Theme 1. Reflections on role

This theme is about the role of the commissioner, how it is informed by their background and their ‘positioning’ in the system in which they work and how this influences their approach to commissioning.

Commissioners had a range of different formal responsibilities in terms of the remit and reach of their roles. They came from a range of different backgrounds, including clinical, non-clinical healthcare, and from professions and organisations outside the NHS. There were different perspectives on how prior experience might inform current role. For example, some commissioners from clinical backgrounds described how they drew on this prior experience in their current roles:

I’m one of the few commissioners who is actually a clinician…So my role as commissioner is actually informed by decades of actual clinical work and also frontline clinical management. (C13)

However, another commissioner described the benefits of having a breadth of prior professional experience:

…(it) allows me to have that kind of broad understanding of a wide range of agendas in making decisions for our communities, which helps. (C10)

Some commissioners clearly ‘positioned’ themselves as ‘non-clinicians’, and linked this directly with how they saw their role or the insights they were able to give:

Because I’m not a clinician, I can’t give you an opinion. I can’t interfere in the way the operational model works. I want to know if there are issues with the way the operational model works. (C8)

However, regardless of background, common to many participants was a perception that one of their key roles was oversight and overview of ‘the system’:

So, because I kind of work at the strategic level, I can see the different parts of the system. Whereas if you work in specialist CAMHS, you just see that bit. You don’t necessarily see, ‘Oh, there’s a school next to me here, and there’s, I don’t know, a school nurse there and there’s the family here.’ You’re kind of just dealing with your one part of it. (C9)

One commissioner described being a ‘critical point of failure’ (C8) because of this role. In contrast to the commissioning role, providers were often seen as not having the same overview of the system in terms of asking whether they were best placed to offer a particular service. Without their oversight and understanding of connections within the system, confusion or duplication of services could arise, and the system could be fragmented:

And I suppose I see my role, and I don’t think it is really necessarily what my role is per se, but I feel that it should be this, is to try and bring that system together. (C9)

Several commissioners specifically described their roles as supporting system transformations:

I wouldn’t necessarily describe us as traditional commissioners, per se. We work on large scale transformation, so things like the intermediary between NHS England and our organisation, and the subsequent providers that we work with. (C4)

Many described an increasingly collaborative approach to commissioning in recent years, linked to the advent of provider collaboratives (please see Study context for more detail). Commissioners described working together with providers and other organisations to develop consensus around solving problems and addressing gaps. This was closely related to an emphasis on the commissioner’s role in building and managing relationships with providers. Trust, openness and communication were also seen as central to allowing providers to raise problems and difficulties with commissioners:

So, having an open, trusting relationship with providers, where you can just ask questions, or they feel comfortable and confident enough to flag things that they’re finding really difficult, knowing that we will try to work through together to improve a pathway, or to support a team, or whatever it might be. (C7)

Some commissioners contrasted their approach and role with ‘traditional commissioning’ models, which were seen as more adversarial:

So I’m, sort of, part parent, part grandparent, part commissioner, because there is a formal bit to it, I do need to write the specifications, I do need to work with them on their business cases to secure funding…. But I think the fundamental difference is they should feel their commissioners are more approachable, they can talk to them. It’s not transactional, it’s not adversarial. (C8)

However, commissioners also expressed some uncertainties and concerns over their roles. For some, the shift to provider collaboratives meant that they felt their role had changed, or questioned whether they were even supposed to call themselves ‘commissioners’:

…[there needs to be] clarity on the expectations of commissioners, and the commissioning role. Because it seems to be changing, and then assumptions are being made in terms of what the role should be doing. (C6)

So we are not supposed to call ourselves commissioners anymore because the commissioning function has been stripped with regards to the move from CCG to ICS. (C10)

Theme 2. Priorities and tensions: working in a complex and evolving integrated care system

Commissioners described a wide range of environmental and contextual factors that influenced their work. These factors were perceived to present both opportunities and challenges to the commissioning of mental health services for CYP.

Many commissioners cited key policies and strategies which they felt had influenced their work in their roles. However, commissioners had mixed views about how national policy impacted their work. One commissioner felt a lack of control due to centralised decision-making, whereas another perceived there to be more scope to tailor national policy to local needs:

So we’ll get money from NHS England or money from the central team and they will be like, ‘we’re giving you this money, you have to spend it on X, Y, Z.’ So there’s a lot of stuff that I don’t actually have control over. The stuff that I do have control over is actually really such a small percentage. If anything a lot of the decisions are already made and then just like we’re told we have to just do it. (C7)

I think tailoring national plans, and national objectives, to our local population, is kind of what we do. Obviously we have certain access and activity targets to try and hit, and I guess there are suggestions as to how we do that, but I think what we need to do is really identify how that would work for our local population. (C4)

Participants also discussed the impact of frequent major national healthcare system reorganisations. Several described some of the challenges they faced in adapting to recent system integration and transformation without much information or guidance:

So it keeps on changing from Clinical Commissioning Groups, to ICBs, to Primary Care Trusts, all sorts. I think it’s going to go back to Primary Care Trusts, at this rate. [Laughs] (C6)

Some felt that frequent changes and ‘transformations’, along with a reduction in workforce, had led to a shift towards more reactive commissioning, and to personal stress for commissioners over their own job security:

The demands are unrealistic. Going through a transformation and integration process. We are also going through a restructuring, so we’ve been asked to deliver 30% savings by the end of the next financial year. So my post is safe for this year, but I don’t know if next year there will be a second round of consultation. And this creates a lot of instability because people are losing their jobs, we are going through consultations, so that creates that added stress. (C2)

Related to this, in terms of workload, several participants perceived that they as children’s commissioners had wider remit than they would have in adult’s commissioning:

Resource is not proportionately allocated to children’s commissioning…it’s just not enough. It’s not enough to give the level of attention and the level of time, yes, just the time that is required to do it justice really. (C7)

Some commissioners also felt that CYP as a group were a lower priority in the system. One commissioner directly related this to the change from Clinical Commissioning Groups (CCGs) to ICBs:

(Previously) there was that direct line of responsibility around targeted investment for children and young people and mental health, it felt ringfenced even though it wasn’t but it kind of was because you could not invest in children’s mental health, and commissioning groups were regularly challenged by way of their level of investment through professional bodies, for example, the Royal College of Psychiatrists. For some reason, that connectivity with ICBs, it isn’t the same. I think that’s a major challenge. (C13)

Another felt that other issues were of higher political and media interest than CYP, meaning that young people did not get the ‘airtime’:

Getting airtime to talk about the issues around treatment for young people can be quite difficult because of the operational pressures. You’re on the Six O’clock News with a queue of ambulances outside. Guess what, that’s going to dominate the discussions that week. (C8)

Theme 3. Insights and evidence: the role and use of data and informants

Commissioners described drawing on a range of sources to develop an understanding of child mental health need and services in their local area. Participants used many different terms to describe these sources, including information, evidence, data, insight, observations, hunches, conversations, engagement, deep dives, etc, and had different perceptions on the value and uses of these data.

Service providers were seen as particularly valuable sources of information, being described as commissioners’ ‘eyes and ears’ (C4). Insights and observations from providers were key to ‘verifying’ initial hunches from quantitative data, and prompting deep dives, engagement work or requests for further service provider quantitative data:

I think we are reliant upon our providers, and also our delivery managers, so our borough-based colleagues, to feedback pertinent issues or common trends or presentations, which are either not typical, or they’re increasing. So I think that gives us almost a bit of a hunch. And then I guess what we would do is try to dive a little deeper into some of the activity, outcome and experience data associated with those presentations, or those levels of need. (C4)

This meant that developing strong, trusting relationships with service providers was important, enabling open and honest discussions about problems and levels of need that might not otherwise occur:

[if] they feel comfortable and confident enough to flag things that they’re finding really difficult, knowing that we will try to work through together to improve a pathway, or to support a team, or whatever it might be, is much better than having a dynamic where providers might almost try and consume their own smoke, or to—not hide waiting lists, but feel as though they can’t flag a capacity problem, because they’ll get dragged over the coals for performance issues, and it will just create an industry of perhaps unhelpful dialogue. (C4)

Commissioners also talked of the importance of engagement pieces of work with children, young people and families. This type of information helped commissioners to really understand the needs of their population:

I think the key things that we’ve done in [LOCAL AREA] that I think data will never be able to show you is those engagement pieces of work, so actually understanding what children and young people and families are saying, how they feel about mental health support, what are their needs. (C12)

However, this was not always the case, with one commissioner suggesting that engagement events or co-production was not always helpful as it did not tell them anything new:

[Talking about feedback from children and young people co-production and engagement events] I wouldn’t say that they are to give us a good granular detail direction for developing services, because the narrative is always the same, ‘Oh, I wait too long, I don’t want to go to CAMHS, I want to be seen in the community,’ these are the main themes. (C1)

Commissioners also reported using ‘hard’ quantitative data (eg, service provider data, population-level data, local surveys, academic data) to develop an understanding of child mental health need and identify gaps in service support. Commissioners talked about population data being useful in providing a spotlight on general need, evidence for business cases (with quantitative data carrying more weight than qualitative data) and looking beyond ‘levels of access’ data:

I think looking at prevalence rates in boroughs and PCNs, versus the actual activity or access levels, is able to shine a bit of a light on where we have high level of need, but perhaps low levels of access. (C4)

I wouldn’t need it day-to-day, no, but we would obviously access that when we’re looking at papers or bidding or business cases, recommendations or retendering, all of that type of stuff then yes, or writing papers and we need that information, like going on the JSNA and things like that. (C3)

Often, there was a reliance on service provider data (ie, data on referrals, activity, outcomes and wait times), over other forms of quantitative data, to inform commissioners’ understanding of child mental health need. Service provider data had a range of uses; from identifying emerging context-specific trends to assessing service performance and identifying where services might be failing to meet the needs of CYP. However, some commissioners had concerns about the reliability and accuracy of these quantitative data. For example, service provider data were often reported as missing, coded inaccurately or inconsistently captured. This led to a sense that these service provider data could not always be trusted to inform decision-making, and qualitative data were needed to truly understand child mental health need and to ‘improve [commissioners] view of the accuracy of a numeric’ (C8):

[quantitative] data informs us maybe of some of the work that we need to do, and the areas in which we need to do that work. Then from there, and again, we wouldn’t do this in isolation, as an ICB, we do this with our colleagues, from services, to understand, okay, what is the need? And it may be that we need to do an engagement piece of work in that area. (C5)

The pressure on service providers to provide quantitative data was seen by one commissioner as having unintended consequences; encouraging service providers to chase referral numbers rather than provide quality support. Furthermore, concerns around the reliability, accuracy and novelty of quantitative data led some commissioners to ascribe little value to this type of data:

It’s an odd one, [name] because if you talk to people in health, they’ll say, ‘Everyone knows where the problems are. So why do we need more data to tell us? It’s got feathers like a duck and it quacks like a duck. It’s a duck. We know where we need to make the changes. We don’t need more data or more surveys or more.’ […] ‘I kind of know where the problem is, and I don’t have to have empirical data to help me with that.’ (C8)

There was a clear tension and variation between the use and value of quantitative versus qualitative data. Commissioners’ background and experience often influenced the type of data they used (eg, commissioners with a quantitative background talked about using and valuing quantitative data, whereas commissioners who were clinicians by background often ascribed greater value to initial hunches or conversations with service providers). As a result, this created a commissioning landscape in which there appeared to be no established way of using data and informants; with sources/type used varying, dependent on the individual commissioner.

Theme 4. Children’s mental health in the limelight: influences and expectations

This theme is about commissioners’ perceptions of changes in child mental health in their populations. Most commissioners discussed having seen a rise in demand for services, in terms of referrals and increasing time on waiting lists. Participants listed a range of areas where they felt there had been increases, including neurodevelopmental disorders, disordered eating, depression and anxiety, and self-harming. Many also perceived an increase in complexity and urgency of presentations. Commissioners made a clear link with the impact of the pandemic, but also emphasised that rises in demand were already happening pre-COVID:

I don’t want to pin it all on COVID because we were seeing an increase in demand before COVID. So it’s not as if everything was fine and then COVID, you know, just tipped us over. (C9)

Participants felt that social isolation and online education were key factors that had affected mental health and child development and contributed to school-based anxiety and avoidance. However, commissioners also voiced concern over the impact of other systemic social and economic influences which they felt were driving increases in problems, and which had been exacerbated by the pandemic:

I might be wrong, but I don’t think that there has been a biological shift in how children and young people’s mental health and emotional wellbeing works. I think that a lot of it’s from external factors. (C4)

Inequalities in access to help were also a concern:

I think the pandemic created a larger gap between those who needed help, or need help, and those who access it. I think that’s been disproportionate for certain children and young people, certain demographic profiles as well. (C4)

There was also much discussion of the effects of increased awareness and understanding around mental health, and the impact of social media and wider policy in putting mental health ‘in the limelight’. This was also seen as uncovering new needs and gaps which services then had to meet:

I would say that the demand has increased, that’s a fact because we’ve expanded services and still have issues with waiting times and more children needing support. But alongside the demand, because mental health has increasingly been in the limelight, I suppose, there’s been more attention to mental health, child, adolescent, mental health in the last five years. Perhaps this has uncovered needs and a prevalence that we weren’t aware of before. (C1)

Disordered eating and things like ARFID [Avoidant Restrictive Food Intake Disorder], seem to be something… sort of newly emerging conditions because we don’t have commissioning in place for them. And that’s not because it was a gap… well, it’s a gap now, but it’s a gap that seems to have emerged within recent times. When we, for example, were commissioning our specialist children’s mental health service, disordered eating and ARFID were not really discussed as being something that needed to be considered or perhaps disordered eating was looked at differently. (C2)

In terms of drivers of demand, commissioners also appeared to perceive some tensions between positive aspects of awareness and encouraging help seeking, and risks of ‘over-medicalising’ normal ‘ups and downs’ and expectations of mental health which might be unrealistic:

So there’s an awareness from children and young people that they know what good mental health looks like, and how they can promote it. But there’s also probably an expectation from that as well…I think a young person, after watching a video, or trying to learn some coping techniques, won’t necessarily see a change or an improvement straight away in the same way that, if you’ve got a headache, you have a paracetamol, and then an hour later you’re sorted… (C4)

Theme 5. Responding to need: "CAMHS as the answer to everything"

In addressing the needs of their populations, many commissioners felt that prevention and early intervention were key priorities within child and adolescent mental health. They discussed an increasing role for a broader range of agencies including the voluntary sector, social care and education, with several referencing the THRIVE model (a needs-led framework to help create communities of mental health and well-being support, with a focus on proactive prevention and promotion).21 Participants also cited a range of initiatives aimed at triaging referrals and expanding first-line support and emphasising the role of CAMHS as a specialist mental health service. However, for some commissioners, there were several significant challenges in moving the focus away from specialist child mental health services. For example, lack of capacity in other parts of the system such as schools and communities was seen as a limiting factor in prevention and management of less severe cases, resulting in bottlenecks and pressure on CAMHS:

I think there is a real-time reduction in staff time in schools over the past 15 years and that gets expressed in an increased in referral activity to where the lights are on. That’s the NHS. And free at the point of use. So there is a systemwide bottleneck and things just breaking down. (C13)

Additionally, commissioners perceived that both professionals and young people still had assumptions and expectations that CAMHS was the place for all child mental health concerns. These expectations complicated efforts to develop other pathways, with some early-support services being seen as underused as a result of a preference for CAMHS:

We get reports from services that they are under strain, but there are also parts of other services which are not utilised properly. And then we get feedback from children, ‘I don’t know what provision is available to me, and waiting times are too large.’ So my feeling is we’re still struggling to move the focus away from CAMHS being the answer to everything. (C1)

Some expressed frustration that this might mean CYP spent time on waiting lists when they could have accessed support more quickly elsewhere:

There’s still that mind-set of if someone expresses any concern about mental health, let’s refer them into CAMHS, and that’s where we see those waits because then they’re essentially on a waiting list for support that potentially they might not need and they could have got something a lot earlier. (C6)

Commissioners also reflected on future directions and challenges and what they expected to see coming down the line. One commissioner thought that funding would never be able to meet need for services:

The overarching difficulty is that the money that we’ve got is never going to be able to meet the full demand of need, so we have to think differently about who we support when. (C12)

Commissioners had varying degrees of optimism about whether investment in services and early intervention would happen, and whether CYP’s mental health would improve in future:

Our focus needs to be more on that preventative and early intervention. But that’s a massive culture change, so I think hopefully in that long period of time we will see those—I won’t say probably a reduction—but levelling off of demand. (C12)

I would say unless, coming back to the main point, we invest properly and proportionately in children’s services over the next five years, we’re going to be going backwards in terms of children and adolescent mental health. We’re not going to be going forwards. […] So it sounds pessimistic, but I think we’re going to have a worse situation in the next five years unless we drastically change. (C7)