Delivering a comprehensive CAMHS: Integrated Service Developments for Children in the East Midlands Dr Fiona Gale, East

1. Delivering a comprehensive CAMHS: Integrated Service Developments for Children in the East Midlands Dr Fiona Gale, East Midlands CAMHS Programme Lead – CSIP Paul Farrell, East Midlands CAMHS Tier 4 Implementation Manager - CSIP

2. The importance of mental health National Service Framework for Children, Young people and Maternity Services (DH, DfES 2004) Mental health problems in children are associated with educational failure, family disruption, disability,offending and antisocial behaviour, placing demands on social services, schools and the youth justice system. Untreated mental health problems create distress not only in the children and young people, but also for their families and carers, continuing into adult life and affecting the next generation.

3. POLICY • The CAMHS agenda locally and nationally reflects a number of drivers for change including national policy developments. : • Improvement, Expansion and Reform: the next three years: priorities and planning framework 2003-2006,comprehensive CAMHS be available in all areas by 2006, for a full range of conditions and problems. A key target was to increase investment (PCTs) and service activity (providers) by 10% per annum to 2006. • Every Child Matters (2003) and Children Act (2004) • The National Service Framework for Children, Young People and Maternity Services (2004)is a 10 year programme. The core part of the children’s policy agenda. Key features of this standard include the requirements for comprehensive CAMHS from 0-18 years of age, through comprehensive CAMHS via four tiers of service, to provide timely, integrated, high quality, multi-disciplinary mental health services.. • National Standards, Local Action: Planning Framework 05/06 – 07/08 CAMHS remains a PSA target, with a focus on sustaining development towards a comprehensive level.

4. PSA Targets likely to be supported by improvements in CAMHS Stay Safe Be Healthy • Reduce teenage pregnancies • Reduce drug use • Improve stability for children looked after Achieve Economic Well-being Enjoy & Achieve • Reduce 16’s to 18’s not in education, employment or training • Increase participation in higher education • Improve development at age 5 • Improve school attendance • Improve educational attainment at 11, 14 and 16 (3 targets) Make a Positive Contribution • Reduce crime

5. “Partnership is the key to providing effective services that will improve the lives of all children [young people]. The work is a vital component of securing the future of our society – children are our future…” (Serving Children Well – LGA, 2002)

6. Strategic Framework for Delivering and integrated CAMHS “Out of Authority Placements” Secure Children’s Homes Intensive Fostering Service Severe Mental Health difficulties and highly complex cases Highly Specialist Services TIER 4 Secure Units Neuropsychiatry In-Patient Units Day Services Assertive Outreach Crisis Intervention Home Treatment Moderate to severe mental health difficulties Specialist Services Behaviour Support Services Special Schools TIER 3 Primary Mental Health Workers Specialist Teams Substance Misuse Psychology Psychiatry Primary Mental Health Workers In Need Vulnerable Targeted Services TIER 2 Psychiatric Outpatient Multi-Agency Locality Teams Social Workers Educational Psychology Multi Agency Support services Voluntary Sector Universal Services TIER 1 All Children GP’s School Nurses Youth Workers Voluntary Sector Children’s Centres Extended Schools Surestart Connexions Health Visitors

7. The 4-tier model for CAMHS: Presenting Difficulties & Projected Prevalence 0.075% = 45 Very serious problems – life threatening or very specialist treatment Tier 4 PROJECTED LOCAL PREVALENCE eg LOCAL CHILDREN’S POPULATION : 60,000 1.85% = 1110 Severe and complex problems Requiring multi-disciplinary team working Tier 3 7% = 4200 Moderately severe problems requiring attention from professionals trained in child mental health Tier 2 15% = 9000 Mild early stage problems Tier 1 Example projected local prevalence derived from: Treating Children Well, Kurtz Z., Mental Health Foundation, 1996

8. National Service Framework for Children (NSF) Standard 9 Themes • Early Years • Mental Health Promotion and Early Intervention • Partnerships with Children, Young People and their Families • Access and Location of Services • Improving Service Equity • Partnership Working • Training and Development • Developing High Quality Multi-disciplinary CAMHS Teams • Planning and Commissioning Services

9. CAMHS - 10 Markers of Good Practice: • All staff working directly with children and young people have sufficient knowledge, training and support to promote the psychological well-being of children, young people and their families and to identify early indicators of difficulty. • Protocols for referral, support and early intervention are agreed between all agencies. • Child and adolescent mental health (CAMH) professionals provide a balance of direct and indirect services and are flexible about where children, young people and families are seen in order to improve access to high levels of CAMH expertise. • Children and young people are able to receive urgent mental health care when required, leading to a specialist mental health assessment where necessary within 24 hours or the next working day. • Child and adolescent mental health services are able to meet the needs of all young people including those aged sixteen and seventeen.

10. CAMHS - 10 Markers of Good Practice: • All children and young people with both a learning disability and a mental health disorder have access to appropriate child and adolescent mental health services. • The needs of children and young people with complex, severe and persistent behavioural and mental health needs are met through a multi-agency approach. Contingency arrangements are agreed at senior officer levels between health, social services and education to meet the needs and manage the risks associated with this particular group. • Arrangements are in place to ensure that specialist multi-disciplinary teams are of sufficient size and have an appropriate skill-mix, training and support to function effectively.

11. Issues across the region… • Support and development of Multi-agency strategic CAMHS Partnerships • Integrated Commissioning Frameworks • Continuing improvement of services across all levels of need • Focus on improving services for particularly vulnerable or hard to reach children • Integration within all improvement agendas, even where it seems children might not be the immediate focus • Workforce • Leadership

12. Why we should provide integrated services… Sadie: I had to go through so many channels. It feels like, like for years, I’ve been going through the system… Parent Robyn: …I am very scared…there is something wrong with me…I think I might be mentally ill. Age 11 Angela : “ My child is not a ‘nutter’. It’s getting over to them that he needs help for other reasons, not because he is totally nuts…” Parent

13. Key Elements in a Service that “Works” Strong inter-agency commitment over the medium to long-term, including - a steering group or strategy group willing to tackle tricky issues, and - a commitment to consulting with and acting on children’s and families’ views Links with existing services within CAMHS - including the integration of the service within the CAMHS tiered framework and - CAMHS development strategy Links with other services and initiatives outside CAMHS - e.g. education, the voluntary sector & area-based initiatives

14. Regional and Local Perspectives on Integrated CAMHS Service Delivery: Tier 4 CAMHS - Regional Multi-agency CAMHS – Tier 2 Nottinghamshire Multi-agency consultation forum – Tier 1/2 Northampton

15. East Midlands CAMHS tier 4 • Review the current situation for the population of the East Midlands, across the Tier 4 services and for young people in Out of Area Placements • Examine current commissioning arrangements across the region and across the agencies of health, social care and education. • Consider the development of a shared framework within which future Tier 4 services could be planned and delivered. • Identify care pathways across the continuum of CAMHS services and highlight any gaps within CAMHS Tier 4 provision.

16. Implementation • Commissioning • Regional Model • Local Needs • Networks • Provision • Change the System • Partnership • Needs Led • Workforce • Multi Agency • Diverse

17. MALT is the development of multi agency teams working within Integrated Children's Services. Working together with Youth and Community, Education, Health and the voluntary sector to improve the emotional wellbeing and mental health of children and young people. ulti gency MALT ocality eam

18. MALT PATHWAYS Specialist camhs MALT school referrals MULIT AGENCY ACTION PANELS Children young people and families consultations GPs responsive named link for each school MALT Acute

19. Multi Agency Locality Team referral pathways parents Young person GPS Other professionals Families of schools Community paediatricians Direct work Action Panel liaison MALT Tier 2 School nurse Behaviour support Mental heath specialist Ed psy Family support consultation advice training Parenting courses Tier 3 specialist camhs Family work acute acute

20. Multi-agency Consultation Forum, Northampton CAMHS- Guiding Principles. • Each forum has senior clinical members from each agency in attendance. Members need to have decision making authority. • A partnership plan and agreed mission statement is established for each forum. • Regular reviews and evaluations ensure that aims and objectives of forums are achieved.

21. Aim of Non-School Attenders Forum; • Non-School Attenders Forum – multi-agency forum with members from CAMHS, Hospital and Outreach Ed. Services, Connexions, EWO’s, Educational psychologist, Specialist Mental Health Teachers. • Referrals accepted from any organisation for children and young people that have not attended school for more than 20% of the time. • Parental permission is sought to discuss the case at the forum. • Referrer attends the forum and presents the young persons case, the forum members decide which agency or agencies can meet the young persons needs. • A integration into school action plan is developed, families are informed of this following the forum meeting. • The action plan is implemented and reviewed regularly.

22. People who have referred and presented cases to the forum: predominantly education welfare officers, a school special needs advisor, primary mental health worker, therapeutic care home supervisor. The forum meets monthly for 3 hours. • Over a year we have had • 15 referrals • 5 girls, 10 boys (33% girls to 67% boys) • 2 looked after children (14%) • 1 mixed race child (7%) • 2 (13%) from primary schools – 1 in year 5, 1 in year 6 • 13 (87%) from secondary schools – 1 in year 7 (8%), 7 in year 8 (54%), 3 in year 9 (23%), 2 in year 10 (15%)

23. Results: • 1 went straight back to school when forum supported a change of school for her (7%) • 1 remained in the same school and was supported by behaviour support team to increase attendance (7%) • I young person already had all the agencies involved and the forum could not think of any other support that could be provided. Advice has been given however on an alternative exam scheme, supported by Hospital and Outreach Education which seems to be engaging him and encouraging him to attend school more (7%) • 1 case initially attended the outreach base successfully but parent was unable to support the next part of the suggested plan so this then broke down and he is currently not in school (7%) • 3 cases are currently awaiting the outcomes of initial assessments (20%) • 2 cases are back in school full time (13%) • 2 cases are currently attending the HOE outreach base for 3 full days a week (13%) • 1 case is attending the learning support unit in school for 3 days a week (7%) • 2 LAC cases moved to new accommodation

24. Discussion Point: How do we further develop integrated CAMHS, both Regionally and Locally?

25. Fiona Gale, Regional CAMHS Programme Lead - CSIP Fionagale@camhs.org.uk Paul Farrell, Regional Tier 4 CAMHS Implementation Manager – CSIP Paul.farrell@nottshc.nhs.uk