A postcode lottery in a mental health system ‘full of holes’
Working in a CAMHS hospital liaison team means meeting young people in A&E at their most vulnerable – terrified, exhausted, overwhelmed, and often unsure whether they can keep themselves safe.
Yet behind every urgent assessment lies another reality: discharge decisions that are shaped not only by clinical need, but by gaps in the system that make safe, ethical social work practice extraordinarily difficult.
The reality of hospital discharge
Every young person I assess is technically a ‘discharge pathway’, a ‘risk rating’, or a ‘follow-up plan’ on someone’s desk.
But when you sit with them the child who is shaking, exhausted, dissociating, and still somehow apologising for being in crisis is anything but a statistic.
They are frightened teenagers, traumatised children, and young people carrying burdens far too heavy for their age.
As social workers, we hold the uncomfortable truth that even when hospital is not the safest place for them to stay, home – or wherever they are placed – may be far from ideal.
The reality of discharge planning is a negotiation between immediate risk, psychological vulnerability, placement stability, and what support actually exists beyond the hospital doors.
Working in a liaison role exposes stark disparity. A young person with the same level of distress may receive entirely different follow-up solely based on their postcode.
Where crisis teams exist, hospital staff can discharge with confidence that daily support will hold the young person through the worst of their distress.
Where no crisis provision exists, the same young person is discharged to overstretched families, inconsistent services, or temporary placements, despite needing the same level of care.
These young people are not refusing to cope; they are surviving complex trauma, poverty, family breakdown, neurodiversity, discrimination, and a system that cannot respond quickly enough.
Their lives are shaped by instability, and they deserve more than a brief safety plan and a promise that CAMHS will “pick up next week”.
It demands a system that recognises that crisis care cannot depend on geography.
Until then, hospital liaison social workers will continue doing what we do best, holding the humanity of each young person in front of us, even when the system struggles to see past the statistics.
‘Crisis does not wait for Monday’
Weekends in CAMHS liaison are unpredictable. Some shifts bring no referrals at all. Other are relentless.
And then there are weekends like this: just one young person, but she takes the entire day. Not because she was ‘difficult’, but because the system she needed was closed.
She came in with high risk, openly describing near-attempts, intrusive thoughts that she felt she might act on, and a level of intent that made my stomach tighten. She asked for admission. She was frightened and exhausted.
But her presentation made admission clinically inappropriate. A noisy, unpredictable, trauma-triggering ward would not have contained her risk; it would have intensified it.
This is the contradiction outsiders rarely understand: risk can be high, but admission can still be harmful/inappropriate.
What she really needed was intensive crisis support, the kind that comes to the home daily, checks in, builds safety, holds her through the worst moments. If she lived in the ‘right’ postcode (ten minutes down the road), she would have automatically received that.
But she lives in a postcode where no crisis pathway exists for children, and where everything that might have helped her is locked behind Monday morning.
So instead I spent the day calling everyone who was available which, on a weekend, is skeleton staff across every service. The duty social worker covering the entire county could only offer a brief check-in the next day.
CAMHS managers were available for clinical discussion but could not activate a crisis team that does not exist. The home treatment team were willing to help, but only once CAMHS formally referred, which could not happen until the weekday.
In the end, the only safe option, the only possible option, was discharge with tight supervision from her family. A safety plan held together by family vigilance, restricted means, and a promise that if things escalated she could return to A&E.
People imagine weekend liaison work is quieter. They imagine one case means an easier shift. The truth is the opposite. Sometimes one case is the entire shift because the real work is not the assessment.
The real work is trying to build a net in a system full of hole and where crisis does not wait for Monday.
Tatenda Muskwe is vice-chair of the BASW England Social Work in Health Group