Feedback to Kent From the Children and Young People’s Emotional Well-being and Mental Health National Support Team 23 rd

1. Feedback to KentFrom the Children and Young People’s Emotional Well-being and Mental Health National Support Team23rd September 2010

2. To be Covered Today • Themes of Children and Young People’s Emotional Well-being and Mental Health (EW & MH) • Overall Strengths • The Scale of the Challenge • Recommendations by Theme • Priority Actions • Plenary Session Discussion • NST Contact Details

3. Themes of EW & MH • Children’s Experiences • Vision and Strategy • Leadership and Management • Data and Needs Assessment • Universal and Preventative Services • Targeted Services • Specialist Services • Transitional Arrangements • Workforce Strategy and Training • Commissioning

4. Strengths

5. Strengths • There is strong commitment from the key partners to Children and Young People’s EWMH • The Children’s Trust’s intention to prioritise Emotional Wellbeing and Mental Health (EWMH) for children and young people in the next Children and Young People’s Plan (CYPP). • The Children’s Trust is valued by many partners, and is positioned to develop a good overview of current arrangements and services • There is evidence of colleagues’ local knowledge, networks, and passion and commitment for their communities • There is a move to twelve localities, with the potential for greater synergy with GP consortia and strengthened local commissioning • Lead/Council Members understanding of the issues • Diversity and strength of the voluntary sector

6. Strengths (cont) • Shared initial thinking about the future post-PCTs, and how to move towards sustainable provision • Youth Service targeted provision • Primary mental health support in schools • Professional expertise and individual learning plans • Supporting training, for example using the ‘Solihull Approach’ • Re-tendering of Tier 4 provision • Some excellent local practice including good networking based on individual relationships and managers communicating regarding individual cases.

7. Strengths (cont) • Aspiring and comprehensive Parenting Strategy • The House Project – innovative and informal approach • The Portage work for children with disabilities • The Leuven Programme • 97 Children’s Centres up and running • SPARK - the Targeted Mental Health project in Swale • Local Complex Needs Panel

8. Scale of the Challenge

9. Scale of the Challenge • The current economic climate requires a strong focus on achieving value for money, whilst driving up quality and improving productivity (Delivery of QIPP – Quality, Innovation, Productivity & Prevention) • Impact of White Paper on current commissioning arrangements • Kent has high number of Looked After Children and Unaccompanied Asylum Seeking Children • Complex commissioning arrangements – different internal processes within Eastern and Coastal Kent PCT and West Kent PCT • Two specialist CAMHS providers covering the County – and not co-terminus with PCTs • Health inequalities/affluence and deprivation across the county • Large county

10. Why is Emotional Well-being and Mental Health Important? • It’s a common problem: one in ten children and young people have a mental health problem • It affects educational achievement: with low educational performance and absenteeism • Inter-relationship with risk behaviours and physical health: frequently an underlying factor behind risk behaviours and health outcomes • Poor mental health can be a symptom of a child at risk: children and young people frequently express their internal distress in the form of mental disorders • Increased offending and anti-social behaviour: conduct disorders in particular are associated with anti-social and offending behaviour • Long-term impact and cost to society: the average cost to society of an individual with untreated conduct disorder is £230,000 (71% crime, 13% mental illness, 7% lifetime earning - Friendly and Parsonage, 2007)

11. Key risk factors for EW & MH

12. Associated Risk Factors for Poor Mental Health in Children and Young People

13. Recommendations

14. Summary Kent has some excellent practice in local areas and in some County- wide services. The challenge for Kent Children’s Trust is to develop a strategic ‘whole system’ vision for EWMH which maximises this, and provides a framework for commissioning and planning of all services, both local level and County- wide, and at every Tier. To achieve this there will need to be a strong partnership approach, a coherent understanding of all the contributing resources within the whole system (at every Tier) and agreement to support a more community/consultation model for specialist MH provision.

15. Children’s Experiences

16. Kennedy report, September 2010 p.14, para 45 • ...the ultimate goal must be to shift the focus away from single professional units and identities, with their particular goals, to a single-minded concern only for the outcomes that are needed for children and young people: that is, work backwards and start with the child or young person (“I exist to provide for you”), rather than forwards from “This is what I, as a professional, do”.

17. Recommendations Children and Young People’s Experiences • Commissioning and service development must put the child’s experience at the centre of its decision making processes. Analysis of activity and performance data should be routinely triangulated with experiences of the whole system. • The NST saw some pockets of good practice in involving children and families in service development. We recommend the development of a Participation Programme which would accelerate more systematic approaches and provide appropriate expertise for amplifying the voices and involvement of children and young people, particularly those in high risk groups.

18. Vision and Strategy

19. Recommendations Vision and Strategy • The NST commends the Children’s Trusts intention to prioritise emotional wellbeing and mental health for children and young people within the next CYPP. Building on this, we recommend that the refreshed strategy for C&YP’s EWMH promotes a ‘whole system’ vision andapproach, including all the resources and services which contribute to this agenda at every Tier, and agreement at a senior level that services will support a more community/consultation model for specialist MH services. NST can support a visioning event • This activity should take no more than 6 months and include engagement of stakeholders, including GPs. There needs to be agreement about the principles and characteristics of services at universal, targeted and specialist levels, based on what C&YP want and need. This strategy then sets a framework for all planning and commissioning in the future. NST/RDW can provide examples from other areas. • This vision can support future commissioning by local GP consortia, and provide an ongoing framework for local innovation.While this work is undertaken, short/medium-term ‘fixes’ to the current service mix, that do not detract from the above, are recommended in more detail later in this report.

20. Leadership and Management

21. Recommendations Leadership and Management The NST recommends that as the integrated approach is developed, a Senior Manager (perhaps a joint commissioner) is tasked to lead and implement a change management programme across the Children's Trust, to ensure that: • partnership working is refreshed to better support the desired strategic re-focusing, and enable action to be delivered in line with the strategy • effective change leaders and champions are identified across the system, including within Clinical and Universal services • all staff are supported to develop a shared understanding of what Kent is endeavouring to achieve, and how their core business/roles and responsibilities contribute to delivering this joined up approach • planning and commissioning structures are refreshed to ensure that decision makers and those with access to resources and information are in the right place at the right time i.e. all round the same table

22. Recommendations Leadership and Management Cont’d. • All parts of the system including the third sector need to be able to understand how they feed information in to the planning and commissioning process and the part they can play in affecting change • The need for change is supported by frank and open debate within the relevant services • Staff are supported to manage change within their services whilst maintaining a focus on quality • Behaviour which supports partnership is modelled by senior leads and change champions • Clear governance arrangements are developed to ensure that risk is monitored and managed, and value for money, productivity and efficiency are achieved NST can advise/support

23. Workforce Strategy and Training

24. Recommendations Workforce Strategy and Training • The NST heard that staff development was not always planned as part of a more strategic, integrated approach • There are good examples of services which are investing in staff training, however capacity issues prevent some staff from using new skills in practice, (e.g. Solihull Approach and Brief Solution Focused Therapy approaches) • The refreshed EWMH strategy should include a workforce plan outlining the skills required to deliver the agreed roles and responsibilities and theoretical approaches at the various Tiers. Services can then use this for guidance and a rapid appraisal of gaps and duplication. RDW & Canterbury Christchurch links can support this

25. Recommendations Workforce Strategy and Training Cont’d The NST recommends that: • enhanced models of supervision for groups of professionals are developed, particularly in Universal services, in order to grow their expertise and confidence in relation to resilience-building, risk assessment and low level MH problems • R&D opportunities which support service improvement are identified and exploited, particularly those involving and supporting clinicians • action research opportunities (which present as a result of the number of Kent professionals carrying out academic development), are harnessed, to ensure that learning informs planning and development

26. Data and Needs Assessment

27. Recommendations Data and Needs Assessment • Performance and activity data collection and analysis has greatly improved in Kent with both manual and electronic processes being used to collect data within services. The NST suggest a brief review of the current capacity of IT systems to support this work. • The CAMHS Strategy Group has also commissioned ongoing comprehensive information gathering and auditing. The NST recommend that in order to maximise this, information collected needs to be analysed to produce more ‘punchy’ intelligence in order to support commissioning. • Whilst specialist CAMHS activity is being monitored, the NST was not clear how the performance data was being used i.e. targets, penalties and rewards. CAMHS performance indicators in relation to patient experience were also unclear. The NST recommends clarification on how activity data will be analysed and used in future. NST/RDW can advise. • The NST heard that the LPSA2 project resulted in Strength and Difficulties Questionnaires (SDQs) being used across a range of provision. This work on outcomes for children & young people provides a strong building block for future work which the NST recommends should be further developed

28. Universal, Targeted and Specialist Services

29. Recommendations Universal Services • The NST heard about strong localised initiatives in school clusters which provide preventative services to enhance well-being and learning. The learning from these initiatives should inform the strategic plan so that all children can benefit from this provision. • The Targeted Mental Health project, SPARK, in Swale was reported as working well. The NST endorses plans to expand this approach to a Kent- wide model. • The planned work on pathway development, e.g. for Attention Deficit and Hyperactivity Disorder (ADHD) and Autistic Spectrum Disorder (ASD), needs to include and inform Tier 1 provision, and inform broader commissioning of services and schools provision.

30. Recommendations Universal Services cont’d. • The NST endorse your intention to promote further implementation of SEAL across secondary schools. We recommend you build on the good work to make sure all children get the service as a universal entitlement. • Early years provision was generally strong with good coverage, and the NST saw evidence of parenting programmes and support delivered from Children’s Centres on a county-wide basis. However improvements in targeting families with parental mental ill health could be made. We suggest this provision could be enhanced by securing input/links with adult mental health services.

31. Recommendations Universal Services cont’d. • The NST heard from Universal services about staff confidence being mixed in relation to EWMH. Some cases are being ‘held on to’ and others being passed on quickly due to both capability and capacity issues, and sometimes a lack of clarity about whose role it is to work with a case. Expectations of specialist services were sometimes low due to waiting times (sometimes misinformed). • NST recommends that the strategic planning process clarifies roles and responsibilities with staff, and uses the experiences of C&YP being referred to CAMHS in order to identify and learn from their interface with other services along the way. • Universal services could be better targeted with training and consultation around specific issues arising in Kent such as exam stress/high performance pressure, the impact of family breakdown and increasing referrals for self harm • The NST recommends that greater understanding of the service responses to Deliberate Self Harm (DSH) in particular would be useful. Consideration should be given to developing a DSH protocol for all Tiers of services including Universal.

32. Recommendations Targeted Services • The NST were told of difficulties in the CAF system. The Children’s Trust needs to decide quickly whether to use the CAF system, or to refine the CAF system, or to develop an alternative multi-agency working model, as this is a key mechanism for assessing and identifying need and ensuring effective use of resources. • We recommend that you clarify and strengthen primary mental health work (commissioners, including Kent County Council, could consider increased investment or refocusing of resources) and agree how this workforce will form an integral part of a ‘community CAMHS’ model and how it will support Universal Services across Kent. • The NST found evidence of some good practice in targeting services to high risk groups, (e.g. within youth services and community colleges), however the organisation and targeting of resources in other services towards risk groups was patchy, e.g. Learning Disability, looked-after children, minority groups, BME. The NST suggests that is an area where further review may be helpful locally, focusing on risk groups.

33. Recommendations Targeted Services • The NST heard that staff are holding cases at levels of risk which were felt to be beyond the knowledge and confidence of individuals in various services. The NST recommends that this is reviewed as part of developing a workforce strategy, to ensure skills are developed for the right place at the right time, expectations of staff are reasonable, and that individual Continuing Professional Development plans contribute to agreed service development needs. • Community paediatricians reported holding a range of cases which they would expect to be the responsibility of specialist CAHM services. The issue of thresholds and responsibilities in relation to more complex, high risk cases needs to be reviewed with all providers as part of the development of a consultation model. This model will only work with willing participation and an agreement around shared care between CAMHS clinicians and other professionals. Case studies of crisis presentations will inform planning of more integrated provision ‘upstream’. • Consideration will need to be given to how targeted services can provide EWMH services for groups increasing in size , such as children with life-limiting conditions, where gaps currently exist.

34. Recommendations Specialist Services • The NST heard that many C&YP still have extensive waits to be seen by specialist services, however significant work is already underway to reduce waiting times and increase efficiency within specialist services. The NST heard of pockets of activity which were contributing well, such as ADHD care pathways, Saturday clinics to reduce ASD lists and texting about appointments. Successful initiatives should be championed and rolled out, with robust internal management to ensure that effective practice is adopted. • We recommend that Children’s Trust partners drive activity in other parts of the EWMH system which should be undertaken prior to referral to specialist services and will help reduce referrals – e.g. adherence to NICE guidance for ADHD and Conduct Disorder, GP school liaison, Parenting Groups, SENCO co-ordinated interventions, data collection.

35. Recommendations Specialist Services • In order to ensure effective screening and allocation of cases within specialist CAMHS, providers should ensure that professional disciplines operate as an integrated team including agreement of roles in relation to consultation and training, specialism/specific interests and clinical leadership. • Building on the single point of access approach to specialist services, the NST recommends that more joint consideration should be given to referral screening. This will help to tackle unmet need amongst inappropriate/below-threshold referrals, and ensure that where C&YP are accepted in to CAMHS there is more of a multi agency shared-care approach to complex cases. • The NST perceived confusion about the current referral mechanism and pathways into CAMHS, and recommends reviewing the referral protocols for Universal Service referrers, and ensure that this is widely communicated to ensure equitable access. NST can advise further and provide examples • NST suggest a Clinical/Professional Network across Kent would be helpful for sharing developments, innovation etc and to ensure feed back to commissioners with a consistent voice

36. Recommendations Transitional Arrangements • Access to services for 17 year olds remains inequitable. Thresholds may need to be raised in order to accommodate new, appropriate referrals in this age group. However, strategic partners should also consider the types of referrals/cases being presented, and look for greater joint working with this group as a means of extending capacity. • The most complex cases amongst 16-17 year olds (i.e. CYP with a learning disability, or CYP who have experienced neglect, or sexual abuse, or are in inadequate housing, or are Not in Education Employment or Training (NEET)), need more robust mechanisms for multi agency planning and case management which, if necessary, transcends individual service threshold criteria.

37. Recommendations Communications • Internal communication: • Whilst informal communication exists between individual professionals, we recommend that you develop consistent and widely accessible information on services for all professionals (including in schools and General Practice). This should include the eligibility criteria for specialist services and, as clarity develops, Targeted Services, to ensure that CYP are not “batting around” the system. • In preparation for future engagement opportunities with General Practice forums/consortia, we recommend that ‘punchy’ information on the new strategy and commissioning framework be prepared backed by information on prevalence, risk/vulnerability and services activity in relation to local areas. • External communication: • Parents, carers, children and young people need to understand what is on offer locally, and how they can access services when they need to. This information should form part of the broader Children’s Trust service information • Better utilisation of existing websites is recommended.

38. Recommendations Commissioning • We recommend that work is undertaken to improve the working relationships between commissioners and providers, including clinicians, in order to promote shared understanding and ownership of the strategic and commissioning priorities, along with the best evidence based interventions for achieving them • NST recommends that the Kent Children’s Trust consider appointing a joint commissioner as lead for the change programme required to develop a whole system approach to EWMH. This has accelerated change in other areas and bridged divides between organisations and their drivers and resource allocation processes

39. Recommendations Commissioning cont’d • Adult commissioners should look for opportunities to reinforce the EWMH strategy in relation to parents with mental health problems, and transition issues, through their broader commissioning discussions and contract management with providers • The new EWMH strategy should provide a framework for commissioning, and encourage local flexibility/responsiveness whilst promoting quality, access and value for money across the system • Commissioning and planning structures should be refreshed to reflect the broader system view of EWMH

40. Children’s Trust EWMH Partnership Board EWMHCommissioningGroup Other Strategic Partnerships Locality GP Consortia Schools Consortia Prepare for the Future…

41. Priority Actions

42. Priority Actions Children and Young People’s Experiences • Commissioning and service development must put the child’s experience at the centre of its decision making processes. Analysis of activity and performance data should be routinely triangulated with experiences of the system. (Service leads should be able to account to children and families about what has changed as a result of better understanding their experience)

43. Priority Actions Vision and Strategy – Whole system approach • We recommend that you develop a ‘whole system’ vision and approach for C&YP’s emotional wellbeing and mental health which includes all the resources and services which contribute to this agenda at every Tier, and agreement to support a more community/consultation model for specialist MH provision. • This activity should take no more than 6 months, and needs to include engagement of stakeholders, including GPs. There needs to be agreement about the principles and characteristics of services at universal, targeted and specialist levels, based on what C&YP want and need. This can then become your planning and commissioning framework.

44. Priority Actions Vision and Strategy – Partnerships • In order to achieve a whole system approach, partnerships will need to be refreshed at every level. Effective change leaders and champions should also be identified across the system including within clinical and universal services.

45. Priority Actions Vision and Strategy - Targeting resources • In the current financial climate, guiding principles for the whole system will need to include the targeting of high risk and vulnerable C&YP at every level of service. This means agreeing a coherent approach, identifying those with lesser resilience and more vulnerability, and the allocation of resources accordingly.

46. Plenary Session Discussion • Local Authority and SCT to comment • Questions to clarify feedback points • Comments on Feedback • Any comments on our process • Next steps

47. Support Process

48. Support NST Support Next Steps • Meeting in 6-8 weeks with Chief Executives of the LA and PCT, Director of Public Health, Director of Children’s Services, to negotiate and agree the support to be provided by the NST Examples of the type of support offered: • Sending examples of practice from other areas • Supporting the organisation of visioning/planning events • Helping to find expert consultants for local areas to commission • Providing advice on elements outlined within the NST report • Looking at and advising on strategic documents/plans/performance management frameworks • Being a critical friend through attending partnership meetings/Executive meetings/Strategic partnerships • Mentoring/coaching key personnel • Speaking at local conferences/events • Helping to brief elected members

49. EW & MH National Support Team Contacts