Specialist CAMHS

• 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 new funding that was released was for the following areas:

1. Neurodevelopmental

2. Primary CAMHS

3. Crisis

4. First Episode Psychosis (14-25)

5. Psychological Therapies

Of these funding streams the ones that have had a direct impact on specialist CAMHS are the Psychological Therapies and the Crisis posts. The Psychological Therapies posts have increased the therapeutic time that is able to be delivered within CAMHS within the generic specialist CAMHS teams. The Crisis Teams have impacted by acting as a front line service to A&E and GP’s if a patient presents in Crisis – however the demand for this type of service since they have been put in place has grown significantly.

The ND funding has gone into the ND service that is a cross directorate provision and was to provide additional resources not replacement for what was already being provided. CAMHS had identified the resource which was at that time being used for ND services and had invested that into the tea.  The investment in ND has meant a more co-ordinated approach to the provision of services but has not impacted on those cases that were appropriate referrals for Specialist CAMHS. The investment into Primary CAMHS in Cwm Taf has partly filled a gap that was left when the Local Authority withdrew the funding for 5 Primary Mental Health posts a few years ago. The demand for PCAMHS services remains high due to the Mental Health Measure Part 1 referrals. The First Episode psychosis posts in Cardiff and Vale and ABM have both gone into Adult services which has meant  that there has been little impact in SCAMHS. In Cwm Taf the posts are more integrated into CAMHS and are working with the generic teams.

The expected improvements in waiting times (ie the 28 day target) is not being met in all areas. It was achieved at year end, however this was due to waiting list initiatives that were put in place using slippage on the funding allocated to CAMHS.  Due to the significant recruitment process that CAMHS has gone through over the last year there has been a great degree of instability in the service due to staff movement into new posts and the subsequent backfill of posts. CAPA has now been implemented in all three Health Boards in the Cwm Taf Network and we are anticipating that there will be a decrease in the waiting times once this is fully embedded as has been demonstrated by the service in Cwm Taf where CAPA was implemented in April.

• What the data tells us about the variations in practice (equity of access) across Wales.

Acceptance rates into Specialist CAMHS vary across Wales, with the publication of all Wales referral criteria anticipated during later this year more equity should result, with some small local variation to reflect local needs.

• The extent to which changes have addressed the over-referral of children and young people to CAMHS.

There has been an increase in referrals into Primary CAMHS which is related to implementation of Mental Health (Wales) Measure for Part 1. This has resulted in increased numbers of referrals coming into the service requesting a Part 1 assessment, and limited opportunities to address the other elements of Part 1 within a very small resource. 

The number of referrals accepted by Specialist CAMHS the service has decreased slightly from 72% in September 2016 to 67% for August with an average being 70% accepted into the service over the last 12 months. There is an average of around 30% who are inappropriately referred into the service. The new referral criteria that are about to be released should provide more consistency to the referrers into the service on what an appropriate referral is into S-CAMHS.

• Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS.

There have been national referral criteria that have recently been developed by the all Wales CD’s group that will shortly be sent out for adoption this will ensure that the standards and criteria for access to specialist CAMHS are the same throughout Wales.

• Whether the changes have helped to improve specialist CAMHS’ ability to respond out of hours and at times of crisis; whether out of hours care 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 Crisis teams have enabled greater access to CAMHS due to the enhanced hours and ability to quickly respond when needed. This has enabled the generic specialist CAMHS teams to concentrate on the core work and not be called out to deal with emergencies as frequently. We are pleased to report however that our Crisis Teams are generally  achieved the Welsh Government 48 hour target.  Work needs to be done on developing more robust pathways between Crisis Teams and the Inpatient Service in Bridgend – discussion is planned around this issue with the Inpatient Clinical Lead and Crisis teams in ABMU, Cardiff & Vale, Cwm Taf.

• Whether there is sufficient in-patient capacity in Wales.

The general admission capacity is appropriate for South Wales. There are a number of out of area patients at times when there are patients who present who cannot be managed safely within a general CAMHS unit as the environment is not appropriate to meet their needs. 

The model of service currently in the CAMHS Inpatient Unit is one of assessment and a combination of inpatient and home leave.  We encourage home leave as soon as clinically appropriate to maintain links with family, school etc.  I would therefore suggest that inpatient capacity is sufficient (in South, Mid and West Wales). 

There are discussions underway with WHSSC on adapting Ty Llidiard in order to cater for some of these patients who need conditions of Low Security as this is currently purchased from the independent sector. In addition there is currently a lack of inpatient provision for patients with LD, Neurodevelopment and Forensic presentations within Wales.

In our experience the Services to support looked after children in residential homes are not always adequate in South Wales although not primarily inpatient CAMHS concern there has been pressure placed on the Tier 4 unit due to inadequate residential placements.

Funding

• Annual expenditure on CAMHS in cash terms and as a percentage of the overall spending on mental health, by local Health Board.

The 16/17 expenditure on the Cwm Taf element of the Camhs service (i.e. excluding services provided to other commissioners including C&V UHB, ABM UHB, Tier 4 and Fact) was £3.9m.  These are not fully absorbed costs as this data will not be available until October when the programme budgeting returns are completed.  The expenditure in 16/17 on Cwm Taf Mental health services (again not fully absorbed costs) was £47.6m.  Therefore the Cwm Taf Camhs spend in 16/17 was approximately 8% of the Mental health spend.

• 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.

The new funding for psychological therapies has increased provision however we are still in a period of transition. Some young people  in the system who had previously only been prescribed medication are still not accessing a talking therapy. This is gradually being addressed although the final result – i.e. a reduction in prescribing – will not be seen for some time..

We are now able to offer DBT for young people  with emerging personality problems as a treatment stream across the Network. There is still a shortage of provision in the Network for the treatment of children and young people with attachment problems. This group, along with those with gender identity problems, are an increasing proportion of our referrals and require the development of specific treatments..  

• How the additional funding has been used to improve provision for children and young people in local primary mental health support services.

The additional funding for LPMHSS has enabled PCAMHS to expand the provision for Part One assessments and interventions. There was limited funding given when the Measure was introduced (1 worker in Cwm Taf and 1 worker in C&V, none in ABM) and the demand for this service is much greater than expected. There are plans in place to deal with the backlog of patients waiting including linking back in with schools in order to

The withdrawal of funding for Primary Mental Health Services has had a detrimental effect on services being able to provide the preventative work in schools etc leading to increased referrals into the Service.

• 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.

There has be a funding utilised to establish designated Neurodevelopmental Disorder teams within Cwm Taf. This team is multidisciplinary and is nurse lead, bringing together CAMHS, Child Health and Therapies into one service. There is now a single point of entry into ND services and links have been made with the 3rd sector to provide support. The Integrated Autism Funding Team is now starting to take shape and this will enhance current provision across the age range. 

The funding for forensic services is being utilised to enhance current Forensic Service provision most  new staff have started in post, others are currently in the process of being recruited. 

• The effectiveness of current planning and commissioning arrangements to address the needs of young people who have early onset of a severe mental illness, such as psychosis.

The  planning and commissioning arrangements are inconsistent across the Network.  Within Cwm Taf the Early intervention Psychosis team is embedded within CAMHS and is working well with the generic teams when there are presentations that emerge.  These teams are based within Adult Services in ABM and C&V Health Boards.

Transition to Adult Services

• How well planned and managed transitions to adult mental health services are.

There are transition protocols that have been developed across each Health Board area and regular transition meetings are in place with Adult services in order to ensure that this process is as smooth as possible. The transition process ideally begins 6 months before the 18^th birthday.  

Links with Education (emotional intelligence and healthy coping mechanisms)

• The work being done to ensure children and young people are more resilient and better able to tackle poor mental 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.

Much work is being undertaken in this area as local multi agency plans, strategies and statements of intent are developed in partnership.

There are various work programmes being worked on locally to look at opportunities to redesign the way we work collaboratively across the region including developing work with the Third Sector.

The ALN Bill is also being supported locally with a number of forums looking at the potential impacts on services and the ways in which we work collaboratively in the future.

2.       Children’s access to school nurses and the role schools nurses can play in building resilience and supporting emotional wellbeing.

Each school has a named school nurse who works closely with the Head Teacher and school staff. For our comprehensive schools this includes an open access drop in session for pupils for emotional health and wellbeing. The service is able to support and signpost young people to services, for example, sexual health services.

3.       The extent to which health, education and social care services are working together.

There is a significant amount of joint working across all partners across the Cwm Taf region.  There is a multi agency CYP Emotional and Mental Health Delivery Group that sits under the structure of the Together for Mental Health Board, that has been recently reviewed to strengthen its membership and links across all services areas.

Many of the questions relate to specialist CAMHS but emotional and mental health in its broader sense spans much wider that Sp CAMHS with all partners in Social Services, Education, Paediatrics etc playing key roles in supporting children and young people with a wide range of support needs.

4.       The take up and current provision of lower level support and early intervention services, for example, school counselling services.

The Committee will consider the evidence it receives as part of this inquiry in the context of the implementation of the Social Services and Well-being (Wales) Act 2014, the Well-being of Future Generations (Wales) Act 2015 and the Rights of Children and Young Persons (Measure) Wales 2011.