AGENDA ITEM 7.5 CHILD AND ADOLESCENT MENTAL HEALTH SERVICES Executive Lead: Director of Public Health Author: Rose Whittle CAMHS Commissioning Lead Contact Details for further information: Rose Whittle 029 2053 6816 SITUATION Services for children and adolescents with emotional and mental health needs have been under scrutiny in recent months with concerns expressed about the ability of services to meet need. This report provides an update on the emotional and mental health work programme, which includes development of the commissioning specification for services and the service delivery models including governance arrangements. It includes services across the whole system from early support and intervention through to specialist child and adolescent mental health (CAMHS) provision. BACKGROUND Welsh Government published an all ages strategy Together for Mental Health in October 2012, (replacing previous age specific strategies and frameworks).the strategy has an emphasis on prevention and early intervention, in addition to describing specialist mental health services for those who need them. The Mental Health (Wales) Measure 2010 with its new duties on NHS and Local Authorities plays an important role in support and provision. Childhood mental health problems are unfortunately very common with one in ten children having a diagnosable emotional mental health problem which could benefit from support. The level of emotional mental health problems in our young population is increasing. The increase has not been in severe enduring functional illness but rather the recognition of stress, anxiety, depression and behavioural issues including risk taking behaviours which may nevertheless go on to become enduring problems. The impact of all levels of acuity of these issues on the health and well being of children and young people has become increasingly recognised. However the services required to support this growth simply haven t kept pace. Support required is complicated by the need for a multiagency approach, including local authority services, third sector, carers and families. Education, social services, parenting services as well as health all have a vital role to play. Child and Adolescent Mental Health Services Page 1 of 11 Board Meeting
Growing such multifaceted services in a co-ordinated and responsive manner has proved a serious challenge to public sector services, which the current work programme has to surmount Concerns about inability to access risk assessment in a timely fashion resulting in young people waiting in A&E and on occasion being placed on inappropriate adult wards has informed the current detailed work programme to enable a sustainable service to meet need. But some immediate interim actions have had to be put in place to provide the safest service we can whilst we work to achieve a sustainable service. There have been concerns raised about access to specialist services nationally (HIW/WAO follow-up review of safety issues, published in December 2013) pressures include accessing inpatient beds and children and young people being cared for in inappropriate adult environments. The issue is particularly acute for young people aged 16 18. There are also shortcomings in specialist eating disorder services (this is being tackled through an all Wales task and finish group). Our prevention and support partnership services are provided with our two local authorities, some third sector partners, primary care, our child health services and link with adult mental health services. These provide support services within the community in many different environments. Specialist CAMH services for our children and young people are provided by the Managed Clinical Network operating from Cwm Taf Health Board. These services link closely to child health and adult mental health services, provided by Cardiff and Vale UHB. They aim to deliver a joint approach to meeting the physical and mental health needs of children and adolescents and also to manage the transition to adult services. WHSSC is responsible for the commissioning of highly specialised child and adolescent mental health services, which includes the crisis service (CIT) and inpatient services. For southern Wales WHSSC commissions inpatient mental health beds from Cwm Taf Health Board, which are provided at Ty Lydiard. There are clear criteria for admission to inpatient mental health beds for children and young. In October 2013 the UHB set off a work programme to agree a sustainable service model for emotional and mental health services. It became immediately apparent that a parallel set of actions to manage pressures in the short term was also required The sustainable model: The model needed to be developed with and agreed by all the partners involved in this service. A rapid needs assessment was undertaken to inform the work, a review of service models elsewhere was conducted and expert advice from Royal College publications was considered. A draft service specification was completed by December 2013. At this stage, it became clear that every partner had a different expectation and perception of what each partner should provide to support children and young people (even though there was joint development and partnership delivery in place). Each also had a different interpretation of risk assessment and subsequent support required for each child and young person. These differences were carefully worked through and discussed in a workshop in January 2014, resulting in clarity on what service elements needed to be defined and Child and Adolescent Mental Health Services Page 2 of 11 Board Meeting
provided as well as the nature of partnership provision. Five key areas were agreed and each have a clear action plan and delivery milestones (see below). The short term action: The parallel stream of work set out to understand and contain the immediate operational concerns whilst the longer term service modelling work was being undertaken. This put in place better communication between the UHB and the provider, ensured lead clinical practitioners worked more closely together, tested and strengthened the day to day governance arrangements and developed a referral pathway for children coming through the A&E department. In January 2014 an interim pathway for urgent referral to specialist services from general practice was also put in place. Monthly commissioner provider meetings were commenced from October and operational biweekly meetings were strengthened. Since October the specialist service provider (Cwm Taf) has continued to experience staffing pressures which have required on going review, assessment of service provision, risk assessment and altered levels of service provision to manage risks and pressures. None of these short term actions are ideal however they are known, discussed and being managed and they are actively informing the future sustainable model. The actions are concentrating on safety and risk management. ASSESSMENT Five key areas are being completed: 1. Primary care: The model for delivery of Primary Mental Health Services and Part 1 of the Measure, which includes clear pathways of support to primary care and access to specialist services when required, is required. An integrated service model which meets the needs of all stakeholders and the requirements of the measure is being finalised. Learning from other models operating nationally has informed the work. A final model will be presented to a multiagency workshop session in April 2014 for agreement. The new model will be implemented in July 2014 2. Multidisciplinary risk assessment service: Development and implementation of a multidisciplinary / multiagency response to support those children and young people where a professional judges they need urgent assessment and support is underway. This includes those with risky behaviour who today are likely to present at the Emergency Unit. These young people require: Mental health assessment /risk assessment A place of safety A multidisciplinary strategy meeting A risk management plan (including support package) The work is learning from the FOPAL model in elderly care, which follows the same principles but for a different vulnerable group. The model being developed will be agreed at the multiagency workshop in April 2014, with a view to beginning implementation in July. However once the model is agreed Child and Adolescent Mental Health Services Page 3 of 11 Board Meeting
there will be partnership agreements to be reached, resourcing implications to be jointly owned and resolved. 3. Specialist NHS CAMHS The specialist NHS specification is being finalised and discussed with provider organisations and partners. The specification includes quality and activity performance metrics. It will be finalised by the end of March (2014). In finalising this, some decisions on relative priorities will be required (expert advice has been taken on this). Assuming an unchanged commissioning resource it is unlikely that every service element required for a 'gold standard' service can be commissioned. The resource quantum will finalised before the end of March when discussion on relative priorities can occur, impacts understood and recommendations made. 4. Children and young people involvement Two focus groups are being planned with young people and carers to discuss the service models and identify issues to support service improvement. The groups are planned for April. This work is being led by third sector partners. 5. Links with WHSCC Clear links established with WHSCC Specialist Commissioning to support the interface between specialists and highly specialist services are in place. These five areas are interlinked and successful completion will be predicated on continued and strengthened partnership working. A further phase of work will require moving to a single partnership commissioning plan and speciation for the totality of CAMHS, with aligned budgets as a minimum and joint performance review. Scoping of work required the time table and link to our other joint commissioning work is underway. One final component of partnership working still requires consolidation and this relates to the strategic planning and delivery oversight structures under the Welsh Government s all age strategy 'Together for Mental Health'. At present the Mental Health Partnership has oversight for CAMHS, but the membership finds an all age approach a challenge. Our 'Child and Adolescent Emotional Mental Health and Wellbeing' partnership group which focused on needs and non (health) specialist partnership services, but also provided a forum for ensuring interface discussion with specialist NHS CAMHS, has had a large turnover in membership. Its role in supporting the all ages partnership needs to be reviewed. Its interface with operational service delivery and problem solving is also being reviewed. This will be resolved by the end of April. RECOMMENDATION The Board is asked to: Child and Adolescent Mental Health Services Page 4 of 11 Board Meeting
CONSIDER the actions being taken forward NOTE the update on governance and service development issues in CAMHS. AGREE that a further update be provided to the July meeting. Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance Equality and diversity The working assumption is that all refocusing should be resource neutral. However any resource consequences of the remodelling will be worked through in detail and brought into future prioritisation discussion within the Board. The developments described in the report are designed to improve the quality of CAMHS for Cardiff and Vale residents and ensure robust clinical arrangements are in place between the provider and commissioner. This work contributes to compliance with Standards 3 (Health Promotion, Protection and Improvement), 8 (Care Planning and Provision). Arrangements being put in place to between provider network and the UHB to ensure appropriate governance arrangements in place. Implementation of the Mental Health Measure and the agreement of a commissioned service model will work to improve equity of provision across the community taking account of specific subpopulation needs. Child and Adolescent Mental Health Services Page 5 of 11 Board Meeting
Appendix 1 WORKSHOP HELD ON WEDNESDAY, 15 TH JANUARY 2014 AT 9AM 12NOON OBS & GYANE SEMINAR ROOM, UHW PRESENT: NAME TITLE ORGANISATION Ball, Claire Clinical Director for CAMHS Cwm Taf LHB Birchall, Claire Head of Operations & Delivery, Children & Women C&V UHB David, Catherine Assistant Head of Finance C&V UHB Davies, David Principal Educational Psychologist Vale Council Davies, Paul Assistant Director of Operations (Mental Health) Cwm Taf LHB Downey, Jim Head of Clinical Psychology, CCN Cwm Taf LHB Evans, Rachel Head of Children & Young People s Services Vale Council Eydmann, Conrad Head Of Substance Misuse C&V UHB Herbert, Wendy Hettiarachchi, Callista Head of Children's Nursing and Specialist Community PH Nursing Consultant CAMHS C&V UHB Cwm Taf LHB Hopkins, Sharon Executive Director of Public Health C&V UHB Hunt, Jenny Head of Paediatric Psychology C&V UHB Newton, Linda Director Cardiff & Vale Action for Mental Health Norton, Catherine Consultant Paediatrician C&V UHB Pike, Joanna Educational Psychologist Cardiff Council Proctor, Annie Clinical Board Director, Mental Health C&V UHB Rowlands, Sian Clinical Governance Manager, Primary, Community & Intermediate Care C&V UHB Steer, Chris Senior Nurse, CAMHS C&V UHB Child and Adolescent Mental Health Services Page 6 of 11 Board Meeting
Wei, Anne Strategic Partnership and Planning Manager C&V UHB Whittle, Rose Wile, Ian Head of Paediatric Therapies / Integrated Partnership Head of Operations & Delivery, Mental Health Clinical Board C&V UHB C&V UHB Willett, Julian PMHSS Manager C&V UHB 1. INTRODUCTION / BACKGROUND Dr Sharon Hopkins welcomed members from the various organisations to the session and brief introductions were made. Dr Hopkins stated that the purpose of the workshop was to establish a clear specification of services that Cardiff and Vale University Health Board will be commissioning. She advised that today s session will focus on the NHS component of CAMHS and how to best meet the needs of the population in C&V and that in the slightly longer term, this would need to be put in the context of wider, joint commissioning for CAMHS as a whole. Dr Hopkins reported that the reason for the diverse selection of members was to gain an extensive expert view on what absolutes needed to be included in the specification. Dr Hopkins also reported that there will be some very difficult conversations to overcome as resource is significantly less than the specification requirements and therefore need to establish where the resource would be most effective. She stated that they also needed to be open minded in respect of who this work will be commissioned as this could potentially change from the current provider, Cwm Taf Health Board. 2. DEVELOPMENT OF DRAFT SPECIFICATION Rose Whittle, the author of the specification explained the basis for the content and stated that feedback following circulation had been extremely positive. She advised that, as Dr Hopkins had already reported, the main issue is resource and whether we have the capacity to deliver what is outlined within the specification. 3. CAMHS PROVIDER PERSPECTIVE ON PRIORITIES FOR CORE NHS CAMHS Dr Claire Ball, Clinical Director of CAMHS, gave a presentation on the current service provision and specification. Dr Ball reported that a benchmarking exercise was undertaken and currently the staffing levels do not meet the ratios set by the RCPsych for the population in Cardiff and Vale. She advised that training would also be an issue if the recommendations within the specification were to be met. There were also concerns raised in respect of children place out of county for treatment and assessments not being undertaken prior to agreement of the treatment. Members agreed that there were opportunities to save money but this would need significant work and close working relationships. In response to a query from Conrad Eydmann, Claire Ball advised that she was currently looking into the service specification for substance misuse as there was currently nothing in place. She advised that benchmarking was similar across all three Health Boards. Concerns were also raised as to where neurodevelopment would sit. Child and Adolescent Mental Health Services Page 7 of 11 Board Meeting
4. PRIORITIES FOR CORE NHS CAMHS FROM OTHER SERVICES OR SECTORS Representatives from each organisation gave a brief presentation on what they feel are their absolutes. Children s Service - Cardiff & Vale Covered by specification: Diagnosis Assessment Emergency Treatment Research & Development Strategy for children returning to the area Agreed protocol for Looked After Children Adoption post service Advice to children and carers family assessments Emergency psychiatric disorders Educational Psychologists Clarity - where we go to access different agencies coming increasingly unclear. Concern if concentrate on Part 2 of measure then there will be children who fall through the net or default to education. Do not have the capacity to cope with this. CAMHS to deal with the more complex children. Out of County Children - fall into a void and who has mental health authority lacks clarity. Critical Incidents how we link in with CAMHS maybe not frontline. PMH workers to attend forums in school, however, do not currently have the capacity as a large area to cover in Cardiff. This would be good as a preventative measure. Training Out of area accessing service Provide service in a number of settings i.e. home Access to inpatient setting Complex disorders Respond to issues of self harm Not in specification: Strengthening in detail of those children with complex needs but not diagnosis. Assistant / care co-ordinator roles CAMHS multiagency working to prevent risk. Preventative services Consultation / Training working with Tier 1 agencies is what Education want. Managing risk! The children may get excluded and then get place out of county, lead to substance misuse or YOS service which then impacted on other services and financially. Primary Mental Health - is absolute key Emergency Support for people who self harm / suicidal. Increase support for staff who deal with these type of situations. Support for risk assessment training within schools teachers / schools looking at how incidents impact on schools. Further access to therapeutic psychology Access to CAMHS at multi - disciplinary meetings on how to manage these patients. Child and Adolescent Mental Health Services Page 8 of 11 Board Meeting
Appropriate trained specialists Child Health Need to be clear who does the assessment element as CAMHS lacks capacity. Look who has the skill sets to undertake this Adult Mental Health Quality of transition to Adult Services Primary Care Governance needs to be central and firm relationships with all agencies need to be established. Clarity around referral process and those who do not fit criteria. GPS confused. Need to be systematic and organised Dr Claire Ball reported that emergency cases present to CAMHS at the Inpatient stage. She advised that they were currently in talks with WHSCC to discuss funding for a ward with five uncommissioned beds. She added that they can then look at their own position with these children and discuss with partner agencies. The group agreed that is would be beneficial to look at other resources with a view to merging these funds and prioritising services. Claire Birchall suggested inviting someone from the Innovation Team to look at efficiencies. 5. WORKSHOP SESSION How we balance these perspectives to determine what the NHS component of the overall service model looks like. GROUP 1 Primary Mental Health Shared recognition of the challenges around balancing the need to meet the legal requirements of Part 1 Mental Health Measure (MHM) via the LPMHSS model against the clearly stated value and priority placed by partners and local clinicians on the CAMHS primary mental health service model of working (this is primarily into schools and other community services where CYP needs are recognised and where they often receive their immediate support). Agreement of need for specific piece of work to determine how we should best use the limited collective resources so that services are more aligned against what we are measured against in the MHM, while retaining the primary mental health service model that more appropriately meets the needs of children and young people. Real opportunity in Cardiff and Vale to shape a way of working that improves the existing interface, increases the visibility within primary care of services available to support CYP and facilitates a culture change amongst GPs. This work could be undertaken by the LEAG; potential additional input from PCIC/GP with special interest required. Child and Adolescent Mental Health Services Page 9 of 11 Board Meeting
Assessment of Neuro-developmental Disorders Can we develop a different model for assessment that moves away from the fixation with assessment by particular professionals? Can we learn from the substance misuse model that reallocates the assessment function into a single hub, bringing together input from different professionals who are trained in a common assessment process, with the assessment and care plan travelling with the young person into whatever service subsequently provides treatment? A great deal of assessment already happens but is not co-ordinated or well communicated, and does not necessarily generate the information needed for another service to provide a professional opinion without separate assessment. Agreement of need for specific piece of work to develop a multi-agency assessment model that aligns with the TAF and Families First processes. This has the potential to enable limited CAMHS resources to be utilised more effectively and efficiently as well as benefiting the service user, their families and other service providers. More generally it was noted that all assessments must place consideration of the expressed needs of the client at the forefront rather than becoming too fixated on a professional need to assess. Emergency Assessments Concern that while the numbers are not large, there is a need to clarify how a timely risk assessment can be facilitated when a child or young person presents in A&E that does not inappropriately divert limited CAMHS resources from work that is viewed as being of a higher clinical priority. Agreement of need to look as a matter of urgency at the development of a multi-agency liaison team model in A&E with adult mental health. In addition, need to explore opportunity to extend the role of Substance Misuse Specialist School Nurses, broadening their skill base to support CYP with low threshold mental health problems and the management of risk. Again more generally it was recognised in both of the above areas that a creative review of skills held by various professions might alleviate some of the pressure points e.g. eligibility to assess under Part 1 of MHM, staff within general hospital who could risk assess, etc. N.B. The group did not have a chance to discuss Part 2 MHM which from CAMHS provider perspective is where we should focus specialist CAMHS health resource. GROUP 2 Statutory responsibility of CAMHS and Part 2 Work There was agreement that greater understanding was required from Specialist CAMHS on what the absolute core service they needed to deliver. Partners wanted clarity of referral criteria and greater understanding why referrals are not accepted. Also a process which ensured advice and support on alternative approach required if not a CAMHS referral. Emergency Assessment Clear agreement that we have a cohort of children who are not owned by any one service and therefore present a challenge for all partners. It was agreed that all agencies have a role to play and a shared multiagency approach was required which CAMHS needed to be part of. This would need to clarify the care coordination and require a shared understanding of risk and who had lead responsibility in managing the case. Some form of join protocol is required. It would be helpful to work through a case example to highlight the problems and support the development of solutions. Child and Adolescent Mental Health Services Page 10 of 11 Board Meeting
Primary Mental Health More capacity required in terms of advice available at Tier 1 and through Primary Mental Health Services. Better mapping of available alternative services such as Families First and 3 rd Sector providers. Easy access to advice. Other Ensure that the limited Specialist CAMHS Services is not wasted by: - Sort out shared care and prescribing. Agree who own the neuro-developmental work and the role of Primary Care in supporting this. 6. INVOLVING SERVICE USERS IN THE DETERMINATION OF PRIORITIES Linda Newton reported that she was currently in the process of looking at resourcing a group to include young people and carers to feedback their experiences. Dr Hopkins suggested Linda, Rose and Anne arrange a formal meeting to discuss how the users expressed needs can link in to the strategic work. 7. SUMMARY OF OUTCOME OF MEETING AND NEXT STEPS Dr Sharon Hopkins brought the meeting to a close by advising that another workshop will be required to move forward with this work. 8. NEXT STEPS The workshop has been viewed as a positive step forward and resulted in a clearer understanding of the work required. a) Delivery of Primary Mental Health Services and Part 1 of the measure. To include clear pathways of support to primary care and access to specialist services when required. There was agreement that the primary mental health work should be managed as an integrated service and a task and finish group will be set up to consider. What should that look like Enablers and barriers A decision will then be made on the service delivery. b) A multidisciplinary / multiagency response to support those children and young people requiring urgent support for risky behaviour who often present at the Emergency Unit. These young people require: A place of safety Mental health assessment A risk management plan It is proposed to build on work already started and learn from the FOPAL model in elderly care which follows the same principles but for a difficult vulnerable group. c) Specialist NHS CAMHS Specification to be finalised and discussed with provider organisation to agree delivery and performance monitoring. d) Service user engagement. To support two focus groups with young people and carers to identify issues to support service improvement. e) Continue to develop links to WHSCC Specialist Commissioning to support pathway development. Child and Adolescent Mental Health Services Page 11 of 11 Board Meeting