South Devon and Torbay Clinical Commissioning Groups 5 Year Child and Adolescent Mental Health Services Transformation Plan 2015-2021 1
CAMHS TRANSFORMATION PLAN Contents: Joint Forward Statement 3 Introduction 5 What have we Been Working to Achieve 6 Our Current Position and Ambitions 7 Our 5 Year Transformation Plan 10 Eating Disorders 10 Crisis Response 12 Prevention and Resilience Early Intervention 14 Children in Care, Vulnerable Children and Young People 15 Engagement With Young People and Co-Production 16 Additional Aspirations The 5 Year Transformation 17 Cost of Services 21 5 Year Outcomes 21 Appendices: a Eating Disorder Services 22 b Crisis Intervention and Intensive Treatment Team 26 c Provider Workforce Data 29 d A children s and Young Peoples Emotional and 31 Mental Health Joint Commissioning Strategy e Draft Public Health Self Harm Strategy 32 including recommendation for the implementation of the Self Harm Suicide Prevention and Emotional Health and Wellbeing Strategies. f JSNA and detailed eating disorder statistics 33 g Child Health Profiles 34 h Equality Impact Assessment 35 i Torbay CAMHS Redesign Board Terms or Reference and Action Plan 36 2
Forward Statement on Behalf of Both South Devon and Torbay, and North, East and West Devon Clinical Commissioning Groups Dr Tim Burke Clinical Chair Northern, Eastern and Western Devon Clinical Commissioning Group Dr Nick Roberts Chief Clinical Officer South Devon and Torbay Clinical Commissioning Group The emotional health and wellbeing of children and young people is everybody s business. Children and young people who feel good about themselves and are confident and optimistic about their future will be more resilient to deal with the stresses that life will inevitably bring. This is important. It is known there are links between poor mental health and social exclusion, leading to reduced education and employment opportunities, and financial, social and health inequalities in later life. There is also impact on a life course with approximately 75% of adults with a mental health diagnosis having acquired their condition by the age of 18. Promoting good mental health and building emotional resilience is therefore critical, across all stages of a child or young person s journey into adulthood. The Child and Adolescent Mental Health Services (CAMHS) Transformation Plans for Northern, Eastern and Western Devon, and Torbay and South Devon, Clinical Commissioning Group areas provide an opportunity to achieve this. We expect these services will enable children and young people to better meet the challenges they face as they move into adulthood and to support them when they are most vulnerable. We also expect services to work with front line staff including colleagues in education, children s services, social care, primary care, secondary care and voluntary/ community organisations, so they too have knowledge to recognise problems at an early stage and guide children and young people to the right help and support first time. We are already making progress. Our Transformation Plans build on this and set out 5 years of improvement to services across Devon, Plymouth and Torbay. Each CCG is required to produce an individual CAMHS Transformation Plan and whilst each part of our geography 3
has its own needs, nuances and community level priorities there is also benefit in working together with a combined high level vision and objectives for meeting the emotional and mental health needs of children and young people across the whole area. Local authorities play a central role in the emotional and mental health and wellbeing of children and young people and in our area there have been significant advances in partnership working and in some areas full integration of commissioning and provision. So although each CCG is accountable for the Transformation Plans, these are very much developed and delivered in full collaboration with our public health, social care and education colleagues in Devon, Plymouth and Torbay local authorities. We are therefore working together on a shared platform for seamless services which make the most effective use of all available resources, talents and budgets in the interests of children, young people and their families. We know that through effective and carefully designed Transformation Plans which invest in the future emotional health and wellbeing and mental health of children and young people we can make a real difference in experiences and outcomes. The priorities in our respective plans for each of our CCG areas have been identified with the support of parents and young people, schools, voluntary/ community sector organisations, both primary and secondary care, the police, local authorities, specialised commissioning and public health experts, and we are aware that their continued engagement is key as we translate the words on the pages that follow into action. We recognise that over the next five years the local priorities will develop and change and our Plans will be flexible and responsive too. The Transformation Plan that follows is for the area covered by South Devon and Torbay CCG. It is presented against this backdrop of collaboration to achieve consistency of outcomes and a coherent system wide offer across our wider geography and the ongoing development and delivery of emotional health and wellbeing and mental health services for children, young people and their families. This Plan is a unique opportunity to make a step change in the way the system works for children, young people and families. We know locally that emotional and mental health and wellbeing is their top health concern to and we are listening. Working against a backdrop of rising demand for services and significant financial challenges in the public sector, through service redesign and use of the additional national investment we will: Achieve a comprehensive offer that promotes emotional resilience and better mental health and wellbeing in children and young people Break down historical barriers and design support services around children and young people and based on need Shift the focus towards earlier and evidence based interventions and reducing demand on targeted services to achieve best value for children and young people 4
1. INTRODUCTION: 1.1 This is South Devon and Torbay Clinical Commissioning Group s Child and Adolescent Mental Health Service 5 year Transformation Plan. This plan outlines how South Devon and Torbay s Clinical Commissioning Group, (SDT CCG), will use its allocated funding in conjunction with existing resources, to fundamentally change the mental health and wellbeing offer made to children and young people across its footprint. The plan considers children and young people who are at their most vulnerable and have reached a point of crisis and how that can be avoided by intervention, but also considers how crisis as a destination, can be averted by focusing on the start of an individual s journey and preempting any deterioration of mental health and well-being. Our Plan has the approval of Torbay s Health and Wellbeing Board and endorsement in principle from Devon s. 1.2 This Transformation Plan should be read alongside A Children and Young Peoples Emotional and Mental Health Joint Commissioning Strategy 1 the Devon Children and Young People s Plan 2 and Torbay Children and Young People Plan 3, strategies for Early Help, Targeted Families and Children with additional needs for those with a dual diagnosis. It is also critical that this strategy interfaces with the Mental Health Commissioning Strategy for adults 4 and Public Health Mental health and wellbeing strategy (all age). 5 1.3 SDT CCG works with two CAMHS providers, Torbay and South Devon Foundation NHS Trust, (TSDFT), in Torbay and Virgin Care Limited, (VCL) in South Devon. Our neighbouring CCG, Northern, Eastern and Western Devon, (NEW Devon), have worked with us in developing our Transformation Plan, supported by periods of co-location with our two providers to ensure co-production of the plan. SDT CCG is seeking to ensure equitable access and provision for children and young people using our providers, and to provide a comparable offer for those who live in other parts of Devon. An Equality Impact Assessment has been completed at appendix h. 1.4 Services in Torbay have a history of working in partnership to achieve their ambitions. Before the inception of the CCG, social care and community health services for adults were merged in Torbay and more recently SDT CCG has also been actively working to support our community and acute providers merging to become an Integrated Care Organisation 6. SDT CCG has been awarded Vanguard status for the delivery of urgent and emergency care and SDT CCG became a Pioneer site focused on the integrated delivery of services for children and a frailty hub for older people linked to our models of locality commissioning. Our community health care provider is managing adults provision through Local Multi Agency Teams and children s services in Torbay are aspiring towards a similar model, made possible by funding from the Social Work Innovation Fund, which will see locality based early help and targeted intervention teams which would include CAMHS Primary Mental Health Workers. 1 A joint strategy for SDT CCG, NEW Devon CCG, Devon County Council, Torbay Council 2 Devon Children and Young People s Plan (Draft). Devon Children and Young People s Alliance 3 Torbay Children and Young People Plan. 4 A Mental Health Commissioning Strategy for Devon, Plymouth and Torbay. 2014-2017. 5 Torbay Mental Health and Wellbeing Strategy. 2014-2017 6 On the 1 st October 2015, South Devon Healthcare Foundation NHS Trust and Torbay and Southern Devon Health and Care NHS Trust merged to become Torbay and South Devon Foundation NHS Trust. 5
1.5 The Joint Strategic Needs Assessment, (JSNA), and more detailed public health needs assessments for self-harm and eating disorders provide a good level of understanding of need and prevalence in which Transformation Plan has been developed, more detail is available at appendices f and g. 1.6 The context for future commissioning of children s services more generally, is set by the significantly challenging financial environment in the public sector and outcomes from recent inspections. Resources available for commissioners are subject to substantial pressure and this has inevitably led to commissioners, providers and stakeholders considering options for future services which reduce demand for targeted services, and promote earlier intervention and ensure the best value for money 7. The impact of the resources available through Transformation Plans will need to be considered against this backdrop and the impact successful services might have on the wider landscape of childrens services. 2. WHAT WE HAVE BEEN WORKING TO ACHIEVE 2.1 In 2014/15 SDT CCG spent 1,341,000 on the CAMHS Service provided in South Devon and 1,368,000 on the CAMHS service provided in Torbay. In addition to this SDT CCG has committed Parity of Esteem funding for an Out of Hours Service from Virgin Care which will provide crisis assessments and mental health Act Assessments when core services are not available. The cost will be 126,000 circa We have also part funded with our colleagues in NEW Devon a children s and young person s Place of Safety 24,268 circa. 2.2 Prior to this Transformation Plan SDT CCG had already recognised the gap between the demand for CAMHS and the existing capacity within the service, due to increasing numbers of new referrals and greater acuity of patient needs, compounded by operational difficulties in maintaining staff. We had focused on addressing these gaps, reducing waiting times, commissioning a more appropriate place of safety and working with schools as a prime partner in building the resilience of our young people, and had allocated specific and additional funding. SDT CCG has taken a wider view of mental health and wellbeing as a partner in producing A Children and Young People s Emotional and Mental Health Joint Commissioning Strategy, working alongside NEW Devon CCG, Torbay Council and Devon County Council, and is working in partnership with Public Health Teams, Primary and Secondary Care providers, local schools and early years provisions, children s centres and importantly the voluntary/ community sector. 2.3 Torbay CAMHS Redesign Board action plan and Terms of Reference are attached at Appendix i, as evidence of multi-agency on-going commitment to developing the CAMHS Service; this includes representation from the Southern Devon provider to ensure continuity. In South Devon SDT CCG will be part of the single system wide governance group which will oversee the development and implementation of the Torbay CAMHS 6
transformation plan. NHSE could be represented at this group to further co-commissioning opportunities. 2.4 The development of plans so far has been aligned with the priorities listed in Future In Mind and has directly involved the Torbay and Virgin Care CAMHS Service Managers, Public Health, Torbay and Devon Councils, schools Children s Centres, Commissioners for CAMHS and AMHS and the GP Clinical Lead for Children and Maternity. This has been supported by co-ordinated input from the Paediatric Clinical Pathway Group; actions from the CAMHS Redesign Board, the Adult Mental Health Redesign Board and what children and young people have told us. 2.5 This Transformation plan considers the needs of the two different population groups, the CCG footprint as a whole and the sharing of resources across the two CAMHS providers. 3. OUR CURRENT POSITION AND AMBITIONS: 3.1 SDT CCG s vision is to commission excellent, joined up care for everyone and decisions about the commissioning of that care must be built on the needs of our local population and must be commissioned in partnership with other statutory services, the voluntary sector, children and young people and their families working. Its vision is articulated in A Children and Young Peoples Emotional and Mental Health Joint Commissioning Strategy, (attached at appendix d), and is a strategy across both councils and both CCG s that serve the people of Devon. 3.2 Our Redesign Board has been working since January 2015 looking at the local priorities, aligned with those set out nationally within Future in Mind. The Multi Agency Torbay CAMHS Redesign Board s detailed action plan will underpin the ambitions and proposals set out here for Torbay and they will monitor progress at their monthly meetings. As an Associate Commissioner to the Virgin Care Limited, service provided for South Devon, we will have one action plan for Devon which will be monitored through bi monthly IPAM governance meetings. 3.3 Any significant risks will be recorded on SDT CCGs risk register. Both groups will be responsible for monitoring progress against plans, supported by a number of implementation groups such as the acute care pathway redesign group. A CAMHS Transformation Group across geographical boarders; Provider/Commissioners, NHS England and the voluntary sector will provide the system wide change needed. 3.4 SDT CCG anticipates that our services will address inequalities on many levels. Our work with schools will focus on some of our more deprived areas and also on some of our children demonstrating the most challenging behaviour and mental health needs, and their parents to deliver sustainable changes for individuals and families. This work will focus on promoting resilience, prevention and early intervention, as will our Direct Access Selfreferral Project and an online offer which will improve the access to effective support without tiers. Our plans for Crisis and Intensive Home Intervention would directly impact on those who are most vulnerable. Throughout our work we are looking to improve the CAMHS workforce, this is clearly demonstrated by the scrutiny Torbay and Southern Devon 7
Health and Care Trust have already given their own service and our pre-existing multi agency Redesign Board shows a level of commitment to transparency and accountability from both commissioners and providers. We will need to support solutions to recruiting sufficient staff, which remains a risk and consider fit for purpose IT which enables our two providers to work more effectively together. 3.5 Baseline data for 14.15 3.6 Torbay position: 3.7 Southern Devon position: 3.8 Workforce data for both CAMHS providers is attached at appendix c. Prior to Transformation Planning, Torbay CAMHS have also been the subject of increased scrutiny considering workforce, workflow and clinical pathways. 3.9 The investment of Partners 3.10 Torbay Local schools in 14/15 schools in Torbay, independent of the CCG, commissioned primary mental health worker roles at a cost of circa 130K PA, from Torbay s CAMHS provider, for 3 years to support their students with their emotional health and wellbeing and build resilience. 8
3.11 Torbay Council - in 14/15 230K of services were commissioned from Torbay CAMHS by Torbay Council, including practitioners for trauma/ abuse, young people displaying sexually harmful behaviour, Looked After Children, Therapeutic Support for Foster Carers and also to work as part of a multi-agency high risk team, with social care, and the Voluntary sector, working with vulnerable young people on the edge of care, those experiencing domestic abuse or those at risk of exploitation. 3.12 South Devon Devon County Council Devon s Public Health Team have invested in the provision of an online and new face to face counselling service for the whole of Devon, incorporating SDT CCGs Southern Devon area. This service is provided by Young Devon and Kooth.com 3.13 Virgin Care has also been commissioned to provide the Early Help for Mental Health service into schools which will deliver bespoke, regular consultation and mental health training to staff employed by state schools across Devon. The aim of this provision will be to support colleagues in education through building on existing knowledge around mental health conditions, symptoms and response with an aim of improving confidence and skills in responding to issues related to mental health supporting mental health promotion, prevention and symptom management through to recover. Both of the newly commissioned services went live September 2015. 3.14 NHS England in 2014/15 Commissioners at NHSE had 35 children or young people in Tier 4 placements. With the average cost of these beds being 670 per day and the total length of stay for all patients being 3897 days, this represents an approximate cost of 2,610,990. SDT CCG has also directly financially supported families visiting their child in Tier 4 placements. If our plans as a whole reduce Tier 4 admissions over all by 50%, this would be a financial saving to both the CCG and NHSE. If NHSE were able to release this saving to local commissioners we could look further at prevention and resilience building. 3.15 In Devon CAMHS the Assertive Outreach has been providing intensive support to high risk children and young people since the beginning of the year with significant impact on admissions to Tier 4. This service has been jointly funded in South Devon by NHSE. SDT CCG are contributing 17,500 PA as a 20% share of this service coving the South area of Devon. 3.16 We would therefore hope for continued and enhanced levels of collaborative commissioning with NHS England, who we recognise as the experts in commissioning Tier 4 inpatient facilities, along with a standard level of support that our local CAMHS teams can expect in accessing this support. SDT CCG has historically commissioned community based CAMHS forensic assessments with the support of our CAMHS providers, but we understand there is work nationally to focus on a single provider for Secure CAMHS Outreach Services which could be commissioned by CCGs. This would obviously streamline our processes. 9
4. OUR FIVE YEAR TRANSFORMATION PLAN 4.1 Our overarching local ambitions are absolutely in line with and additionally add to the national strategy vision Future in Mind. In year one we intend to: a) Improve Children and Young Peoples experience b) Reduce the number of young people with Mental Health problems admitted to paediatrics and to Tier 4 beds. c) Reduce the number of young people presenting in crisis d) Meet the access and waiting times for Eating Disorder services and psychosis e) Meet waiting times for assessment at 1 week for urgent cases and 6 weeks for nonurgent. f) Increase levels for direct access (self-referral) and increase the skill set of those working with children to recognise mental health issues and how they can support young people with referrals to more specialist services. 4.2: EATING DISORDERS 4.3 Torbay SDT CCG commissions services for two distinct populations of similar sizes, circa 27,800 children and young people in Torbay under the age of 19 and 28,700 in South Devon. We had initially considered a major overhaul of our current eating disorder provision and two separate services for our two populations, with cross over points at paediatrics and dietetics. Our focus in this was the need for frequent travel for both staff and patients who could be seen daily as part of an intensive pathway, as well as access to notes and the fact that paediatric input/ admission would come from SDHFT. In talks with both our providers, our plans have evolved to see Torbay encompassed by the existing spoke and hub Eating 10
Disorder service in Devon. This service is already commissioned by NEW Devon CCG for Devon and incorporates TSD CCGs Southern Devon area. The model, already provided by Virgin Care Limited, is nationally recognised and cited in NICE Guidance and will meet and requirements set out under transformation. 4.4 For our Torbay patients, our plans see Torbay as an additional spoke to Devon s Eastern hub which would address the concerns for patient and staff travel with paediatric and dietetic support remaining at Torbay Hospital. Our ambition is to follow a prime contractor model with one pathway and one hub for the whole area, but to ensure that expertise, resources and existing partnerships are maximised from the existing service in Torbay. Both our providers have committed to coming together to clearly map out governance and supervision arrangements as well as considering IT solutions. We have already made the changes outlined below to enhance Torbay s existing pathway and bring it closer to the desired model, prior to the support of Transformation Funding. - GP education re. physical monitoring of ED CAMHS Patients. - GP education session led by consultants at Torbay Hospital. - CAMHS staff now attend Torbay Hospital s ward round for both South Devon and Torbay Patients every Wednesday morning. - There is a specialist ED Dietician seeing patients alongside a clinician once per month. - 4.5 Data from NHS England shows that two young people from South Devon were in tier 4 beds for eating disorders in 2014/15, staying 385 nights between them. This represents a total cost to NHSE of 257,950 for 2014/15. We believe the real figure may be higher and include Torbay patients who have been coded against a primary need but also have an eating disorder. Our intent will be to half admission rates to tier 4 beds. Age Av: 15yrs 10-11.9 12-13.9 14-15.9 16+ 4.6 South Devon Health Care Foundation NHS Trust, (now part of our local Integrated Care Organisation, Torbay and South Devon Foundation NHS Trust), had 23 medical admissions to its acute children s ward, for eating disorders in 2014/15, for their 3 week refeeding 11
programme, as detailed in the chart above. If our new model reduced paediatric admission by 50%, by managing eating disorder patients in the community and preventing them from reaching the need for medical admission, this would reduce the total cost by 12 patients PA. 4.7 Fundamental to our model is increased home intervention and family therapy with a robust, community led MDT and faster initial assessment. Currently Torbay CAMHS receives 20 new referrals for eating disorders per year and admits approximately 1 of those per year to Tier 4. A more detailed plan for the eating disorders service in Torbay is set out at appendix a. Our ambition is to reduce the length of treatment by 2-4 months through more timely assessment and intensive support, and reduce the number of Tier 4 admissions by 50% of the first year. 4.8 South Devon Virgin s CAMHS Service already operates a hub and spoke model across the whole of Devon, linked to the Royal Devon and Exeter Foundation NHS Trust, which is nationally acclaimed and recognised in the NICE Guidance. It differs slightly from the Maudsley model, helping families understand the seriousness of the illness, engage with them in developing strategies to overcome the illness and to hand responsibility for their child s recovery to the parents whilst supporting throughout. Devon s model provides multi-disciplinary clinics on a Friday, to offer young people support for the coming weekend and avoid crisis, and use of an assertive outreach team with home eating support to enable young people to remain in the community and avoid inpatient admissions. Cases of eating disorders were significantly higher in South Devon than in Torbay in 13/14 and funding from core CAMHS Services has historically been diverted to support eating disorders which have already greatly reduced admissions to Tier 4. South Devon CAMHS wishes to invest in paediatric and dietetic time and these resources across the CCG footprint would be provided by Torbay and South Devon Foundation NHS Trust. In addition there is a need for more Band 6/7 therapy time to ensure sufficient capacity to enable more individualised work, sufficient family therapy resources, and the ability to focus on transitions for those young people moving into adult s services. As the CAMHS provider across Devon (excluding Torbay), VCL are looking to use some of the transformation funding to work with Exeter University on evaluating the eating disorder model in Devon, approximately an 18% share of 15k, ( 2,700.) PA would come from SDT CCG s allocated transformation funding and would potentially enable further transformational change during the life time of the plan. 4.9 Both CAMHS providers in Torbay and South Devon are committed to working together and multi agency meetings have been running for some time looking at all aspects of CAMHS. The new service across the CCG geography will meet the Access and Waiting Time Standard with urgent referrals being seen within one week and routine cases being seen within 6 weeks. Both areas currently already meet this standard and would be expected to report on the national outcome measures which will be included within their KPIs. Torbay s CAMHS Service is currently initiating direct access which offers opportunity for self-referral this is described in more detail in section 3.4. However self-referral could also be supported by the Primary Mental Health Worker role in schools across Torbay, which also provides direct access for students and school staff. South Devon CAMHS has offered selfreferrals for several years and work is being undertaken to publicise more widely. More detail on our eating disorder plans can be found at appendix a. 12
4.10 CRISIS RESPONSE 4.11 Crisis Intervention and Intensive Home Treatment Team Torbay and South Devon are jointly developing multi-agency care pathway reviews with partners including acute and primary care, public health, local authority social care, early years and safeguarding, police, GP s, voluntary sector and schools. 4.12 This work will be conducted over a 2-3 year period (starting immediately) with the prioritisation of a range of pathways. In recent years our acute care provider, Torbay and South Devon Foundation NHS Trust has experienced a significant increase in mental health crisis, in children and young people presenting to A&E, this is supported by the findings of Torbay and South Devon s Public Health Self Harm Strategy, at appendix e. Whilst next working day mental health assessments are provided there is no crisis intervention service for those young people who present in mental health crisis and no out of hours assessment. 40% of those presenting to A&E are already known to local CAMHS services. The priority coming from this has been to transform our acute care pathway at the direction of a multiagency redesign group. 4.13 Considering the main focus of the Crisis Care Concordat, our plan would improve the urgent and emergency access to care. We aim to transform care for our young people at their most vulnerable point, and in the longer term prevent a great number from ever reaching the point of presentation at A&E. The outcomes of our plans will be a reduction in both secondary care admissions and presentations at A&E from year 1 leading ultimately to a reduction in the use of Tier 4 beds by the end of year 5. We are proposing an intensive home treatment service which could be hosted at CAMHS. The service would operate Monday Friday 9am-10pm and 9am-5pm Saturday and Sunday, undertaking Mental Health assessments and seeing patients on the ward with emotional health and wellbeing needs when not out on visits. The service would be supported by an additional 0.5 psychiatrist to assist both South Devon s Assertive Outreach Team and Torbay s Intensive Home Treatment Team. During hours when the service was not operational, where a young a person was experiencing crisis, telephone advice could be sought from the on call child psychiatrist, a service provided by Virgin Care Limited on behalf of the entire CCG footprint for crisis work and mental health act assessments. Support services including nursing advice and assessment are referenced at 4.13. The change to an on call psychiatrist is supported by feedback from paediatricians with experience of the existing service. This new service would provide access to various levels of support 24 hours a day and the intensive home treatment team would ensure that individual s paths to recovery progressed in the community. 4.14 In addition to the transformation funding SDT CCG has commissioned a GP 0.1WTE to undertake a 12 month patient/ family engagement exercise with young people whose journey leads to an acute admission, looking at how this journey could have been avoided or improved. The work will also look at supporting A&E and paediatric staff in making risk assessment and safe discharge decisions for those between 16-18 years. In the longer term as part of contract negotiations, SDT CCG requires an all age mental health psychiatric liaison service based at our acute trust, to enable mental health assessment and Mental 13
Health Act Assessments to take place 24 hours per day this would replace our on call provision. Progress towards this may be driven by our intent and ambition as part of the Vanguard Programme, and progressed by the non-recurrent funding being centrally allocated, to develop a more integrated arrangement for psychiatric liaison and crisis support which is not constrained by age barriers and would support those whose journey continued into adults services. 4.15 The Intensive Home Treatment Service in Torbay and Assertive Outreach Team in South Devon would, and have already, helped prevent admission to Tier 4 beds by Specialized Commissioning Teams. Working with Specialized Commissioning it is clear that if we reduced annual admission figures to all Tier 4 beds by 50%, this would represent a cost saving to NHS England. It should be noted that this is approximate and some patients can cost in excess of 1200. Per day where very specialist treatment and 2 to1 care is required. More detail on the service planned and costs is at appendix b. 4.16 Devon CAMHS are implementing a new out of hour s crisis response service which will be in place from October, ensuring that urgent assessments, including Mental Health Act assessments can be carried out in a timely manner. The service will have three levels: 4.17 Band 7/8 on-call rota first point of contact, telephone advice and triggering of assessment, hold operational responsibility for assessments done out of hours. Available weekdays from 5pm until 9am the following morning and from 5pm Friday until 9am Monday morning. 4.18 Band 6 duty systems for urgent assessments. Available weekdays from 5pm until 9am the following morning and from 5pm Friday until 9am Monday morning. 4.19 Consultant Psychiatrist on-call advice to Band 7/8 on-call and undertaking of Mental Health Act Assessment. Available weekdays from 5pm until 9am the following morning and from 5pm Friday until 9am Monday morning. 4.20 In addition Devon CAMHS are proposing to improve access standards by embedding a new self-harm/depression pathway across all of its three areas including South Devon. This is in response to the increase in incidence of self-harm and will deliver a NICE compliant, evidence based pathway. The implementation will require an additional CAMHS psychiatrist and 6 band 6/7 practitioners across the County. 5. PREVENTION AND RESILIENCE - EARLY INTERVENTION 5.1 There is a recognition from all parties that while supporting children and young people at their most vulnerable is critical to ensuring a path to recovery, enabling transformational change for a generation of children and young people requires the metamorphosis of our provisions that offer early help and intervention as well as building the capacity of this cohort in empowering them to maintain their own mental health and wellbeing through the development of personally robust strategies and support at the best point of access for them. 14
5.2 Our first ambition in Torbay would be the development of an evidence based adolescent peer mentoring model for those consider to be most at risk, which understands the core components of effective mentoring relationships. Adolescents considered at risk (for example those Young People in contact with Youth Justice Services) will increase emotional resilience and their ability to stay mentally healthy and to be educationally and socially successful in the face of significant adversity. The pilot will be delivered in the 2 secondary schools who have committed to this scheme. Both the mentors and the mentees have improved mental health outcomes as well as improved educational outcomes. 5.3 Our second ambition is to deliver emotional resilience training programmes to pupils within schools. CAMHS and schools will co-deliver a life skills programme for all year 8 students within the 2 secondary schools who care committed to this scheme. The Pilot will use The Decider Manual which includes areas of proactive student mental health, improve resilience, increase life coping skills, manage stress effectively, gain effective positive coping skills, prevent & reduce emotional distress, promote mental wellbeing, increase staff confidence & effectiveness, whole school approach, develop a common language for students, teachers, parents & carers, consistent approach and a range of evidence-based interventions. If successful this programme will be rolled out to all secondary schools with a sustainability plan for schools to continue to deliver this confidently going forward. 5.4 Our third ambition would be to extend the Understanding Your Child s Mental Health Workshops, co-delivered with primary schools, providing emotional tools and creative resources to parents/carers that they might use. Rather than this being a parenting course, or prescriptive and based on behavioural models the workshops are experiential, drawing from the same evidence base as programmes such as Solihull, Mellow Parenting, Thrive and the Nurture Programme. 5.5 Finally Torbay would like to develop a Metallization-Focussed Multi Family Group programme in schools focused on supporting families in the most deprived area with some of the most vulnerable children at risk of exclusion or developing mental health problems in the future. This would pilot the work that has been developed by the Anna Freud Centre who has evidenced an effective way in bringing about change for children presenting with emotional, behavioural and mental health difficulties at schools. These families frequently are in situations where they are unable or unwilling to make use of traditional CAMHS style interventions. This transformational pilot aims in the first instance to reintegrate those children already excluded and stretching the specialist education provision in Torbay, back into mainstream education. Working in tandem with the first three ambitions this combination of provisions may negate the need for such specialist provision in the longer term. 5.6 In addition to the transformation funding the Torbay CAMHS Direct Access Project Manager is co-ordinating drop in sessions linked to school clusters, for both parents and young people which will be led by a CAMHS Practitioner and another member of the Early Help Panel e.g. a youth worker or social worker. The sessions will offer an immediate initial screening, leading to sign positing, and the opportunity for parents or the young person to make an informed self-referral into CAMHS or immediate resolution. 15
6. CHILDREN IN CARE, VULNERABLE CHILDREN AND YOUNG PEOPLE 6.1 Children in care are among our most vulnerable. Devon CAMHS has been working with senior local authority staff as part of a children in care re-design group which reports directly to IPAM.This groups terms of reference is to look at the current service provided /best practice and propose any changes required by end of October 2015. Case study methodology has also been used to review current provision. This group is well placed to continue to support /review any new funding providing as part of the transformation funding. 6.2 The proposal is to: enhance the capacity of core CAMHS teams through the addition of a practitioner with a lead for children in care into each locality CAMHS team. This is based on the findings of the planning group where it is felt that more capacity is required within core CAMHS to support CiC, specifically young people who require therapeutic intervention including those known to youth offending services. This would include a new consultation provision which would allow social workers to access support much earlier and may even prevent the need to refer into CAMHS. 6.3 The delivery of the enhanced services will require an additional 3WTE band 6 across Devon. 6.4 Targeted Peer Support 6.5 Devon CAMHS are proposing to work with Young Devon to establish a model of targeted peer support for young people who are already known to specialist CAMHS and are either in transition waiting or for treatment. The focus for this would be noneducational settings as this is already commissioned by Devon s Public Health Team. 6.6 This proposal would focus initial work on 16-19 year olds in two areas: to build capacity in YP to manage transition (majority of YP do not transition to adult services), and support YP waiting for CAMHS service through the delivery of three groups across the county who would be supported by a youth worker and qualified MH practitioner. This approach supports self-care and expert patient models used in adult services. 7. ENGAGEMENT WITH YOUNG PEOPLE/ CO-PRODUCTION 7.1 This plan has been developed with the views and experiences of children and young people, specifically taking account of: Devon Children, young People and Families Alliance Draft Plan Torbay Children and young People Plan Emotional, Health and Wellbeing Strategy Public Health Devon Co-production of the Emotional, Psychological and Social Wellbeing Support for Children and Young People Health watch Devon report Healthwatch Torbay report Young Devon Engagement Groups 16
7.2 In addition since publication of the guidance we have been using engagement opportunities such as the Fair Play day in August to speak to parents and young people with physical, sensory and learning disabilities, and the October Devon Parent Carer Voice conversation event to inform and shape our thinking. Email consultations have also taken place to access families and young people over the summer holidays. Thus far young people and families have confirmed what we believe our priorities should be, around reducing waiting times, providing a crisis services, building resilience in young people, and pursuing peer and online support. Further engagement events and opportunities are being planned for implementation of the service developments including more regular attendance at Young Devon s groups and an accessible strategic meeting with providers and commissioners. 7.3 The CCG and partners in developing this plan have reviewed a range of national information and evidence. We have also learned through links on a wider basis e.g. the Southwest Shadow Board and SW CAMHS Operational Delivery Network; CYP Mental Health & Wellbeing Board; the work of the Peninsula CLAHRC. 7.4 Torbay and Devon CAMHS are second phase partners in the CYP IAPT programme, with the South West collaborative. As part of CYP IAPT funding, Torbay and Devon CAMHS commissioned Young Devon, a VCO, to undertake on-going engagement with young people and parents/ families. This has involved young people undertaking Passport to Participation training, which has enabled them to evaluate services, work with commissioners, take part in staff interviews, train staff and train Cognitive Behavioural Therapy students at university. The group has run 3 mental health events already and Torbay is the only CAMHS Service to have received a mystery shop, this was undertaken by Young Devon s engagement group. They plan to go into school assemblies in 15/16 supporting the work in schools being undertaken by Torbay CAMHS. In South Devon a young people s board has been formed to sit alongside the professionals project board and there were two joint meetings organised. Three young people have also worked with a Virgin Care film crew to make a series of short films highlighting the value and importance of young people s participation. 7.5 As part of the transformation plan, given the innovation already undertaken, SDTCCG will explore with the group future options for engagement and dependent on the group s views would pick up the funding of this engagement from CYP IAPT for 16/17 at its current level, building this into the existing CAMHS service contract over the course of the 5 years based on the savings the plan will incur. 8. ADDITIONAL ASPIRATIONS THE 5 YEAR TRANSFORMATION 8.1 If funding were released following years 1 & 2 of the Transformation Plan from reduced NHSE admissions and our aspiration to reduce 50% of admissions to Louisa Cary for eating disorders and self-harm our priority for transformational funding would be further investment into prevention and early help services focused on infant mental health and neurological assessment. 17
8.2 Perinatal and infant Mental Health Whilst perinatal mental health received additional funding in 14/15 and now provides an all age service to mums during pregnancy and the first two years of childhood, one of the gaps noted through this process was the lack of services around children between the ages of 2-5 years and the lack of existing contacts with statutory agencies. Our vision would be to have an adult or dual trained mental health practitioner supporting the perinatal team, who could work with parents of children between the ages of 18 months to 5 years, where they do not meet the threshold for perinatal mental health services. This practitioner would provide a brief psychological therapy intervention to help parents reach a point of change when they are at a personal stage of being less receptive to more traditional interventions such as Health Visiting. This could be further developed with specialist Health Visitors linked to localities. The scope of our plans for perinatal infant mental health will be impacted by confirmation of further centrally released funding. Whilst we believe the focus for this funding will Tier 4 mother and baby inpatient beds, if there is opportunity for local commissioning we would hope to explore our needs in conjunction with our local authorities usage of mother and baby/ parenting assessment placements and what might be achieved with multi functional facilities. 8.3 An improved Neurological Development Assessment Service SDTCCG also has two different providers for Autistic Spectrum Disorder diagnosis, Torbay and South Devon Foundation Trust and Virgin Care Limited for Torbay and South Devon respectively. Both services had limited investment and focus on them in 2014/15. Funding released could support the development of a Neurological Development Assessment Service, merging staff supporting ASD and ADHD diagnosis in both providers this could also involve a review of sleep services, how they could expand their remit and the impact this might have. Potentially waiting times could be reduced as SDT CCG recognises these are currently unacceptable, and a level of intervention could be offered which is currently unavailable. For Torbay a neurodevelopmental nurse prescriber at band 7 could be appointed, which will reduce the time to follow up appointments and attendance at clinics and, 2 x WTE bands 4/5 could be appointed who would provide parenting courses, support transition and self-management for older children and support schools in managing these individuals so they achieve their potential. The cost for these three staff would be circa 85,500. PA. This would be dependent on the agreement of the teams involved. Increased investment would be needed for South Devon where there is no ADHD nurse role currently. Any allocation of funding would be dependent reductions in waiting lists given the measures already undertaken. 8.4 Going further in transformation To build on our early intervention agenda we will be delivering an emotional resilience training programme to pupils within schools. CAMHS and schools will co-deliver a life skills programme for all year 8 students within secondary schools. In Torbay we will use The Decider Manual which includes areas of proactive student mental health, improve resilience, increase life coping skills, manage stress effectively, gain effective positive coping skills, prevent & reduce emotional distress, promote mental wellbeing, increase staff confidence & effectiveness, take a whole school approach, develop a common language for 18
students, teachers, parents & carers, consistent approach and a range of evidence-based interventions. 8.5 We will also be extending the Understanding Your Child s Mental Health Workshops, codelivered with primary schools, providing emotional tools and creative resources to parents/carers that they might use. Rather than this being a parenting course, or prescriptive and based on behavioural models the workshops are experiential, drawing from the same evidence base as programmes such as Solihull, Mellow Parenting, Thrive and the Nurture Programme. 8.6 Within Torbay we are reviewing our offer to children and young people who are on the edge of care. At present this service is mainly provided by a single agency, we will build on this work and develop a multi-agency team who are trained in delivering evidence based therapeutic programmes for these families. This will reduce the amount of children and young people entering into the care system and support reunification. 8.7 Year 2 In year 2 we would firstly focus on improving our Early Help and early intervention provision within Torbay with a specific emphasis on the development of a robust system wide Parenting Strategy across the age range. This strategy and programme of work will be developed and delivered across the multi-agency sector including Health, Local Authority, Children s Centre s and Education. More recently within Torbay due to austerity measures and cuts we recognise that these services have reduced significantly. We want to build on what we know works but develop this within a multi-agency framework. It is well known the impact that evidence-based parenting programmes have on reducing mental ill health on a child or young person. This in turn also reduces the risk of school exclusion, family breakdown and criminality. We will ensure that programmes are delivered by workforces who have been trained in delivering evidence based parenting programmes, including robust clinical supervisory processes to ensure there are clear governance and accountability systems in place. These programmes will be delivered within a variety of settings building on the local multi-agency teams that are in development through the Torbay SWIFT programme. 8.8 Our second ambition would be the development of an evidence based adolescent peer mentoring model for those considered to be most at risk, which understands the core components of effective mentoring relationships. Adolescents considered at risk will increase emotional resilience and their ability to stay mentally healthy and to be educationally and socially successful in the face of significant adversity. This will be delivered in Torbay secondary schools. Both the mentors and the mentees will have improved mental health outcomes as well as improved educational outcomes. 8.9 Within Torbay and South Devon there is a dedicated perinatal service. This service is a multi-agency and multi-disciplinary service across AMHS, CAMHS, Midwifery and Health Visiting. Thirdly, we want to develop this service further and work more closely with children s social care to provide a therapeutic service to those parents that would not traditionally meet the criteria for an adult mental health service but would have significant 19
emotional difficulties that would affect their attachment relationship with their new-born. This service would provide evidence based therapies to parents in supporting and improving their emotional well-being so that they can provide a good attachment relationship to their new-born. This will reduce the amount of babies, children and young people entering into the care system as well as reducing adoption rates. 8.10 SDT CCG already takes a co-ordinated multi agency approach to joint commissioning placements for all children, those who are looked after children or those needing respite, with learning disabilities or needing step down support following intervention at Tier 4. We have recognised that facilities are limited locally and have worked on individual cases with adults providers for those in transitions and on a more regional basis to meet the needs of those who are younger. Our particular need would be to look at more adolescent placements and work with some of our existing provider. A showcase event is planned in October 2015 for existing providers in Torbay to look at what they might be able to offer in the future. Moving this forward would enable our young people to benefit from supportive accommodation, as well as the crisis intervention service already described and the Learning Disabilities practitioners within CAMHS. 8.11 Year 3 Within Torbay there is a limited diagnostic service for children and young people where there are neurodevelopmental concerns. This pathway is not joined up and at present ADHD and ASC are separate pathways. For children and young people with ADHD they receive assessments following NICE guidelines and a limited treatment service, similarly for ASC, however on-going support for these families is not available from experienced practitioners. We will be extending this pathway to ensure that children and young people and their families receive on-going support and treatment that is evidenced based across a multiagency pathway involving all services working with children and young people. This will provide a comprehensive offer of care to ensure that this vulnerable client group receive the most appropriate and responsive support and treatment. We will also be developing an MDT whereby prescribing responsibility and monitoring can be managed by nurse prescribers and therefore releasing paediatric time. Treatment offers include evidence based parenting programmes, behavioural support programmes within education settings and individual therapy for children and young people where indicated. 8.12 Year 4 & 5 During year 4 and 5 we will be transforming and working on developing an all age service for children, young people and adults who present meeting the requirements of the Crisis Care Concordat. 8.13 We will also be transforming and developing a similar service for children and young people with neurodevelopmental concerns. This will provide a seamless service to this vulnerable client group. 8.14 IT infrastructure will also need to be considered and developed within the lifetime of the funding. Initial scoping will take place in year 2. 20
8.15 Evaluation: Our agreed Key Performance Indicators will be a tool to monitor performance against national and locally agreed indicators. We can also review our compliance with the selfassessment tool on an annual basis to review progress. However keeping patients, their families and carers at the heart of our service design means we also need their evaluation of the service. We intend to look at some of the funding released by CAMHS Transformation to continue the work public engagement work of CYPIAPT. We have agreed to regular engagement with Young Devon s families and patients groups and we have agreed to organise an accessible strategic meeting so that young people can attend and put their questions directly to senior providers and commissioners as well as seeing how CAMHS planning takes place. 9. COST OF SERVICES IN YEAR 1 9.1 Transformation Fund Service detail Cost in year 1 Eating Disorders Torbay and South Devon 157,724. Total to invest in other services in 15/16 394,798. 10. 5 YEAR OUTCOMES 10.1 In Summary SDT CCG would anticipate that by the midpoint of our 5 year plan we would have achieved our aspirations for reducing tier 4 admissions by 50% overall and reduced admissions to our acute children s ward for eating disorders and those presenting in crisis as well as reducing those known to CAMHS presenting at A&E in crisis, as well as reducing length of treatment time for eating disorder patients. At this point we would more accurately know if we were able to support our plans for infant mental health, continued work with schools and neurological assessment. Undoubtedly it will take 5 years of increased intervention to bring about truly transformational change for this current generation of children and young people, new challenges will come along the way and only continued stakeholder and patient/ parent engagement will keep us on the right track. At the end of our 5 year plan there is the potential to review the impact on adults services that investment in these changes has brought about, which might continue to drive the focus on children and young people s mental health and wellbeing as the determining factor in shaping their needs for adults provisions. 21
Appendix A: Eating Disorder Service (Torbay) Costings and staff requirements for the new model. Recommended levels based on referrals PA Current staffing in Torbay Current staffing in South Devon Staff increases for South Devon Staff increases for Torbay Additional Cost from Transformation Funding Head of service (psychiatry/psychology) Specialty Doctors (psychiatry registrars) Paediatric Consultant 100 1.2 1.6 0.2 0.1 0 0 Staff for Devon CAMHS is outlined at appendix C but is not broken down by 0.1 WTE 0 0 0.1 WTE 0 0 20,800 South 2PAs per week At 200 each. One for Torbay and one for Senior Clinical Staff (Band 8a/8b) 1.7 0.1 specific service 0.1 WTE 4,756 ED therapists (Band 7) 6.7 0.2 area. 1.6 WTE 0.5 WTE 86,100 Home Treatment 2.5 0 1.0 WTE 35,000. Specialists (Band 6) Assertive outreach Intensive \practitioner Dieticians (Band 6) 1.5 0.1 0.2 WTE 0.2 WTE 14,000. Support Staff/ psychology assistants (Band 4) 1.8 0 0.4 WTE 0 9,000. Administrative support 1 WTE band 3 For Torbay and South 19,461 To achieve the national model proposed, (already being run in South Devon at the expense of core CAMHS services), SDTCCG anticipates it will cost approximately an additional circa 31.5K per year to run the service across the population of South Devon and Torbay. 189,117. However, we are taking account of this through our overall strategic planning for CAMHS as well as the whole system change we expect to see through the Vanguard programme for urgent care. 22
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