Young people in England access NHS mental health support via referral from their General Practitioner, School or self-referral to an NHS Children and Young People’s Mental Health Service (CYP MHS, also known as Child and Adolescent Mental Health Services, CAMHS).

These are community services, funded by local NHS Integrated Care Systems for young people with moderate-severe mental health needs. If the young person’s needs are particularly complex or severe, it might be considered that specialist support from Tier 4 CAMHS is required which usually means admission to a specialist children or adolescent mental health unit.  Tier 4 CAMHS services are commissioned by Lead Provider Collaboratives. In Cheshire and Merseyside this is the Level Up Provider Collaborative, led by Cheshire and Wirral Partnership NHS Foundation Trust.

Access to a Tier 4 CAMHS service is usually via a community CYPMH team referral but may also be through a young person presenting in mental health crisis at an Emergency Department where the assessing clinician makes a referral. Young people may be admitted on an ‘informal’ basis when they have given consent to spend time in hospital for assessment and treatment or they may be admitted under the Mental Health Act (1983) where they are detained in hospital without their consent.

In Cheshire and Merseyside, the Tier 4 CAMHS General Adolescent Unit is provided by Cheshire and Wirral Partnership NHS Foundation Trust in Ancora House in Chester in North West England. It is a 26 bedded unit based across two wards. The service also has an Assessment and Outreach Team that provides a gatekeeping function and a specialist community Eating Disorder service (CHEDS). 

The service covers the population of young people aged 13-17 registered with a General Practitioner in Cheshire and Merseyside.  Young people from other areas in England or other devolved nations may also be admitted if there is capacity in Ancora House and where bed capacity elsewhere in the UK is limited.

More specialist Tier 4 CAMHS provision for young people from Cheshire and Merseyside (Psychiatric Intensive Care, Eating Disorders, Low Secure) is provided by the Independent sector in units in the Greater Manchester area and provision for young People with a Learning Disability is provided for in Sheffield.  All Tier 4 CAMHS units are funded by the Lead Provider Collaborative, Level Up.  See Appendix A for more information about Tier 4 CAMHS.

For some children and young people, admission to Tier 4 CAMHS is necessary and helpful, however for others admission it is neither necessary nor helpful and comes at a cost (Cotgrove & Northover, 2021). In 2017, the Cheshire and Merseyside Health and Care Partnership Mental Health Programme Board prioritised the development of a new model of care for the delivery of Tier 4 CAMHS in line with the national direction of travel towards the Five Year Forward View (NHSE, 2016) and the NHS Long Term Plan (NHSE, 2019a). 

The focus of the service change was to improve outcomes for young people through reducing avoidable admissions, enabling shorter lengths of stay and ending out of area placements.

A clinically led, co-produced Tier 4 CAMHS New Care Model (Appendix B) was developed by 2019 with stakeholders across Cheshire and Merseyside including young people and families using an Appreciative Inquiry approach (Cooperrider, Whitney & Stavros, 2008).  The stakeholder group designed three main elements to the Cheshire and Merseyside New Care Model are:

  1. Ancora Care: A Tier 4 CAMHS intensive home treatment service for young people as an alternative to inpatient admission.
  2. A multiagency Gateway meeting to be held in each Local Authority footprint to ensure that all agencies take responsibility for meeting the needs of young people at risk of admission to Tier 4 or receiving inpatient mental health treatment.
  3. A complex needs stratification tool to provide an evidence-based way of identifying young people for whom admission is likely without support (the CNEST –, Appendix C).

  • Whole family approach to care that meets individual need close to home and, in the community, where possible and appropriate.
  • Person-centred approach - young people and their family’s needs, views and wishes are of paramount importance.
  • Seamless care pathways with shared/multi-agency ownership, coordination, commitment and accountability to meet needs safely.
  • Clear, unambiguous, open and seamless inter-agency communication, shared language and information sharing with clear roles and responsibilities of all professionals and family members in care planning and delivery of care.
  • Standardised, equitable consistent approach across Cheshire and Merseyside providing the right care, at the right time, in the right place, by the right professional.
  • Resilient, flexible, skilled and resilient workforce with mutual respect and support across disciplines.
  • Formulated understanding of risk and challenges available to all involved.


Since the development of the Tier 4 CAMHS New Care Model there has been a widening of focus to young people with complex needs, supporting young people to remain in their communities and avoid going into care, custody, or hospital. This is called the Cheshire and Merseyside CYP complex needs escalation and support framework (Appendix D).