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TRANSCRIPT
www.england.nhs.uk
Friday 10th July 2015
#CAMHITS3.5
CAMH Intensive Treatment
Services (Tier 3.5)
National Learning Event
www.england.nhs.uk
Steve Jones - Chair
CAMH Clinical Advisor, Y&H Children’s &
Maternity SCN
Special Advisor, Child & Adolescent
Health Programme, NHS England
www.england.nhs.uk
Future in Mind
and CAMHS
Intensive
Treatment
Services
• Kathryn Pugh
• Child and Adolescent Mental Health Programme Manager
• June 2015
www.england.nhs.uk
I am going to cover
• Policy direction
• Transformation planning update
• What NHS England is working on now
www.england.nhs.uk
The litmus test of any local
mental health system is
how it responds in a crisis
Future in Mind 2015
www.england.nhs.uk
Seize opportunities
• Five Year Forward View
• Opportunities to be more creative
• Breaking down the barriers of how care is divided
• New models - Vanguard site Urgent and Emergency Care applications due in 15th July
• Collaborative Commissioning oversight groups – many of which have CAMHS on their radar
• Crisis Care Concordat
• Other programmes : Liaison and Diversion, MST
• Ministerial and Media attention
www.england.nhs.uk
Intensive Treatment - integral to system
of support children and young people
4.17 The Crisis Care Concordat describes the actions required of commissioners and
providers to ensure that those experiencing a mental health crisis are properly
supported. This includes the provision of mental health support as an integral part of
NHS 111 services; 24/7 Crisis Care Home Treatment Teams; and the need to ensure
that there is enough capacity to prevent children, young people or vulnerable adults,
undergoing mental health assessments in police cells.
4.18 CCGs should work with other local commissioners to invest in community child
and adolescent mental health services. Investing in children and young people’s
mental health and good transition planning improves outcomes for patients and
families and generates economic benefits. Investing in effective community services
will minimise the use of expensive and often out-of-area tier four services, and the
incidence of young people being admitted to inappropriate settings.
The Forward View into Action – planning guidance for 2015-16
www.england.nhs.uk
What did Future in Mind say to
young people and their families?
• If you have a crisis, you should get extra help straightaway, whatever time of
day or night it is. You should be in a safe place where a team will work with you to figure out what needs to happen next to help you in the best possible way.
• If you need to go to hospital, it should be on a ward with people around your age and near to your home. If you need something very specialised, then you and your family should be told why you need to travel further, and the service should stay in touch to get you home as soon as possible. And while you are in hospital, we should ensure you can keep up with your education as much as you can.
• If you need help at home, your care team will visit and work with you and your family at home to reduce the need for you to go into hospital. If you do need to go in to hospital, the team should stay in touch and help you to get home quickly.
www.england.nhs.uk
And there is more ……..
• Improved care for children and young people in crisis so they are treated in the right place at the right time and as close to home as possible. This would be delivered by:
• ensuring the support and intervention for young people being planned in the Mental Health Crisis Care Concordat are implemented;
• no young person under the age of 18 being detained in a police cell as a place of safety;
• implementing clear evidence-based pathways for community-based care, including intensive home treatment where appropriate, to avoid unnecessary admissions to inpatient care.
www.england.nhs.uk
Not reinventing any wheels
• Today exactly embodies Future in Mind
• What do we know now?
• How can we help each other?
• What can we do with existing resources?
• What could we do with more?
• How do we make this stick?
• QNCC standards
www.england.nhs.uk
Future in Mind Update
www.england.nhs.uk
Overall Governance
• Department of Health working with other Departments
to set overall governance framework to bring together
all the key organisations who have an interest in
children and young people’s mental health and well
being
• Series of programmes in development
• Negotiations underway regarding resources and
which agency will lead on which programme
www.england.nhs.uk
Recent announcements to improve access to
services
Autumn Statement 2014 £30M recurrently
• Develop evidence based community Eating Disorder services for children and
young people: capacity in general teams released to improve self-harm and crisis
services.
Budget Announcement Spring 2015 £250M recurrently
• Build capacity and capability across the system so that by 2020, 70,000 more
children and young people are treated per year.
• Roll-out the Children and Young People’s Improving Access to Psychological
Therapies programmes (CYP IAPT)
• Improve perinatal care
• Pilot a joint mental health training programme for single points of access in
specialist CAMHS and schools, testing it over 15 CCGs.
Implementation of these announcements will be via Transformation Plans
www.england.nhs.uk
Transformation plans : where are we
now?
• Working with partners to develop guidance and a bespoke assurance process
• Everything you need to get going is in Future in Mind
• You will need to show evidence of partnership working and sign up not just locally but also with NHS England specialist commissioning
• You will need to show that children, young people and parents are involved in planning and delivery
• Letter alerting CCGs and NHS England teams has been sent out via CCG Bulletin in May
www.england.nhs.uk
Working with system partners
• Working with Health Education England
• workforce mapping and planning
• CYP IAPT roll out
• Working with DH, DfE, LGA, ADCS, PHE to ensure
guidance sits in the frameworks that match CAMHS
commissioning and delivery
www.england.nhs.uk
Local Plans should
• Cover the spectrum of services - prevention to interventions, for existing or emerging mental health problems, as well as transitions between services.
• Include local leadership and governance arrangements to secure a whole system approach to delivery at local level
• Demonstrate collaborative commissioning within and across sectors to promote effective joint working and establish clear pathways. This includes working with collaborative commissioning groups in place between NHS England specialised commissioning teams and CCGs
• Demonstrate that schools are given the opportunity to contribute to the development of Transformation Plans.
• Be coherent with local priorities, and the child mental health requirements in the existing joint planning guidance.
www.england.nhs.uk
Transformation plans will need to
• Be Transparent – publishing
• Baseline investment by local commissioners
• What services are provided including workforce information
• Referrals received, accepted, waiting times
• Demonstrate Service transformation in line with principles covering
• range and choice of treatments and interventions available;
• collaborative practice with children, young people and families and involving
schools;
• use of evidence-based interventions; and regular feedback of outcome
monitoring to children, young people and families and in supervision.
• Monitor improvement
• Development of a shared action plan and a commitment to review, monitor
and track improvements with appropriate governance structures.
www.england.nhs.uk
Mental health access and waiting times
Better Access by 2020
October 2014
Autumn Statement
December 2014
Budget
December 2014
Access and waiting times are
part of a wider commitment to
parity of esteem for mental
health
Prevention
Early intervention
Effective care
Recovery
Right care
Right time
Right setting
Early Intervention in Psychosis
50% of people experiencing a first episode of
psychosis treated with a NICE-approved package
of care within two weeks of referral
£40m recurrent, held in CCG baselines; indicative
tariff uplift to providers
Improving Access to Psychological Therapies
75% treated within 6 weeks, and 95% within 18
weeks
£10m non-recurrent, held in NHSE programme funds
Liaison Psychiatry
Support effective models of liaison psychiatry in a
greater number of acute hospitals
£30m non-recurrent, held in NHSE programme funds
Eating Disorders
Improve CYP access to specialist evidence-based
community services
£30m recurrent, held in NHSE programme funds
Perinatal
Process underway to inform allocation and
implementation
£15m recurrent, held in NHSE programme funds
National approach to implementation
1. Bringing together the
required expertise
National expert reference group, NCCMH ‘hosting’, highly
collaborative.
2. Developing the
required dataset
Specifying the dataset, intervention and outcome
measurement requirements and commissioning national
clinical audit & accreditation scheme
3. Publication of
commissioning guidance
Service specifications, service model exemplars, staffing /
skill mix calculators etc
4. Design of levers &
incentives
Planning guidance, payment system development,
standard contract etc. Engagement with Monitor, TDA,
CQC.
5. Implementation
support Regional preparedness programmes, national events etc.
6. Workforce
development Joint work with HEE
www.england.nhs.uk
Eating Disorders
• NCCMH Expert Reference Group
• Model of care/care pathways for community ED services.
• Access and waiting time standard to be in place 16/17
• Training and workforce plans
• Support for commissioners
• ED Teams will be population-based - minimum 500K so may span more than
one CCG
• Start thinking about other CCGs, Providers and NHS England clusters now
• Your Transformation plans will need to demonstrate how monies released or,
where comprehensive services are in place, will be used to benefit self harm and
crisis
• Guidance due this month
www.england.nhs.uk
Perinatal
• ERG looking at how to: use additional resources, support effective commissioning, define NICE-concordant pathway of care and possibly introduce access and waiting-time standards
• Building baseline picture of current services: NHS Benchmarking collection, RCPsych Perinatal Faculty data, Maternal Mental Health Alliance)
• Whole pathway of care (GPs, Maternity, Health Visitors, Primary/Secondary/Inpatient mental health) and Public Health
• Led by MH adult programme, working closely with Maternity, Midwifery and PHE
www.england.nhs.uk
Named points of contact project
• Working with Department for Education
• 15 CCGs working with up to 10 schools or other services
e.g. LAC, PRU
• Joint training between nominated links for specialist
CAMHS and school or other services
• Match funding available to CCGs and schools/other
services
• Will need to be part of Transformation plans but also
exploring how we can accelerate expressions of interest
to ensure schools can be contacted before end of term
www.england.nhs.uk
CYP IAPT
• National commitment to embedding evidence based, outcome focussed collaborative service transformation with full participation
• Increased geographical coverage of service transformation programme to100 % by 2018
• Breadth and depth – ensuring enough therapists trained
• Continuing to offer training across partnerships
• New curricula – evidence based interventions including
• Children and young people with learning disabilities or autistic spectrum disorder
• Working with 0-5s
• Counselling
• Prescribing and therapy
www.england.nhs.uk
Further developments from NHS
England
• Life course Mental Health Taskforce - due to report in
July includes Future in Mind
• System Dynamic Model beta version available now
https://www.scwcsu.nhs.uk/camhs
• Support for Transformation nationally building on the
CYP IAPT change agents - discussions with
individual Clinical Networks
• Testing CAMHS currencies
www.england.nhs.uk
Hannah Beale Team Manager, Leeds CAMHS Outreach
Service
Lou Watts Service User Parent
www.england.nhs.uk
Leeds CAMHS
Outreach
Service
Intensive Intervention CAMHS Projects - the Y&H Experience.
10th July 2015 Ashley Wyatt, CAMHS Lead Yorkshire and Humber SCN
"High Quality Care for All, Now and for Future Generations"
Some Models for intervention •Yorkshire and Humber Review of CAMHS Tier 3.5/ Intensive Projects – in April 2014
•Usefully sets the scene for today’s conference
•Summarise the findings and provide an update
"High Quality Care for All, Now and for Future Generations"
The review process
•Four such projects across Y&H in early 2014 •Small project group •Gathering of data from the four projects •Peer review visits between the four projects •Final report - for use by each project, and for wider dissemination
"High Quality Care for All, Now and for Future Generations"
The four different types of service
•A joint ‘crisis response service’ (liaising predominantly with A&E) and ‘home treatment’ service. (Service A)
•An intensive home treatment team that has recently also started taking crisis referrals. (Service B )
"High Quality Care for All, Now and for Future Generations"
Four services (cont.)
•An intensive home treatment service (as an alternative to Tier 4 in-patient admission), not taking crisis referrals. (Service C) •A home treatment/crisis response service staffed by a mix of some dedicated staff and some ‘generic’ Tier 3 staff with a dual role. (Service D)
"High Quality Care for All, Now and for Future Generations"
Some basic data •Admissions to projects per ‘000 child population: 0.32, 0.54, 0.77,
3. 7
•Size of teams: 6.2, 5.8, 3 and 4.8 w.t.e.
•Reasons for admission into the teams varied –
•Project A - mainly DSH.
•Project B - main categories: DSH, depression, psychosis.
• Project C - eating disorder largest single category.
•Project D - suicidal ideation, depression and eating disorder most common categories
•Hours of operation – mainly extended Mon to Friday hours with limited weekend work.
"High Quality Care for All, Now and for Future Generations"
Key themes and challenges (1)
Staffing levels •These projects depend on a critical mass of staffing (more so if they provide an on-call service.) •Not possible to propose a minimum viable number - but projects performing a dual role (crisis response and home treatment) place more pressure on minimum numbers.
"High Quality Care for All, Now and for Future Generations"
Key themes and challenges (2)
Discharge back to Tier 3 •None of these teams can operate without effective and timely discharge back to Tier 3 ‘core’. •With rising referrals to Tier 3, and smaller Tier 3 teams - this is under pressure in all four projects. •Without timely discharge, the USP of these projects - speedy response to avoid Tier 4 admission, and/or addressing crisis - is lost.
"High Quality Care for All, Now and for Future Generations"
Key themes and challenges (3)
Outreach and crisis functions - can they be combined? •Three of the four projects are attempting to combine both functions. •Home treatment elements in danger of losing out in this scenario. •A combined team may be the only way to establish a critical mass of staffing. • Balancing these two functions raises the question: ‘Why are intensive services commissioned?’
"High Quality Care for All, Now and for Future Generations"
Keeping young people out of Tier 4/ enhanced Tier 3 provision
•Two related, but ultimately different, priorities: •Avoiding Tier 4 admissions or reducing their length - Service C has this as its sole function. In this case, one commissioner (CCG) is funding a project, which ‘assists’ another commissioner (NHS England) •Enhanced Tier 3 provision – (which will of course contribute to reducing Tier 4 admissions). On the enhancement spectrum: ‘crisis response’ perhaps closer to Tier 3, ‘home treatment’ towards the tier 4 boundary.
"High Quality Care for All, Now and for Future Generations"
Do these services work? •Data analysis didn’t try to evaluate whether a Tier 3 intensive service results in a more effective Tier 3 service. (This would be interesting.) •It did however correlate the existence of such a project with admission rates to Tier 4 from that area. •Disclaimers - small number of Tier 4 admissions, therefore significant annual variability. Only two years worth of data. •The following Table presents this analysis. Only included adolescent, child/adolescent and eating disorder placements
"High Quality Care for All, Now and for Future Generations"
"High Quality Care for All, Now and for Future Generations"
Project 12/13 inpatient
admission rate per
000 child pop.
13/14 rate
A 20 16
B 4 10
C 9 6
D 6 9
Rest of region* 19 23
*12/13 range from 8 to
31
* 13/14 range from 4 to 31
Update - July 2015
•Some of the 4 projects have struggled in terms of budget pressures.
•Now 7 projects across the region - either in place or advanced stage of planning.
•Such projects increasingly seen as a critical element for every service.
"High Quality Care for All, Now and for Future Generations"
Current Issues •Link this type of service with very varied admission rates to Tier 4 provision across the Region, and continuing pressure overall on Tier 4 within the region. •What does ‘collaborative commissioning’ mean in this context? •How can smaller services run such projects? Is there scope for sharing projects across neighbours?
"High Quality Care for All, Now and for Future Generations"
Final Comment
•Can Tier 3 services afford to run such projects with other demands now on them, ( e.g. providing links to school clusters, and to GPs)? •Can CAMHS partnerships afford not to run such projects - with increased numbers of more complex cases that don’t really need an inpatient admission?
"High Quality Care for All, Now and for Future Generations"
www.cmscnsenate.nhs.uk
@cmscnSenate
CAMHS Admission
Avoidance Services
in Cheshire & Merseyside
Cheshire and Merseyside
Strategic Clinical Networks &
Senate
CAMHS Admission Avoidance Services
in Cheshire & Merseyside
Tim McDougall,
Children and Young People’s
Clinical Network Lead
Cheshire & Merseyside SCN
@timmcdougall69
@cmscnSenate
Introduction
• Describe a range of clinically effective services that are good value for money and acceptable to the young people that use them
• Erroneously called ‘Tier 3 plus’, ‘Tier 3 enhanced’ or ‘Tier 4 minus’ services they have remained neglected in commissioning since the NSF was published – ‘no-mans land’
• 5YFV, Future In Mind and co-commissioning provide the context for a fresh start
Some common features
• All commissioned by NHS England as Tier 4 CAMHS
• Cheshire and Merseyside footprint – fiercely preserved
• Manualised, outcomes focused and continuously monitored
• Clinically effective
• Excellent value for money
• Acceptable to young people and their carers
• Complimentary
•
Assessment and Outreach Team
• Introduced in response to National ‘beds crisis’
• Prevent inappropriate or harmful admissions through gate-keeping assessments
• Provide outreach to young people in crisis to prevent unnecessary admissions
• Support transition through timely discharge
• Reduced LOS from 38 to 14 days (national 59 days)
• ‘Assumed savings’ of £14,700 per admission
• Budget of £300k which is equivalent to 10 ‘average’ hospital admissions
Cheshire & Merseyside Adolescent Eating
Disorders Service (CHEDS) • Evidence of clinical and cost effectiveness from Toucan trial and RCT of
cost effectiveness and user satisfaction with treatment
• Greater use of inpatient beds following treatment in generic rather than
specialised CAMHS
• Cheshire and Merseyside one of the lowest areas of bed use in country –
services treats about 100 young people annually and has about 12
admissions
• Manualised treatment package: 12 sessions of CBT; 4 sessions parental
counselling; 3 sessions dietary therapy; 4 multi-rater monitoring and
feedback
• National exemplar of good practice in NICE Access and Waiting Time
guidance
• Budget of £600k which is equivalent to 6 average ED admissions
Home based treatment services • 6 months treatment at home – planned, fixed and manualised
• Similar to US ‘family preservation services’ – MST and ‘Homebuilders’
• Lack of comparison services and evidence of effectiveness
• Changes over course of treatment:
• HONOsCA (44%)
• CGAS (33%)
• MFQ (49%)
• CYBOC (54%)
• Good outcomes for young people who have become ‘stuck’ in hospital
• Budget of £400k which is equivalent to 13 average length admissions
Acknowledgments • Professor Simon Gowers – CHEDS
• Toby Biggins – Home Based Treatment Service
• Catherine Phillips – Assessment and Outreach Team
Learning from Multisystemic Therapy (MST) Dr Simone Fox [email protected]
Deputy Clinical Director & Senior Lecturer, Royal Holloway, University of London
July 2015
What is MST?
• A community, systemic intervention for young people with aggressive/antisocial behaviour
• Main aim is to provide caregiver with the skills to tackle future problems to prevent risk of out-of-home placements (care/custody)
• Based on the assumption that antisocial behaviour is multi-determined and related not only to the characteristics of the young person, but also the ecology (family, peers, school and community)
• Strong evidence base (Henggeler et al, 2009; Fonagy et al, 2002; Schaeffer & Borduin, 2005)
Conduct disorder and associated antisocial behaviour
• Most common mental & behavioural disorders in children & young people (NICE, 2013)
• 5% children age 5-16 years, 40% looked after children
• Associated with poor educational outcomes, substance misuse & contact with CJS
• Most common reason for referral to CAMHS (NICE, 2013) – comprise a considerable proportion of work for health & social care systems
• Mulitple agencies may be involved
NICE guidelines for conduct disorder (March 2013)
For children and young people aged 11-17 with conduct disorder then the recommendation is multimodal interventions. The guidance goes on to set out what is meant by a multimodal intervention:
• Have an explicit and supportive family focus
• Be based on a social learning model with interventions provided at individual, family, school, criminal justice and community levels
• Be provided by specially trained case managers
• Typically consist of three to four meetings per week over a three- to five-month period
• Adhere to a developer’s manual and employ all of the necessary materials to ensure consistent implementation of the programme.
Other systemic approaches to conduct disorder
Younger children:
• Behavioural parent training (Barlow et al, 2002; Farrington & Welsh, 2003)
Older children: (see Fox & Jones, in press)
• Functional Family Therapy (FFT)
• Multi-dimensional Treatment and Foster Care (MTFC)
• Multidimensional Family Therapy (MDFT)
• Mileu therapy and therapeutic communities
The difference between MST & traditional models for young people with antisocial behaviour (Ashmore & Fox, 2011)
Traditional Models MST
Individual – focus on young person (YP) Systemic – includes whole family, school, peers,
community etc
Onus is on YP to engage Onus is on MST to engage YP & family
Clinic base – prison, secure setting, YOT office Home/community based
Fixed times – limited working hours Flexible 24/7
High caseloads Low caseloads
Less intensive Highly intensive
Treatment is non-contextual Treatment is ecologically valid
Needs focused Strength focused
Many professionals involved Therapist is multi-skills – main treatment provider
Supervision of professional behaviour Quality assurance – outcome assessed
Programmes/intervention generalised to the
population
Interventions individualised to needs of YP
Group work – association with negative peers Focus on YP remaining with pro social peers
Treatment provider from one discipline Treatment provider from range of disciplines
Model is managerial – meeting performance
targets and programmes are accredited
More professional governance and quality
assurance based
Table 1:
Limitations of traditional interventions
• Main target is the individual risk factors – caregiver may minimise responsibility in the behaviours
• Onus on YP to engage – typically hard to reach
• In contact with negative peers
• Lack of flexibility
• Focus is on risk and not strengths
Advantages of MST (& the evidence-based
systemic interventions) (Utting, 2007; Fox & Jones, in press)
1. Flexibility & Collaboration with families and key stakeholders
• Goals developed with key participants
• Reduction in practical barriers to engagement (Tighe et al, 2011; Paradisopoulos et al, 2015, Kaur et al, unpublished)
• Increased ecological validity
• ‘Whatever it takes’ mentality – onus on the service to engage the family
2. Model of delivery
• Based on theory of social ecology – behaviour is multi-determined
• Targets both individual & contextual factors – multi-modal and multi-dimensional
Advantages of the evidence-based systemic interventions (Utting, 2007; Fox & Jones, in press)
3. Evaluation & Outcome
• Programme fidelity
• High Level of Accountability
• Strong emphasis on outcome measurement
• Good evidence base
• Service user feedback
How does MST do this? The importance of the FIT circle
Aggres
sion in
the
home
Low warmth -
not having
positive time
together
Mum responds
to button
pushing
Mum and Jason
unable to
problem solve
together
Family members
have different
personal styles No
consequences
for any
behaviours
Young person is
impulsive and
has poor
communication
skills
Mum’s low mood, tired and reactive
Young person’s
peers
encourage
negative
attitudes
towards mum
Qualitative research
“I started trying to get help for my son from the age of 7 and had countless referrals to
agencies I was finally passed to MST when my son was 13. Due to a number of factors
including my divorce, his behaviour had spiralled out of control and our relationship had
almost broken down completely. I therefore felt MST was my last chance to fix things.
My son said "What's the point as they will cancel and stop coming like all the rest" but I
persuaded him to give it a go. We began work on turning my son's behaviour around, (NOT
THAT HE WAS TOO IMPRESSED TO START WITH) and things began to change. We've
had the occasional big hic-cup where he's kicked off when things have gone against him
but these have lessened considerably even when he doesn't get his own way or the results
he wanted. Working with Dad has also helped in that it brought home to his father the
significant problems we were having at home, making him offer more support. Life
is definitely more peaceful now and his outbursts and defiant behaviour happen far less
often. Most of the time he is just an annoying teenager and not a complete nightmare. We
even laugh and joke now (something we hadn't done for a long time) and boundaries are no
longer constantly ignored.
Some of the things I found really helpful were evening appointments, the 24hr support line
(which on occasion was invaluable) and the fact that I could be honest without feeling I was
being judged.
Without MST I honestly believe my son would now be in care because I didn't
have the confidence
or the energy to fight with him anymore.”
Limitations of the evidence-based systemic interventions
• Specific inclusion criteria
• Not widely available
• Time-limited
• Services are usually seen as separate and specialist to mainstream CAMHS
What can CAMHs services learn? • Strong clear clinical leadership and supervision
• High fidelity to the model
• Tight inclusion/exclusion criteria
• Outcome measurement
• Time limited
• Service user involvement in improving clinician practice
• Value of understanding the ‘FIT’ of the problem
• Flexibility
• High level accountability
• Multi-disciplinary learning – working closely with other agencies
• Health & social care – improved communication & resourcing
Why should commissioners fund MST (or similar interventions)?
• Political agenda – aim is to produce better targeted and focused interventions that are evidence-based & applied early enough to prevent escalation of problems
• NICE recommended intervention for CD
• Comorbidity of CD & other mental health conditions (PTSD, ADHD, substance misuse, anxiety, depressive disorders, self-harm etc)
• Life-time course of mental health problems and CD – high costs to society – average potential savings from early interventions estimated at £150k per case
• Impact on family systems
• MST US outcome research on psychiatric symptomatology
Takeaways
Have a think about how and what you can apply from this talk in your professional capacity
• www.mstservices.com
• www.mstuk.org
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www.england.nhs.uk
The Opportunities and Challenges
of Commissioning
Intensive Treatment Services
Tim McDougall - Chair
www.england.nhs.uk
On The Edge
Produced by Chilypep – Children’s and Young Peoples
Empowerment Project
The experience of emotional health
and wellbeing services for Children
and Young People
www.england.nhs.uk
To Tier or
not to Tier?
North Region Specialised
Commissioning Team (North East and
Cumbria)
Caris Vardy Mental Health Lead and
Programme of Care Lead
www.england.nhs.uk
• Tier 2: Emotional health and well being services
• Tier 3: Community CAMHs
• Tier 4: Inpatient services
• Secure CAMHs
• Inpatient Eating Disorders
• Learning Disability
• Mental Health
• Complex neurodevelopmental services
• Then along came CAMHs Tier 3.5
The Tiered Approach
www.england.nhs.uk
• Reducing bed numbers
• New purpose built unit
• Development of functional units
• Reinvestment in Tier 3 CAMHs
• Development of intensive home treatment services
• Specialised and dedicated Eating Disorders service
• Complex and Neurodevelopmental service
Re-provision 2010-2013
www.england.nhs.uk
• Changes in commissioning arrangements – single operating model.
• Case management – Reduced length of stay. Smoother transitions. Managing young people when placed out of area. Liaising with clinical teams. Improving efficiencies
• Developing CAMHs database – improving data flows, understanding service efficiency. Knowing where the young people are
• Standardising assessment – access assessment
• Clinical reference groups – standard setting, quality initiatives, service specifications
Then Along Came NHS England
www.england.nhs.uk
The Observer 1st February 2015
‘Beds crisis hits NHS care for
mentally ill children’
‘Teens aged 16-18 put on adult
wards’
• ‘Emails reveal emergency new
steps’
www.england.nhs.uk
Service Map: C07 T4 CAMHS
92 services shown by blue dots
Map shaded to show population density (excludes secure CAMHS
& Deaf CAMHS which are
included in other maps)
www.england.nhs.uk
• Young people travelling hundreds of miles to access
inpatient services.(North East has become net
importer of young people from other areas)
• Challenges – are the beds in the right place? Do we
have the right type of beds
• Delayed discharges
• Case management
• Understanding activity and information flows
Challenges
www.england.nhs.uk
• Relationship between requests for admission and availability of 24/7 community services
• Increase in number of delayed discharges
• Issue of looked after children and responsibilities of home area teams
• Transitions at age 18
• The working relationship between adult services and CAMHs and the differences between services for adults and young people
• Should we be planning for growth?
www.england.nhs.uk
The Here and
Now
www.england.nhs.uk
• Daily sitreps
• Additional 50 CAMHs beds nationally
• Developing the information system
• Understanding growth - where are the beds, do we
need so many? Are they the right type?
• Why are more young people requiring admission?
• CAMHs Tier 4 procurement (Sounding event 2nd
April 2015 for providers)
National Picture
www.england.nhs.uk
• Case Management
• National referral forms
• Weekly now daily sitreps
• Weekly National teleconference
• National database – (improved information system)
• CAMHs Taskforce
• Collaborative Commissioning pilots
Reducing the pressure
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• 5 o’clock Friday cases
• Challenging behaviours
• Emerging Personality Disorder
• Complex presentations
• Autistic Spectrum Disorders
• Services for children
• Has the tiered model unintentially created boundaries
What do we do about these?
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The Future in Mind
Future in Mind – key messages
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• Development of access points for young people when in
crisis 24/7
• Preventative models of care
• One stop shops
• Services accessible culturally to young people
• Thinking out of the box – using contemporary methods of
communication
• Appropriate admission to hospital (access assessment)
• A needs based integrated service model which flows
• Collaborative commissioning
What would we like to see
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• When young people present to services it is often in crisis. How can we respond more effectively without resorting to hospital admission
• Creating services without boundaries – imagined or perceived
• Having a workforce fit for purpose. Clearly defined competency framework
• How do we provide an accessible service that is skilled in triaging every possible presentation
• What would work – what do young people tell us they would like
• How can we measure outcomes more effectively
• Do reduced bed numbers equate to success
• What can we do to make sure any hospital admission is appropriate and as short as possible
Need to consider
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Prevention
is the Key
CAMHS T3.5
Improving Services through
co-commissioning
Rita Thomas, Mental Health Supply Manager, NHSE
Kate Laurance, Head of Commissioning, NHSS CCG
Where did we start?
• Conversation around the provision that
transitioned to specialised
commissioning back in 2010
• Following that, the development of new
data collection that gave us more
information
• A clear evidence base of high use of T4
for Sheffield Young People
• Challenges around how existing provision met national T4 Children’s/Adolescent spec and meets local need
• T4 providing outreach and day care - a greater intensity and flexibility of interventions into community CAMHS
• Day-care places and outreach provision for 5 to 11 year olds – local redesign of education and CAMHS
Current T4 provision
• Money does not follow the patient
• Supporting and proposing suggested
service change
• Ensure better patient experience and
improved health outcomes
• Improve equitable access
Challenges/Benefits
• There were parts of provision at the
inpatient unit that mainly provided a
service to Sheffield Children and Young
People
• Some parts of the inpatient service
provide a service that could be provided
differently
What did we agree?
• Clinical conversation to test a case for
changing service models
• Conversation with provider to test
assumptions
• Agreeing outcomes
Where did we go?
• We are agreeing a plan to work together between the provider, NHSE and NHSS CCG
• We will need to involve our local stakeholders to work through how things could work in the future
• We will have to ensure there are joint benefits and gains- To Patients, to the NHS and to local communities and stakeholders
What Next?
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