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example, medical assessment, pharmacotherapy, or integrated packages
of pharmacotherapy and psychological therapy. It will rarely be a good
use of resources to use doctors to deliver psychological therapies when
there is no medical component. Similar considerations apply to all other
professionals, including psychologists, nurses and family therapists: Are
their unique skills being used appropriately? Could parts of their job
be done as well (or better) by other people who cost less? Using highly
qualified staff for simple tasks is likely to waste money that could be used
to help more people. But don’t forget that using under-qualified staff
can do harm and reduce cost effectiveness if poorer quality treatment
undermines successful outcomes. It may be a good idea to have simple
cases treated by cheaper staff with less extensive training, but it is vital
that they should be well supervised by more experienced staff.
4 Use a graded approach. Children and adolescents with mild problems do
not usually need lengthy and complicated assessment and treatment –
brief single-handed assessment and therapy may be all that is required.
If a simple approach does not work, it may then be appropriate to
move on to a more detailed multidisciplinary assessment and lengthier
treatment packages. On the other hand, if the referrer makes it clear
from the outset that a child has a complicated and puzzling disorder
that is going to need a multidisciplinary assessment, it would be a waste
of resources to do a single-handed assessment first. A flexible range of
options is more efficient than a ‘one size fits all’ approach. It may be
helpful to have a hierarchy of services:
1.For the majority of children with mild and moderate problems,
the assessment and treatment can be delivered by single-handed
child and adolescent mental health professionals working in schools
and primary health centres. These professionals need a broad-based
training that allows them to deliver relatively simple treatments for
a wide range of problems.
2.Individuals who do not respond to simple approaches can be referred
to the area’s specialist CAMHS. Those with severe problems might
best be referred directly to CAMHS at the outset. Since services are
delivered by several professionals, there is room for specialisation and
a flexible mixture of single-handed and team working.
3.An even smaller number of children and adolescents with rare and
hard-to-treat disorders need to be seen by highly specialised regional
or national services, whether as out-patients or in-patients.
A good example of a graded approach is the Triple P parenting
programme. Level 1 is the provision of universally relevant parenting
information through TV and radio programmes. Level 2 consists of two
20-minute consultations by a primary care worker using a manual to
tackle isolated behavioural problems. Level 3 involves four 40-minute
sessions for wider-ranging problems, delivered by a more experienced
practitioner. Level 4 is a ten-week programme of two hours per week
led by a qualified mental health practitioner. Those who do not respond
well to this go on to level 5, which involves a further eight weeks of
more intensive family work.