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Lead Director |
Executive Director of Primary, Community Care and Mental Health |
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Author |
Julie Richards, Women and Children’s Service Manager Mary O’Grady, Head of CAMHS and LD |
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Service |
Child and Adolescent Mental Health |
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Inquiry |
Powys Response |
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Specialist CAMHS |
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The extent to which new (and/or reconfigured) services are helping to reduce waiting times in specialist CAMHS. Whether the improvements in waiting times Welsh Government expected from CAMHS have been met. |
The current service provision is predominately reactive with little opportunity for proactive opportunity to focus on creating resilience for dealing with emotional health and wellbeing pressures such as exam pressure or skilling up stakeholders with Mental Health first aid skills.
Waiting times have fluctuated over the past year with periods when the target has been exceeded and periods when it has been of concern. This has been due to increased referrals over some periods and also a reduction in staffing. The addition of dedicated time for crisis work ensures that the 48 urgent assessments are completed on time.
The service received an increased number of referrals between January and March 2017 which has adversely affected the targets both in respect of assessment and interventions. Due to increasing demands, inadequate responsiveness and non-compliance with Mental Health measure a CAMHS service review is currently being undertaken.
The 1st stage approach of the review has been undertaken with the following scope: · Primary Mental Health and Specialist CAMHS provision for Children and Young People in Powys · Specialist CAMHS provision for Children and Young People in Powys · Administrative and infrastructures to support Primary Mental Health & CAMHS.
It is recognised that similar work should be considered for the Emotional Health and Wellbeing agenda and the Together for Children and Young People (T4CYP) framework.
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What the data tells us about the variations in practice (equity of access) across Wales |
The outcome of the All Wales Benchmark exercise (2016) reflected a positive comparative picture for Powys but there some key points to consider such as the higher senior nurse bands and plans for managing DNA rates (7% for Powys) such as a text service to follow up.
The outcomes from the External Quality Network for Community CAMHS (QNCC) which included patient experience and identified key areas for development
· Proactive offer of training, development and consultation to wider stakeholders · Initial appointment has been offered in a timely way but delay from assessment to intervention plans · All stakeholders not being able to directly refer · Variance on availability of identified duty doctor
The CAMHS service review will be able to utilise the information from the National Benchmarking report and recommendations from QNCC to improve services.
Care and Treatment plan audit for Powys CAMHS - There was excellent feedback on the standard of Care and Treatments plans, Smart orientated goals and evidence of person centred planning. They also highlighted the compliance with WARRN, an exemplar example of person centred letter to support transition to Adult services and relationships / engagement with young people, parents / stakeholders such as Education.
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The extent to which changes have addressed the over-referral of children and young people to CAMHS |
In Powys there is still a view of over referrals to CAMHS. PMHW posts are now filled therefore discussion with relevant refers including GP’s is now taking shape. The CAMHS service review is undertaking an audit of 3 months worth of referrals to understand:
§ Where the referral came from § What the referrer was looking for § How the service met the need § Patterns of referral and demand
By developing this level of understanding, the new service model will be better able to address the over-referral of children and young people to CAMHS.
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Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS
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The table below highlights that referral numbers have continued to stay high. The CAMHS review currently being undertaken has led to a more detailed review of referrals with a breakdown of the GP referrals as part of the Welsh Government Mental Health Measure with the service now considering two figures, GP referrals (Mental Health Measure) and in brackets all referrals.
The timeliness of assessments and interventions has recently been an area of concern and although the target of 80% has not yet been achieved the position is improving.
Despite the continuation of increasing referrals the service has been able to address the target figure and as can be seen from the table below the service is almost on target. The service utilised all staff who are able to do assessments i.e. crisis and CITT staff who would not normally undertake this task as routine to their posts.
Concentration on undertaking assessments and the increased number of referrals can have a knock on effect to targets for both assessment and interventions. The service has also addressed the situation and again the target is almost met.
The issues raised above and the structure of the team are being addressed in the CAMHs review focusing on demand and capacity.
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Whether the changes have helped to improve specialist CAMHS’ ability to respond out of hours and at time of crisis; whether out of hours is working effectively, and specifically looking at the needs of those children and young people who present and are assessed at hospital A&E departments. |
The service has recently faced a number of escalating concerns and crisis situation with increase demand / referral to specialist CAMHS service, challenges with geography and links to commissioned services and timely access to crisis & tier 4 pathways when critical situations arise.
Powys does not have an A & E therefore all young people presenting in A & E do so in neighbouring DGH’s. This can be up to seven hospitals with two being across the border in England. This gives some additional complications as service specs each area do differ. This is further complicated in England as arrangements are different for admission to Tier 4 beds. The situation then for Out of Hours is an added complication.
Significant problems are experienced in the North East of Powys with vulnerable young people presenting to Royal Shrewsbury Hospitals (SaTH). The cross border challenges often result in PTHB CAMHS patients experiencing unacceptable delays in assessment and treatment when accessing hospital services through A&E in SaTH.
The RAID service available in SaTH A&E is delivered by South Shropshire Foundation Trust and is an adult only service. In addition, SaTH are not responsible for the delivery of CAMHS in Shropshire. SaTH are only been able to manage the situation by holding the patient in A&E, which is not a conducive environment or, by admission to a general medical bed while waiting for a mental health assessment and therefore fulfilling their duty of care.
Many are young adults and not suitable for paediatric ward admission nor is it a suitable environment in the majority of cases.
Staff are doing their best to respond and provide effective care for young people with complex needs, but there is definite room for improvement with strengthened interagency relationships, care coordination and oversight.
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Whether there is sufficient in-patient capacity in Wales |
Powys does have young people in inpatient Tier 4 units in England due to capacity within Wales and the appropriateness of units.
There continues to be ongoing delay in arranging Tier 4 admission with a recent case taking 14 days (26th August until 5th September). The challenges of WHSCC commissioning, all Wales gatekeeper roles and Psychiatric completion of Forms 1 and 2 will be raised at a planned roundtable discussion to influences changes in process that are needed for the future Powys CAMHS model.
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Funding |
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Annual expenditure on CAMHS in cash terms and as a percentage of the overall spending on mental health, by local Health Board |
The direct spending on CAMHS (budget) is £1.201m (this excludes WHSSC or commissioned services).
The allocation for the Health Board is £301.618m, therefore CAMHS is 0.39% of the total allocation for the Health Board.
The total Mental Health budget is £23.699m (£22.498m MH + £1.201m CAMHS). CAMHS equates 5.06% of the mental health total budget.
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The extent to which access to psychological therapies for young people has improved. Whether there has been a subsequent reduction in the use of medication for young people. |
Powys does not currently record the number of young people on medication in a way that can be compared between periods. We are therefore not in a position to ascertain whether the changes to psychological therapies and any changes that this has made in the reduction in medication.
Powys is currently undertaking a review of its CAMHS services to ascertain if the structure is appropriate for the needs of the young people.
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How the additional funding has been used to improve provision for child and young people in local primary mental health support services. |
The CAMHS service benefitted from Welsh Government investment to develop a number of posts to support the primary mental health and specialist CAMHS service which has included the implementation of the Crisis Intervention Treatment team (CiTT), Crisis Intervention Practitioner roles, High Intensity posts and Psychological wellbeing practitioner.
Powys now has 3 primary mental health workers who are working with schools, partner agencies and GP’s.
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The extent to which the funding has been used to meet the needs of vulnerable children and young people, for example, children who are in care, children and young people with ADHD and autistic spectrum disorders, and those who are already in or at risk of entering the youth justice system, including those who are detained under section 136 of the Mental Health Act 1983. |
Following a long period of recruitment challenges, we have now successfully appointed a Clinical Nurse Lead for the Neurodevelopment service who is due to start on the 16th October 17, This recruitment will enable us to extend the existing SCAT process into a wider Neurodevelopmental service. We are also interviewing for a band 6 Neurodevelopmental Nurse for the North of Powys.
CAHMS and the Youth Justice Service are working together on the development of a psychologist post to advice and work with young people through the Enhanced Case management model but combining it to provide support for children and young people who are LAC and experience many changes of placement.
CAMHS provide a CPN to the YJS to support those children and young people who are in the criminal justice system or are at risk of entering it.
Powys has very few young people detained under section 136 of the Mental Health Act but nevertheless work constructively with partners when this does occur. These young people would fall into the remit of the Crisis workers.
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The effectiveness of current planning and commissioning arrangements to address the needs of young people who have early onset of a severe mental illness, sus as psychosis. |
The funding provided for young people who have early onset psychosis was incorporated into the funding for the Crisis Practitioners in Powys.
The Crisis Practitioners case manage these cases. All Adult Mental Health Services have recently returned to Powys and it is therefore now timely to discuss the planning and commissioning of such services.
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Transition to Adult Services |
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How well planned and managed transitions to adult mental health services are. |
Transitions to adult mental health services in general are well planned. There is a transition policy in place which is being reviewed in light of the guidance that has been recently published in T4CYP. This will also form the basis of transitions planning across children and young people, not just in relation to mental health.
There is a transitions working group and a regular monthly meeting to consider all young people in transition.
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Links with Education (emotional intelligence and healthy coping mechanisms) |
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The work being done to ensure children and young people are more resilient and better able to tackle poor mental health well-being when it occurs including:
1. The development of the Health and Wellbeing Area of Learning and Experience as part of the new curriculum.
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Schools in Powys are positive about the focus on Wellbeing in the new curriculum. There is wide, and growing understanding of the importance of readiness to learn, to learning.
Several pioneer schools are already implementing parts of the curriculum into their whole –school approach. In addition, there are many ways in which schools are already supporting pupil’s mental health and well-being. For example, our regional consortia, ERW, has provided training in Emotion Coaching and Attachment Awareness.
Schools support (and usually host) TAFs (Teams Around the Family), working with Action for Children (Primary) and the Youth Intervention Service (Secondary). YIS meet with High schools termly to review all their pupils, focussing on attendance, exclusions and pupils at risk of becoming ‘neets’ (not in education, employment or training.
Most Primaries have adopted the Incredible Years approach and support/signpost to parenting classes. Many run nurture groups and similar programmes (e.g. Thrive, Kiva and more) to support pupils holistic needs. Many High schools run Kiva or other supportive approaches and have counsellors available for pupils. In short, the new focus on well-being will ‘spotlight’ and increase the good work that is already taking place.
PTHB are taking part in the CAMHS schools in-reach project and are one of 3 pilots over the course of 2017 to July 2020, ensuring two full academic years are covered. Working with North Gwent, services in South Powys will work to better link schools, health and social services using a multidisciplinary model and formal “face to face” liaison combined with a telephone model, with regular, named link professionals working across schools and health teams. To reduce emotional distress and prevent mental illnesses by offering early support, and appropriate referrals and interventions as appropriate. This will be achieved through:
§ Support for teachers to better understand childhood distress, emotional and mental health problems, and reduce stress in teachers concerned about their pupils. To be achieved through education and up-skilling teachers to recognise and deal with low level mental and emotional distress within their competence; § Ensuring that when teachers identify issues which they consider outside their competence and skills then liaison, consultancy and advice is available in a timely fashion from CAMHS to enable the young persons needs to be met either by CAMHS or to advise where best to refer on (e.g. Local Primary Mental Health Support Services), and to support the teacher and school in providing for the young person’s educational needs; and § Ensuring systems are in place to share appropriate information between CAMHS and schools, shared care arrangements are agreed between CAMHS and schools for those young people requiring more intensive support, and that arrangements are in place to escalate/de-escalate as the young person’s needs dictate.
These pilots are linked to other agendas aimed at improving the emotional wellbeing of children and young people. An integrated approach is important to ensure the best possible outcomes for children and young people, in line with the Well-being of Future Generations (Wales) Act 2015:
· The development of the new curriculum and in particular the Health and well-being Area of Learning and Experience (AoLE). · Changes to Initial Teacher Education to ensure practitioners are equipped to deliver the new curriculum, using research-informed practice. · Changes to the professional learning approach for teachers, which offers consistency of approach for teachers. · School improvement plans, and the importance of a comprehensive ‘whole school’ approach to well-being. · The Adverse Childhood Experiences (ACE) agenda and the establishment of the ACE Support Hub. · Families First which aims to improve outcomes for families to ensure they are confident, nurturing and resilient and enjoy healthy relationships. · The Welsh Network of Healthy School Schemes (WNHSS) - all of the proposed pilot schools are part of the network.
Expected outcomes of the pilot:
§ Teachers feel more supported and able to mange low level problems without anxiety. Measured through questionnaires and evaluation interviewing. § Children are more emotionally resilient and fewer require assessment by specialist CAMHS as issues are identified and resolved earlier, and there are fewer inappropriate referrals to CAMHS. § Earlier identification of those few children who are developing serious mental health problems with appropriate referral on to services and reduced later demand on provision |
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2. Children’s access to school nurses and the role schools nurses can play in building resilience and supporting emotional wellbeing.
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All school nurses are trained in mental health first aid and deliver the APAUSE programme which aims to develop positive changes in young people’s knowledge, attitudes and behaviour around sex and relationships, including myth-busting, resisting unwanted peer pressure and raising confidence and self-esteem.
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3. The extent to which health, education and social care services are working together.
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PTHB and Powys County Council continue to work closely together. This is assisted by the Chief Executive of PTHB having a joint role of Strategic Director of People within Powys County Council with responsibility for both Children and Adult Social Care.
PTHB are currently engaging in a recommissioning exercise with education and social care colleagues regarding the Families First funding.
The Neurodevelopment service will use a single point of access, managed on a partnership basis.
Counselling services are commissioned through the CYPP and families first steering group.
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4. The take up and current provision of lower level support and early intervention services, for example, school counselling services |
Lower level support provision is mainly offered through the:
Youth Intervention service
This is a targeted intervention through families first commissioning and managed through the youth service. All young people are voluntarily referred to the service a 6 month snap shot shows issue.
Jan – April 17 - 139 young people were supported individually. 175 young people supported through group work. They have supported schools to run sessions on emotional wellbeing, Joe Blagg, FRIENDS and in 3 high schools in the North of Powys the YIS worker continues to run basketball sessions to promote constructive use of leisure, team work and health lifestyles. The reason for referral that give an indication that it would be linked with emotional and metal health are as follows: Anger - 15 Emotional wellbeing – 77 Learning and behaviour – 64 Self esteem 34 Family issues 16 Experiencing mental health issues - 3
Staff have been trained in CBT approaches to assist in the direct intervention with the young people for those young people who would benefit from such an intervention.
School and online counselling
This is provided through commissioned services. In 2016 – 17 the number of young people accessing the service was
Average new referrals per month were 43 over the year this breaks down as
TAF in 2016/17, there were 76 TAF cases which showed an improvement in their Health & Wellbeing out of 88 cases (86.4%). |
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