CAMHS progress questioned amid lack of standardisation across Scottish health boards

Earlier this month, in the programme for government, John Swinney told Holyrood that Scotland had met its target to bring down children and adolescent mental health waiting times. Over 90 per cent of young people were starting treatment within 18 weeks of their referral – the first time this has happened since the standard was set in 2014. 

While, on the face of it, this is good news  – something which has been lacking in the mental health sector of late – there was little else to be excited about over the next 12 months for those working in the sector. There was barely any mention of how mental health services will be improved, despite the clear message that improving the NHS is the government’s chief ambition ahead of the Scottish Parliament election next May. 

For years clinicians and third sector organisations have warned that services are overstretched as demand for mental health services have increased sharply. 

As of March last year, figures show that the number of general psychiatrists in full-time equivalent posts remained at 804, unchanged from a decade earlier, while the third sector is at breaking point due to shrinking funding and increased National Insurance contributions.  

Figures from the 2022 Scottish census show that 617,000 people, that’s more than one in ten Scots, have a mental health condition – up from 4.4 per cent of the population in 2011. And in the three years between 2019 and 2022, calls to NHS24 regarding mental health have increased by 580 per cent. As of December 2024, 145 children and young people had been waiting over a year to begin mental health treatment, while the overall number waiting to start treatment was over 4,300 – up three per cent on the previous quarter.  

The figures paint a bleak picture, and Billy Watson, the chief executive of SAMH, Scotland’s national mental health charity, says that since the pandemic the “demand has been unprecedented” and the system “is now in crisis”.  

“[The figures] are a population behaviour change. During the pandemic, there were hundreds of millions of pounds being spent on social marketing for public health aimed at getting people to pay attention to their mental wellbeing. 

“We’ve seen a population shift towards a system that already couldn’t cope, that was already failing almost all of its targets. We have seen a seven-fold increase in demands in some areas of the system. My concern is that I don’t think politicians and government are seeing the enormity of that.”  

Stephen Lawrie, chair of psychiatry and neuroimaging at the University of Edinburgh, argues the swelling demand for services is down to multiple influences. Like Watson, he says people have become “more likely to consult and look for help” as the stigma around issues like anxiety and depression has decreased. 

“From a historical context, I think we are all still suffering from the 2008 banking crisis and years of austerity under the Conservative government,” he says. “And of course, the pandemic had an impact, both on people, who are less socially active than before, and on services, which have been decimated and haven’t really recovered.” 

Lawrie and Watson speak of a fundamental change to Scotland’s mental health services, highlighting that the Scottish Government’s current mental health strategy, which has been underway for eight years and was billed as a transformative plan to shift mental health care in Scotland toward early intervention, prevention, and parity with physical health, has not been effective enough.  

Lawrie says that most of the spending on mental health is on the most severely ill, which he believes is the correct approach. “However, most of the strategy is focused on the much more common problems with anxiety and depression.  

“Take mental health first aid, which is a preventative intervention that the Scottish Government advocated for in the strategy. There is no evidence for it being a relevant measure. It’s really bad and is a classic example of how mental health is more prone to fads and fashions than the rest of health.” 

Nearly a decade on from when it was launched in 2017, there have been only pockets of progress. Meeting the CAMHS (Children and Adolescent Mental Health Services) waiting target that Swinney mentioned in his PfG is one of those pockets and it has been something the first minister has been keen to reiterate over the last eight weeks. However, it may not be the victory the Scottish Government is claiming it to be. Earlier this month, Scottish Labour leader Anas Sarwar accused Swinney’s government of “fudging the numbers” during first minister’s questions.  

He told the chamber: “Some health boards are now counting an initial assessment as treatment when in fact young people may still be waiting for months or years for their actual treatment to start, and now they are removing autism and ADHD diagnoses from CAMHS waiting lists. 
“The SNP are fiddling the figures.” 

Holyrood asked the 14 territorial health boards if they defined an initial assessment as the beginning of treatment. Every board except NHS Dumfries and Galloway replied.  

Six health boards – Lanarkshire, Ayrshire and Arran, Fife, Borders, Tayside and Orkney – confirmed they determine the start of treatment as the initial assessment. Only two boards, Lothian and Highland, do not treat the initial assessment as the beginning of treatment.  

NHS Lothian explicitly stated that treatment only starts once active therapeutic intervention begins, not at assessment, while NHS Highland said it has a structured “engagement appointment” system and non-urgent patients do not start treatment at assessment; they remain on the waitlist until treatment starts. 

Some health boards do it differently. NHS Grampian said the beginning of treatment is left to a clinician’s discretion and treatment may start at the first or second appointment.  

NHS Western Isles says treatment starts when there’s goal-setting, psychoeducation, or a diagnosis requiring further intervention. NHS Shetland operates an “assess to treat” model and said there is currently no gap between assessment and treatment unless specialist services are needed. 

NHS Forth Valley and NHS Greater Glasgow and Clyde did not offer a direct answer as to whether treatment begins at the initial assessment, the latter adding it “complies with national guidance”. According to Public Health Scotland, the definition of treatment is either the start of a planned programme of intervention, the start of a coordinated treatment plan, a consultation when an intervention plan is agreed upon, or the start of a condition-specific multidisciplinary assessment for a specific developmental disorder. 

It is clear there is a lack of standardisation across boards, and it suggests that the 90 per cent referral-to-treatment target may not reflect the reality of access to therapeutic interventions. It echoes the reaction of the chair of the Royal College of Psychiatrists in Scotland’s CAMHS faculty, Dr Kandarp Joshi, who said in March: “Alarmingly, waiting times may be even higher because the Scottish Government doesn’t report on the wait after a young person’s first assessment. They also don’t take into account the waiting times for neurodevelopmental conditions such as autism or ADHD – which are also on the rise. 

“Working on the frontline, we see a postcode lottery of specialist mental health services across the country, but our vulnerable children and young people deserve so much better than this.” 

Access to mental health services is something that Professor Martyn Pickersgill, who holds a personal chair in the Sociology of Science and Medicine at the University of Edinburgh, has been researching for years. He says that there are three key elements that “configure psychological practice” and which exert increasing pressure on services. They are waiting time targets, referral criteria, and did not attend (DNA) policies.   

“Those three things are all connected and speak to a broader ethic of access. But they can act as what medical sociologists call a form of ‘exclusionary inclusion’. They allow people to come in but then referral criteria or service specifications for instance may be so tight that a person could be screened out even though everyone might agree that they need some kind of therapy. 

“DNA policies can sometimes be a version of ‘three strikes and you’re out’, and it’s not always clear that policies are developed by clinicians themselves in response to the question of ‘what policy is right for this service and the people who are likely to access it?’ I’ve had psychologists tell me that there can be pressure to make decisions more on administrative than clinical grounds.” 

With the system so overstretched and underfunded compared with other areas of health, and access to clinical treatment hampered by waiting times and administrative requirements, there is a feeling that reform is inevitable if the service is to meet the demand.

Watson describes the need for “radical reform”. “The first minister speaks about reform [of the health service], but never mentions mental health,” he says.  

“I’ve heard the minister for mental health talk about parity of esteem for mental health with physical health. It’s a parity of action that we need, and a parity of spend. They can talk about how the mental health budget has risen, but on a like-for-like basis it hasn’t – it’s gone backwards.  

“Reform has to start with money and then we need to look at the system. Thresholds of illness are getting higher to get treatment. There has to be an earlier intervention that people can ask for once and get help fast and doesn’t medicalise a lot of what is emotional as well as mental health. We need reform at the lower end of the spectrum, based in communities, not so much in the health service. There has to be greater investment predominantly in the third sector and other community provisions.”