampled from the service map; because of coronavirus disease 2019, case study data were collected remotely. ‘Young co-researchers’ assisted with case study data collection. The integrative review and case study data were synthesised using the ‘weaving’ approach of ‘integration through narrative’. Defining ‘service model’ was a challenge. Some service initiatives were too new to have filtered through into the literature or service map. Coronavirus disease 2019 brought about a surge in remote/digital services which were under-represented in the literature. A dearth of relevant studies meant few cost-effectiveness conclusions could be drawn. The study coupled evidence syntheses with primary research, using a sequential, mixed-methods design. There were four work streams: (1) conducting a scoping review and an integrative review of the international literature; (2) mapping service provision across England and Wales; (3) conducting a collective case study of several services in England and Wales; and (4) building a model for high-quality service design for CYP experiencing CMHPs. Patient and public involvement We involved young people and parents/carers, as well as those who commission and provide mental health services throughout the study. Young people and parents/carers were members of the study’s advisory group and the director of a young people’s ‘lived experience’ consultancy was a coinvestigator. We also collaborated with a mental health charity to employ six young adults with lived experience of mental health issues as ‘young co-researchers’. Relevant bibliographic databases and resources (including grey literature resources) were searched in May 2019. Any service provided for CYP experiencing CMHPs. Services across England and Wales were identified via an online survey created in SelectSurvey and internet (desk-based) searches. English or Welsh services identified through the literature search and still in operation were also included. A collective case study involving nine services sampled from the service map. Services were purposively sampled to capture the spread of models in the typology and to reflect characteristics such as service sector, locality/setting, target age group and mode of delivery. Ninety-six interviews involving 108 participants (41 CYP, 26 parents, 41 staff) from 9 case study sites.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/17/09/08

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/DKRT6293

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/DKRT6293

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk