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

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BACKGROUND TO THE DEVELOPMENT OF THRIVE

Children and Young People Mental Health Services in Context 

Services to support child and adolescent mental health have grown from diverse roots. On the one hand, this 

provision is the descendant of the child guidance movement of the 1920s onwards, which sought to support 

child wellbeing and deal with problems before they became significant. On the other hand, its antecedents lie 

in medical psychiatry which focused on mental illness and serious problems. There is a third element which 

has increased in prominence in recent years: the necessity of managing risk for some of the most troubled 

children and young people in the community. In many ways, this tension between promoting wellbeing (where 

education language and metaphors are dominant), treating illness (health language and metaphors dominate) 

and managing risk (social care language and metaphors dominate) still lies at the heart of debate over service 

provision (Wolpert, 2009).

Children and young people mental health services are almost inevitably a smaller part of a bigger system, 

whether representing the child part of mental health or the mental health part of child services. Whilst there 

has in recent years been an increased policy focus on CAMHS specifically (National CAMHS Review, 2008), 

the tendency for CAMHS to be an afterthought to wider policy or funding initiatives remains. Differences 

in language and philosophy between the wider systems (health, education, social care) make cross-agency 

working hard and agreement on coordinated policies challenging.

Historically underfunded, and vulnerable to cuts because of its location within larger systems, the more recent 

context of austerity has resulted in extensive disinvestment in services, with 25% cuts reported in some areas 

in 2013 (YoungMinds, 2013). The last UK epidemiological study suggested that at that time (ten years ago) less 

than 25% of those deemed ‘in need’ accessed support (Green, McGinnity, Meltzer, Ford, & Goodman, 2005).

Attempts have been made to conceptualise children and young people mental health services, the most 

long-lasting and influential of which a model dividing service provision into four tiers as outlined and described 

below (North East London NHS Foundation Trust, 2014):

Tier 1: non-specialist primary care workers such as school nurses and health visitors working with, for instance, 

common problems of childhood such as sleeping difficulties or feeding problems. 

Tier 2: specialised primary mental health workers (PMHWs) offering support to other professionals around 

child development; assessment and treatment in problems in primary care, such as family work, bereavement, 

parenting groups etc. This also includes substance misuse and counselling service.

Figure 1: 

Four tiers of 

service provision

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Tier 3: specialist multidisciplinary teams such as child and adolescent mental health teams based in a local 

clinic. Problems dealt with here would be problems too complicated to be dealt with at tier 2, e.g. assessment of 

development problems, autism, hyperactivity, depression, early onset psychosis.

Tier 4: specialised day and inpatient units, where patients with more severe mental health problems can be 

assessed and treated. 

This model was very useful at its time of development in 1995 (NHS Advisory Service, 1995) for helping 

differentiate between the forms of support that might be available to children and young people, but has 

increasingly been critiqued (including by its developers) for leading to a reification of service divisions. As 

we will argue below, we feel that the THRIVE model offers a more helpful conceptualisation to address the 

challenge and opportunities of the current situation.

Current Context: Challenges and Opportunities

There is evidence of extensive and rising need in key groups, such as the increasing rates of young women with 

emotional problems and increasing numbers of young people presenting with self-harm (Bor, Dean, Najman, 

& Hayatbakhsh, 2014). There is also increasing policy acceptance of the long-term consequences of ongoing 

difficulties, including significant impact on employment, physical and mental health, with the oft-quoted figure 

of 66-75% of adult mental illnesses (excluding dementia) being apparent by the age of 18 (Campion, Bhugra, 

Bailey, & Marmot, 2013). 

Recent audits have found increases in average waiting times to first appointment in specialist mental health 

provision for children and young people (up to 15 weeks in some areas) and that less than half of all providers 

(40%) reported providing crisis access (Health Committee, 2014). Service providers report increased rates of 

self-harm referrals, and increased complexity and severity of presenting problems (Health Committee, 2014).

In terms of opportunities, there is increased provider coherence of what ideal children and young people 

mental health services might look like, with increased focus on work in schools and promotion of community 

and individual resilience (HeadStart, 2014), agreed sets of best practice standards collated by the service 

transformation initiative

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, shared sign-up to a vision of personalisation of care aligned with use of evidence and 

rigorous review of outcomes with buy-in from a range of professional and other groups

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. 

To enable this to happen there needs to be increasing alignment to shared standards of routine outcome 

measurement and performance management

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. 

A major opportunity for developing and refining thinking around children and young people mental health 

services came from the payment systems development work. This drew on the increasing evidence base in 

children and young people mental health services (Fonagy, 2002), emerging thinking around targeted payment 

systems to distinguish the needs of different groups of children, young people and families seeking help and 

support (NHS, 2013), and a determination to support service delivery based on both values and value (Fulford, 

2004: Porter & Teisberg, 2006). The links between THRIVE and the Payment Systems project development are 

detailed on pp.12–16 below.

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 The Children and Young Peoples’ Improving Access to Psychological Therapies Programme.

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Quality Network for Community CAMHS, Child Outcomes Research Consortium, Youth Association, Royal College 

of Psychiatrists, Association for Family Therapy and Systemic Practice, British Association for Behavioural and Cognitive 

Therapies, and British Association for Counselling and Psychotherapy.

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 Quality Network for Inpatient CAMHS, the Choice and Partnership Approach.

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