Four tier framework

The framework works as a basis for planning, commissioning and delivering services. Despite differences in delivery and application across the country, it has created a common language for describing and commissioning services. 

It is important to remember that neither services nor people fit neatly into a specific tier. For example, many practitioners work in both Tier 2 and Tier 3 services. 

There is often a misconception that a child or young person will move up through the tiers as and when their condition is recognised as more complex. In reality, some children and young people require services from a number of the tiers at the same time. 

The tiers are not a model to be applied rigidly, but rather as a framework for ensuring commissioning and availability of a wide, comprehensive range of services which can meet all the mental health needs of children and young people in an area, with clear referral routes signposted between tiers. 

Tier 1

Services at this level are provided by practitioners who are not mental health specialists working in universal services; this includes GPs, health visitors, school nurses, teachers, social workers, youth justice workers and voluntary agencies. 

Practitioners will be able to offer general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development, and refer to more specialist services. 

Tier 2

Practitioners at this level tend to be CAMHS specialists working in community and primary care settings in a uni-disciplinary way (although many will also work as part of Tier 3 services). 

For example, this can include primary mental health workers, psychologists and counsellors working in GP practices, paediatric clinics, schools and youth services. 

Practitioners offer consultation to families and other practitioners, outreach to identify severe or complex needs which require more specialist interventions, assessment (which may lead to treatment at a different tier), and training to practitioners at Tier 1. 

Tier 3

This is usually a multi-disciplinary team or service working in a community mental health clinic or child psychiatry outpatient service, providing a specialised service for children and young people with more severe, complex, and persistent disorders. 

Team members are likely to include child and adolescent psychiatrists, social workers, clinical psychologists, community psychiatric nurses, child psychotherapists, occupational therapists, art, music and drama therapists. 

Tier 4

These are essential tertiary level services for children and young people with the most serious problems, such as day units, highly specialised outpatient teams and in-patient units. These can include secure forensic adolescent units, eating disorder units, specialist neuro-psychiatric teams, and other specialist teams (e.g. for children who have been sexually abused), usually serving more than one district or region.