Seats of learning

    Social workers and other professionals are being encouraged to
    undergo specialist training as primary mental health workers to
    improve child and adolescent mental health services. The new role
    aims to bridge the gap between mainstream children and families’
    services and specialist Camhs. This follows government, research
    (1) and campaigns by charity YoungMinds and Community Care that
    highlighted the urgent need for improved Camhs.

    These new postgraduate courses have been developed with the
    Department of Health as it seeks to achieve a comprehensive Camhs
    by 2006. But there are concerns that the expansion of the Camhs
    workforce is going to place unrealistic expectations on primary
    mental health staff.

    Courses for the new role are unlikely to attract enough students
    to begin to address the shortfall in numbers already
    highlighted.(2) It has been estimated that as many as 900 primary
    mental health workers are needed in England to achieve a minimum of
    four in each local Camhs in England by 2006.3 No reliable evidence
    has been used to substantiate this number. Previous studies have
    showed that existing Camhs were understaffed in health authorities,
    although the level of demand was a fraction of the actual need for
    services in the community.

    Existing Camhs staff who are eligible to become primary mental
    health workers are usually already well-qualified. For them there
    is little incentive in undertaking post-graduate training.

    The number of staff with the required experience – plus a degree
    – is likely to be smaller than the number needed to hit the 2006
    target. Also there is no formal national accreditation or career
    structure for primary mental health worker roles. This means
    individual universities can vary the content of their courses or
    build on existing ones, while employers in primary care trusts or
    social services can design their own job descriptions. The result
    will be uneven national service development especially as Scotland
    and Northern Ireland have not been covered by this programme.

    Expectations being placed upon the new role seem unrealistic.
    The National Camh Support Service (NCSS) set up to help develop
    better services has produced guidance and a definition of the role
    of the primary mental health worker. There are seven key components
    to the role:

    Liaison: The liaison role anticipates the
    primary mental health worker “facilitating collaboration between
    all agencies… to enable the definition of the best approach to
    meet the mental health needs of the child”.

    Words in the guidance such as “networking” and “being a
    catalyst” are used without much explanation of their meaning, or
    how much of the practitioner’s time is expected to be devoted to
    this and the other six roles.

    Consultation: The role of consultation is also
    poorly defined and replicates some of the tasks mentioned in the
    roles of supervision and intervention.

    The term consultation is open to multiple interpretations and
    will mean different things to different professional staff.

    The potential for tension or confusion or both being generated
    between line managers and primary mental health workers seeking to
    offer advice and support is high, particularly where there are
    child protection concerns.

    Training: The training role is likely to become
    a focal point of pressure given the predicted shortfall in
    workforce numbers. The guidance from the NCSS suggests “regular
    multi-agency training programmes should be offered to the range of
    professionals working with children… enabling them to recognise
    and manage child mental health problems at an early stage”.

    So how are primary mental health workers going to be trained to
    train others and what controls will be in place to measure the
    effectiveness of this training. There are staff eligible for
    undertaking the job of primary mental health worker who may be put
    off undertaking training if by doing so they are going to feel
    burdened with unwanted extra responsibilities and work.

    Supervision: The aim of the supervision role is
    to “improve tier one staff skills and knowledge base to achieve
    early intervention, preventive work and aid assessment”. Yet the
    skills of supervision are complex, with different models. There
    will be a lack of fit between individual primary mental health
    workers’ supervision experiences and methods of working, and
    between the various professionals at tier one.

    Intervention: The guidance states that the
    intervention role can be provided on two levels – through joint
    work with tier one staff or direct work with children and families.
    Each of these tasks is labour intensive. Joint work requires time
    and planning, the building of trusting relationships and
    negotiation of roles and appreciation of different working
    practices. In addition with the enormous waiting lists in tier
    three together with demand in the community it is expected that
    primary mental health workers will initially be subjected to
    considerable pressure to undertake large volumes of work.

    Strategic planning: The guidance suggests that
    strategic planning “includes the development and agreement of joint
    agency protocols for pathways of intervention, treatment or care…
    and contribution to the development of inter-agency structures to
    ensure joint planning and collaborative working relationships”.

    These strategic, time-consuming tasks will be unattractive to
    many prospective primary mental health workers.

    Research and development: Finally, the role of
    research and development envisages “identifying service needs and
    gaps across agencies with regards to children’s mental health and
    obtaining users’ views and involving users in the design and
    delivery of accessible Camhs provision”.

    The implications of this are profound. Needs assessment and
    analysis are notoriously difficult to implement but produce
    statistically robust data. Involving children in service
    development is also difficult as it raises tricky ethical
    considerations.

    There is anecdotal evidence that new posts are being filled by
    poaching staff working at tier 3 who face the stress of long
    waiting lists and entrenched complex caseloads.

    The prospect of moving to tier 2 with a light touch preventive
    role is attractive especially as many staff will earn the same
    money. In the short-term there will be no overall net increase in
    the workforce just re-badging of existing staff.

    The aim of building workforce capacity and improving the quality
    of Camhs over the next two years as specified in the children’s NSF
    is looking more unrealistic.

    Abstract

    The National Service Framework for Children has specified
    improvements in staffing child and adolescent mental health
    services. New primary mental health worker posts are proving
    attractive to social workers seeking to develop their special
    interest in child and adolescent mental health. This article sets
    out some of the prospects and problems for these new jobs and
    suggests they carry an unrealistic burden of expectation.

    References

    1. S Walker, Social Work and Child and Adolescent Mental Health,
      Russell House, 2003
    2. YoungMinds, Briefing on the National Service Framework for
      Mental Health, YoungMinds, 2001
    3. DfES/DoH, NSF for Children, Young People and Maternity
      Services, HMSO, 2004

    Further Information

    For YoungMinds go www.youngminds.org.uk and
    Youth in Mind is at www.youthinmind.net

    Contact the Author

    Email s.walker@apu.ac.uk

    Steven Walker has worked in child protection and child
    and adolescent mental health services. He is currently Camh
    programme leader at Anglia Polytechnic University and is the author
    of Social Work and Child and Adolescent Mental Health, and Working
    Together for Healthy Young Minds, Russell House
    Publishers.

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