Camden: inspiring transitional care for young people

Camden has developed Minding the Gap, delivered by a partnership between the council, the CCG and the voluntary sector, to improve the mental health of young people aged 16-24.

In particular, the project aims to improve the experience and outcomes of transition between CAMHS and AMHS to avoid what is often referred to as a ‘cliff edge’ for young people at age 18. The service has been fully co-designed with young people and stands as a good of mental health provision.

View Minding the Gap's presentation slides

The challenge

The service was decided to be developed in 2014, in response to the tragic suicide of a 19-year-old young man, while he was in the waiting list to access AMHS. A strategic review of mental health provision was carried out, which highlighted significant failings in the way Camden provided support for vulnerable young people with mental health needs, and in particular a lack of integration amongst mental health services working with vulnerable young adults. The recommendations from this review, as well as extensive consultation with young people, led to the creation of Minding the Gap in 2015. ‘Since its launch it has received significant national attention and it is one of Camden’s flagship projects for mental health provision’, says Marta Calonge-Contreras, Strategic Commissioning Manager. The service is funded jointly by Camden Council and North Central London CCG.

The solution

Minding the Gap has invested in transitional care for young people with the following services:

A transitions champion post, in which a dedicated clinical psychologist based in AMHS supports young people throughout their transition into adult services, co-produces a holistic care plan with the young person before they turn 18 and helps them navigate and access services.

A transition protocol starting at the age of 17. It defines timeframes for referral into adult services, period of shared care and flexible ways of working between the services. Young people familiarise themselves with the transition process and the change of services; for example, they are given the opportunity to visit AMHS and meet their staff before the transition has been completed. The protocol was co-created by professionals and young people.

A bi-weekly transitions meeting, which acts as a consultation forum open to professionals seeking advice on care pathways for young people with complex needs and/or who may be at risk of disengaging with services. The meeting is attended by senior representatives from CAMHS, AMHS, social care, substance misuse services and voluntary sector providers. A lead agency for the young person is decided based on the closest fit between the young person’s needs and local service provision.

The Hive, which is an integrated, innovative youth hub. It was co-created with young people and in response to their feedback about the need for a more welcoming and non-stigmatising setting for mental health services. The strength and uniqueness of the service is in the holistic, integrated and wide-ranging offer to young people (aged 16-24) under just one roof: from individual interventions to social and wellbeing activities and education workshops. Provided by a consortium led by Catch-22, a voluntary sector organisation, the Hive has CAMHS and AMHS workers seconded from local NHS Trusts working side by side based on a needs-led model. Unlike in a traditional mental health service, particularly adult mental health service provision, there is no pre-determined intervention, and the workers have the flexibility to be creative in terms of how they support young people.

Additional Counselling and Psychotherapy for young people aged 16-24, provided by the Brandon Centre (a VCS organisation), for young people with low to moderate-level mental health need, who do not meet the threshold for AMHS services. Young people can self-refer to the service, but the Brandon Centre also accepts referrals from a range of sources. For example, AMHS usually have long waiting lists, and both the Hive and the Brandon Centre can support young people during the waiting period to access AMHS.

The impact

‘The project has shown an improvement in outcomes for young people accessing these services, as well as an improvement in the rates of successful transition into AMHS in Camden’, says Marta Calonge-Contreras reflecting on a recent evaluation of Minding the Gap. And she continues: ‘The partnership between the council, the NHS and voluntary sector organisations has been key to the success of the project. Having NHS workers seconded into the Hive makes the service clinically safe, while the voluntary sector brings a wealth of knowledge and expertise in the delivery of community services. It also makes the service much more cost-effective’.

I think one of the most important aspects of Minding the Gap is that it brought in the different expertise from a wide range of partners and input from Camden young people"

– Marta Calonge-Contreras (London Borough of Camden)

How is the new approach being sustained?

Minding the Gap is delivered by a consortium of providers including Camden Council, NLC CCG, Catch-22, the Brandon Centre, the Tavistock and Portman NHS Trust (Camden’s CAMHS provider), and Camden and Islington NHS Trust (Camden’s AMHS provider). There is a Partnership Board which meets quarterly to monitor and discuss service delivery and development. There is also a Young People’s Board which feeds into service delivery and development at the Hive. This means young people are continuously involved in decision-making around service development. The Camden RISE website is where information and details about the available support and services are being hosted, so that they are accessible to as many young people as possible.

Lessons learned

Integrated commissioning, where the voluntary sector, NHS partners and the council come together, is crucial in the delivery of community mental health services. So is prioritising early intervention and prevention, as well as involving young people at all stages of the project design and delivery. The Minding the Gap model has been an inspiration for other councils to plan for the implementation of similar projects. Other councils have been visiting the Hive to get ideas for the development of their own 0-25 mental health services.


Marta Calonge Contreras - [email protected]

Strategic Commissioning Manager (Children and Families), London Borough of Camden