an appointment longer than the 18 weeks target, and in Glasgow the average waiting time was 26 weeks. 131 new CAMHS beds were commissioned by NHS England in 2018, increasing the existing 1,440 bed base by more than 10%. 56 will be in London, 12 at Bodmin Hospital and 22 at St Mary’s Hospital in Leeds. Service framework In the UK CAMHS are organised around a four tier system: Tier 1 general advice and treatment for less severe problems by non-mental health specialists working in general services, such as GPs, school nurses, social workers, and voluntary agencies. Tier 2 usually CAMHS specialists working in community and primary care, such as mental health workers and counsellors working in clinics, schools and youth services. Tier 3 usually a multi-disciplinary team or service working in a community mental health clinic providing a specialised service for more severe disorders, with team members including psychiatrists, social workers, board certified behaviour analysts, clinical psychologists, psychotherapists and other therapists. Tier 4 highly specialist services for children and young people with serious problems, such as day units, specialised outpatient teams and in-patient units. Specialist CAMHS – Tiers 3 and 4 Generally patients cannot self-refer to Tier 3 or 4 services, which are sometimes called specialist CAMHS. Referrals can be made by a wide range of agencies and professionals, including GPs and school nurses. The aim is to have a team led by a consultant psychiatrist, although other models exist and there is limited evidence of what system works best. It is suggested that there should be a consultant psychiatrist for a total population of 75,000, although in most of the UK this standard is not met. The Tier 4 service includes hospital care, with about 1,450 hospital beds provided in England for adolescents aged 13 to 18. Typical conditions that sometime require hospital care include depression, psychoses, eating disorders and severe anxiety disorders. The service may, depending on locality, include: Art therapy Child psychiatry Clinical psychology Drama therapy Educational psychology Family therapy Music therapy Occupational therapy Play therapy Psychiatric nursing Social worker interface Speech therapy Child psychotherapy Forensic CAMHS, working with young offenders or those at risk of offending Performance As of December 2016, some young English people with eating disorders were being sent hundreds of miles away to Scotland because the services they required were not available locally. Not withstanding good care in Scotland it was said