Warrington and Halton Children and Young People’s Mental Health and Wellbeing

1. Warrington and Halton Children and Young People’s Mental Health and Wellbeing Local Transformation Plan (LTP) Refresh October 2018

2. Contents • Slide • Executive summary 3 • Introduction 4 • Ambition 5 • Governance 6-7 • Cheshire & Mersey Health and Care Partnership 8-9 • Needs Assessment & Engagement 10-13 • THRIVE – a whole system approach 14 • Promotion & Prevention 15-16 • What has been achieved? 17-18 • Vulnerable Children 19-23 • Youth Justice 24 • Data and Performance 25-30 • Workforce Planning 31 • Financial Investment 32-33 • Future Plans and Roadmap 34-35 • Risks to Delivery 36 • Appendices 37-38

3. Executive Summary • This 2018 refresh of the Warrington and Halton children and young people’s ‘Local Transformation Plan’ is a reflection of the commitment locally to improving the mental health and wellbeing of our children and young people. • Nationally, there is an ambitious 5 year plan (up until 2015 - 2020). At the midway point we can demonstrate that significant progress has been made in Halton and Warrington. • This includes: • A continued focus on prevention and early support and intervention • An increase in the number of children young people being able to access help • Easier access through self referral, drop in sessions and support in schools • A more integrated model of care which includes more choice for young people about what help they can get, including online support • A dedicated specialist eating disorder service • A focus on having an appropriately skilled workforce that can provide the best evidence based interventions • Next Steps: • We are still committed to a greater focus on our most vulnerable young people and there is work underway to improve care for young people in the youth justice service, with neurodevelopmental conditions and those young people on the edge of care/in care. • We will continue to work in partnership to drive forward the plans for 2018-2020 to ensure we deliver the national and local ambitions for our young people.

4. Introduction • Children and Young people’s mental health has been a national priority since the launch of Future in Mind (2015) and the Five Year Forward View for Mental Health (2016). • NHS Clinical Commissioning Groups (CCGs) have been required, in partnership with a wide range of local and regional stakeholders to publish a local transformation plan (LTP) and to refresh this annually. This 2018 refresh should be viewed in conjunction with the documents from previous years which can be found on the relevant CCG websites. • Over the last few years, Halton and Warrington CCGs have worked in close partnership on a number of initiatives focussed on transforming mental health and wellbeing services for children and young people. Some of this work has been on a wider geographical footprint with neighbouring Mid-Mersey CCGs. • Following the appointment of a joint Chief Accountable Officer for NHS Halton and Warrington CCGs, in February 2018 it was proposed that a joint Halton and Warrington LTP refresh be undertaken. In many areas, where the priorities and aims align and where there is a single main provider of mental health services, it makes sense to have a consistent approach across the two boroughs. However, through local placed based partnership arrangements within the wider ‘One Halton’ and ‘Warrington Together’ programmes, there continues to be scope and plans to tailor services to local need and local pathways. • To reflect this joint approach, the 2018 LTP refresh is therefore a joint Halton and Warrington Plan. • Through local partnerships, there continues to be a recognition of the importance of the 5 key themes from Future in Mind: • Promotion resilience, prevention and early intervention • Improving access to effective support • Care for the most vulnerable • Accountability and transparency • Developing the workforce

5. Ambition • The partnerships across Halton and Warrington continue to be ambitious in delivering transformation change across the system to ensure we achieve the best outcomes for children and young people with mental health and emotional wellbeing needs. • Our ambitious objectives require close partnership working with all stakeholders, including children, young people and their families; clinical commissioning groups; local authorities including early help; children’s services, education and schools; voluntary Sector; specialised commissioning; youth justice services, Primary Care; and regional assurance teams. • For both CCGs, plans and priorities cover the full range of need from promotion and prevention to specialist in-patient care including: • Early help • Evidence based routine care (in line with children and young people’s improving access to psychological therapies programme) • Crisis care and intensive interventions • Supporting vulnerable children and young people including those who have experienced trauma or abuse/adverse childhood experiences, looked after children, children with learning disability and/or autism, young people in the youth justice system. • Slides 15 and 16 provide a high level summary of the promotion and prevention streams of work underway across both boroughs. • A focus on understanding local need has been ongoing over the last 3 years (see previous LTP refresh documents). This year, there is a much greater focus on specific vulnerable groups. A high level overview for each borough can be found on slides 11 and 12. The focus on vulnerable group continues (slides 19-24) through a placed based approach to ensure integration with both Halton and Warrington local authorities. • Slides 25 -33 show a significant improvement in the use of data to ensure accountability and transparency; there is the ambition is to ensure this continues and develops further, including through more consistent use of and reporting of outcome measures. • We want to ensure that the changes we make deliver real improvements in the experience of care and the outcomes for the children and young people of Halton and Warrington.

6. Governance - Halton • Halton’s oversight and governance arrangements have remained consistent and have enabled a balance of wide engagement and operational input and delivery, with strategic oversight and decision making when required. • The structure has been updated this year to reflect the emerging governance for mental health across the Cheshire and Merseyside region (further details on slide 8). • Wider stakeholders • NHSE & Specialised commissioning • Senior and |Primary head teachers Forum • Halton Children's Social Care service • Improving Access to Psychological Therapies • Voluntary Sector • Engagement carers /CYP • Health Watch representation on emotional health and wellbeing board • Involvement and engagement via relevant groups including: • Riverside College events • Halton Peoples Health Forum • Health Watch Halton • SHOUT young person user group • Halton Youth Parliament Health and Wellbeing Board MH Oversight Group CCG internal governance Emotional Wellbeing for Young People’s Partnership Board Cheshire and Merseyside Mental Health Programme Board Transition Group for YP Young People’s Reference Group ( in development)

7. Governance - Warrington • Warrington’s oversight and governance arrangements have remained consistent and have enabled a balance of wide engagement and operational input and delivery, with strategic oversight and decision making when required. The structure has been updated this year to reflect the emerging governance for mental health across the Cheshire and Merseyside region (further details on next slide). • Wider Stakeholders • NHSE & Specialised commissioning • Warrington Association of School and College Leaders • Warrington Association of Primary Heads • Warrington Association of Special School Heads • Improving Access to Psychological Therapies • Voluntary Sector • Parent/carer representation on emotional health and wellbeing board • Service user representation on Warrington mental health programme board • Involvement and engagement via relevant groups including: • Health Forum • Healthwatch Warrington • SHOUT young person user group • Oi Listen! • Warrington Parents & Carers • Youth Council • Youth Service forums Health and Wellbeing Board Integrated commissioning and transformation board Cheshire and Merseyside Mental Health Programme Board CCG internal governance Healthy children and young people’s partnership Warrington Mental Health Programme Board Mental Health Promotion and Prevention Group Links to neurodevelopment steering group CYP’s emotional health and wellbeing board

8. Cheshire and Merseyside Health and Care Partnership Mental Health Programme Board • The Cheshire and Merseyside Health and Care Partnership is the second largest Sustainability and Transformation Partnership (STP) in England. • It is made up of a collection of organisations responsible for providing health and care services in Cheshire and Merseyside including the NHS, GPs, local councils and the community and voluntary sector. • The purpose of the Partnership is to plan together how best to deliver these services now and in the future so that they meet the needs of local people, are of a high quality and are affordable. • The Partnership agreed that ‘Mental Health’ should be a strategic priority in Cheshire and Merseyside and established the Mental Health Programme Board. The Board’s membership includes Mental Health NHS trusts, local authorities, Third Sector, NHS Clinical Commissioning Groups (CCGs) and the Police and Crime Commissioners Office. The Board’s purpose is to accelerate the implementation of the Five Year Forward View (FYFV) for mental health and following a re-focus of its work, informed by partners across Cheshire and Merseyside, is now leading on FYFV objectives which are best developed at scale. The Board also has oversight of developments taking place on all other FYFV Mental Health objectives – described as ‘place based’, however does not hold accountability for these.  • The ten objectives that the Board lead on are set out on the next slide. • A number of working groups have been established to deliver on these work programmes, all of which are clinically led and supported by staff from within Board member organisations. • The workstream most relevant to children and young people has been highlighted on the following slide:

9. Cheshire and Merseyside Mental Health Programme Priorities

10. Halton: Needs Assessment, Engagement and Equality – a Focus on Vulnerable Groups • Children in Care - the Local Authority are procuring a bespoke service to support the mental health needs of children in care and support to fostering/adoption carers. The specification has been revised from the current service to acknowledge the increasing complexity of problems experienced by children in care who may have been subject to abuse/neglect • Neurodevelopmental issues – it is recognised that children with autism spectrum disorder (ASD) and/or attention deficit hyperactivity disorder (ADHD) are at greater risk of developing associated emotional wellbeing/mental health issues. Following investment in 2016/17 into nursing support for children with ASD/ADHD, an audit has been undertaken which has identified some significant issues with delivery of diagnostic pathway which has lead to an intensive review of the service offer during 2018/19 and associated recommendations.

11. Warrington: Needs Assessment, Engagement and Equality – a Focus on Vulnerable Groups • NHS Warrington CCG has undertaken extensive engagement and needs assessment to inform the development of the newly commissioned THRIVE model. Detailed information can be found on the CCG website in both previous LTPs and supporting documents. • Following implementation of THRIVE, there continues to be a need to focus on some specific vulnerable groups e.g. children looked after or that have been abused, and children with neurodevelopmental conditions. Neurodevelopment and Special Educational Needs and Disabilities (SEND) Based on national prevalence data, it is expected that in Warrington there are 407 children with autism spectrum disorder (ASD) and between 740 and 1851 children with attention deficit hyperactivity disorder (ADHD). A joint strategic needs assessment for SEND in Warrington can be found here. Specialist services cautiously report (due to coding issues) 348 children known to health services with ASD, and 608 with ADHD. This does not include children receiving support from services that have not as yet been given a diagnosis and not all children will stay open to services continuously. It is therefore likely that there is an appropriate level of expected demand in Warrington based on prevalence figures. Over the last 2 years, there have been numerous opportunities to engage with families around their experiences of services. Broad engagement around the THRIVE model, specific engagement in relation to specific neurodevelopmental pathways, and representation by Warrington Parents and Carers at meetings has shown some consistent themes: wide variation in waiting times with some families waiting extensive periods of time for a diagnosis, some aspects of support and intervention only being available after a long process to gain a diagnosis, some families falling between the gaps of community and mental health services. Recent quality reviews of the neurodevelopmental pathways have highlighted some clear opportunities to improve services. Needs assessment, engagement and quality review information will directly inform commissioning intentions.

12. Warrington: Needs Assessment, Engagement and Equality – a Focus on Vulnerable Groups Children in Care/Children that have been Abused • The rate of children in care (85 per 10,000) during 2017 in Warrington was significantly higher than England (62 per 10,000), but slightly lower than the North West (86 per 10,000).  When compared to our CSSNBT (Children’s Services Statistical Neighbour Benchmarking Tool) statistical neighbours, Warrington had the highest rate • The rate of children subject to a child protection plan in March 2018 was 37.62 per 10,000. This was in line with statistical neighbours (37.0) and lower than England average (43) and North West average (54). This is a significant reduction on prior years • The rate of children in need in March 2018 was 277 per 10,000, which is low compared to statistical neighbours (307), England average (330) and North West average (372) This data indicates that children and young people’s needs may not be being identified as early as possible to prevent escalationto child protection or children becoming looked after. Parental and/or child mental health were identified as the most prevalent presenting need during early help assessments. Locally, the Corporate Parenting Forum requested a deep dive on the available local information and data in relation this cohort of young people and mental health (see appendices).  The main findings were that children in care are under represented in services, however there is a trend of improvement and evidence of increased consistency in the use of the strengths and difficulties questionnaire with a possible indication of improved outcomes. However, the numbers are too small to draw strong conclusions at this stage. The joint strategic needs assessment for children in care in scheduled for a refresh this year.

13. Warrington and Halton – Youth Justice • National and Local Mental Health Prevalence (Youth Justice) • Key Points – Mental Health of Youth Justice Cohort (Cheshire Youth Justice footprint): • 57% of young people in the sample were recorded as having some level of mental health need affecting their daily functioning; 17% had a formal diagnosis recorded. Compared to national prevalence estimates for young people (11.5%) this is a relatively high proportion with a mental health condition • Of the recorded diagnosed conditions, ADHD was the most common, accounting for 28% of those diagnosed (n=8) or 5% of the total sample. 26% (n=45) were in contact with mental health services at the time of assessment, and 23% had a history of self-harm and/or suicide attempts. • The children and young people in the sample had higher levels of recorded learning difficulties (9% compared to local prevalence estimates equivalent to 2-3% of school-age children and young people), ADHD (7%, above the national estimated prevalence of 2-4% of teenagers) and autistic spectrum disorders. • 24% (n=42) of the sample – 34% of statutory cases and 14% of diversion programme cases – were noted as having a statement of special educational needs (SEN). • Of the 70 (40% of the sample) young people assessed as requiring intervention, all but 2 had an intervention or onward health referral recorded

14. THRIVE – a whole system approach NHS Warrington and Halton CCGs have now commissioned a THRIVE model of care and this is in the process of full implementation. Work has been undertaken to model capacity and demand in line with THRIVE to ensure increased access at least in line with national access targets. Young people and parents/carers can self refer and access prompt information, advice, signposting via open access drop in sessions. Named link practitioners are allocated to each secondary school and early help and children’s services can directly access consultation via a practitioner being co-located within multi-agency safeguarding hubs. There is increasingly dedicated support to the Youth Justice population.

15. Halton – Promotion and Prevention • "You're never too young to talk" mental health campaign - This mental health campaign has been developed by the Anna Freud National Centre for children and families and is targeted at Year 6 • 5 Ways to Wellbeing Award - This is a local award based on a framework of 5 everyday activities that boosts children's wellbeing, • In Your Corner campaign - A short mental health campaign developed by Time To Change which teaches students they don't need to be an expert to support their mate through tough times. • A framework for mental health and resilience in schools (MHARS)-The MHARS Framework sets out the components of school practice and ethos that effectively develop resilience, promote positive mental health and support children at risk of, or experiencing mental health problems. • Basic Mental Health Awareness -Training is approximately 3 hours and is for anyone who works with children and young people in Halton. • Self Harm Awareness training -Training is approximately 2 hours and is for anyone who works with children and young people in Halton. • Suicide prevention training -Training is approximately 3 hours and is for anyone who works with children and young people in Halton. • Help when we need it most: How to prepare for and respond to suicides in schools and colleges -Nobody likes to think about a death in school. Yet suicide is a leading cause of death for young people in the UK and Republic of Ireland. Sadly it is always a possibility that a student, parent or member of staff might choose to take their own life. However upsetting this must be, schools play an important role in reducing the likelihood of copycat behaviour and helping recovery by preparing and responding to the situation properly.

16. Warrington – Promotion and Prevention • Warrington’s Public Health Team leads an all age mental health promotion and prevention strategy that is aligned with the children and young people’s local transformation plan • Prevention & Early Intervention is a key element within universal settings, schools, colleges and primary care • Public Health promote a whole school/setting approach, as part of overall THRIVE model, through: • 0 to 19 public health commissioned service with specific KPI’s around mental wellbeing • PSHE network meetings • Academic delivery plans • Youth Health Champions • Training • Promotion of evidenced based mental wellbeing campaigns e.g. In Your Corner • www.happyoksad.org.uk website • Suicide Prevention and Postvention • There is a named lead in each primary and secondary school for mental health who has received mental health first aid training. This includes a senior lead and an operational lead. In addition, every secondary school has a named CAMHS link worker. • There is some early data to indicate that there are increased opportunities for the wider system to get support and advice on managing and containing lower level mental health needs at home and in schools, leading to a reduction in referrals to specialist services. It is hoped this then creates capacity for a greater number of the appropriate referrals to receive evidence based interventions.

17. Halton and Warrington – What has been achieved?

19. Halton – Vulnerable Children • Halton Borough Council commission a wide range of services for vulnerable young people in the borough. • Their main provider is Young Addaction who deliver: • Information and awareness around drugs and alcohol • C Card and sexual health screening and information • Information on how to keep safe and address risk taking behaviours • One to one support for young people with drug and alcohol issues • They support LGBT young people via a weekly support group (GLOW) • They are part of the Pan Cheshire Exploitation and missing from home service • Additional Needs Open access group Make it Happen • Outreach support • Amy Winehouse Resilience Programme

20. Halton – Vulnerable Children - continued • There is a regular monthly children in care emotional wellbeing panel where cases are brought by social care to a multi agency panel including CAMHS staff, for advice and guidance, support on making referrals and on appropriate placements. • Halton Borough Council are embarking on two projects to improve provision for children and young people with emotional health and wellbeing needs and displaying challenging behaviours. The first project (which has confirmed funding from the DfE for £500,000), is for two resource bases in key stage one for children with these needs.  • A second project is a bid for a special free school for key stage three and four for pupils with the above needs. Halton BC has embarked upon this bid with St Helens LA and is preparing a bid to be assessed by the Regional Schools. • The CCG and LA are currently bidding for a pilot project to support more robust assessment for mental health needs of children in care.

21. Warrington – Vulnerable Children • Needs assessment information in relation to this group of children is detailed on slide 12. There are a large number of other factors that can increase the vulnerability of children and young people who are experiencing mental health problems. Our early help services and social work teams have a range of interventions to work with these children identified with early help needs, or where they are open to social care as children in need or are looked after. There is increasing alignment and integration of these services with health services to achieve the best outcomes for children and young people, e.g. in moving to a THRIVE model.

24. Halton and Warrington – Youth Justice • Health and Justice is a priority for 2018 – 2021 in the ‘Implementing the Five Year Forward View for Mental Health’ • (NHS England) • “By 2020/21, there will be evidenced improvement in mental health care pathways across the secure and detained settings. Access to liaison and diversion services will be increased to reach 100% of the population, whilst continuing to ensure close alignment with police custody healthcare services.” • All age liaison and diversion services have been commissioned by NHS England and the Police and Crime Commissioner’s Office • Local Developments • Across the Cheshire Youth Justice footprint, there has been notable variation in dedicated health services for young people in the youth justice system. Six CCGs, including NHS Halton and Warrington CCG were successful in a bid to NHS England to develop and consistent health offer across the area. Once established, this health offer will include: • Dedicated mental health provision • Dedicated speech and language therapy provision • Co-location of staff • Shared training and development • Consistent service specification and key performance indicators • Plans to explore a conduct disorder pathway and trauma informed/adverse childhood experiences informed practice • Linking with local authorities in relation to AIM assessments for sexualised behaviours

25. Data – including flowing data to the Mental Health Services dataset (MHSDS) and Outcome Measures • The CCGs recognise the importance of accountability and transparency in the delivery and performance of children and young people’s mental health services. All fully or partially NHS funded services are contractually required to flow data to the mental health services data set. In Halton and Warrington, through the new lead provider arrangements, all providers are now flowing face to face data. There are plans over the next two years to continue to improve data quality.

26. Halton – Data and Performance • NHS Halton CCG is on track to meet the national targets in relation to CYPMH: • Nationally - • Eating disorder target – on track to achieve 95% for both routine and urgent cases by 2020 - on track to achieve 32% Access by March 2019 • Is meeting the early intervention in psychosis target of 50% seen within 2 weeks • Locally - • Comprehensive Performance Outcomes Framework in place with new THRIVE based Service specification • Third sector provider is flowing face to face activity onto NHS Digital to support delivery of national access target • Online counselling support will be captured and reported from December 2018 to support delivery of access target • Outcomes reporting in place

27. Activity Data Average waiting time to start of treatment (as of 31st August 2018) = 83 days Total number waiting = 293 Please note this now combines what was previously tier 3, tier 2 and commissioned third sector provision into one single point of access waiting list.

28. Early Intervention Psychosis IAPT Transition out of CYPMHS 2017/2018 CQUIN compliance for young people transitioning from CYPMHS in North West Boroughs Healthcare into Adult Services or Primary Care was assessed at 75% (limited assurance) in 2017/18. Systems, processes and controls are either not fully in place or working effectively to capture information. A significant number of areas have been identified that require improvement.

29. NHS Warrington CCG – Data and Performance Eating Disorders CYP MH Access

30. Warrington – Data and Performance • Warrington CCG is on track to meet the national targets in relation to CYPMH: • Eating disorder target – on track to achieve 95% for both routine and urgent cases by 2020 • Achieved the national access target of 30% at the end of March 2018; on track to achieve 32% by March 2019 • Is meeting the early intervention in psychosis target • Has a baseline performance for improving quality of transition to adult services. Plans in place to demonstrate improvement. • Progress against these measures are shown in the following slides. In addition there is local data related to delivery of services e.g. referrals, waiting times etc. It should be noted that the services have been undergoing change to move to delivering a THRIVE model of care. This will therefore be the last time data is reported in this way and is able to be compared with 2018/2019 data onwards.

31. Warrington – Data and Performance Eating Disorders CYP MH Access

32. Activity Data Early Intervention Psychosis Improving Access to Psychological Therapies Transition out of CYPMHS 2017/2018 • CQUIN compliance for young people transitioning from CYPMHS in North West Boroughs Healthcare into Adult Services or Primary Care was assessed at 75% (limited assurance) in 2017/18. • Systems, processes and controls are either not fully in place or working effectively to capture information. A significant number of areas have been identified that require improvement. Average Waiting Times Average waiting time to start of treatment (as of 31st August 2018) = 83 days Total number waiting = 293 Please note this now combines what was previously tier 3, tier 2 and commissioned third sector provision into one single point of access waiting list.

33. Using Data to Inform Improvements • Future in Mind highlighted the need for improved transparency and accountability in relation to children and young people’s mental health services. Historically, there has been very limited information/data to inform commissioning and support improvements in services. This is now changing. In addition to CCGs publishing local transformation plans, there is an increasing range of data sources, benchmarking and monitoring/evaluation to enable an evidence based approach to improvement. • This includes: • New local outcomes and reporting framework monitored through contract arrangements • Involvement in local and national evaluation of THRIVE implementation • Mental Health Services dataset • National and regional dashboards (in development) • Rightcare data packs • Hospital data (SUS data) • Development of local dashboards to track key measures through partnership arrangements • Accountability to NHS England through local ‘deep dive’ meetings to confirm and challenge • Accountability to local health and wellbeing boards, safeguarding children’s boards and other local forums • Supporting capacity and demand planning to enable effective flow • Supporting workforce planning and staff development needs in order to provide appropriate evidence based interventions

34. Workforce Planning • Following the publication of the CYP mental health Mid-Mersey workforce plan, capacity and demand modelling has been undertaken in line with THRIVE to plan the required workforce. • An overview is shown below: • Warrington • 0-19 CYP population = 49,927 • Estimated prevalence = 10.1% • Modelling of access based on 50% • Estimated no. = 2,521 • Average no. of sessions = 7.9 • Model 11 or 16 sessions per clinician - 80% face to face • Current workforce = 25 wte (not including sub – contracted providers workforce) • Required workforce = 31.6 • Halton • 0-19 CYP population = 31,424 • Estimated prevalence = 10.1% • Modelling of access based on 50% • Estimated no. = 1,587 • Average no. of sessions = 7.9 • Model 11 or 16 sessions per clinician – 80% face to face • Current force = 15.2 wte • Required workforce = 20.6 This information suggest that within core children’s mental health services, there is approximately 5 or 6 fewer staff than is needed to ensure 50% of children needing help will be able to access it. However, the figures do not include the NHS funded workforce employed by the voluntary and independent sector. This means that locally we should have enough staff to meet the national access target of 35% by 2020.

35. Warrington – Financial Investment 3 Year Plan • As outlined in the October 2017 Warrington Local Transformation Plan refresh, it was planned that the funding arrangements for the core children and young people’s mental health services would change to support implementation and delivery of the THRIVE model. This change commenced at the beginning of January 2018; the actual figures for THRIVE shown below are an accurate estimate over the financial year whilst a change process was undertaken. The actual spend in some areas is lower than planned – this was due to the CCG being in financial turnaround from October 2017 leading to some areas of development being put on hold. The investment has since been reinstated for 2018/2019. Financial information from previous years is available in the refresh from October 2017. (NOTE – growth has not been included in the figures below)

36. Halton – Financial Investment 3 Year Plan

37. Halton Road Map – Key Priorities

38. Warrington Road Map – Key Priorities A detailed action plan can be viewed on NHS Warrington CCG’s website or via the link in the appendices

39. Risks to Delivery

40. Appendices - Warrington • Warrington Action plan 2018 - 2020 • Warrington children’s mental health joint strategic needs assessment • Warrington children’s special educational needs and disabilities joint strategic needs assessment • Mid Mersey children’s mental health workforce plan • Corporate parenting report 2018

41. Appendices - Halton • Mid Mersey Children’s mental health Workforce Plan • Halton’s children’s JSNA