Warrington Children and Young People s Mental Health and Wellbeing Local Transformation Plan 2015-2020
1 Introduction 1.1 Welcome to the update on Warrington s Local Transformation Plan for Children and Young People s Mental Health and Wellbeing (LTP). The original plan (October 2015, click here) sets out the five year forward view for improving outcomes in mental health and wellbeing for children and young people, in line with the recommendations in Future in Mind (2015). This document is a refresh. It includes an update on progress; summarises findings from more in-depth engagement and incudes the most up to date information on local investment and performance of services. There is much progress locally and this collective effort combines to give greater clarity on local priorities going forward. 1.2 The plan is developed and owned by Warrington s Emotional Health and Wellbeing Board in partnership with wider stakeholders including children, young people and their families, local clinicians, Warrington Borough Council, 5 Boroughs Partnership NHS Trust, Bridgewater Community Healthcare NHS Trust, Warrington and Halton Hospitals NHS Trust, Primary Care, Third Sector partners and other non-statutory organisations, Youth Justice and Education providers. There is a high level of commitment to working together towards a shared vision and whole system change in order to deliver improved outcomes.
2 Integrated Commissioning and Governance Arrangements 2.1 Since the publication of the original plan, governance arrangements have been updated to include further detail and to reflect the groups that are leading on aspects of the plan. 2.2 2.3 Partners in Warrington have a good track record of partnership working to deliver local shared priorities and improvements. Over the previous six months, engagement and involvement of partners wanting to work together to improve children s mental health and wellbeing has strengthened and will be a foundation from which to explore different options for more joined up and integrated commissioning and delivery of services. For example, there is now a wide commitment to exploring a whole system approach to improvement. A steering group is in the process of being formed with representation from health, local authority, schools, third sector and service users, to oversee the development of a model.
3 Engaging with Stakeholders 3.1 In the original LTP, there was a clear intention for engaging further with children, young people and their families, and wider partners; and for continuing to involve them throughout the process. Between January 2016 and July 2016, local partners undertook the first phase of an experience based co-design process. This included in-depth experience based interviews with young people (or carers) that have experienced services. In addition, questionnaires were used to gain wider views and all the experiences were captured and presented at an event in July, where a wider group were able to add their own experiences. 3.2 A summary of the themes based on the experiences of children, young people and their families was compiled and is available here. 3.3 Some consistent themes emerged which will inform Warrington s priorities going forward: Need for earlier support and intervention that is easily accessed via schools, e.g. specialist services working more closely with schools. Better information/communication/signposting about pathways, what services are available, how to access them and what to expect when you do. Young people want more accessible services, which are available at times when they can access them independently, with the option for greater anonymity. Waiting times are too long. There is a need for more information about what to expect whilst waiting, how long it will take, and what help can be accessed in the meantime. Relationships, trust and being listened to are very important to young people when accepting help. The length of time for assessment and being able to access help for anxiety when a young person has autism or other neuro-developmental conditions is a concern for a significant number of families. We need to do better to prevent repeat crises and avoid inpatient stays by offering more intensive support in the community when needed and a better managed transition out of service to prevent relapse. Transition and hand offs between services, after a period of support or when young people transition into adult services continues to be an area for improvement. Easier access back into support is important. 3.4 We will continue to strive to involve service users to be key partners in the process of any re-design and improvement.
4 Update on Progress 2015/2016 4.1 The original plan published in October 2015, included an action plan for 2015/2016. This is shown below with minor amendments and a clear outline on progress. Given the first full year allocation was received in November 2015, a pragmatic approach was taken with regard to the best use of this funding. The focus was to direct the money to some priority areas to increase capacity and to test out some new models/ways of working. Additional funding was given on the basis that providers report more detailed data and information that can inform the development of the longer term plan and priorities. 4.2 Some of the funding was allocated non-recurrently and includes investment in workforce development, engagement and commissioning and procurement support. Table 1. 2015/2016 Action Plan Key theme What are we going to do? By when? Promoting Resilience, Prevention and Early Intervention Improving Access to Effective Support Extend the planned offer for online counselling services and engagement with schools Offer opportunity for small project bids for this academic year to support workforce development. Explore joint commissioning with schools/ opportunities for match funding to ensure sustainability Investment in a pilot to test new model and support management of ED cases in line with guidance to ensure best use of resources and preparedness while new service is developed. June 2016 July 2016 Mobilise staff by Nov 15 How will we know if we have achieved this? 1 year contract in place with extended offer Outline criteria for projects, review bids and allocate money jointly with LA, release money to school by end of March 2016 Framework for pilot agreed, commitment from mental health provider and acute provider to release staff, key measures agreed to support evaluation and inform longer term planning and commissioning of a 500K ED services Who? WCCG and Kooth WCCG, LA and schools WCCG. 5BP, WHH NHS Trust Update on Progress Contract commenced 1 st February New relationships developed with schools. Schools have carried out an audit. 4 school staff successful in gaining a place on IAPT course. Joint plan developed to initially focus on staff development, in process of being implemented and will be evaluated Parameters of project agreed and joint meetings between 5BP and Warrington hospital have commenced. Key measures agreed and reflected in CAMHS service spec and to be supported by a CQUIN. Start
Allocated money to backfill staff time. date delayed but now fully up and running. Jointly commission 8-18 ED disorder. St Helens CCG as lead CCG for ED to host a project lead for 6 months Enhance out of hours crisis response into A&E for CYP to ensure timely access to mental health assessment and discharge. This is a pressure point at the moment and will help release pressure short term to inform longer term planning around crisis care. Aim for go live April 16 March 16 Project lead in place November 15 Project plan developed to complete the process within 6 months An 8pm midnight service will be accessible. CCGs x4 WCCG, HCCG, WHH NHS Trust Procurement completed and contract awarded. Mobilisation plan underway. Original go live date was overly ambitious An 8pm midnight service enhanced offer now in place at Warrington Hospital. Recruitment of staff has been completed and the service has commenced. Slippage on time frame Investment in a pilot to test a pathway for management of self-harm cases. Evaluation to enable improved information and evidence to inform longer term planning. Jan June 2016 5BP to identify staff to focus on selfharm and organise backfill WCCG, 5BP Project outline and KPI s agreed. Staff identified with arrangements for backfill underway. Work is on-going Caring For the Most Vulnerable Additional capacity for St Joseph s (tier 2 provider) Pilot SLT as part of YOS team to support integrated working and care coordination Additional capacity within third sector organisation to offer life-story work for looked after children. March 2016 Aim for Jan 16 for 6-12 months Aim for Jan 16 for 6-12 months Framework for pilot agreed, member of staff released from community provider and backfill provided, key measures agreed to support evaluation Variation of contract in place, additional counselling hours provided to deliver life-story work and evaluation of impact undertaken. WCCG, St Joseph s WCCG, PH/YOS, Bridgewater, 5BP WCCG, LA, Third Sector organisation, 5BP Additional funding provided to increase number of sessions Project outline and KPI s agreed, staff in place and project underway. Work is on-going Variation to contract explored, decision taken by LA to carry out procurement for a 12 month period to open up the market, go live date amended to 1 st October. Contract
Accountability and Transparency Developing the Workforce Commission experience based co-design (or equivalent) to inform whole pathway planning for the next 5 years Support 5BP to release staff for IAPT training Schools based pilots to support workforce development (see above) CAMHS staff to be trained in VIG (Video Interactive guidance) to support parentinfant relationships Training to be delivered to Family Support Workers, CAMHS and Health Visitors to deliver Mellow Babies Mar 16 On-going Jan 17 Mar 16 Commissioning of an organisation completed. Communication and engagement plan in place. CAMHS staff offering VIG as an intervention to support the parent-infant relationship Mellow Babies groups offered to parents and infants at risk of attachment difficulties WCCG, LA, PH WCCG, 5BP, LA 5BP 5BP, Bridgewater, LA awarded. Phase 1 of engagement work Completed As above Plans amended. Video Interactive Guidance will be utilised as part of the CAMHS offer to support attachment issues of service users. May be offered as part of the Infant Mental Health service dependent upon workforce allocation. Plans amended. 21 Health Visitors trained in NBO (Neonatal Behavioural Observation) and 3 staff due to be trained in NBAS (Neonatal Behavioural Assessment Scale). Bridgewater commissioned to provide Time for Me (Therapeutic Art Group for Perinatal Mental Health), 3 groups over a 12 month period. 4.3 Warrington has made good progress in delivering on the initial short term action plan with all areas in the plan progressing. In working to deliver on this action plan over the last 6 months, relationships have developed and further intelligence has been gained that highlight areas of priority for Warrington to enable delivery on the recommendations in Future in Mind.
5 Update on Progress 2016 2018 5.1 Partners have worked together locally to develop a whole system action plan in line with the Future in Mind recommendations. This action plan available here is an iterative document that will be updated over time. This plan is aligned with the broader promotion and prevention plan for which Public Health is the lead. An initial 12 month plan for schools is has been developed available here. 5.2 The focus for 2016/2017 has been to continue with the streams of work that commenced with the additional funding from 2015/2016, whilst working with partners to refine priorities and develop sustainable longer term plans. This maintains additional capacity in the system and enables learning to inform further improvement. The joint strategic needs assessment for children and young people s mental health is in the process of being updated. This will ensure that locally there is a much clearer understanding of needs and gaps. Work has been undertaken to understand the experiences of children and young people along with engagement with wider partners as described above, both of which will continue throughout any re-design that may be undertaken. 5.3 Some key elements of the full action plan are outlined below: Table 2. Key aspects of 2016-2018 Action Plan Key theme What are we going to do? By when? How will we know if we have achieved this? RAG Promoting Develop a service for infant mental health June 17 Service in place Resilience, Prevention and Early Intervention Continue to support schools with a borough wide whole schools approach to PHSE, including mental health champions in schools and staff training. To include evaluation. Explore joint commissioning April 17 Named mental health champions for every school, Borough wide strategy for PHSE and school staff training Improving Access to Effective Support Review and re-design tier 2/tier 3 services (including online provision) to enable easier access along a continuum of need in partnership with Halton CCG and 5BP. Explore the THRIVE model. Commission eating disorder service with 3 partner CCG s Develop existing emergency response service for children and young people in crisis to meet responses times in line with national guidance Sept 17 Oct 16 Mar 17 Dec 17 Mapping of current services, needs analysis and user engagement completed, new pathways developed, business case completed and service spec developed. Procurement process complete Service fully operational National response times achieved
Caring For the Most Vulnerable Accountability and Transparency Developing the Workforce Explore an integrated home treatment service for the most vulnerable/children, as part of a THRIVE model if appropriate To develop additional roles to improve support, make best use of resources and ensure a more joined up approach between community health and mental health services for children and young people with neurodevelopmental difficulties. Consider need for a wider review of the pathway. Sept 17 Sept 17 Proposal for a service or pathway is proposed/approved as part of the wider whole system model Service users report improvements in getting support for comorbid mental health concerns Develop system wide dashboard Jun 17 System wide dashboard up and running Engagement with young people, families and schools to inform improvements On-going To support any changes proposed Continue to support roll out of IAPT On-going Local workforce accessing IAPT training Develop a workforce strategy explore doing this in partnership with other CCGs Mar 17 Workforce strategy developed
6 Accountability and Transparency - Data Refresh 6.1 NHS Warrington Clinical Commissioning Group, Warrington Borough Council and Public Health spent 5,733,439 on emotional health and wellbeing during the period 1 st April 2015 to 31 st March 2016. This is an increase of 720,439 from the previous year (14.4% increase). 313,586 of this was Public Health increasing funding for Health Visiting, School Nursing and Family Nurse Partnership. The additional 406,853 was for targeted and specialist children s mental health provision or related support. Note, there is an amendment to the 2014/2015 data due to rounding of the figure in the LTP published October 2016. Table 3. Overview of Investment for 2014/2015 and 2015/2016 2014/2015 2015/2016 Commissioner Service Amount ( ) Commissioner Service Amount ( ) CCG CAMHS 1,455,000 CCG CAMHS 1,611,500 Borough Council CAMHS (tier 2) 138,000 Borough Council CAMHS (tier 2) 138,000 CCG CAMHS (tier 2) 22,000 CCG St Josephs (tier 2) 20,000 CCG St Josephs (tier 2) 50,216 Borough Council St Josephs (tier 2) 20,000 Borough Council St Josephs (tier 2) 20,000 Public Health School Health, Health Visiting and Family Nurse Partnership 3,220,000 Public Health School Health, Health Visiting and Family Nurse Partnership 3,533,586 Public Health Risky behaviours team - Youth Service 160,000 Public Health Risky behaviours team - Youth Service 160,000 CCG Project / Commissioning Support 24,176 CCG Vulnerable Children/Core Assets 40,000 CCG Perinatal MH Workforce Development 31,561 CCG Kooth 72,400 CCG Borough Council - YOS / SaLT 30,000 Total: 5,013,000 Total: 5,733,439
6.2 A refresh of key service level data is shown below in table 4. It was noted in the LTP published October 2016 that the data should be considered with caution. This is also the case for 2015/2016 as the mental health provider transitioned to a new IT system called RIO. It is expected that going forward the date for 2016/2017 onwards will be more reliable and there will be increasing scope to provide more detailed data. Table 4. Updated CAMHS service data Please note: Additional funding has increased the staff complement within core CAMHS (on a temporary basis while we undertake a review); however due to the time taken for staff to start in post an increase in staffing could not be reflected in 2015/2016 data. There is 7.8 additional clinical staff that have started at various points from April 2016 onwards. 2014/2015 2015/2016 (wte at year end due to restructure) includes CART Tier 3 CAMHS includes CART Tier 3 CAMHS Total number of clinical staff (WTE) 10.6 wte tbc 10.6 wte (2.0 psychiatry, 1.0 clinical team manager, 8.6 other clinical) Total Number of Non-Clinical Staff (including admin) (WTE) 6.6 wte Admin 4.0 wte Number of children and young people referred into service 1132 279 1137 207 Number of children and young people accepted into service 844 275 734 204 Average waiting time to assessment (days) 17.9 30 Average waiting time to treatment/intervention (days) 76.8 58
Total Number of consultations offered (not face to face/indirect contacts) 42 140 18 95 Total Number of face to face appointments offered 1556 5308 950 4381 Average length of time in the service 61.1 410 61.1 410 Average number on caseload 147 328 139 298 Number of discharges 1204 284 1119 258 Types of MH intervention offered CBT, Psychotherapy, family therapy, psychology include neuro assessments, behavioural assessments, parenting assessments, mental health risk assessments and other interventions as per NICE guidance CBT, Psychotherapy, family therapy, psychology include neuro assessments, behavioural assessments, parenting assessments, mental health risk assessments and other interventions as per NICE guidance 6.3 Specialist Commissioning has commissioned 1,388,499 of provision for supporting emotional health and wellbeing during the period 1 st April 2015 31 st March 2016. This is a significant increase on the previous year and is broken down as follows: Table 6. Data from Specialised Commissioning Tier 4 (commissioned by NHSE) Amount 14/15 ( ) Amount 15/16 ( ) Occupied Bed Days Number of YP Eating Disorders 168,480 367,250 602 3 Other 558,830 1,021,249 1867 23 PICU 111,375 0 0 0 Total 838,685 1,388,499 2469 26 Please note: NHS Warrington CCG and 5 Boroughs Partnership NHS Trust are carrying out some local verification of this data.
7 Refining Priorities 7.1 Over the last 12 months, wide engagement, the emerging picture from the refresh of the joint strategic needs assessment and the gathering of more in depth data locally are all combing to give a clearer understanding of local need and an understanding of unmet needs and gaps where greater efforts will be required to deliver improvements. When viewed in the context of national guidance, key priorities have been identified. 7.2 Eating Disorders: through dedicated investment, a specialist community based eating disorder service has been commissioned (following a procurement process) and will be operational by March 2017. 7.3 Whole system model: work is underway in partnership with NHS Halton CCG, to undertake a whole system review of pathways for children s mental health and wellbeing with CAMHS at the heart. Locally, this must address a number of key issues: Easier and earlier access to support at lower levels of need, e.g. specialist services working more closely with schools, increased access to evidence based interventions, reduced waiting times Addressing the issue that some vulnerable groups are less able to access support because they do not meet current criteria, despite significant risk of poorer outcomes. Locally this includes where young people s difficulties are attributed to contextual factors (such as poor attachment, unstable family circumstances and behaviour difficulties) or those with neurodevelopmental difficulties with associated mental health concerns. Addressing these gaps will require more integrated solutions. It has been agreed that a system wide steering group will oversee the development of a local model representatives have been nominated from NHS Warrington and Halton CCGs, 5 Boroughs Partnership NHS Trust, Warrington Borough Council and Halton Borough Council, schools and the Third Sector. 7.4 Peri-natal and infant mental health: locally we will work in line with national guidance to improve support for peri-natal mental health. In addition, there is commitment to develop a specialist infant mental health service (as part of a whole pathway of support) that will use evidence based interventions to improve attachment with key caregivers to prevent longer term difficulties developing. 7.5 Better crisis care and intensive support: a new service to respond promptly to young people in crisis that present to hospital in the evening is now up and running. National guidance is expected soon to support improvements in this area. More detailed plans will be developed in light of this guidance.
8 Summary 8.1 This document is a refresh of the Warrington Children and Young People s Mental Health and Wellbeing Local Transformation Plan. It is to be read in conjunction with the original plan (October 16) and associated documents (embedded). It provides an update on plans and progress to date, a refresh on data, and an overview of plans and priorities going forward. 8.2 Over the last 12 months, with additional investment, capacity across services to support children s mental health and wellbeing, across a range of need, has increased. A specialist community based eating disorder service has been commissioned. Work is well underway to have a much clearer and more in-depth picture of local need. Engagement across partners (including schools) to work collectively to develop an integrated, jointly commissioned model is developing; the associated governance to support the work is strengthening. Priorities on which to focus collective time and effort have been refined. 8.3 Much progress has been made in the last year. There are challenges ahead and decisions to be made that require collective support and effort. With continued and sustained effort and commitment across partners with established relationships, we are in a good position to take forward real transformational change by 2020.