Purpose and scope of the book

Child and adolescent mental health services (CAMHS) comprise a small, unusual specialty often ill understood by those who work within, those trying to use and those trying to commission them. In an attempt to make order out of the possible chaos, Together We Stand (NHS Health Advisory Service, 1995a) offered a review of and a strategic framework for, the organisation and management of CAMHS. This strategic approach was sanctioned by the House of Commons Health Committee (1997) and provided the benchmarks against which CAMHS have been measured (Audit Commission, 1999). Unfortunately, since the publication of the first edition of this book, the application of the principles and strategic approaches that informed Together We Stand has been subject to individualistic variation.

The tiered system has been bastardised or ‘moved on’ over the past 10 years to an incomprehensible ‘lingo’ in which many writers assume all ‘specialist’ or ‘core’ CAMHS operate at Tier 3, and Tier 2 has been confined to limbo, beneath the dignity of so-called ‘senior professionals’ of whatever discipline. The differing interpretations have resulted in the very confusion about services that the tiers were intended to overcome, so the risk of the confusion that reigned prior to 1995 has reoccurred, indeed it has been amplified. There is a serious risk that CAMHS will again become marginalised as they cannot be understood and are subject to changes and targets from those in power who do not understand their functioning, as advisors to government ministers have no real understanding of what the tiers are about. The tiered system is an integrated approach in which CAMHS professionals work across tiers: it is not and cannot function as a hierarchical system in which ‘senior clinicians’ are seen to operate at Tiers 3 and 4 only. The creation of ‘Tier 2 teams’ is a contradiction in terms, and reinforces the hierarchical attitude that only senior staff work at Tier 3 and above, which undermines both an integrated approach and true multidisciplinary working. It is worth restating the following.