Challenging The Way Things Work

by Dr. Sarah Maxwell MA (Oxon) MB BS MRCPsych, Consultant Child & Adolescent Psychiatrist, Norfolk and Suffolk Foundation Trust, Honorary Senior Lecturer UEA School of Medicine, Winston Churchill Fellow 2016 

I confess that I was asked to write a blog about our Youth service set up by the Norfolk and Suffolk NHS Foundation Trust (NSFT) a few months ago and that I have been avoiding it ever since! The idea of condensing anything about the Youth Service into 1000 words was just overwhelming.

So where to start – perhaps the beginning?


I started out as a Child and Adolescent Psychiatrist many years ago working in London and now in Norfolk. Over that time, I became aware of how difficult it could be for young people to access services. Often they had to tell their story many times in order to reach the right person. They were turned away or told they had to wait for too long before they could see anyone. If they got through to a service, they could only be seen at certain times or in certain places with limited if any choice about this.

It is not just my view as national surveys, policy recommendations, and studies repeatedly call for changes to the way mental health services are delivered to young people with emerging mental health difficulties (DoH, 2015; McGorry, Bates & Birchwood, 2013; Mental Health Foundation, 2014; Young Minds, 2014).

The other thing that troubled me was what happened to people once they got to 18 and had to move to an adult service. They had to be referred to a separate team with completely different staff and different ways of working. Often they did not get a service at all, or they were offered something that did not fit with what they wanted or felt they needed (Singh et al. 2010).

I was lucky enough to be given a CLAHRC (Collaboration for Leadership in Applied Health Research & Care) Fellowship and together with a colleague mapped out what services were available to young people with mental health problems in Norfolk.

This highlighted the complexity in what was available and how difficult it was for young people to navigate this. In addition, when we looked at the data collected by NSFT and compared referral rates with contacts (which we used as an estimate for how much time young people were being seen in services) it also illustrated the difficulty at transition for those needing a service beyond 18 and just how many within NSFT appeared to “fall off the cliff” (Report for CLAHRC, Dr Sarah Maxwell and Dr Uju Ugochukwu 2013).




About five years ago a group of people locally started to think about ways of challenging the assumption that this was just the way services are set up, and there was nothing to be done about it. From this, the idea that we could re-jig how we arranged ourselves so as to become more young-person-centred and to avoid the transition at 18 started to become a reality.

Where are we now?

The NSFT vision is to provide young people aged 14 to 25 with a service that enhances their mental and social well-being, which is flexible, welcoming and innovative in partnership with them and other agencies.


  • To be youth orientated and non-stigmatising.
  • To actively engage young people with complex mental health difficulties and those at highest risk of developing enduring mental health difficulties.
  • To be recovery focused and to maximise the potential of the young person.
  • To provide a range of interventions according to choice and need of the young person.
  • To ensure that the young person is linked to appropriate community resources.
  • To work in collaboration with other statutory and non-statutory agencies providing advice and/or consultation as appropriate.

To do this, we have completely reorganised our teams into the Norfolk Youth service requiring significant changes for lots of people in terms of where and how they work. We work with other local organisations and have a number of different treatment pathways within the service according to what individuals need regarding help or treatment.

Key to this is partnership with young people – involving them in the development and growth of the Youth service at every stage as well on an individual basis for their treatment. We work with service users in each area and actively seek feedback from young people and their experience of our service(s).

What Next?

Excitingly we were the first region in England to make such a radical change to how we work with young people. So we have had lots of people asking to come and visit us to hear how we made such a change and how it is going. These have included Politicians, Chief executives of other organisations, as well as other NHS services looking to make a difference. Myself and others have also been asked to talk about it all over the country which has been exciting and sometimes frankly scary!

However, this means that it is crucial that we work out whether the changes we have made have made things better for young people rather than simply moving the problem(s) elsewhere. To do that, we need to keep researching what we are doing. We have an active group within the service looking at research with the aim that we will keep asking the difficult questions to make sure we know what is working or not.

From my perspective, it has been an exciting time and helped me think about what I do and why rather than assuming we have to do things in a particular way because that is how we always have done things.

“Begin challenging your own assumptions. Your assumptions are your windows on the world. Scrub them off every once in while or the light won’t come in.”

Alan Alda


Suggested Reading

National Advisory Council (NAC) (2011). How many times do we have to tell you? A briefing from the National Advisory Council about what young people think about mental health and mental health services.

Plaistow, J., Masson, K., Koch, D., Wilson, J., Stark, R., Jones, P. & Lennox, B. (2014). Young people’s views of UK mental health services. Early Intervention in Psychiatry, 8, 12-23. doi: 10.1111/eip.12060

Social Care Institute of Excellence (SCIE). (2011). Mental health service transitions for young people – Accessible and easy to use mental health services: Welcoming, approachable and flexible services. (Guide 44)

Wilson, J., Lower, R., Ugochukwu, U., Maxwell, S., Clarke, T., Horne, R., Hodgekins, J., Wheeler, K., Goff, A., Mack, R., & Fowler, D. (2016). Creating an innovative youth mental health service in the UK: The Norfolk Youth Service. Submitted for publication.

About the Author

Blog photo

Dr. Sarah Maxwell is a Child and Adolescent Psychiatrist working in Norfolk primarily in the Youth service but also in Early Intervention, Eating Disorders and CAMHS teams. Sarah has been actively involved in the development of the Youth service in Norfolk as one of the Clinical Leads from the outset nearly five years ago. She remains involved in the development of this service as well as research around the Youth model and adolescent mental health.

Sarah was a Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Fellow in 2012 in the East of England. She worked with a colleague to look at service provision in Norfolk for young people with mental health problems between 14 and 25 years old. This work helped the subsequent development of the Norfolk Youth service.

Sarah is an Honorary Senior Lecturer at UEA where she teaches communication skills.

In addition, Sarah has been awarded a Winston Churchill travelling Fellowship in 2016 ( and plans to visit the HYPE service in Melbourne which is part of the internationally acclaimed ORYGEN service for young people. The aim is to start to think about specific services for young people with emerging personality disorders and how best to design and deliver this within the NHS.


NSFT logo (2)

This blog post is based on the opinions of the author and does not necessarily represent the views of the University of Oxford or the Oxford Department of Psychiatry.

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