Under 5s Meeting. Facilitated by Duncan Law, David Levy, Camilla Rosan, Linda Pae

Transcription

1 Under 5s Meeting Facilitated by Duncan Law, David Levy, Camilla Rosan, Linda Pae

2 Introductions Duncan Law

3 Agenda Introductions Launch of Infant Mental Health (0-5s) curriculum Summary of Early Intervention Foundation review Transformation and Peri-natal services Lunch Update on use of measures Workshop topics TBC. Could include: Consensus on recommended measures Transforming 0-5s services Integrating the system

4 Launch of Under 5 s CYP IAPT curriculum Camilla Rosan

5 Children and Young People s Improving Access to Psychological Therapies Programme National Curriculum for 0 5s

6 Who am I? Dr Camilla Lead, International Training School of Infancy and the Early Years/ 0-5s CYP IAPT for LDNSE Perinatal and Infant Clinical Psychologist

7 The training structure 7

8 Training structure January 2017 start 2 years part time programme Trainee in teaching 1 day/week Trainee has protected clinical time 1 day/week Core skills and 0-5s curriculum a integrated throughout 2 years Trainees finish training with a 120-credit postgraduate diploma accredited from UCL

9 The curriculum 9

10 Core skills module (60 credits) Structure Integrated throughout two year programme Adapted to be infant mental health specific Content: Engagement Assessment Formulation Outcome measures Therapeutic alliance NICE guidance Working with diversity Assessment: Assessment will include case studies, whole session recording, oral presentation and reflective analyses. Location: Anna Freud centre 10

11 0-5s module (60 credits) Clinical presentations 1. conduct problems (e.g. excessive crying, persistent defiance, screaming, tantrums, whining, hitting out, destroying their toys and objects around them); 2. regulatory difficulties (e.g. sleep, persistent crying, feeding and toileting difficulties); and 3. social and emotional difficulties (e.g., separation anxiety, specific fears, and stressor related adjustment.) 4. (Pre)-attachment problems 11

12 0-5s module (60 credits) Structure/content 3 submodules 1.Fundamental Principles 0-5 s an overview of the relational and ecological developmental context of the infant in terms of the factors that promote normal development and contribute to atypical development. knowledge and skills to undertake assessment, engagement and formulation in terms of working with families with children in the 0 5 age range. 2.Interventions to Support Attachment using Video Feedback Techniques Videofeedback for Positive Parenting (and sensitive discipline) 3.Interventions for Existing Diagnosable Problems in Children Aged 1.5 to 5 Years Incredible Years for Toddler/Preschool and individual parent training Assessment: 3 case reports, clinical log and whole tapes of ViPP, individual parenting and group parenting sessions with accompanying reflective 12 analyses.

13 Caseloads ViPP Minimum of 4 completed cases (seen across 6 sessions or more from start to completion or termination). At least one of these cases must be with a family with an infant under 18 months. Parent training Group programme: Able to run one (Incredible Years) group of at least 14 sessions, with another therapist. Individual Parenting Cases: These are likely to be families where additional sessions are offered to parents attending the parent group. You will need to complete a minimum of 3 cases and 1 case should be at least 6 sessions in duration. 13

14 14 ViPP

15 ViPP-SD Video Feedback Intervention to promote Positive Parenting (Juffer, Bakermans- Kranenburg, van IJzendoorn, et al.) Adapted to include Sensitive Discipline methods (Mesman et al., 2008) 6 home visits Manualised Home based Strengths-based Underpinned by attachment and coercion theory Includes psychoeducation on child development

16 Clinical Methods

17 ViPP Methods: Seeing the child s perspective

18 Sensitive Discipline Explanations: helping children learn about rules and reasons Compliments & praise: reinforcing positive behaviours, ignoring negative behaviours Distraction: helping children manage difficult situations with distractions & fun Delay: Explaining a child can play with something later Understanding/ empathy: vocalising & showing affection Sensitive time out: to calm a situation down

19 Adaptations

20 20 Incredible Years

21 Structure Co-facilitated in a group Toddler (1-3 year olds) 13 weekly sessions Pre-school (3 6 year olds) weekly sessions

22 Content Parents learn strategies for interacting and communicating positively with their child, promoting optimal social and emotional development and discouraging unwanted child behaviour. Discussions take place around video vignettes, problem solving exercises and structured practice activities addressing parents personal goals for themselves and their children.

23 Evidence 14 RCTs 3 in UK. The 10-year follow-up study observed reduced antisocial behaviour and improved reading ability amongst IY children in comparison to those whose parents who did not receive the intervention. The study also observed higher levels of warmth and supervision amongst IY parents. Hutchings, J., Bywater, T., Daley, D., Gardner, F., Whitaker, C., Jones, K., Eames, C., and Edwards, R.T., (2007). Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial. BMJ, 334, Scott, S., Spender, Q., Doolan, M., Jacobs, B., and Aspland, H. (2001). Multicentre controlled trial of parenting groups for childhood antisocial behaviour in clinical practice. BMJ, 323, 1 7. Gardner, F., Burton, J., and Klimes, I. (2006). Randomised controlled trial of a parenting intervention in the voluntary sector for reducing child conduct problems: outcomes and mechanisms of change. Journal of Consulting and Clinical Psychology, 47, Scott, S., Briskman, J., & O Connor, T. G. (2014). Early prevention of antisocial personality: longterm follow-up of two randomized controlled trials comparing indicated and selective approaches. American Journal of Psychiatry, 171(6),

24 How will we measure outcomes? 24

25 0-5 outcome measures Parental mental health Kessler-10 Child behaviour Infant behaviour questionnaire-short form (0-18 months) SDQ (18 months +) Parent-infant relationships NICHD sensitivity scales Global functioning PIR-GAS Family context SCORE-15 Co-parenting/couple relationship quality Relationship quality index 25

26 Who might be suitable to apply? 26

27 Entry requirements 1. A training in a mental-health related profession (e.g. psychology, nursing, health visiting; social-work, occupational therapy, speech and language therapy, special needs teaching, psychiatry, other psychotherapy, counselling). 2. Two year s experience of working within a professional setting concerned with the mental health, development and wellbeing of children and young people or families. 3. Some experience of delivering clinical work with families. 27

28 Service provision Backfill post Backfill funding over 2 years is 30K, or 15k per year. Agreement from service & line manager to be released for 2 days per week throughout the year Established local care pathway to receive referrals for 0-5s 2 days per week applies during both term time and vacation time. During this time the student will not be able to work on non- IAPT caseload. The 2 days includes time working on CYP IAPT caseload, attending university and studying / working on assignments. The service the student works in must have a history of receiving infant mental health referrals for children and infants under 5 so that an appropriate caseload can be accessed. Two students Two practitioners are required to deliver Incredible Years groups. available to complete training per service Arrangement of Infant Mental Health Supervisor Named site supervisor with experience and/or training in evidence-based approaches to working with children under 5 and their families and must have at least 1 year supervisory experience. This supervision should entail 1 hour of individual supervision or 2 hours of group supervision per week. This supervision will be part of the student s learning support and should be in addition to caseload management. 28

29 Reflections and questions

30 Collaborative Website cypiapt.wordpress.com

31 Module Lead Post annafreud.org/vacancies/

32 Summary of Early Intervention Foundation review Camilla Rosan & David Levy

33 + DR CAMILLA ROSAN & DR DAVID LEVY What works to support parent-child interactions in the early years

34 What Works Network 34

35 + Encouraging sensible commissioning

36 EIF s Evidence Quality Indicator 36

37 Developing evidence

38 FOUNDATIONS FOR LIFE: WHAT WORKS TO SUPPORT PARENT + CHILD INTERACTION IN THE EARLY YEARS July 2016

39 + What was included? 39

40 + Inclusion/exclusion criteria Programmes that: Were either currently being used in the UK, or relevant to the UK context Targeted improved child outcomes in one of three domains: Attachment Behaviour Inclusion (Early cognitive and language development) Worked with families where there was an index child between conception and aged 5 Were Universal, Targeted-Selective (i.e. families with risk characteristics include economic hardship, single parenthood, young parents and/or ethnic minorities, Targeted-Indicated (i.e. families with a child or parent with a pre-identified issue or diagnosed problem requiring more intensive support), and Specialist. Programmes that: Exclusion Were judged as a multi-component system or initiative, such as Sure Start or Head Start Targeted children at the edge of care Were identified as practices rather than specific programme models

41 + So what worked? 41

42 + Quality of evidence 75 programmes reviewed Level 3 or 4-17 programmes Level 2 18 programmes Not level 2 35 programmes No effect 5 programmes

43 + What programmes came out well? Three domains: Attachment Behaviour (Early cognitive and language development) Any suggestions which programmes did well?

44 + A closer look at the highest rated programmes Attachment Child-parent psychotherapy Infant-parent psychotherapy Family Foundations FNP Child First Empowering parenting, empowering communities Family Check-up Helping the non-compliant child Hitkashurut Behaviour Incredible Years Preschool ParentCorps The New Forest Parenting Programme Triple P

45 + Attachment programmes Defined as those that improve children s attachment security or attachment related behaviours (??). Attachment was hard to measure and can change through childhood. Programmes can find it difficult to demonstrate impact. Four out of the five evidence based attachment programmes were relatively high cost, involving frequent contact with vulnerable families for a period of a year or longer.

46 + Programmes aiming to improve behaviour Behaviour programmes had the best developed evidence of effectiveness relatively low cost often based on group activity Short dosage Best evidence involved families with a noncompliant child aged two or older. When well targeted, these programmes can keep problems from becoming worse and improve the parent child relationship. Less evidence for the effectiveness of programmes that aim to prevent problems emerging in the first place.

47 + What didn t work? 47

48 + Which programmes received a rating of NE not effective? Maternal Early Childhood Sustained Home-visiting (MECSH) Social Baby Approach Family Links Nurturing Programme Toddlers without tears

49 Why did so many + programmes fit in the NL2 category? 49

50 + What are some of the challenges to developing high quality evidence in 0-5s programmes?

51 + This is what the EIF said

52 Lack of an evidenced logic model: The how of an intervention 52 Inputs The resources require to deliver the intervention; costs, staff time, venue, etc. Activities The activities thought to improve specific child outcomes Outputs Units of service resulting from the activities; e.g. number of children participating, etc. Short term Outcomes The immediate, measurable benefits of the intervention Long term Outcomes The longer-term benefits for the child and ultimate social value of the intervention

53 Unclear Theory of Change: The who, what, why of an intervention 53

54 + Confused specificity - who the programme is for?

55 +

56

57 + Thank-you for listening.

58 EIF: what the review means for Commissioners

59 Overview Many programmes are full of potential but in need of developing evidence base Commissioners have critical view in both growing and applying evidence base through monitoring and testing of innovative interventions Building evidence takes time Careful implementation is as important as evidence it has worked previously

60 Recommendations for Commissioners Commissioners should use Foundations for life evidence to inform spending decisions Consider evidence alongside wider factors such as population need and local context Develop clear approach to assess risks across the early years system for children at key stages of development Supporting the development of a test and learn culture of evidence use and development of UK evidence base for early intervention

61 A family focused approach Report should be looked at in conjunction with evidence on the impact of supporting the interparental relationship in improving child outcomes Where there are high levels of parental conflict it is difficult for parenting based interventions to succeed Need for family focused approach which integrates the research and findings on parenting and the parental relationship and considers the family system as a whole

62 Transformation and Perinatal services Linda Pae & David Levy

63 Group discussion Integrating the system linking things up locally Current plans for transformation and how that s working

64 Perinatal Mental Health Transformation First Perinatal Mental Health Networks Meeting 7 th June 2016

65 Designing a better future Growing awareness and momentum across the system of need for change with all system partners becoming engaged Perinatal mental health identified as key national priority: Closing the gap: priorities for change in mental health (DH, 2014) Prime Minister s announcement and Life Chances strategy Jan 16 Five Year Forward View for Mental Health Feb 16 Better Births independent report Feb 16 Backed up by commitment to new investment Using momentum to deliver significant service improvement and improve outcomes for women and their families

66 The challenge Mental health problems in the perinatal period are very common, affecting up to 20% of women. Perinatal mental illnesses cost the NHS and social services around 1.2 billion for each annual cohort of births*. A significant proportion of this cost relates to adverse impacts on the child. Almost a quarter of women who died between six weeks and one year after pregnancy died from mental-health related causes. 1 in 7 women died by suicide. *LSE and Centre for Mental Health, The Costs of Perinatal Health Problems (2014) **MBRRACE-UK, Confidential Enquiries, 2015

67 The challenge variation and inequality There is variation and fragmentation across the country in provision of and access to specialist perinatal mental health services. The 2014 report by Centre for Mental Health and LSE highlighted that only 3% of CCGs had maternal mental health strategy. Also that fewer than 15% of localities provided specialist services for women with complex or severe conditions at the full level recommended in NICE guidance, and more than 40% provided no service at all. In 2015/16 NHS Benchmarking also completed analysis of access to specialist Mother & Baby Units (MBUs) across the country. Baseline 15 MBUs with 115 beds. Significant gaps in local provision looking at distance travelled for women and babies Some women travel over 100km to access an MBU Significant variation in clinical interventions *Map - Maternal Mental Health Alliance, Everyones Business campaign 2015

68 Building better services: principles of a good service Good perinatal mental health services should promote prevention, early detection, diagnosis and effective treatment and be part of a clinical network. Providers and commissioners work in partnership with parents and their families to design, develop and improve the delivery of services to meet local need. A good service will have a comprehensive perinatal mental health strategy and there should be clear patient pathways which promote seamless, integrated and comprehensive care for women and their families, and across organisational and professional boundaries. There is partnership working across organisations with an expectation to share information and data as appropriate. Treatment is timely, evidence based, effective, personalised and compassionate.

69 *Joint Commissioning Panel for Mental Health, Guidance for Commissioners of Perinatal Mental health Services (2012), NICE, APMH guidance (2014), London Strategic Clinical Network, Draft PMH Service Specification (2016), NHS IQ, Improving Access to Perinatal Mental Health Services in England A Review, (2015). Building better services: principles of a good service The specialist component of perinatal mental health provision should support services across the pathway through training, supervision and consultation. The specialist service should also ensure there is engagement with services that provide for vulnerable mothers, their partners, infants and families who are at risk of experiencing mental disorder during the perinatal period. Mother and Baby Units should be closely integrated with specialised community teams to promote early discharge and seamless continuity of care. Specialist perinatal mental health services are members of the Royal College of Psychiatrist Quality Network for Perinatal Services and subject to their accreditation process. Information is available for women, partners/family and professionals at all stages about mental health and wellbeing during the perinatal period.

70 Outcomes for women and their families All women can access appropriate, high-quality specialist mental health care, closer to home, when they need it during the perinatal period. Women and their families have a positive experience of care, with services joined up around them. There is earlier diagnosis and intervention, and women are supported to recover and fewer women and their infants suffer avoidable harm. There is more awareness, openness and transparency around perinatal mental health in order that partners, families, employers and the public can support women with perinatal mental health conditions.

71 Building better perinatal mental health services

72 Item 2 NHS England transformation programme

73 Policy and funding announcements Total investment from 2015/16 to 2020/21 = 365m (Government announced 290m Jan 2016, building on spring budget announcement). February 2016: Mental Health Task Force s 5YFV for MH recommends additional investment so that by 2020/21, an additional 30,000 women in all areas of the country should receive access to evidenced-based specialist support, closer to their home, when they need it, including access to psychological therapies and right range of specialist community or inpatient care. Enables NHS England to design a phased, five-year transformation programme to build capacity and capability in specialist perinatal mental health services, with the aim of enabling women in all areas of England to access NICE-concordant care by 2020/21.

74 Five-year phasing 2016/ / / / /21 Preparation and planning: pathways, networks, workforce development Building capacity in MBUs Securing transformation: Building capacity in specialist community teams Rolling out new model of care for MBUs Data, metrics and payment levers

75 Funding flows 2016/ / / / /21 Transformation support (clinically-led implementation teams and networks, support for workforce via HEE, analytics, Innovation Funds, etc.) funding distributed centrally via NHS England Procurement and establishment of new Mother and Baby Units via NHSE Specialised Commissioning Development and delivery of community specialist perinatal MH teams via initial pump-priming funding and then CCG baselines Levels of funding increase overall across the period. 2016/17 to 2018/19 setting infrastructure, including investment in workforce development, MBU procurement and pump-priming community services. 15m in 16/ /20 onwards new money begins flowing to CCG baselines.

76 Deliverables and objectives (1) Deliver improved services which cover every area of England: Increase mother and baby unit provision, including delivery of new MBUs in the areas of the country with insufficient provision and increasing capacity in existing MBUs where needed (with an expected minimum of 8 beds per unit). Ensure that NICE-recommended specialist community perinatal services are available in each locality which provides direct services, consultation and advice to maternity services, other mental health services and community services. Increase the supply and capacity of specialist MDT teams and teams providing psychological and parenting interventions. Support implementation of robust, evidence-based care pathways, which are integrated with universal maternity and primary care, and wider mental health services, and incentivise early intervention, holistic approaches to care and recovery. Healthcare professionals are trained, competent and confident in recognition, treatment and support for women with perinatal mental health problems including education and training of both specialists and non specialists in perinatal mental health.

77 Deliverables and objectives (2) Enable perinatal clinical networks to operate in all regions of the country and to provide clinical expertise and leadership for consistent, high quality and evidence based care for women, babies and their families. There is strategic commissioning of perinatal mental health care based on need, and specialised perinatal services are organised so that inpatient mother and baby units serve the needs of large populations and are closely integrated with specialised community perinatal mental health teams. Incentives in the system support improvement. There are standardised data and outcome measures for all perinatal mental health services (including maternal and infant outcomes), to measure and monitor improvement activity and service provision.

78 Implementation principles Collaborative commissioning and innovation to improve outcomes and experience for women, their families and babies. Everyone in the system has a role in implementation and delivery, especially those who have lived experience. Flexible models that integrate specialist and community services aligning with maternity and children services. Measuring and evaluating the difference that investment has made in the local system. Raising the quality and accessibility of services to women and their babies.

79 Progress to date Expert Reference Group recommended focus of early investment in MBU capacity, perinatal networks (NICE-recommended) and community specialist teams informed by bespoke analysis by NHS Benchmarking. Building MBU capacity three regions with particular access issues identified (South West, North West and East of England) and roundtable discussions held. Review of current MBU capacity begun. Funding made available to regions to develop clinically-led implementation teams and networks. Building clinical leadership capacity RCPsych to establish bursary scheme to support training of perinatal psychiatrists in partnership with HEE. Appointment of Associate National Clinical Directors Giles Berrisford and Jo Black. Launch of NHSE Perinatal Mental Project Board bringing together system partners (including PHE, HEE, HSCIC, MMHA, DH, NHSI) to oversee and ensure delivery of the perinatal mental health transformation programme of work. Commissioned further data collection and analysis to support commissioning development.

80 Building the approach: key project areas Assurance Mental Health Programme Board Chair: Claire Murdoch PMH Board Governance Workforce capacity and capability Perinatal clinical networks Data and metrics New care models Levers and incentives Commissioning development MBU capacity Community specialist perinatal teams Communications and engagement (including co-production)

81 Initial national priorities for 2016/17 Governance and accountability launch national project board to oversee implementation delivery with all system partners and develop five-year programme. Developing MBU provision: Complete procurement of new units Complete existing capacity review and build any additional beds into contracts. Continued investment in implementation teams and networks. Launch and delivery of clinical leadership bursaries. Workforce and development support HEE to develop workforce strategy to identify requirements, training events and development of competency framework. Support for commissioners in planning future requirements through analytics and seminars.

82 Item 3 A collaborative approach to improvement and innovation

83 An effective perinatal mental health network Aims Support and enable development of integrated perinatal mental health services (reduce variation in commissioning of services, drive improvement and bring consistency). Spread knowledge, best practice and share learning. Support professional development. Act as a source of information / raise awareness of perinatal mental health illnesses. Increase patient satisfaction and experience of high quality / timely access of care. Promote clinical excellence. Provides Access to specialist expert advice / guidance and a multidisciplinary team approach (allows for good communication and a whole system approach). Clear pathways (including defined roles and competencies) and management protocols for services. Coordination of training and education opportunities.

84 Composition of the Perinatal MH Network NICE costing template (CG192) recommends that the core team responsible for coordinating and managing the network should include a network manager, network coordinator and psychiatric consultant sessions. Links to other clinical networks key; including mental health, neonates, maternity, children and their commissioning reps. Work embedded and assured by four NHSE regions bringing networks together Managers Commissioners (Mental Health and Maternity and engagement of specialised commissioning for inpatient care) PMH Network Voluntary sector, Social Care Health and care professionals People with lived experience and families Health professionals to include (dependent on local services / need); Perinatal Psychiatrists Obstetricians Specialist Midwives Paediatricians Psychologists Health Visitors GPs Psychiatric nurses Community MH team, inc. crisis CAMHS, Childrens Services and MBU reps Regionally; HEE local lead and NHSE specialised commissioning to be involved.

85 Inspiring clinical leadership Identifying the movers and shakers Engagement with key regional leaders Role of clinical champions Supporting peers / mentoring

86 National priorities for networks 2016/17 Establish and/or continue to develop effective networks in line with good practice. Continue to engage and collaborate with CCGs and providers to deliver best practice and reduce fragmentation in service provision. Identify and assess baseline positions in terms of availability and access to specialist perinatal mental health services (gap analysis in line with NICE guidance) in order to determine strategic plans for coming years and respond to availability of new funding. Ensure that a broad range of perinatal mental health support is available locally, with clear pathways available for identification and timely access to psychological therapies and specialist perinatal services in line with NICE guidance. Establish local workforce strategies.

87 Update on use of measures

88 Last meeting Measures currently on offer for Under 5s work included in the CYP-IAPT Data Specification (and therefore likely to be included in the MHSMDS): Parent Strengths and Difficulties Questionnaire (SDQ; 2-4 years) Parent version of the Outcomes Rating Scale (ORS) Brief Parental Self-Efficacy Scale (BPSES) Sheffield Learning Disabilities Outcome Measure (SLDOM- for parents of children with LD of 3 yrs and over) Goals Based Outcomes (GBOs) NB: These measures can be found on the CORC website in the table drawn up by David Trickey here:

89 Last meeting Wish list of measures to be added: Child Behaviour Checklist (CBCL)* Parenting Stress Index- Short Form (PSI-SF)* Patient-Infant Relationship Global Assessment Scale (PIRGAS) These measures incur a cost. There was a discussion around the difficulty with advocating for the use of measures services have to pay for and a general query as to whether a consortium-based approach might enable the fee to be waived as has been the case with some other measures historically.

90 Workshop Recommended Measures