Community Treatment Orders Number of CTO Requests [1] :

1. AMPHA SEMINAR“SURVIVING THE DANCE OF CHANGE” – MENTAL HEALTH; POLICY AND PRACTICE – “ONLY CONNECT”26th JANUARY 2010SUE BAILEYPROFESSOR OF CHILD & ADOLESCENT FORESNIC MENTAL HEALTHUNIVERSITY OF CENTRAL LANCASHIREEmail : Nicola.Tattersall@gmw.nhs.uk

2. Community Treatment Orders Number of CTO Requests[1]: In first year (3 November 2008 to 2 November 2009): 4163 No cancelled subsequent to SO request: 648  To 31/12/09: 4874 No cancelled subsequent to request: 685[1] All figures correct as of 11 January 2009. Breakdown of CTO Second Opinions requested by month

3. Average time to SO visit: From date of start of CTO: 48 days From date SO request received by CQC: 14 days Average time to receipt of request from date of start of CTO: 34 days Percentage of CTO SO requests received 28 days+ from start of CTO: 41% No of live CTO SO requests: 356 No over 28 days from date of section: 307 No over 28 days from date request received: 182 Action: CQC to issue requirement that CTO SO request made within 48 hours of start of CTO. Over 20% CTO SOs could not be completed by a SOAD due to patient no-shows. In real terms this has meant the Care Quality Commission has had to arrange well over 950 extra SOAD visits which would not have been required had the patient attended the agreed appointment. Action: CQC to advise that a further request must be made where a second opinion cannot be completed due to patient no-show. SOAD Recruitment Current size of SOAD panel: 112 11 candidates scheduled for interviews in January 2010. A further 9 awaiting confirmation of suitable interview date 8 further applications undergoing initial sift

4. New HorizonsFuture VisionsImplementation of Mental Health ActCTO’s and solutionsMental Health Tribunals and “unlicensed Drs” ? The shape of things to comeCQC, NPSA, NCISH, CEMACH, PART 8 reviews

5. POLICY IS CHANGEPOLICY APPEARS TO LACK HUMAN INTEREST Global perspective (John Bowis MEP, 2004) • 450 million people in the world live with a mental disorder • 1:3 of us will be affected directly or indirectly in our lifetime • 1 million people in our world commit suicide • 10 million try, including far too many children and young people • We know that mental health especially in the young is rarely given the attention and priority it needs

6. MAKING SENSE OF POLICY (Learning Disability and Mental Disorder) HORIZONS ARE CLOSER THAN YOU THINK AND MOVE WITH YOU FAIR RESOURCES, quality and funding, use process and outcomes (all perspectives), equity of access, financial information - INTEGRATE COMMISSIONING STIGMA WELLBING CHANGE CONTEXT CAPITAL QIPP MARKET INVESTIGATION PBR THE NEW NATIONAL INEQUALITIES HORIZONS REQUIRING HORIZONS CLOSER THINK VISIONS LEARNING FRAMEWORK LEAN PRACTICE INCIDENTS DISCRIMINATION TOWARDS VISION SERIOUS MENTAL AND BASED MENTAL FORMS FOR SYSTEMS QUALITY GOVERNMENT INFORMATION FUNDING (IFQO) RISK PUBLIC HEALTH SHARED OUTCOMES REFORM PUBLIC

7. Patient benefit and influencing commissioners (or those who decide about funding of services) (even in Wales with no commissioning provider divide) The defined elements of world class commissioning are in reality those of commissioning alone. The challenge of local commissioners either not knowing about national policy or the way they interpret it. Are they equipped to deal with the autonomy in decision making they have been given when decisions now to take place at local level of “pathways of care” for those with learning disability and mental disorders. Piecemeal commissioning with no whole systems approach – commissioning architecture

8. SENSE OF IDENTITY For mental health and social care • SENSE OF SELF professionals • PARTNERSHIPS AND PARTICIPATION • SOCIAL ENTERPRISE AND COMMUNITY TRUSTS • COMMISSIONING ARCHITECTURE Current mantra is of: • Mental capital and wellbeing – to achieve resilience • The art of resilience – to maintain resilience in face of adversity and change

9. Improving the Mental Health of the Population – Policy Briefing – for EU PACT on Mental Health and Emotional Wellbeing – June 2008 Mental Health in Youth and Education (Jane Llopis and Braddien, 2008) Mental health problems are high in the EU • 80% of young people in Europe report a high level of mental wellbeing but • One fifth of children and adolescents suffer from developmental emotional or behavioural problems. • One in eight have a mental disorder • Half of all mental disorders begin before the age of 14 years • Suicide is one of the three most common causes of death in youth • Non-fatal self-harm is 10-40 times more common than actual suicide

10. Mental Health in Youth and Education (Jane Llopis and Braddien, 2008) Mental health problems are high in the EU • Data is incomplete and not comparable across the EU. • Deprivation and inequalities are key determinants of poor mental health • Early exposure to risk factors lead to mental health problems later in life • Mental health facilitates learning and education achievement • Mental health problems lead to early school learning • Youth unemployment leads to mental health problems.

11. Costs to other sectors • Costs of poor mental health are larger for other sectors • Lost employment • Reduced productivity • INCREASED LEVELS OF CRIME Costs of conduct disorder at age 10, are estimated 18 years one, to be: • 6 times larger for the educational system • 20 times larger for the social justice system • Than for the health care system They conclude therefore: • Need for intersectorial approach • Health dimension, promotion from the early years of life • School are setting for mental health promotion • Youth participation

12. QUALITY IMPROVEMENT AGENDA Current Mantra : QIPP Improvement at no extra cost LEAN • Sustainable quality in mental healthcare • NICE guidance implementation as must do but MDT climate and culture where innovation is valued alongside delivery of pathways of care populated by evidence based interventions.

13. THE FOUR E’s Integration of quality and funding mechanisms: • Experience (of service users, including their safety and dignity), • Efficacy (evidence based interventions), • Effectiveness (what the impact of our efforts is in real life) • Efficiency (how much of the above we get right for x amount of money).

14. Dialogues in research – What are the take home messages for Government, commissioners and clinicians Eisenberg warned us we should not replace brain psychiatry with a mindless psychiatry. • The value of listening to patients and appreciating role of mental mechanisms • Coming together of different types of psychotherapy and greater appreciation of real life experiences past and current • Need to avoid the ideologies that seek to avoid empirical evidence irrespective of whether • Pharmacological evangelism • Biological determinism • Psycho analysis • Family therapy • attachment • Avoidance of reliance on single treatment model • Ecological concepts of individual, family and community nesting

15. KEY DEVELOPMENT IN LAST 50 YEARS : Establishment of value of developmental psychopathology (Gamzey, Sroufe, Cicchetti & Rutter) MIKE RUTTER ESCAP AUGUST 2009 e.g. applied to CAMHS • Neurodevelopmental origins of both autism and schizophrenia (Rutter & Lockyer; Weinberger & Murray) • Age differences in response to drugs (Rapport) • Age differences in response to lateralised brain injury • Long-term consequences of sexual abuse (Kendler & Prescott) • Childhood origins of adult mental disorders (Kim-Cohen) • Adult outcome of childhood reading problems (Maughan) • Vulnerability features and pathways to depression (Brown & Harris)

16. HOW TO SHAPE POLICYTHE WHOLE SERVICE PRESS THE RIGHT LEVERS ENTER ALL POLICY SILOS and use the information for your patients benefit Know • What is current policy? • Who owns it? • How is policy made? • Who is already influencing it? • Who is on your side? • Will it cost anything? • AVOID the ENDLESS delay loop • PREPARE, then seize the day • The world is run by people who turn up to meetings and write and respond. YOU HAVE TO BE INFORMED, ATTRITIONAL, LIVE IN HOPE AND HAVE A SENSE OF HUMOUR

17. Solutions looking for problems – non evidenced based policy • Complex needs do not mean complex systems • Care in a cold climate • Communities that care • Families that function • One meaningful trusting and non-abusive relationship • One meaningful thing to do each day • Advantage from adversity • CAMHS IMPLEMENTATION STRATEGY – public mental health – Getting the Right Start – Strong economic argument to reduce lifetime costs – and transitional services concept of “Youth Psychiatry” • FORENSIC – BRADLEY topical • OLD AGE – shifting population demographics, DEMENTIA – disease burden of later life – delayed discharge • Symptom clusters that present as challenging behaviours – what government and society fear and avoid

18. Issue of Vulnerability and Developmental Immaturity and Maturity There is extensive evidence that important developmental changes continue throughout the teenage years. Even pre-school children appreciate distinction between right and wrong although they approach the distinction more in terms of fear of detection and the punishment that will follow, rather than internal justice principles and concern for the victims of wrong acts. During early adolescence young people's thinking tends to become more abstract, multi-dimensional, self-reflective and, in addition, they are able to generate more alternatives in their decision making. There is a marked increase in emotional introspection together with a greater tendency to look back with regret and to look ahead with apprehension. The transition to more adult modes of thinking does not emerge at any single age but it is clear that it is very far from complete at age 10. It should be added that, as with any aspect of development, there are marked individual differences in which children achieve maturity. Children who commit acts of serious sadistic violence are likely to be seriously psychologically disturbed and they have often experienced serious adversity. This means that, usually, they will require residential care in order to receive the intensive psychological treatment that they urgently need. But also it means that, in many cases, rehabilitation is a realisable goal.

19. THE HUMAN RIGHTS PERSPECTIVE INTERNATIONAL STANDARDS European Convention on Human Rights Article 3 Prohibition of Torture Article 5 Right to Liberty and Security Article 6 Right to a Fair Trial Article 8 Right to respect for private and family life

20. UN Convention on Human Rights • Article 3 - Whatever the context, primary consideration best interests of child • Article 12 - if “child” can form own views, right to express freely • Article 37 - No child subjected to torture or other cruel inhuman or degrading treatment or punishment • Article 40 - Every child alleged to have, accused of or recognised as having infringed the penal law, treated in a manner consistent with child’s sense of dignity and worth which reinforces the child’s respect for human rights and fundamental freedom of others

21. United Nations Standard Minimum Rules for Administration of Juvenile Justice (Beijing Rules) Part One General Principles Fundamental Perspectives Age of Criminal Responsibility Aims of Juvenile Justice Scope of Discretion Rights of Juveniles Protection of Privacy Part TwoInvestigation and Prosecution Initial contact Diversion Specialisation within the Police Detention pending Trial

22. United Nations Standard Minimum Rules for Administration of Juvenile Justice (Beijing Rules) Part ThreeAdjudication and disposition Competent authority to adjudicate Legal consent, parents and guardian Social Inquiry reports Guiding principles in adjudication and disposition Various disposition measures Least possible use of institutionalisation Avoidance of unnecessary delay Records Need for professionalism and training Part FourNon-institutional treatment Effective implementation of disposition Provision of needed assistance Mobilisation of volunteers and other community services

23. United Nations Standard Minimum Rules for Administration of Juvenile Justice (Beijing Rules) Part FiveInstitutional Treatment Objectives of institutional treatment Application of the standard Minimum Rules for the Treatment of Prisoners adopted by United States Frequent and early recourse to conditional release Semi-institutional arrangements

24. Part SixResearch, Planning, Policy, Formulation and Evaluation Efforts shall be made to organise and promote necessary research as a basis for effective planning and policy information. Efforts shall be made to review and appraise periodically the trends, problems and causes of juvenile delinquency and crime as well as the varying particular needs of juveniles in custody. Efforts shall be made to establish a regular evaluative research mechanism built into the system of juvenile justice administration and to collect and analyse relevant data and information for appropriate assessment and future improvement and reform of the administration. The delivery of services in juvenile justice administration shall be systematically planned and implemented as an integral part of national development efforts.