www.england.nhs.uk

Tier 4 Review-

2 years on

Margaret Murphy

16 March 2016

www.england.nhs.uk

Commissioning Tier 4 CAMHS Services

• Following passage of HSC Act responsibility for commissioning tier 4 CAMHS inpatient services and some highly specialised ASD services transferred to NHS England from April 2013 (so-called prescribed services)

• Some Tier 4 CAMHS previously nationally commissioned ( medium secure services) – bid for Tier 4 CAMHS children’s units to be nationally commissioned

• Pre April 2013 – variable arrangements for much of Tier 4 – from ‘spot purchasing’ in some areas to areas where groups of PCTs/SCG collaborated to commission the care pathway including inpatient-crisis –home treatment

www.england.nhs.uk

The Tier 4 Review

• Commissioned by the NHS E specialised commissioning oversight group (SCOG) in late 2013 to provide more accurate picture of the current usage of Tier 4 and issues for inpatient services

• Focus on Tier 4 CAMHS for practical reasons although with an understanding that Tier 3 and social care issues impact

• Aim was to describe the current situation and analyse data from providers and commissioners to inform any further work

www.england.nhs.uk

Reasons for the Review

• Concerns re quality/safety in some providers

• Concerns re access (i.e. capacity, availability, timeliness, distance from home for some children and young people)

• Need to understand nature of problems in order to find solutions – evidence that it was more than simply a change of commissioner

www.england.nhs.uk

The method

• Independent steering group

• Data collection and analysis was led by the

CCQI

• A survey was sent out to all inpatient CAMHS

providers in England – where possible

compared 2012-13 and 2013-14 data

• Ten area team leads who look after specialised

commissioning also completed 10 case studies

following patient journeys (100 in total)

www.england.nhs.uk

How many beds were there in England?

• In 2014 - 1264 beds identified in the report commissioned by NHS

England

• These were:

618 General CAMHS

232 Eating disorders

141 Low secure

92 Learning disability

92 PICU

47 HDU

42 Medium secure

• An additional 65 un-commissioned beds nationally (mostly over 13s

general CAMHS and ED)

www.england.nhs.uk

Who was admitted?

Case history information – number of cases Yes No Don’t know

Young Person had had a previous Tier 4 admission 38 60 2

Young Person was known to social services 47 53 3

Looked After Child 13 87

www.england.nhs.uk

What’s their primary diagnosis?

www.england.nhs.uk

Length of stay

www.england.nhs.uk

Main Issues for Inpatient CAMHS

www.england.nhs.uk

Referrals

www.england.nhs.uk

Admissions

www.england.nhs.uk

Bed Occupancy

www.england.nhs.uk

Delayed discharges

www.england.nhs.uk

Most common causes of delayed

discharges

www.england.nhs.uk

Bed closures during 2013

www.england.nhs.uk

How many young people travel out of area

for a bed?

www.england.nhs.uk

Key challenges from the T4 report T

The report(1) was published by NHS England in July 2014 and highlights challenges for commissioners and

providers including:

• Decommissioning of Tier 3 or Local Authority children’s services. Inadequate Tier 3 resources/ provisions

was cited by commissioners as the most common reason for inappropriate referrals and factor impacting

on the care pathway experienced by a young person;

• Children and young people having to travel long distances to access a bed due to an uneven distribution

of beds around the country, resulting in some patients being admitted to a service a long way from home;

• Difficulty in recruiting experienced or specialist staff leading to capacity problems.

For England as a whole, the report says, “it is impossible to conclude definitively whether the current level

of bed provision is sufficient to meet the need.” The number of NHS-funded T4 beds increased from 844 in

1999 to 1128 in 2006, rising further to 1264 in January 2014. (As of July 2015 this is 1442)

(1) (http://www.england.nhs.uk/wp-content/uploads/2014/07/camhs-tier-4-rep.pdf

www.england.nhs.uk

Key Actions – Progress

•National access and assessment protocols have been

implemented to ensure consistency in referral thresholds

and access arrangements.

•CAMHS case managers appointed

• Tier 4 CYP IAPT

• 56 additional beds have been commissioned:

www.england.nhs.uk

Other

•Weekly survey of available beds, delayed

transfers/discharges, difficult-to-place patients, patients

inappropriately placed, out-of-area, over 18s in CAMHS

units

• Investment in community eating disorders teams ( reduce

reliance on inpatient care / improve outcomes and release

capacity within Tier 4 CAMHS)

• Future in Mind

• Transforming Care

www.england.nhs.uk

Working with CCGs across the

system

In 2015/16, NHS England invited CCGs to collaboratively commission with each other and with NHS

England for the majority of specialised services. The aim of this approach was to formally build upon

some local working arrangements between CCGs and NHS England already in place. This is intended to

drawn upon the benefits seen of national standards and oversight, with local ownership across the totality

of the pathway. Each of the 10 Specialised Commissioning Teams across the country have CAMHs as a

priority area and will be using the benefit of the recently developed transformation plans to support taking

this work further

This work is aimed at greater integration across the Tiers 2, 4 & 4 pathway to ensure the benefits of a

wider system approach and oversight can be seen by the patients and their families. The impact being

more joined up responsive care targeted at individual needs.

Alongside the development of the transformation plans, NHS England is running the procurement

process with one of its identified objectives to ensure appropriate distribution of beds across the country.

This process will be undertaken alongside CCGs to ensure opportunities of collaborative procurements

and service integration can be capitalised on.

Work also being undertaken to look at the use of place-based budgets for CCGs from 17/18, the aim of

this being to ensure the funding is in the right place to appropriately support the care pathways.

www.england.nhs.uk

Geographical Spread of Units - April 2015

www.england.nhs.uk

Travel Impact of Additional Capacity

• To date this has had a noticeable impact on the average travel distances for patients from

the South West as seen in the table below. National trends for average and greatest

distance from home are

Team of

Patient

Origin

Average

Distance from

Home (Miles)

September 15

Average Distance

from Home

(Miles)

DECEMBER 14

East

Midlands

30.9 35.0

East of

England

24.6 34.0

London 45.7 18.5

North East 28.4 42.1

North West 18.3 21.3

South

Central

55.0 46.0

South East

Coast

39.5 30.2

South West 39.8 114.4

West

Midlands

33.1 24.9

Yorkshire

and Humber

36.7 29.6

www.england.nhs.uk

Bed Availability by type

www.england.nhs.uk

Weekly sit rep – number of patients

by location OA (out of Area) = number

patients who are outside

their normal catchment area

for capacity reasons only

Inappropriately placed =

number of patients that are

awaiting a T4 bed and are

being held in a setting

awaiting transfer

Over 18s = number of

patients in a T4 service

awaiting either discharge or

transfer to an adult service

Delayed Discharge = those

patients who are clinically fit

to be discharged but can not

due to factors outside the T4

units control

www.england.nhs.uk

Thank-you