Specialist CAMHS
1. 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.
CAMHS services across North Wales have made significant improvement through investing new funding in service development in primary mental health and psychological therapies, and reconfiguring and investing in neurodevelopment services. Progress has been excellent. It is acknowledged that improvements to date need to be maintained and developed – further work is needed to make this happen, operational plans are in place.
Improvements in waiting times for primary mental health assessment and intervention met Welsh Government targets across the Health Board during 2016 – 2017. It has been challenging to maintain these improvements in all teams in light of staff turnover and maternity leave, combined with difficulties in recruiting to vacancies. New ideas are being tried to increase the appeal of North Wales to potential applicants from outside the area.
The graphs below demonstrate the improvement in waiting times; all teams have met the Mental Health Measure assessment target since March 2017. Further capacity needs to be identified for all teams to meet and maintain the intervention target.
2. What the data tells us about the variations in practice (equity of access) across Wales (the following response refers to North Wales)
In preparing for the introduction of the Mental Health (Wales) Measure 2010, an integrated primary and secondary care approach to redesigning the service for children and young people was adopted in North Wales. Entry into services for children and young people was redesigned, and all specialist CAMHS teams introduced a standard procedure for access – the specialist CAMHS single points of access. These operate on a Local Authority area basis and have developed considerably over time. They have reduced variation in thresholds for acceptance into the service and increased consistency of response through the implementation of standard access criteria. Children and young people no longer wait on waiting lists without first being discussed where necessary with the professional who has requested involvement to determine the level of need. If necessary, conversations will also be held with the parent/carer. Those who need the help of the specialist service are booked in for primary mental health assessment and where required, primary or secondary mental health services will be offered. Primary and secondary care services are available from all teams who deliver both in a seamless manner, allowing assessment and intervention to be tailored and matched to the needs of the individual. Those who do not need the direct help of specialist services but who have some needs can access help from a professional working in front line services who themselves can access support and consultation from a specialist mental health professional.
More recently, there has been a move towards delivering specialist CAMHS SPoA in communities via links into GP practice (pilot underway in Denbighshire), schools (most areas have formalised arrangements for regular contact with secondary schools), and the introduction of standardised pathways, initially in Education but with potential for roll out to other agencies for jointly managing initial risk in self harm and suicidal behaviour.
Some years ago, one area (Conwy & Denbighshire) introduced the Choice and Partnership Approach (CAPA), a framework for managing demand and throughput in specialist CAMHS. CAPA uses language to promote engagement and choice, and aims to engage with families from a position of shared responsibility for change. Anglesey and Gwynedd, and Flintshire and Wrexham have recently introduced CAPA. This will bring all teams in line with the same framework for managing demand and throughput. This will increase consistency in the style of first appointments and emphasise goal focused working. The same outcome measures are also being introduced in all teams. This is work in progress.
3. The extent to which changes have addressed the over-referral of children and young people to CAMHS
The introduction of single points of access in specialist CAMHS has proactively invited discussion with referrers about any and all concerns about children and young people’s mental health. This has allowed all the specialist CAMHS services to introduce standard responses based on need at the point of entry, resulting in an overall reduction of inappropriate referrals with signposting, and faster responses for those who need the service the most.
Work with GP Clusters and Primary health care teams to ensure that they are supported in discussing potential referrals and risk management of young people receiving care and treatment. This has been welcomed by the GPs.
4. Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS
Specialist CAMHS SPoAs are available for children and young people age 0 – 18 years where there is a concern about emotional or mental health. Providing the child or young person is resident in the relevant Local Authority area, there are no restrictions imposed on referrers requesting help. All specialist CAMHS teams operate with standard access criteria for SpoA, standard ‘offers’ from SPoA and standard definitions of presentations requiring primary mental health assessment and secondary care.
As outlined in 3 above, children and young people who need the help of the specialist service are booked in for primary mental health assessment and where required, primary or secondary mental health services will be offered post assessment. Primary and secondary care services are delivered by all teams who deliver both in a seamless manner, allowing assessment and intervention to be tailored and matched to the needs of the individual. Those who do not need the direct help of specialist services but who have some needs can access help from a professional working in front line services who themselves can access support and consultation from a specialist mental health professional.
5. 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.
Crisis responses are not yet where we want them to be but considerable development has occurred. New funding has resulted in weekend cover in all district general hospitals. This has led to earlier completion of initial primary mental health assessments including risk assessments of young people admitted in crisis. Hospital cover is now in place as follows;
· Ysbyty Gwynedd (West Area) – The CAMHs hospital team is based on the Paediatric ward and currently operate six days per week. The team undertake assessments and follow up appointments offering short packages of work where required.
· Ysbyty Glan Clwyd (Central Area) - The seven day service became operational following additional recruitment in April 2017 with CAMHS clinicians based on the paediatric ward between 0900 – 1700 on Saturdays, Sundays and bank holidays. During the week a team of CAMHS clinicians undertake primary mental health assessments and safety planning on the ward as required. Additional recruitment has taken place with two new band 6 nurses due to commence to extend capacity for the services to provide direct same day clinic or community based urgent assessments or joint consultation to prevent avoidable hospital admissions. The team will also be involved in further self-harm consultation pathway training to professionals in non-education based third sector or statutory services.
· Ysbyty Wrexham Maelor (East Area) – A 7 day service has operated at the Maelor Hospital since April 2016 with CAMHS clinicians based on the Paediatric Ward on Bank Holidays and Saturday and Sundays from 09.00 – 17.00. They provide risk assessments, action plans and advice to staff, young people and their families. During the week days there are dedicated CAMHs clinicians that undertake risk assessments on the ward as required.
Consultant Child and Adolescent Psychiatrists have extended their working hours so that face to face emergency assessments can be carried out between the hours of 9.00 am and 5.00pm 7 days per week throughout the year. This ensures that all children and young people requiring an urgent psychiatric assessment including section 136 assessments under the mental health act can be seen within 24 hours.
The number of S136 assessments undertaken by Consultant Child and Adolescent Psychiatrists has increased:
· 2015/16 – 38% of S136 assessments were undertaken by Consultant Child and Adolescent Psychiatrists
· 2016/17 – 88% of S136 assessments were undertaken by Consultant Child and Adolescent Psychiatrists
· 2017/18 Apr - Jun – 77% of S136 assessments were undertaken by Consultant Child and Adolescent Psychiatrists
In addition Consultant Child and Adolescent Psychiatrists provide a regional telephone on call cover rota that allows access to advice by phone to colleagues in paediatrics and adult mental health out of hours.
Arrangements are in place for initial crisis assessments to be undertaken out of hours by adult mental health staff for 16 and 17 yr olds and paediatric staff for children up to and including age of 15 years.
6. Whether there is sufficient in-patient capacity in Wales.
Access to inpatient beds continues to be challenging. In North Wales there is very significant use of acute paediatric beds to manage brief crisis admissions. Each of the North Wales district general hospitals now has dedicated CAMHs staff working 6/7 days per week on the acute paediatric units.
There has also been an ongoing need for out of area referrals for specialist tier 4 psychiatric in patient treatment. The graph below details the number of OOA placements each month and of those which were due to capacity in the Unit. The unit wasn’t able to take admissions between April and the end of May 2017.
It has not been possible to designate age appropriate beds within adult mental health for older adolescents due to pressures within the adult mental health service and this in turn has contributed to reduced access to beds for older adolescents and a requirement for out of area referrals
Recruitment difficulties led to a temporary reduction in the North Wales tier 4 inpatient unit.
The requirement for inpatient capacity is directly linked to the quality and effectiveness of intensive community interventions and the capacity of community services to take positive risks. This has been significantly enhanced with the new investment.
There will need to be ongoing review of the requirement for access to beds and overall inpatient capacity. It is anticipated with full recruitment to the inpatient staff team and ongoing development of the community service that there will be sufficient capacity. The service are currently undertaking a review into crisis services with partners (Adult Mental Health, North Wales Police, Paediatrics, Emergency Dept, CAMHS Tiers 3 and 4, Local Authority) to review this.
When there is a need for Psychiatric intensive care this will always need to be outside North Wales as there is insufficient need to warrant development of this service in North Wales
Funding
7. Annual expenditure on CAMHS in cash terms and as a percentage of the overall spending on mental health, by local Health Board.
· 2016 -17 expenditure on CAMHs - £8,581,203
· Percentage of the overall spending on Mental Health – 6.63%
8. 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.
All teams now offer cognitive behavioural therapy (CBT), family and systemic psychotherapy, dialectical behaviour therapy (DBT), and eye movement desensitisation and reprocessing (EMDR).
Behaviourally focused parent skills training and Video Interaction Guidance (VIG) focusing on attachment relationships is being delivered in teams where early years work has progressed. Gaps exist in the availability of Child and Adolescent Psychotherapy, Interpersonal Therapy (IPT) and behavioural interventions for those with complex difficulties. Further development is required so that all teams are able to deliver the same things to all families.
A regional approach to the assessment and management of young people presenting with eating disorders is now underway using the Maudsley model. Training has been delivered to practitioners from all teams and one consistent assessment and treatment approach is now in operation.
New funding has supported the development of 3 new posts in family and systemic psychotherapy, 1 new post in child and adolescent psychotherapy and 1 part time post in training and supervision of CBT – accredited modules are available at Level 6 and Level 7 in partnership with Bangor University with additional modules for CBT relating to specific disorders in development. Over 40 staff have completed Level 6 and 7 modules which has increased access, raised standards and improved quality.
Neurodevelopmental services have seen an increase in funded capacity for specialist roles including clinical leadership and access to psychological interventions which were not previously available. In addition there has been an increase in capacity from Nursing, Clinical Psychology and Psychiatry for specialist input to young people with First Episode Psychosis (FEP), including delivery of psychological therapies; working jointly with colleagues from Adult Mental Health in shaping services for early detection and intervention for young people.
A plan for consolidation and further development of psychological therapies is being finalised, so priorities are clear in all teams. The goal is to further develop formulation driven approaches to the delivery of psychological therapies in the context of children’s development within families. This work will also link to regular review of NICE guidelines in all teams, and to national work on the development of psychological therapies for children and young people.
We do not have access to data that can test out whether the development of psychological therapies has had a subsequent impact on prescribing of medication, and even if we had, this would not necessarily confirm a causal relationship. It is worth exploring whether there has been an increase in the number of young people who are being offered and accessing psychological therapies prior to receiving medication, and in parallel alongside the use of medication, through using audit in teams. The NICE guideline for depression was updated in March 2015 and specifically refers to considering the use of medication at the onset of treatment for moderate to severe depression in combination with psychological therapies.
9. How the additional funding has been used to improve provision for children and young people in local primary mental health support services.
The Health Board welcomed the Welsh Government investment into CAMHS this investment has led to the development of SPoA in each team and cover is now available every day of the week Monday – Friday. As outlined in answers above, access criteria and responses at the point of referral into the service are now standardised, and include the option of support to front line colleagues working in primary care, Education, Social Services and third sector agencies where children and young people’s needs do not require direct input from the specialist team.
In addition, developments alongside and with local area departments of Education have led to the introduction of a pathway for managing initial risk in self harm and suicidal behaviour when presenting in schools, this work is being rolled out in all counties. A jointly led prevention of anxiety programme is also underway in all areas with local plans for development and sustainability in progress.
Support to primary care services is growing in all areas, and includes ‘hubs’ in schools where specialist CAMHS staff visit secondary schools on a regular basis; regular delivery of training and consultation and parallel implementation of the 5 ways to Wellbeing and Better with Books schemes. One area has worked in partnership with primary care cluster leads to develop a senior post to work alongside GPs and other staff in North Denbighshire, starting September 2017. Links to cluster leads in neighbouring areas is planned.
10. 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.
West Area
· The service have recently developed guidance to provide clarity for all other health and statutory professionals about their roles and where to seek help appropriately. Primary health care team are encouraged to proactively identify Children Looked After who are presenting with emotional health difficulties. Where this highlights emotional health needs, we recommend that the Looked After Children’s Nurse completes a Strengths and Difficulties Questionnaire with the young person and their carers. The CAMHS clinicians who provide consultation can support in the interpretation of these screening questionnaires. It is recommended that whenever there is an identified unmet emotional health need this is recorded. These are audited regularly by CAMHS and can inform any future service change.
· The West Service meet regularly with Anglesey Social Services. Discussions involve the appropriateness of referrals to Social Services and the pathway for these and some joint training. Development of partnership working with Gwynedd Social Services.
Central Area
· Arrangements are in place to provide a range of consultation opportunities to social services and foster carers via SPoA, working together meetings or other interface meetings across both counties.
· In Conwy joint consultation from CAMHS systemic psychotherapist in partnership with the social services therapeutic team is offered to front line social workers and team managers. The social services “Edge of care” is now attended by a specialist CAMHS clinician in order to contribute a psychological formulation based understanding of the needs of individual children and young people at risk of or entering the care of the local authority. Team managers across the two services have close working relationships which facilitate timely and appropriate responses where concerns arise about risks of placement breakdown or other increased vulnerability in looked after children.
· The Denbighshire CAMHS team has close working relationships with the social services therapeutic team held within IFSS. This facilitates early consultation, assessment and intervention for looked after children in the authority. In addition CAMHS have a rolling 2 day placement for a member of the IFSS team to work within the CAMHS which facilitates joint learning and skill acquisition in both services and seamless care for young people requiring the support of both services.
· Bi-monthly working together meetings are held in both counties where senior clinicians, team managers and service managers meet to discuss complex cases and any learning in relation to these, agree joint service development and training initiatives and resolve or celebrate any interface issues between the services. Terms of reference are in place and action logs are completed for each meeting. At present the services are working together to develop a clear joint working pathway to best meet the needs for children looked after.
East Area
· The additional funding has increased the clinicians with dedicated time to work with vulnerable young people. A dedicated CAMHS Looked After Team offer assessment and tailored interventions to all children & young people Looked After this has also been extended to include the support for those adopted – this work is provided on a long term basis. These staff work closely with the Social Services and the Third Sector and a dedicated project for looked after children which is jointly commissioned. Regular consultation meetings are in place with the various Social Work Teams and CAMHS input into the multi-agency training programme.
A recent review of CAMHS response to Child Sexual Exploitation has been undertaken and training has been provided across North Wales for all CAMHS staff and identified leads nominated in each service. Close working relationships with North Wales Police (ONYX) and Barnardos enables improved information sharing and response to these vulnerable young people.
All Youth Justice Services (YSJ) across North Wales have seconded CAMHS staff allocated, to ensure that young people, either already within the YJS or at risk of entering the system and are involved with the Bureau, are able to access timely assessments and interventions as required. YOT have added to this investment to meet the current demand.
The YJS CAMHS Clinicians also provide training and consultation to partners in the YJS. In Flintshire there is close working with the Substance Misuse services for those young people with dual diagnosis issues.
All YJS have access to Consultant Psychiatrists / Mental Health Advisors to consult on complex cases and are currently extending the provision from the FACTS service with the additional monies, the agreed provision to North Wales was 0.8 WTE psychology post which has subsequently been increased to a full time post – this post is likely to be appointed to on the 6th October this year and will provide additional time to general FACTS work as well as support for the Enhanced Case Management approach in Flintshire and subsequently the other YOTs in the BCUHB area. FACTS continues to work very closely with the YJB, YOT managers, MH Advisors and other stakeholders to ensure that the work undertaken by FACTS from all funding streams is in keeping with local need and national strategy.
In Flintshire YJS, the Trauma Recovery Mode / Enhanced Case Management Pilot has increased the involvement of CAMHS and positive outcomes have been demonstrated for the young people involved.
At a Strategic Level, CAMHS Management are represented on the YJS Executive Boards and attend the North Wales Criminal Mental Health Justice Board as well as Substance Misuse Area Planning Board.
The new investment has enabled the development of a specific Neurodevelopmental Service which supports children, young people and their families with diagnosis of ADHD and Autistic Spectrum Disorders. This includes assessments and tailored intervention packages, parenting programmes / support groups, group work and a helpline. Pathways have been developed in each Area. A waiting list target of 26 weeks from referral to start of assessment is to be introduced; latest figures indicate that there are 1,013 children and young people waiting for a Neurodevelopmental Assessment with the longest wait being at 86 weeks. Additional investment is required into the Neurodevelopmental services to meet and maintain the target and to develop intervention services.
There has been a significant increase in the number of young people brought to the designated places of safety under a Section 136 of the Mental Health Act, as shown in the table below. It is important to note that of the total 16 attendances, one young person aged 16 years attended six times in April and four times during May. The young person is known to CAMHS Tier 3 and Social services, has become a Looked after Child and is now placed out of area by the LA.
This increase has occurred mainly in area East. Work is underway to review the situation and work with partner agencies and colleagues from Adult Mental Health services to address concerns and identify ways to improve the situation. Commissioning a service to support the development of participation is underway, this work will talk to young people and their families who have been admitted via Section 136 (including retrospective cases).
Consultant Child Psychiatrists are now available 7 days per week between the hours of 9.00 – 5.00 ensuring that all children and young people can be assessed within 24 hours. Arrangements are in place for initial assessments of 16 and 17 yr olds to be carried out by adult psychiatrists out of hours. Paediatric medical staff are available to carry out initial medical assessments of children aged up to and including 15 years out of hours
Consultant Child Psychiatrists are available by phone on a regional rota out of hours to provide telephone advice
Young People Not in Employment Education or Training – ADTRAC
CAMHS across North Wales is directly involved in a new three year European Social Funded project focusing on young people age 16 – 24 years who are not in employment education or training. In close partnership with Coleg Llandrillo Menai and all six Local Authorities, mental health practitioners and Assistant Psychologists will work as part of Local Authority hosted multidisciplinary teams to support non specialist staff and young people in addressing emotional and behavioural difficulties which create barriers to work and/or education, and where necessary, facilitating referral onto core services.
11. 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.
A North Wales Steering Group has been established, meeting on a monthly basis. Representatives from all areas attend the meeting, which is chaired by Dr Mike Jackson, Consultant Clinical Psychologist in first episode psychosis. The purpose of the steering group is to liaise and network, and establish and agree clear plans for development and sustainability.
Dedicated staffing in the teams for the First Episode Psychosis service, established through new funding, are as follows:
West – 1 Consultant session, 0.30wte Nurse and 0.30wte Psychology.
East – 1 Consultant session, 0.40wte Nurse and 0.40wte Psychology.
Central – 1 Consultant session, 0.30wte Nurse and 0.30wte Psychology.
In area West, a dedicated team has been established, building on an existing arrangement within adult mental health clinical psychology; this has resulted in new jointly funded clinical psychology and nursing posts working entirely within the first episode psychosis speciality. This is the model aspired to for all areas. Different arrangements currently exist in areas Central and East with dedicated CAMHS sessions from disciplines as outlined above. Commissioning additional capacity to add to these sessions is the goal, the steering group is leading the development of a Business case to address these gaps.
Transition to Adult Services
12. How well planned and managed transitions to adult mental health services are
A shared policy is now in place, jointly developed across Adult Mental Health and CAMHS, which was launched in March 2016, implementation of which is due to be audited, to include feedback from young people and their families. Observations thus far indicate that transition needs a lot more work and much earlier conversations between services to ensure the continuity of care, including a requirement for Adult Mental Health to identify a named link sooner.
Links with Education (emotional intelligence and healthy coping mechanisms)
13. 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:
a. The development of the Health and Wellbeing Area of Learning and Experience as part of the new curriculum
Within BCUHB there is a North Wales Transformation Group with representation from the Local Authorities – Social Services and Education, Voluntary sector, North Wales Police, Youth Justice; and health services – Midwifery, Paediatrics, CAMHs, Health Visiting School Nursing, Disabilities, Adult mental Health, Safeguarding, Public Health Wales.
This group has been discussing the development of the Health and Wellbeing Area of Learning and Experience within the new curriculum and are keen to contribute to developing the vision and key deliverables for this. Further discussions with the Association of Directors of Education Wales are planned.
The six Local Authorities (directors and heads of service) and the Health Board directors meet on a monthly basis to discuss shared priorities, the needs of children and young people are a high priority for this group, Public Service Boards and Part 9 Board. Specifically the prevention of Adverse Childhood Experiences and intervention to support those affected, the First 1000 days and children with complex needs. Building child and family resilience is a shared goal for partners.
b. Children’s access to school nurses and the role schools nurses can play in building resilience and supporting emotional wellbeing
A baseline assessment of the All Wales Standards for School Nurses for the promotion of Emotional Wellbeing and Supporting the Needs of School Age Children has been undertaken by the Child Psychology Lead with School Nursing Service Managers and Operations Manager
Each of the 22 standards within the competency framework have been RAG scored for each Area and initial discussions around actions required to achieve compliance were held. A baseline document is to be produced by the end of August 2017 along with an Action Plan detailing priorities by quarter.
c. The extent to which health, education and social care services are working together.
Child and Adolescent Mental Health Service (CAMHS) leads in BCUHB Children’s Services are aware of the WG proposal to pilot two ‘CAMHS-Schools In-reach’ projects in North Wales, one in Denbighshire and one in Wrexham. Strong joint working relationships already exist in North Wales between CAMHS and Education, the pilots will therefore build on work that is already underway between specialist CAMHS and Education in each area. The pilots are planned to run from the end of 2017 to the end of 2020, allowing for two full academic years of intervention.
Local work to identify leadership roles and define how each pilot will work is now required. It is important that new development dovetails with existing arrangements and interventions to avoid duplication and wherever possible to address gaps.
Gwynedd and Mon are going ahead with the Nurturing Schools programme. This work is being led by the CAMHS Education lead. The National Nurturing Schools Programme is a programme that allows staff to develop and embed a nurturing culture throughout their schools, enhancing teaching and learning, promoting healthy outcomes for children and young people, all by focusing on emotional needs and development as well as academic learning in a whole-school environment. The programme is based on the six principles of nurture that have successfully underpinned nurture groups for over 40 years but does not replace nurture groups as a more focused intervention for those identified in need of nurture group provision.
As referred to earlier the Self Harm Pathway is being rolled out with each Education Authority. This has included training of teachers and identify a champion within the school to take a lead. This pathway is being rolled out across north Wales, with the plan to extend it further to Primary Care and North Wales Police.
d. The take up and current provision of lower level support and early intervention services, for example, school counselling services.
As outlined above, regular contact with secondary schools including school based counsellors, delivery of SPoAs, delivery of consultation and training provision is underway in all areas. Specific early and preventive interventions led by CAMHS include the prevention of anxiety cognitive behavioural focused ‘Friends’ suite of programmes; Seasons for Growth, a programme focused on loss and bereavement; Five Ways to Wellbeing and Better with Books; each Local Authority has engaged in discussion and delivery of programmes is negotiated and driven locally with development at different stages. Data on the numbers of children and young people who have benefitted directly from these interventions is not currently available.
School Counselling data is available through Education services.
Feedback from Stakeholders - Local Authorities, Therapies and Youth Justice
The BCUHB Children’s Transformation Group has representation from the Voluntary sector, Youth Justice, Police, Local Authorities and all aspects of children’s health services. This paper was shared with the group who have provided comments.
The theme running through these comments included the need to work more closely in partnership with the Local Authority and Youth Justice to enable those children experiencing mental health crisis’ to have more timely joined up service provision.
The Local Authorities that responded do not believe that they have seen the impact of the WG investment, they have not seen a reduction in referrals to social services for children with mental health needs or a reduction in their out of area placements.
Two of the Local Authorities raised issues regarding CAMHS practitioners advising that children needed to be in a stable placement for therapy to be commenced, this is being addressed locally.
Although CAMHS and Social Services per Local Authority meet at a practitioner and or team leader level, strategic meetings are not happening in four out of the six Local Authority Areas which will be addressed.