Clinicians should complete this tool for children and young people in the getting more help/getting risk support quadrants of the Thrive framework, based on a young person’s current presentation.

To ensure the CNEST is up to date and reflective of the current presentation and level of risk, clinicians should review scores:

  •  At assessment.
  • When there is a change in presentation.
  • When there is a change in circumstances.
  • When there is a change to the formulation.
  • t regular or key intervals in the patient journey e.g. review of care plan and risk plan, transitions etc.

Young people in England can 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 (CYPMHS, also known as Child and Adolescent Mental Health Services, CAMHS).

These are community services, funded by local NHS Integrated Care Systems for young people who need extensive and specialist interventions for their 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 intensive community support or admission to a specialist children’s or young people’s mental health unit.  Tier 4 CAMHS services are commissioned by Lead Provider Collaboratives for young people (13-18) and NHS Specialized Commissioning for children (under 13). In Cheshire and Merseyside for young people 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 (GAU) is provided by Cheshire and Wirral Partnership NHS Foundation Trust in Ancora House in Chester in Northwest 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, a specialist community eating disorder service (CHEDS) and an intensive home support service, Ancora Care.  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 inpatient provision for young people from Cheshire and Merseyside (Psychiatric Intensive Care, Eating Disorders, Low Secure) is provided by the independent sector in hospitals in the Greater Manchester area and provision for young people with a Learning Disability is in Sheffield. 

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). 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 A) was developed in 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:

  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 who are at an increased likelihood of being admitted to Tier 4 or receiving inpatient mental health treatment.
  3. A stratification tool to provide an evidence-based way of identifying young people who have an increased risk of admission to Tier 4.

The principles of the Cheshire and Merseyside Tier 4 CAMHS New Care Model are:

  • 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 needs and challenges available to all involved.


Since the development of the Tier 4 CAMHS New Care Model there has been publication of the NHS Long Term Plan which outlines significant investment in mental health care and prioritises the delivery of community-based care (NHSE, 2019a).  Within Cheshire and Merseyside, there has also 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 children and young person complex needs escalation and support framework (Appendix B) and the stratification tool that was developed was called the Complex Needs Escalation of Support Tool (CNEST).

CNEST: The development of a needs stratification tool

The Complex Needs Escalation and Support Tool (CNEST), goes beyond its stratification role within the Complex Needs Escalation and Support Framework. It identifies unmet needs in children and young people (CYP), enabling individualised care. Stratifying based on complexity and level of need; it avoids a one-size-fits-all approach. CNEST efficiently facilitates the mobilisation of appropriate support to address diverse needs. Its multifaceted approach plays a vital role in mitigating hospital admissions, placement breakdown and averting custody situations.

Stage One

A review of the literature was conducted, to determine whether there were already any valid and reliable tools assess all young peoples’ who have an increased likelihood of a Tier 4 CAMHS admission. This review concluded that there were no current tools in use other than the CYP DSD-CST (CWP, 2019), which was developed specifically for young people with a diagnosis of Learning Disability and/or Autism. From the literature reviewed, risk factors were identified and documented using a Data Collection Tool.

A review of admissions data for all young people admitted to Ancora House (Tier 4 CAMHS General Adolescent Unit in Chester) after 1st March 2019 and discharged before 29th Feb 2020 (pre-Covid-19) and a thematic analysis of factors leading to admission were identified and documented. Focus groups were held to elicit the views and experience of qualified healthcare staff from Community CYPMH services; Early Intervention in Psychosis teams; Tier 4 inpatient wards; Tier 4 Assessment and Outreach teams; and Tier 4 Home Treatment teams across the three Cheshire and Wirral Partnership localities (Cheshire West, Cheshire East, and Wirral).

After collating the information from the three sources and reviewing the factors included in the CYP DSD-CST, a list of suggested factors was created and put into a draft tool format.

Stage Two

The second stage used a Delphi process to refine the tool. A Delphi process is used to arrive at a group opinion or decision by surveying a panel of experts (Hasson, Keeney & McKenna, 2000). Experts respond to several rounds of questionnaires, and the responses are aggregated and shared with the group after each round. 

The experts can adjust their answers each round, based on how they interpret the "group response" provided to them.  The ultimate result is meant to be a true consensus of what the group thinks. A final refinement of the factors and the scoring system was then completed by the research team.

Stage Three

Stage three involved gathering opinions of people with lived experience (young people, parents, and carers) around the individual factors in relation to what professionals need to consider when planning support for the young person. This was then used to further refine the tool and support the CNEST guidance.

Stage Four

Stage four was a pilot of the first version of the CNEST between July 2022– September 2022 across CYPMH services within Cheshire and Wirral Partnership NHS Foundation Trust. Information was gathered from clinicians in the form of anonymous questionnaires and focus groups about the clinical utility of the CNEST. This information was then used to make changes to the CNEST and associated guidance.

Stage Five

Stage Five was a pilot of the second version of the CNEST between October 2022– December 2022 in CYPMH services across Cheshire and Merseyside. This included Cheshire and Wirral Partnership NHS Foundation Trust (CWP), Mersey Care NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust. Information was gathered from clinicians in the form of anonymous questionnaires about the clinical utility of the CNEST. This information was then used to make final changes to the CNEST and associated guidance.

The CNEST has an initial screening question to identify young people who require a referral to Tier 4 due to the presence of a severe mental health difficulty that cannot be treated in the community. If the answer to this question is yes, then the rating is automatically high and the CNEST can continue to be completed for information about additional complexity and unmet need.

The CNEST consists of 18 factors. It is divided into two scored sections and one non-scored section for information only. Section A contains five clinical factors including those relating to mental health and risk to self and/or others. Section B contains four impacting factors that relate to the young person’s system and the ability of that system to keep the young person safe.  Section C contains nine additional vulnerability factors that are important to consider in developing a contextual understanding of need.

Clinicians should complete all sections of the tool and score sections A and B.  This will produce a Section A rating and a Section B rating of high, medium, or low level of need. The overall rating is obtained by using these two ratings in the CNEST rating matrix (Table 1) to give a final rating of high, medium, or low.  Section C is for information purposes only to facilitate formulation and discussion.

Table 1: CNEST Rating Matrix


Section B: Impacting Factors




Section A: Clinical Factors














Who is the CNEST for?

The question of who the CNEST can be used for can be considered in terms of the evidence base and clinical utility. We have grouped children and young people into three main categories:

  1. Those for whom the CNEST is evidence based and has good clinical utility.
  2. Those for whom more evidence is required but there is early indication of clinical utility.
  3. Those for whom further research and clinical utility data is required.


  • Dr Fiona Pender, Consultant Clinical Psychologist, Cheshire and Wirral Partnership NHS Foundation Trust
  • Dr Lesley Doyle, Consultant Clinical Psychologist, Cheshire and Wirral Partnership NHS Foundation Trust
  • Faye Bohen, Assistant Psychologist, Cheshire and Wirral Partnership NHS Foundation Trust
  • Clare Cooper, Advanced Nurse Practitioner, Cheshire and Wirral Partnership NHS Foundation Trust
  • Dr Karen Ryder, Clinical Psychologist, Cheshire and Wirral Partnership NHS Foundation Trust
  • Prof Sujeet Jaydeokar, Consultant Psychiatrist, Cheshire and Wirral Partnership NHS Foundation Trust and Visiting Professor, University of Chester



  • Young people accessing support from Ancora House (Tier 4 CAMHS Services)
  • Parents and Carers of young people who have previously accessed support from Ancora House
  • Health and Social Care Professionals across Cheshire and Merseyside
  • Carla Brown-Ojeda, Assistant Psychologist, Cheshire and Wirral Partnership NHS Foundation Trust
  • Dr Anjan Mandara, Consultant Child and Adolescent Psychiatrist, Cheshire and Wirral Partnership



The Complex Needs Escalation and Support Tool (CNEST) builds on learning from the Child and Young Person Dynamic Support Database Clinical Support Tool (CYP DSD-CST; CWP, 2019) and the Decision Support Tool for Physical Health (DST-PH; Acton et al., in press). We would like to acknowledge the invaluable work and support from the DSD-CST team of contributors and authors. The authors would also like to acknowledge the input from young people, families and colleagues who have co-designed this tool.