Organisation of Services 373Clearly defined boundaries
Many services are for a defined geographical catchment area. Within this
area, it is important to decide which disorders should be the concern of
mental health services. For example, will CAMHS be involved in the as-
sessment and treatment of stuttering, obesity, enuresis, or dyslexia? Some-
times there will be pressure to do so, particularly if there is no other service
for these problems. The price for doing this may be that the service then
has to cut back on the assessment and treatment of ‘core’ mental health
problems such as anorexia nervosa or obsessive-compulsive disorder. One
area of controversy is how far mental health services should be involved
in the assessment and treatment of disruptive behavioural disorders. These
disorders are undoubtedly common, severe and costly to society, and there
are evidence-based treatments (see Chapter 6). Clearly, these disorders
need identification and treatment – the question is whether this should
be done by health, education, social services, the voluntary sector, or
some combination of these. At present, disruptive behavioural disorders
account for over half of the work of many CAMHS. The advantage of this
is that these children are getting help that might not otherwise have been
available; the disadvantage may be the relative neglect of other disorders
that require the sort of help provided by mental health services rather
than education, social services or any other agency. Some hard-pressed
CAMHS have responded to this pressure by dropping disruptive be-
havioural disorders from their remit in order to concentrate their resources
on ‘core’ mental health problems – a potentially reasonable response
provided someone takes responsibility for the management of behavioural
problems.
Age boundaries may also be useful. At some point, child and adoles-
cent services give way to adult services (hopefully with good transition
arrangements). Should this transition happen at 14, 16 or 18, or according
to clinical judgement? The advantage of the latter is that an immature 17-
year-old who is still in school might best be seen by adolescent services,
whereas a mature 16-year-old who has left school might best be seen by
adult services. On the other hand, a fluid age limit may make it harder
to allocate funding between services. Older teenagers are more likely
than young children to have serious mental illnesses requiring lengthy
or repeated hospital admissions – so extending a service from 0–15-year-
olds to include substantial numbers of 16–18-year-olds could potentially
double total costs. This is fine if the extra funding is made available,
but could be a disaster if it diverts funding away from the treatment of
under-16s.
Budgets that are fair to the young
Throughout the world, considerably more money is spent on mental
health services for every million adults in the general population than on