Authors' objectives: National Health Service Child and Adolescent Mental Health Services are specialist teams that assess and treat children and young people with mental health problems. Overall, 497,502 children were referred to National Health Service Child and Adolescent Mental Health Services between 2020 and 2021, and almost one-quarter of these referrals were not successful. Unsuccessful referrals are often distressing for children and families who are turned away usually after a long waiting period and without necessarily being redirected to alternative services. The process is also costly to services because time is wasted reviewing documents about children who should have been referred for alternative help and may prevent young people who need specialist help receiving it in a timely way. The overarching aim of this study was to understand what the problems are with Child and Adolescent Mental Health Services referrals and identify solutions that could improve referral success. A key objective was to talk widely with young people and families, people working in Child and Adolescent Mental Health Services and mental health professionals so that we could understand fully what the problems were and how we might develop their solutions. We gathered individual pseudonymised patient data from nine Child and Adolescent Mental Health Services, and referral data from four National Health Service Trusts to look at what data are available and how complete it is. We report wide variation in the numbers of referrals between and within Trusts and in the proportions not being successful for treatment. Data on factors such as age and gender of children and young people referred into Child and Adolescent Mental Health Services and who made the referral are routinely collected, but ethnicity of the children and young people's reason for referral are not as well collected across all Trusts. We also conducted focus groups with over 100 individuals with differing perspectives on the Child and Adolescent Mental Health Services referral process (children and young people, parents and carers, key referrers, and Child and Adolescent Mental Health Services professionals) and asked about current difficulties within the referral process, as well as potential solutions to these. In 2017, 12.1% of children and young people (CYP) aged 7–16 years had a probable mental disorder, this rose to 16.7% in 2020 and rose again to 18.0% in 2022. Almost one-quarter of referrals to Child and Adolescent Mental Health Services (CAMHS), whether referred by general practitioners (GPs), schools or parents/carers, are unsuccessful. This may be for reasons which include: not following the correct referral process, or because the child is not deemed appropriate for secondary care services within the CAMHS provision. For many children and families, who may have waited a long time for such an assessment, this may be both disappointing and distressing; particularly if they are not signposted to alternative sources of support. This is often the case, even if assessment suggests the young person is less unwell than previously thought. Unsuccessful referral into CAMHS is not without a cost: for example, services’ time assessing documents for children who could have been referred for alternative help; and delays in children accessing the care they do need. We know that children are referred inappropriately to CAMHS for a variety of reasons including, but not restricted to: lack of awareness by referrers, such as GPs and schools about what CAMHS does and does not provide; lack of knowledge by referrers about other support services; referrers not completing the correct documentation. Our objectives were to: Map and describe CAMHS service configurations (including service eligibility criteria). Map and analyse referral and inappropriate referral rates against possible Explanatory variables (e.g. age, sex, ethnicity, Index of Multiple Deprivation). Extensively engage CAMHS stakeholders across different sites and CAMHS providers. Explore what does and does not work in the current referral processes. Identify sustainable solutions to support more successful and appropriate Referrals in collaboration with CAMHS stakeholders. Identify complexities of implementing sustainable solutions across CAMHS settings.

Authors' results and conclusions: Problems identified included: confusion about what Child and Adolescent Mental Health Services is for, that is what it does and does not provide; and lack of support provided during the referral process. Possible solutions included: streamlining the referral pathways through digital technologies with accompanying standardisation of referral forms for National Health Service Child and Adolescent Mental Health Services; and early ongoing communication throughout the referral ‘journey’ for the referrer/family. Child and Adolescent Mental Health Services referral data analysis: Generally increasing number of referrals into CAMHS since 2016. There is such variation between Trusts that a single number (and indeed this and the previous statement) is not reflective of the situation. There was an increase of around 10% points in Trust D and Trust B between 2016 and 2020, but a non-linear change in Trust A, so comparing 2020 with 2016 the proportion actually decreased by about 2.5% points. Differences were observed in CAMHS referral success rates between different Trusts as well as within the same Trust. This could be the result of: different referrer/patient characteristics, demographics within a location which may influence the success of CAMHS referral; or CAMHS referral processes may differ between Trusts/regions. GPs were the largest contributor of referrals in three out of the four trusts, on average accounting for approximately 43% of referrals. CAMHS is being transformed, in part through the digital transformation agenda and the introduction of the new integrated care boards (ICBs). Consistent data collection and reporting of CAMHS referral data are required to establish monitoring and benchmarking for future improvements and quality assessment. Framework analysis of the focus group transcripts suggests problems within the CAMHS referral process related to: all stakeholders having different expectations of what CAMHS is and what CAMHS does, that is can/cannot provide; variability in referral processes, referral forms, and support available across CAMHS both between and within Trusts; inconsistent (and often poor) communication between stakeholders; long waiting times between referral and subsequent contact; and lack of signposting to alternative support both if a referral is unsuccessful, and while waiting for support from CAMHS. In the solution-focused workshops, stakeholders highlighted aspects of the referral process which people feel should be changed. These included: greater transparency of stages within the referral process and what to expect at each stage; better signposting pre-referral, especially if an alternative service to CAMHS may be more appropriate for a CYP; improved communication both during the referral process and if referral is unsuccessful into CAMHS. The findings from the quantitative and qualitative analyses, patient and public involvement and senior stakeholder consultations during dissemination activities identified the following as important aspects of solutions to the current problems within the referral process: Must haves: Increased understanding about what CAMHS can/cannot provide. A nationally standardised referral process for all CAMHS. A mechanism for updating people during the referral process. Early signposting to alternatives for all referrers. Add in-person aspects where this is achievable at low cost (or can provide clear cost savings). Like to haves: Develop a referral process that can adapt to local/regional variation in CAMHS/alternatives. Achieve this at low cost. Sustainable model of delivery. Co-ordination with existing systems, for example triage. Intelligent system – learning from data. Collect accurate referral data at every service to support monitoring. A future piece of funded work aims to: develop a simple, clear way for children to get the right support for their mental health problems when they need it; explore barriers and enablers to widespread implementation of the new CAMHS referral mechanism across different referrers and CAMHS with various configurations; understand how it can become widely successful and therefore embedded in services nationally; and evaluate its potential to reduce unsuccessful referrals and the potential cost benefits to services, CYP and families.

Authors' methods: The study took parallel quantitative and qualitative approaches to examine the extent of the problem in local and Northwest regional CAMHS services, and to determine how this translated into people’s experiences; and to identify realistic and implementable solutions.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR131379

Year Published: 2025

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/GYDW4507

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/GYDW4507

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