Abstract
Referrals of ‘people you know’ to Child and Adolescent Mental Health Services (CAMHS) raise issues around anxiety, equity and confidentiality. Research in this area is limited. The framework approach was used to analyse interviews with CAMHS teams across Yorkshire. Issues identified included choice (and whose choice this is), power and perceived imbalances of power and relative lack of ‘professional distance’. The notion that health staff should receive preferential treatment by right was not widespread, but nevertheless existed. Standard procedure has to be flexibly applied to offer the best quality care. Families should not be inappropriately advantaged by ‘knowing us’, but disadvantage should be recognised and kept to a minimum.
Introduction
Child and adolescent mental health services are different to health services in general in several ways. Multidisciplinary working is considered to be best practice, with clinicians from different professional backgrounds independently holding cases and often working together in order to bring the correct skills mix to a specific difficulty. The traditional ‘medical model’ where the consultant is seen as the most senior clinician, who will offer the highest order advice, does not necessarily apply in CAMHS. Additionally, the systemic theoretical background from which many CAMHS professionals work is less likely to identify the ‘child’ as the ‘patient’, and may often need to work quite intensively with the whole family, sometimes touching on highly personal issues. Attention to the detail of how referrals are managed prior to direct contact with the family, communication with the referrer, transparency and confidentiality issues are seen as important in terms of the outcome of the transaction.
Partly for these reasons, when people are referred who are known (professionally or personally or both) to the CAMHS professional, there are particular challenges to be met. For example, primary care staff may worry about confidentiality if they are registered at the practice where they work, parents may feel uneasy about discussing their own relationship (and may not have realised that it may be relevant) and some may see it to be a ‘professional perk’ to see the ‘consultant’ or to move quickly up the waiting list. For the CAMHS professionals there may be issues around power differentials, reticence about asking the same questions as usual or concerns about equitable practice. Expectations and assumptions (some explicit, some not) around this process exacerbate pre-existing anxieties on both sides. In addition, concerns around confidentiality and respect mean that often the process is not discussed openly either within or between teams.
There is little evident literature in this area. In adult mental health there is some research describing the difficulties faced when the patient’s relatives work in mental health (Leffley, 1998). These included reluctance to engage in the first place and guardedness with respect to self-disclosure.
This research endeavours to explore this area by using qualitative methodology and interviewing CAMHS professionals.
Method
This study was initially developed and piloted in the local CAMHS research group. The proposal was to interview CAMHS colleagues and use the framework approach to analyse the data.
It has been argued that six interviews are sufficient to provide saturation of themes where the sample is judged to be homogenous (Guest, Bunce & Johnson, 2006). In this study, one team from each of the 10 CAMH services in North, East and West Yorkshire was approached. This large area comprises rural and urban populations and has considerable ethnic and economic diversity. The teams were asked to identify people who routinely managed referrals and who in practice represented different professional groups. Each interview was conducted by both interviewers with two or three members of each team (on one occasion only one person was available). A topic guide was used and refined with successive interviews. Signed consent was obtained from each participant.
Formal interviews lasted 35–45 minutes and were tape-recorded. All tapes were transcribed verbatim. Each meeting started with a discussion of how each team managed their referrals. This information was not analysed for the study but was necessary to inform the subsequent interview.
The transcripts and contemporaneous interview notes were systematically examined and annotated with numerical codes relating to specific areas. Via an iterative process of abstraction and synthesis, the codes were grouped into themes. Associations between themes were identified and ordered to reflect the sequence in which referrals are managed.
Ethical approval was obtained (Hull & East Riding LREC; Ref No: 04/Q1104/96) and the study was registered with the relevant R&D departments. The tapes and transcripts will be securely stored for five years post publication of the research.
Findings
The team members interviewed included an art therapist, nurses, psychiatrists, psychologists, social workers and team managers. The settings in which the participants worked were either community based (primary mental health workers) or specialist CAMHS.
All of the participating teams accepted team referrals, as opposed to direct referrals to named clinicians. Most were from primary care and child health, but some were from education, social care or the voluntary sector. Where necessary clarifying information was requested, and some referrals ‘signposted’ onto other agencies.
Several particular types of relationships with referred families were highlighted as presenting challenges to the receiving team. Common examples that emerged from the interviews were families of local GPs, consultants (including paediatricians and psychiatrists), teachers and social workers. Further examples were the friend of a close relative of a CAMHS clinician, senior executives in a local Trust and previous and current colleagues.
The themes arising from managing referrals of these families were identified from the transcribed interviews and are described below.
Choice for client and clinician
The issue of choice is a live political issue, usually in the context of ‘client choice’. In clinical practice, choices arise for both clients and clinicians at many points, often collaboratively. Prior to the family being seen for assessment, a series of choices would have been exercised, including the decision to seek help in the first place, from whom to seek it, and – from the professional point of view – whether a referral would be accepted. During the clinical episode there may be many more decisions taken that could be informed by client and clinician choice.
Participants in this study highlighted two areas that were specifically relevant to this group of families. The first was whether the local CAMHS team was the most appropriate one to help the family, and whose choice this might be; the second, once the referral had been accepted, was which specific clinician(s) would be involved.
Some teams were guided by the family’s preference, but there was an acknowledgement that their choice may be limited by wishing to appear compliant and not upsetting the local team by refusing care there: I think it’s difficult for people to say ‘I don’t want to go to the local team’ even if there is a legitimate reason such as confidentiality or just wanting some distance.
Participants were less spontaneous in considering the appropriateness of professionals also having a choice, though others were clear about what they normally do in these circumstances.
There’s some instances where … it needs to be made clear to families that it is not appropriate for them to be seen by this team … it’s not just about whether the family are comfortable but whether the professionals feel comfortable about working with them.
Some clinicians felt it was difficult to refuse to see a family who had explicitly asked to see them due to their reputation preceding them in the professional grapevine.
The last one I had…there was someone who…worked for the local authority … and she requested [to] see me professionally … and that was slightly difficult … because she seemed a very balanced, mature sort of person, I thought it would be OK and I did in fact take it, and I saw them for quite a while but it makes me realise that it’s a case by case kind of thing really and it could in fact have worked disastrously.
Where the family difficulties were considered to be severe or complex enough to require very specialist treatment, the imperative for ‘neutrality’ of the therapist was overridden by the need for specific expertise.
I think that … when [the referral issue] is more severe, then it’s less easy to ensure or protect confidentiality. I think professionals in the team would all know but that you still might be able to not be directly working with the family.
Perceptions of power differentials could give rise to anxieties in the team: There was a referral of a consultant psychiatrist and that came in and they had some discussion in the filtering team about what to do … and I guess it sort of brings up lots of emotions, doesn’t it? You … think, gosh, how should we deal with this?
In some instances, senior members of the team managed the referrals and thereby allocated referrals as they saw fit: Our allocations process is that we [three senior team members] allocate referrals … so it is a fairly managed process, it is thinking about who is the best person to manage this case.
Departing from standard pathways
Referral
All participants described how referrals were routinely managed, and there were varying opinions around how closely protocols should be followed. While acknowledging the security of having a clear pathway, most participants identified a tension between this and adopting a flexible approach for individual families.
The broad consensus was that, if well thought through, usual practice was usually the most helpful. For example, most teams had referral management structures which would preclude direct approaches from potentially referred families to individuals in the team: Things have changed quite a lot recently, things have been firmed up, the likelihood of individual clinicians being approached has reduced.
However, in some teams it was acknowledged that consultant-to-consultant conversations still went on: [Following a team discussion on this issue] we wondered whether the [parent] consultant would ring the [CAMHS] consultant and [the rest of the team] wouldn’t know about that, so we asked the doctors, and they said ‘yes that has happened, that can happen’.
In other teams, even when individual clinicians were approached about the referral, protocol was followed thereafter.
If an individual member of the team gets a request from an allied health professional saying ‘would you see so-and-so’ … we would try and feed [it] into the team process.
Risk and quality
When usual procedures were departed from, participants recognised that there was a risk that outcomes may be compromised.
There was one instance a long time ago … and it really taught us a lesson, and something hadn’t been done in a formal manner [notes had been kept differently], and it ended up as a child protection issue, and so at that point we thought ‘this isn’t on, we’ve got to explain to people that these are the boundaries and these are the issues around the treatment of this referral and it has to be the same as it is for everyone else’.
Sometimes deviation from usual practice was seen to be appropriate with few attendant risks.
I think I would deal … the same way with [standards of] confidentiality; what I would expect of a CAMHS team that they would all apply the same confidentiality standards. What we have done though, and I’m thinking of a head teacher, is be careful about appointment times, because if you’re a head teacher and you’re sitting in the waiting room, your pupils might walk in so we would think carefully about venues and that would be the same about certain professions because it could be embarrassing.
At other times, it appeared finely balanced as to whether flexibility enhanced or detracted from quality of care. For example, in a specialist eating disorders team where one of the clinical members had a link with the referred family, I don’t think we’d change how we ran it, but we would address that with the family when they arrived, and normally what we would do is if whoever who had been allocated to be in the room with the family felt uncomfortable, we would switch people round … it’s much easier when you have got a team to do that.
However, the respondent reflected further that excluding a core member for reasons of confidentiality risked compromising the quality of the intervention.
Geographical considerations
Most CAMHS teams accept referrals from a geographically defined catchment area. However, most participant CAMHS acknowledged that at times it was appropriate for certain families to be seen ‘out of area’, although none had developed formal arrangements to facilitate this departure from usual practice. This meant many arrangements were made on an ‘ad hoc’ basis.
Within an urban, densely populated area there may be several teams managed by one service, but with discrete catchment areas. Here an ‘ad hoc’ approach was described as being relatively straightforward.
Within the team we have an agreement that we don’t pick up anyone [known to us professionally or personally] from within our geographical area.
More challenges arose in large rural areas served by a single team: … and the other thing I suppose that we have to consider is we have had mental health professionals to whom we have suggested they go to alternative CAMHS. For them then as a family they’re thinking about a 35-mile journey which is huge. The families are expected to travel miles anyway because [our] catchment area is about 900 square miles. I think [if the same issue] occurred again, I’d be more likely to say to the referrer … ’do you want to go back to the family and talk about the distance, the lack of knowledge of the local area, the problems of trying to liaise with schools …’, the fact that at the end of it [e.g. group] treatment offered may be … not easy to take part in … because they may not be able to travel.
One team judged it useful to geographically compartmentalise treatment so the family was seen both in the local team and by a neighbouring service.
[We were engaged in] some good-quality individual work. There was a role for family work, again it was a medical family, not in mental health, and the option was [put to the family] to do the family work elsewhere.
Prioritisation
Many participants described situations where they experienced pressure to treat professionals’ families preferentially. In the CAMHS context, this generally related to such referrals being seen quickly rather than waiting.
They wouldn’t have been prioritised if they hadn’t been health professionals, but we felt … ‘yeah, let’s see them …’ because they are fellow colleagues rather than keep them waiting. You’re basically talking about a perk aren’t you.
Sometimes it was a third party who placed the expectations upon the receiving CAMHS team: The Ward Sister phoned and asked if she [nurse on the ward] could be seen earlier so she could get back to work.
At other times, participants were approached by Trust managers and requested to prioritise particular families. They described a conflict between what they felt was ‘best practice’ and the need to follow instructions by line management.
[The referral] definitely went through the back door and we didn’t have any choice in that at all. It was one of the senior managers, and it was a close friend of his and there was pressure to see – and we did.
However, some respondents cited reasons related to the professional status of the parent that may have made it clinically appropriate for the family to be seen relatively quickly. Having some relevant knowledge may result in presenting either with heightened anxiety or with more advanced difficulties.
I guess from my experience [referred professional families] try to resolve things without involving services, and by the time they need a service they are almost at crisis point.
Professional proximity
Participants were consistent in advocating the use of a relatively objective stance when dealing directly with families. A clear link was made between rigour and thoroughness (by, for instance, asking what might be seen as more intrusive questions around trans-generational and abuse issues) and the overall usefulness of the assessment.
However, there was recognition that this may be compromised by prior knowledge of the family and may be additionally complicated if a parent works in the same field as the clinician. This could lead to assumptions on either or both sides which may adversely affect any attempt at therapeutic neutrality.
… you might not ask the right questions. Ninety-nine percent of the time it would not matter but three years later you might wish you’d asked that question.
Such assumptions may even alter the subsequent therapeutic course.
I guess it begs the question as to whether it compromises the quality of work that you do … would you be choosing the same treatment options if they weren’t health professionals?
Where a professional link was known in advance, some teams had a strategy to preserve neutrality.
I advised for that person to have a link with somebody who didn’t know them … so the person who is working does have a clean slate, they’re not cluttered by all the other stuff they know about the person.
However, a connection may only become apparent when the family are seen at the first appointment. Here a straightforward and transparent approach was seen as helpful.
As a team we’d address that, we’d help each other out in that situation. We’re confident enough to change clinicians and as a team we’re confident enough to let the family know the reasons why.
Confidentiality and communication
Families of fellow professionals present specific and at times conflicting challenges around privacy and confidentiality. Reconciling the housing of notes, the transfer of information and ‘need-to-know’ principles are issues both within the team and between team and referrer.
In general, the old-style practice of keeping certain sets of notes in individuals’ desks was seen to be out of date. Nevertheless, some described situations where they judged that notes needed to be housed separately: One was a request from a parent with a mental health background for particular confidentiality and we housed the notes slightly differently.
Where the notes were not kept separately, it was acknowledged that when clients were known to the team it was incumbent on individual clinicians to act professionally.
I know personally several of them and I could get access to their notes very easily, we do have an agreement that we won’t do that, but it’s a moral thing.
Sometimes tailoring confidentiality around a specific set of needs created a new set of problems in itself: In the end it’s actually being treated in a much more open and transparent way because that [visiting at home] just seemed to create additional obstacles and hurdles.
There were some assumptions made around cases in which confidentiality was considered less important. For example, when discussing one particular family, the concerns were seen to be less pressing because ‘[i]t was only a young child with conduct problems’.
GP receptionists’ families (registered with the practice) were acknowledged to have particular issues around confidentiality.
Her mum is one of the clerical workers at the local GPs, that throws a different dynamic onto it, what [she] is quite anxious about letters going back to the GP and other people, and equally the young person as well, she worries that her mum is going to read it.
Discussion
It was apparent during the research that teams were aware of this subject, but there was little agreement on what constituted good practice. In addition, by the very nature of the issue, it was difficult to establish its extent.
It should be acknowledged that both an advantage and disadvantage of the project was that we, as researchers, were drawn from the same population as the participants, the referred families and the intended readership of the finished article. Although requiring particular sensitivity around confidentiality, this ensured that we understood the subject matter and could communicate with the participants. However, we risked being blinded to material due to familiarity with the subject matter, reducing our ability to ask pertinent questions and leading to a greater likelihood that our own opinions on the subject may be incorporated into the text. The challenge was to differentiate where possible between confirming or disproving our own prejudices, and recognising genuinely ‘new’ ideas.
Interestingly, the project seemed to have had somewhat of a ‘Hawthorne’ effect (where productivity is increased allegedly simply because the participants are being observed). Several teams explicitly reported that they had had discussions in their teams about the project before we visited, and it was apparent in some of the interviews (all but one of which involved more than one member of a team) that people were hearing colleagues’ thoughts on the subject for the first time – at which point they began to engage in discussion about it there and then. In this way, some of the interviews were more like focus groups.
Indeed, coming from a CAMHS and systemic background, it felt natural to be conducting the interviews as a pair, and to be interviewing participants in groups. However, it seemed that this did not fit well into some orthodox views of qualitative research (where index interviews wereone-to-one) and that our methodology would be considered more as a focus-group approach. We did not consider individual interviews to be an appropriate or alternative methodology here as this might reduce the richness of the content, due to participants having different and separate experiences. We were also interested in how a team might process the issue together (rather than an individual) and felt there would be other topics involving CAMHS workers where individual interviews would be more appropriate (e.g. views on the utility of CBT in CAMHS working). In this research there was a strong sense that the team was equivalent to an individual (a focus-group approach would require several teams to be interviewed together!). Framework analysis has been proposed as an appropriate methodology for this type of healthcare research (Pope, Ziebland & Mays, 2000).
Underlying the research was the concept of ‘professional courtesy’, which dates back to Hippocrates. Nowadays it largely refers to the waiving of fees (particularly where there is no public health system) for treating medical families in order to avoid physicians ‘treating their own’, which could be construed as unethical and possibly unsafe. In the context of this study, such ‘courtesy’ is often understood to mean that waiting lists may be bypassed, or more ‘senior’ clinicians allocated. At face value, the ethical and safety issues here are quite different. It may be considered unethical to bypass waiting lists, for example. There may also be a quality issue related to setting up therapeutic relationships around pre-existing relationships and the difficulty of establishing any kind of therapeutic neutrality. This could be construed as being less of an issue in physical health settings.
The principle of choice is now central to health and social policy. In the context of this study, choice was seen as an issue not only for referred families but also for clinical teams. In addition, power and status differentials may influence apparent freedom of choice. Participants recognised that in acute situations, choice was less of an issue – for example, in the case of a suicidal young person, speed of response may be more important. In such an instance, clinical judgement is required to decide the balance between choice and risk.
The participants described using standard procedures for the allocation, assessment and management of referrals, as well as for the confidential handling of clinical material. All acknowledged that certain referrals challenged these processes. Furthermore, in order to optimise clinical quality, at times it was deemed appropriate or even necessary to deviate from standard procedure, having considered the risks and benefits of doing so. Treating everyone the same may appear fair but may disadvantage some; fairness and equality are not necessarily equivalent.
Common to health services in general, CAMH services have undergone significant developments in recent decades. Specifically, there is a shift away from the medical model towards systemic approaches. This is reflected in decisions and processes being more centred on the multi-professional team, rather than based on an often medically led hierarchy. Cohesive and well-functioning teams are likely to be more confident in their decision-making. The issues and dilemmas discussed in this research are now owned more by the teams than may have been the case in the past.
In conclusion, although we were not setting out to devise practice guidelines, some principles of good practice can be extrapolated from this research. Standard practice around referral management is helpful, even if it simply functions as a ‘line in the sand’ from which to deviate when judged necessary, Reasons why deviation may be necessary include professional proximity, issues around choice and power imbalances. However, the best care of the young person must be the overriding concern, and decisions around deviation from standard practice will depend, for example, on severity of presentation or availability of other appropriate resources.
Research of this type is helpful in understanding how teams process and accommodate challenging situations. The methodology might also be utilised to investigate how teams manage, for example, organisational change, multidisciplinary relationships and complex clinical situations. In terms of the content of this research, further investigation could include comparing the clinical outcomes of various approaches, encompassing the experience and opinions of the referred families.
Footnotes
Acknowledgements
We thank the participants in the study and our colleagues who commented on the protocol and earlier drafts of the paper.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.