Since the last Child and adolescent mental health services (CAMHS) JSNA report in 2013 a transformation has occurred with the support of all agencies working with children and young people. This has included:
The key themes of the local Slough CAMHS strategy (2015-19) reflect the vision which is to promote resilience and early intervention in our communities to help children, young people and their families to become resilient.
The Slough CAMHS strategy recommends that partners use effective interventions derived from a new national resource called Mental Health 4 Life (MH4L). Mental Health 4 Life National Resources.
The Slough strategy is also based on the new national model of CAMH services called THRIVE. Instead of the previous four tiered model described in the 2013 JSNA, which parents and children did not understand, this contains four domains as shown below in Figure 1.
The model encourages people who work with children and families to consider what domain they are working in e.g those who offer one off support or signposting to self management are enabling parents or children to ‘cope’. When delivering evidence based goals focused programmes under 12 weeks then staff providing these interventions are ‘getting help’ for individuals or groups. Intensive programmes of over 12 weeks in duration are described as ‘getting more help’ (usually provided by specialist services).
Where the evidence is weaker and risk management is the goal the measures used pertain to those agreed by the local safeguarding board. (For example the work of social care and youth offending services, targeted youth support or any other groups working with those affected by domestic abuse, child sexual exploitation, those who are looked after or who are leavers of care).
Services now record their work across the four domains and transparency of reporting has been encouraged through the CAMHS transformation work now underway based on the national report the Five Year Forward View (NHSE, 2014). This work has only just begun and is funded by NHS England.
Examples of THRIVE services in Slough
Information and signposting – this includes all universal services listed under the Slough Family Information Service guide, which includes the voluntary sector, early years, general practitioners, schools staff, social workers and others. These services provide on line or face to face information. Over 435,900 hits were received on the Slough Family Services guide in 2015 and many of these related to health and wellbeing enquiries. Examples of universal work include the PSHE programme in schools and general assemblies on topics such as bullying and child sexual exploitation.
Young people have been engaged in designing the THRIVE website which will enable them to self assess their wellbeing and access information or when needed will link them to on line counselling This site is now live at www.puffell.com/thrive.
Evidence based interventions under 12 weeks in duration. These include those individual counsellors that schools commission or those that can be contacted through the early help process that offer cognitive behaviour therapy, Mindfulness etc. These can be on line or face to face and are accessible to those in school settings. Services which offer support include the primary mental health team, the on line offer via Kooth (funded through the Transformation Fund) and the work of the educational psychology team. When the child is much younger in an early years or primary school setting then an early help approach is taken and family services and the early help advisors work with the family to create a team around the child or family.
Specialist CAMHS are commissioned to work with the most complex cases across eight pathways. GPs refer through the common point of entry and current waiting times are shown below. Evidence based interventions of 12 weeks or more are offered through this route.
Risk reduction and management – services include targeted youth support, social services, the Slough Emotional and Behavioural Difficulties Outreach Service (SEBDOS) domestic abuse services and the youth offending service. Individual care packages are put in place according to agreed pathways and local safeguarding procedures.
A comprehensive needs assessment has been undertaken to inform the CAMHS Transformation Plan.
Vulnerable groups identified as over represented in the CAMHS needs assessment include; those living in households where one or more parents have a disability, those from migrant communities, children in need, those on child protection plans, those suffering from child sexual exploitation, those affected by domestic abuse and child poverty, those who are carers
In the period 2015-16
The current waiting list shows that as of December 2015 there remained a backlog within specialist CAMHS of 289 young people mainly those awaiting a diagnosis - 143 young people on the ASD pathway, 21 on the anxiety and depression pathway, 43 on the ADHD pathway and 11 who have been accepted into the Berkshire Adolescent Unit, .
Local mapping of the numbers of children and young people entering CAMHS from our hotspot areas of domestic abuse indicate these areas should be a priority for partnership work to enhance resilience within the community. Any targeted work undertaken with children and young people in schools in these areas should also be aligned to mental health promotion for the wider community.
Young people trained as mental health champions, school mentors, school staff and voluntary sector services in the community have valued the mental health first aid programme used as an introduction to mental health conditions. The Youth Parliament have valued being able to design a bespoke website to promote positive mental health and challenge the stigma of mental illness.
Schools are required to promote the mental health and wellbeing of their pupils and the early intervention and detection approach using agencies who can promote an early help model has allowed 90 young people to improve their mental health in non clinical settings.
There is a significant difference between the estimated numbers of children with vulnerabilities such as autism and those diagnosed with the condition. Despite the higher rate of case finding the backlog to diagnose new cases remains high.
The total costs of specialist referrals for specialist eating disorder services in Slough is double that of neighbouring boroughs suggesting significant needs locally. A business case has been accepted by NHS England to change the way in which eating disorder and other specialist services are offered to allow young people access to a local support service rather than being sent to out of area providers.
As a result of optimising pathways for anxiety and depression and self harm the total referrals into specialist CAMHS remain the lowest in the Thames Valley and this is real and reflects a universal and targeted support system that is working effectively
The fact that 289 young people still needed to be stepped down to primary CAMHS from specialist CAMHS indicates that in these cases the referrals (the majority being from GPs) were inappropriate and the Transformation Fund has identified training for general practitioners in mental health as one of eight projects in 2015-16.
Pilot work with secondary schools has been well received and complements work in primary schools. What is not known is the extent to which schools have adopted the national guidance for commissioning psychological services. An audit is planned for 2016 and the results will inform the next steps for staff training and commissioning.
There is a real need to improve the consistency of recording outcomes in line with the THRIVE model of recording and the new national reporting system.
As well a strong focus on the social and emotional wellbeing of the wider children and young person population, it is well evidenced that certain population groups are more likely to suffer from poor wellbeing and have mental health problems and there is a call to focus efforts on improving outcomes for these groups.
Particular groups who may be at an increased risk of having poor mental health have been identified as including those who:
Other groups who may be at increased risk include those who have a parent with substance or alcohol misuse problem, those who have a parent in prison, those from low income households, those who are refugees or asylum seekers, those who are from a traveller community, those who are Lesbian, Gay, Bi-sexual or Transgender (LGBT)
Another group whose needs are often not taken into account when CAMHS are commissioned are those children of an age where they are transitioning between services. In particular:
The CAMHS transformation plan sets out the unmet needs under the four headings that follow taken from the Five Year Forward View (NHSE 2014)
Promoting resilience, prevention and early intervention
Work is required to tackle the stigma of mental ill health. An anti stigma campaign is required and will be run in 2016 in our local schools.An audit is needed of local schools to investigate the range of the use of evidence based resources in PSHE and within school support services to build children’s and young people’s resilience
Early years and voluntary sector settings need further support for parents and carers in regard to recognising and responding appropriately to a range of mental health problems which if not addressed early can develop into disorders e.g. anxiety and depression and eating disorders.
Improving access to effective support – a system without Tiers
Care for the most vulnerable
There is an urgent need to ensure there is better, co-ordinated post-diagnosis support, particularly for children with Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).
Other more vulnerable young people e.g. looked after and care leavers, those with a learning disability and victims of Child Sexual Exploitation need to be prioritised for help to address their emotional health and wellbeing concerns at the appropriate level. A local project will offer evidence based cognitive therapy to those who have been identified as suffering from child sexual exploitation.
Developing the Workforce
The ongoing training needs of GPs, school staff and community volunteers has been identified in the CAMHS transformation plan
The Health & Social Care Act 2012 gives CCGs the power to commission certain health services under Section 3A NHS Act 2006. Each CCG has the power to arrange for the provision of such services or facilities as it considers appropriate for the purposes of the health service that relate to securing improvement in –
(a) the physical and mental health of persons for whom it has responsibility; or
(b) the prevention, diagnosis and treatment of illness in those persons.
A CCG may not arrange for the provision of a service or facility if the Board has a duty to arrange for its provision under sections 3B or 4.
The CCG will need to expand perinatal mental health provision within Secondary Care Mental Health teams, including improved access to psychological treatment and medication management as well as post traumatic birth support and support to mothers suffering from depression who do not attend Increasing Access to Psychological Services