Discipline Needed

Up to a quarter of children and adolescents are estimated to
have mental health difficulties. Although families can experience
these difficulties daily, they often go unrecognised by
professionals. There is, then, a need for more awareness of mental
health difficulties in children and young people and ways of
tackling problems at an early stage.

Standard nine of the Children’s National Service Framework (1)
states that all child and adolescent mental health services (Camhs)
should provide a comprehensive service, including mental health
promotion and early intervention, by 2006. Although investment is
being made in these services, they remain under-developed in many
areas. A report from the Health Advisory Service identified a gap
in service provision between primary care services and specialist
Camhs.(2) It also recognised and appreciated the work that
non-specialists carried out in relation to mental health. In
addressing this gap the report recommended the introduction of the
primary mental health worker. The role and function of the primary
mental health worker would incorporate the following
principles:

• The development of the existing skills of tier 1 professional
  and non-professional workers though training, consultation and
  joint working.
• The improvement of links between tier 1 staff and specialist
  Camhs.
• The formalisation of supportive collaborative relationships and
  networks.
• Workers should offer assessment and intervention for children
  and adolescents, in partnership with tier 1 workers, where the
  level of need would not require specialist Camhs input. This would
  enable families to address difficulties at an early stage.(3)

The identification of this role has led an increasing number of
Camhs and other services to deploy primary mental health workers.
Previous studies have found that several Camhs have begun to
develop these type of posts.(4),(5) However, little is known about
how these roles are being implemented and supported to ensure they
are effective. This study sought to address this gap in knowledge.
The research question was: what are the current service issues for
primary mental health workers in child and adolescent mental health
in the UK?

A questionnaire was developed with local primary mental health
workers to identify the relevant issues. More than 200 were sent to
primary mental health workers across the UK. Of these, 44 per cent
were returned. The questionnaire was used to gather information
about provision of service, professional background, titles, grades
of posts, location, function, management and supervision
arrangements, training and development. It also asked workers to
identify any changes needed to improve their role.

Twelve disciplines were identified in the study. The largest was
registered mental health nurses at 31 per cent, followed by social
workers at 28 per cent. Although the most common title used for the
post was primary mental health worker, 25 titles were identified.
Many professionals were using their own discipline to identify
themselves. Reasons for this may be that the primary mental health
worker title does not as yet carry a professional identity in its
own right. As one respondent said: “Primary mental health worker
roles differ hugely around the country, with different targets. It
needs to be a profession in its own right.”

Within the study 11 different grades for the posts were found.
Most, 41 per cent, were graded on a nursing scale G or equivalent,
with scale H at 22 per cent. This would indicate that the majority
of services recognise the seniority of this role requiring highly
skilled and experienced staff. Just under a third of primary mental
health workers had only been in post for between one and two years
and only 2 per cent had been in post for six years or more. This
seems to indicate that many services are at an early stage of
developing primary mental health workers’ role and may benefit from
the experience of others. Networks are being established to support
this.

How primary mental health worker posts are funded is crucial to
their development and sustainability. Many posts started out as
temporary, requiring joint funding. However, almost all of the
posts studied are now permanent.

Although most primary mental health workers had a clear
understanding of their role and its function, many reported a lack
of understanding and clear expectations of the role by others
within their own services and other agencies. This was highlighted
as a major barrier to increasing their effectiveness. To address
this, services should consider the need for consultation with all
stakeholders prior to, and during the development of the posts.

Although the functions of the role seemed clear, the proportion
of time dedicated to these seemed to vary greatly. Providing
consultation was seen as a main function of the role, but workers
could spend from as much as 60 per cent to as little as 20 per cent
of their time engaged in this. Offering training and support to
tier 1 staff ranged from 85 per cent of their time to just 10 per
cent. Time spent on direct clinical work ranged from 80 per cent to
16 per cent. The maximum range for direct work is considerably
higher than found in a previous study where the highest was 20 per
cent.5 This suggests that there may be a greater expectation in
some areas for the primary mental health worker to work directly
with children and young people where there are mental health
difficulties. This may then lead to less time engaged in the
development of the consultation, joint working and training aspects
of the role with
tier 1 staff as originally envisaged.

The study found a growing interest in the development of primary
mental health workers across the UK and recognition of the
potential the role had to offer in developing a comprehensive
Camhs.

As one primary mental health worker said, “This has been the
most challenging role in my career. I love every part of it. The
role allows me to be responsive, flexible and creative in all areas
of my job. The diversity of the work is enriching and I am able to
see the impact of my role in primary care.” 

Recommendations for practice

• A greater level of consultation is needed within both Camhs and
  tier one services prior to, and during implementation of the
  role.
• A clear and shared definition and understanding of the primary
  mental health worker’s role across agencies.
• Having clear and dedicated management arrangements for workers
  and a clear primary mental health worker service model. Many
  favoured having workers’ teams rather than posts being “bolted on
  to traditional services”.
• Workers should have specific protocols and guidelines for their
  work.
• The development of specific training courses for workers.
• Having effective methods of monitoring and evaluating the
  impact of the role, which involves service users.

Training and Learning

The author has provided questions about this article to guide
discussion in teams. These can be viewed at www.communitycare.co.uk/prtl
and individuals’ learning from the discussion can be registered on
a free, password-protected training log held on the site. This is a
service from Community Care for all GSCC-registered
professionals.

Abstract

This article looks at the findings of a study that explored how
the role of primary mental health workers in child and adolescence
mental health has been implemented, supported and developed, from
their perspective. Using a postal questionnaire the study
highlighted crucial practice issues to be addressed by services
developing this role.

References

1. Department of Health, Children’s National Service Framework,
   September 2004
2. The Health Advisory Service, Together We Stand: The
   Commissioning Role and Management of Child and Adolescent Mental
   Health Services, HMSO, 1995
3. F Gale, “When tiers are not enough: the developing role of the
   primary mental health worker”, Child and Adolescent Mental Health
   in Primary Care, 1:1, p5-8, 2003
4. I Lacy, “The role of the child primary mental health worker,”
   Journal of Advanced Nursing 30:1, p220-8, 1997
5. W Macdonald, “Child and adolescent mental health services –
   challenging terrain,” Journal of Health Care Counselling and
   Psychotherapy, 2:4, p2-6, 2002

Contact the Author

E-mail: david.eaton@blackpoolpct.nhs.uk

David Eaton is head of the primary care liaison and
consultation service for child and adolescent mental health at
Blackpool primary care trust. He established one of the first
primary mental health services in the country and is supporting
others in developing similar services. He has worked in the field
of child and adolescent mental health for more than 16 years and
has a long-standing interest in developing early intervention and
preventive approaches.