Second Edition Miranda Wolpert, Rita Harris, Sally Hodges, Peter Fuggle

21

GETTING HELP

Context: There is increasingly sophisticated evidence for what works with whom in which circumstances 

(Fonagy, 2002), and increasing agreement on how service providers can implement such approaches (NHS CYP 

IAPT, 2012), alongside embedding shared decision making to support patient preference (Mulley, Trimble, & 

Elwyn, 2012) and the use of rigorous monitoring of outcomes to guide choices both between different types 

of interventions and within interventions (Bickman, Kelley, Breda, de Andrade, & Riemer, 2011). The latest 

evidence suggests that a significant minority of young people will not be “recovered” at the end of even the 

best evidence-based treatments.

Data: Analysis of data from the Payment Systems Project work (Department of Health, 2014; Wolpert, et al., 

2015) (see above, pp.12-16, for fuller discussion) found that of the 60% of children, young people and families 

who had difficulties that appeared likely to benefit from goal-focused interventions under the heading of 

“getting help”, about half looked likely to be clearly aligned to specific NICE guidance and half were not clearly 

aligned, either because of co-morbidity or because the primary difficulty was not captured by NICE guidance, 

such as family relationship difficulties. 

Resource: The average (mean) number of face-to-face contacts for episodes of care within the payment systems 

pilots was seven. It is hypothesised that the THRIVE model would support more clearly targeted work with some 

young people getting more intervention and others getting less. It is conjectured that the mean number of 

contacts for this group might rise (to e.g. 10 – see Table 2 on p.16) but with fewer young people being seen for 

extended periods of time if it were felt an intervention was not proving effective.

Need: This grouping comprises those children, young people and families who would benefit from focused, 

evidence-based treatment, with clear aims, and criteria for assessing whether aims have been achieved. This 

grouping would include children and young people with difficulties that fell within the remit of NICE guidance 

but also where it was less clear which NICE guidance would guide practice. 

Provision: The THRIVE model of provision would suggest that, wherever possible, provision for this group 

should be provided with health as the lead provider and using a health language (a language of treatment and 

health outcomes) with a greater emphasis on ending an intervention if it was felt not to be working or if was 

felt gains no longer outweighed costs or potential harms. It is our contention that health input in this group 

might draw on specialised technicians in different treatments, possibly allowing less expensive professionals to 

provide more procedurally defined interventions.

The most radical element of what we are suggesting is that treatment would involve explicit agreement at the 

outset as to what a successful outcome would look like, how likely this was to occur by a specific date, and what 

would happen if this was not achieved in a reasonable timeframe.

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22

GETTING MORE HELP

Context: There is emerging consensus that some conditions are likely to require extensive or intensive 

treatment for young people to benefit. In particular, young people with psychosis, eating disorders and 

emerging personality disorders are likely to require significant input.

Data: Analysis of NHS outpatient CAMHS data for payment systems found that “37.8% of all appointments 

were attended by the 5.25% most ‘resource-intensive’ patients, who attended more than 30 appointments 

each”, (Wolpert, et al., p.21) Key problems that were associated with larger amounts of contact included 

eating disorders and psychosis. It should be noted that there was great variation within the groups and that 

the analysis was not able to consider inpatient treatment. The payment system pilot work found the average 

number of appointments for those provisionally allocated by the algorithm to this group was around ten.

Resource: It is suggested that for some young people and families more extensive treatment is likely to be 

required and that these young people are likely to have most impairing difficulties such as those reflected in 

eating disorders and psychosis, though there may be many other issues that lead to significant impairment or 

requirement for more extensive input. It is hypothesised that the THRIVE framework may result in an average 

number of outpatient appointments of around 30 (see table 2 p. 16). However, it is recognised that, for some 

of these young people, individual agreements with commissioners will be needed to arrange payment as the 

range of costs within this group are so wide.

Need: This grouping comprises those young people and families who would benefit from extensive long-term 

treatment which may include inpatient care, but may also include extensive outpatient provision. The THRIVE 

framework proposes that there may be some people currently allocated to this grouping who are not benefiting 

from intervention, and are being held in services solely because of concerns about risk and safeguarding. It is 

hypothesised that around half of the 10% of young people currently allocated to this group (as per the payment 

systems algorithm) might appropriately be reallocated to getting risk support.

Provision: The THRIVE model of provision would suggest that wherever possible, provision for this group 

should be provided with health as the lead provider and using a health language (that is a language of 

treatment and health outcomes). It is our contention that health input in this group should involve specialised 

health workers but again it may be that more procedurally defined interventions can be provided by less highly 

trained practitioners than may be needed for the decision making required for getting advice.

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