18. Have a systematic approach to long term problems

Have you asked your users their view of what long-term services they need? For example what review process would families with children with ADHD like?

Do you have agreements with partner agencies about how to support families with long-term mental health or neuro-developmental conditions?

Can families with recurrent mental health problems access your service quickly and easily when they need to?

Which other agencies can monitor and support families with long term problems, especially those that do not meet threshold criteria for social services e.g. the school nurse, youth service, voluntary agency...

Is there an Expert Patient Programme locally that you could tap into?

This is about a managing the reality of chronic conditions


This is an area with which CAMHS often struggles. Neuro-developmental disorders and some psychiatric disorders are lifelong problems. The “one size fits all” approach does not work well with chronic problems. A more flexible approach is required and ensures CAMHS is not the only source of support. Self-management is crucial. Consider developing the Expert Patient (an expert, successful patient who can advise and support others). This is a new area for CAMHS where previously this expert role has been within support groups. Expert Patient programmes are already available for chronic problems such as schizophrenia and epilepsy. Added bonus: This approach empowers the user.

Ideas for Action

  • Find out about Expert Patient Programmes in your area and consider developing ones appropriate for CAMHS.
  • Integrate care across agencies.
  • Involve users in development of protocols for long-term problems.

This item will also help you implement

High Impact Change number 7