Agenda item

(To receive a report from Andrew McLean (Children's Services Manager for Commissioning) which provides an overview of the commissioning of the Child and Adolescent Mental Health Service (CAMHS), including funding, performance monitoring, local need and delivery against national benchmarking.  The report also includes the proposed revised model of delivery following successful application for Local Transformation Planning NHS England Funds)

A report by Andrew McLean (Children's Services Manager for Commissioning) was considered which described the overview of the commissioning of the Child and Adolescent Mental Health Service (CAMHS).  This included funding, performance monitoring, local need and delivery against national benchmarking.  The report also included the proposed revised model of delivery following successful application for Local Transformation Planning NHS England Funds.

 

Jonas Gibson (Commissioning Manager and Contract Lead for CAMHS – Lincolnshire County Council), Catherine Southcott (Commissioning Officer – Lincolnshire County Council) and Amanda Newman (CAMHS Team Leader – Lincolnshire Partnership NHS Foundation Trust) were all in attendance for this item of business.

 

Members were given an overview of the report which included the background to Children's and Adolescent Mental Health Service (CAMHS).  The service provided highly specialist mental health services delivered by clinical experts from Lincolnshire Partnership NHS Foundation Trust (LPFT) and was funded by Lincolnshire County Council and the four Clinical Commissioning Groups (CCGs).

 

The structure of CAMHS was on a four tier basis with Tier 1 being access to universal support services through to Tier 4 which supported inpatient specialist, acute needs.

 

Tier 1 services were available to all children and young people and were provided by Primary Care and universal service professionals, i.e. General Practitioners, Health Visitors and School Nurses and other support groups or helplines.  These services offered general advice and treatment for less severe problems; promoted good mental health; aided the early identification of problems and referred to more targeted or specialist services.  In addition, schools played a vital role at this level.

 

Lincolnshire County Council Children's Services had the delegated lead responsibility from the CCGs for CAMHS at Tiers 2 and 3 which was agreed in the form of a Section 75 Agreement and due to expire on 31 March 2018.  Services for Tier 2 CAMHS for children and young people experiencing moderately severe mental health problems included:-

·       Primary Mental Health Team offering:-   

o   Free training on understanding mental health concerns for all professionals working with children and young people aged 0-18 in Lincolnshire;

o   Consultation to professionals and families about specific concerns relating to a child;

o   Assessment and treatment for children aged 0-18 with mild to moderate mental health concerns, normally 6-8 sessions.  Maximum waiting time from referral to intervention should be 6 weeks;

·       Looked After Children Team offering:-

o   Training for foster carers, adoptive parents, leaving care workers and residential care staff;

o   Fast track access for assessment and treatment for Looked After Children and care leavers up to age 25.  Maximum waiting time from referral to intervention should be 4 weeks;

·       Therapeutic Services for Children:  Sexually Harmful Behaviours and Victims of Sexual Abuse (including for those with non-diagnosable mental health concerns)

 

Services for Tier 3 CAMHS for children and young people with more severe complex and persistent mental health needs included:-

·       Community Teams providing treatment via a range of therapies.  Maximum waiting time from referral to intervention was 12 weeks;

·       Forensic Psychology Service providing an assessment of risk and planning treatment for children and young people experiencing mental health issues who also posed a risk to the public or had offended;

·       Self-Harm assessment and intervention service which assessed children and young people following admission on to paediatric wards following an incident of self-harm;

·       Youth Offending Service providing assessment and treatment of mental health concerns; and

·       Learning Disability Service for children and young people with profound learning disabilities and mental health concerns.

 

NHS England Specialised Commissioning had responsibility for commissioning Tier 4 inpatient services.

 

CAMHS was available to all children and young people in Lincolnshire from birth to the age of 18 years (or 25 years of age for those leaving care services) with referral criteria that service users were required to meet in order to access support.  CAMHS delivered by LPFT provided screening, assessment and both short and medium term intervention, stabilisation and resolution for a range of newly emerging or low severity mental health problems in children and young people and ongoing treatment and management of more severe, long term and/or complex mental health conditions.

 

Core CAMHS was a multi-disciplinary community mental health service and the type of help provided may include family therapy; individual therapy; cognitive behavioural therapy; solution focused brief therapy; group work; psychiatric intervention; psychotherapeutic intervention; counselling and medication, where necessary.

 

The service formed part of the 'children are healthy and safe' commissioning strategy and the Children's Services strategic objectives of ensuring children and young people were "Healthy and Safe" and "Ready for Adult Life"  Lincolnshire County Council also commissioned "Kooth", an online counselling service for young people aged 11-25 as part of the Universal Offer.  The service was available 24/7 for young people with emotional or mental health concerns. The service helped young people manage their emotional wellbeing concerns at the earliest opportunity before those problems escalated further resulting in the potential need for more specialist service intervention.

 

The current core CAMHS funding was split between Children's Services (£724,589) and the CCGs (£4,843,532) and formed the S75 Agreement.  This gave a total value of £5,568,121 per annum which was then contracted to LPFT.  Further bids for funding and grants had been submitted and awarded, including the Better Care Fund (£350,000), non-recurrent Parity of Esteem money and Local Transformation money, during the contract period.  These funds had been used to support specific developments.

 

Governance arrangements were intended to provide a framework for delivery of multiple working strands, including CAMHS, to monitor the achievement of the priorities of the Health and Wellbeing Strategy.  The arrangements reflected the changing commissioning landscape and would enable health and social care commissioners to have joint engagement and ownership of joint commissioning arrangements.

 

Lincolnshire County Council and the CCGs had jointly funded a Chief Commissioning Officer post to oversee the joint commissioning arrangements between the two bodies.  The post was a key link in the joint commissioning arrangement of CAMHS.  The contract which monitored CAMHS sat within the Children's Commissioning Team and oversaw all aspects of commissioning arrangements for 0-25 years.  Within the Commissioning Team, a dedicated CAMHS Officer undertook quarterly performance monitoring reviews as part of the ongoing contract management meetings which included representatives from Lincolnshire County Council, CCGs, LPFT as well as the Chief Commissioning Officer.  The strategic oversight of CAMHS was also presented through the Health and Wellbeing Board.

 

Performance of the existing CAMHS contract was closely monitored.  Stakeholder engagement, financial information, business continuity planning and Care Quality Commission (CQC) Reporting was also reviewed annually.

 

In comparison to the historic national target wait of 18 weeks, the waiting times for Lincolnshire CAMHS were significantly reduced in order to strive to achieve a better outcome for the young people of Lincolnshire.  Targets for Tier 2 service wait remained the same at 6 weeks, Looked After Children wait remained the same at 4 weeks and Youth Offending Services wait remained the same at 4 weeks (although this saw an actual 6 week wait in 2015/16).  Tier 3 Services wait had been reduced from 12 weeks to a target of 6 weeks despite an actual performance of 3 weeks wait in 2015/16.

 

It was acknowledged that the reduced waiting times for 2016/17 were ambitious but reflected the level of funding being invested versus the greater demand and requirements which must be delivered in order to meet Future in Mind requirements, on which the funding for the transformation bid was targeted.  The target times were based on two response rate targets:  Degree of Urgency and Specific Service Requirement.  The young person would always be subjected to the quicker of the two response targets based on their individual need.  Degree of Urgency would fall into one of three categories:  Emergency, Urgent or Routine.

 

The total number of referrals received into the service during 1 April 2014 to 31 March 2015 was 4,569 which was slightly reduced from the previous year.  For the first three months of this financial year 1,093 referrals were received and 1,586 face to face contacts made. 

 

Within the new CAMHS model, referrals could be made by any professional or agency working with the child or young person through the Single Point of Referral (SPR) mechanism.  This mechanism would also support self-referral, by children, young people and their parents/carers.  Inappropriate referrals could be identified earlier and redirected to Universal Services.

 

In 2014/15 patient experience had been measured through a number of mechanisms, including patient and parent questionnaires.  The number of returns for young people for the period 1 January to March 2015 was 172 with an overall satisfaction rate of 89.12%, in comparison to the previous quarter which was 90.04%. As part of performance information, LPFT detailed feedback from stakeholder questionnaires measuring the individual experience and satisfaction rate of service users.  Negative comments were addressed through the contract management process and tracked for continuous service delivery improvement.  Comments were also provided to each locality team for consideration and discussion.  More generic issues were addressed on "You said – We did" boards within reception areas.

 

LPFT also supported Lost Luggage, a group of young people who were actively involved in the work of LPFT.  The group met outside school hours, explored creative and fun ways of enabling young people's voices to be heard.  Lost Luggage had already championed an anti-stigma message by producing a DVD, a radio jingle and were involved in drama projects and performances at the Drill Hall in Lincoln.

 

On 17 March 2015, NHS England released "Future in Mind" which outlined radical changes for improvements to mental health and emotional wellbeing services for young people nationally.  "Future in Mind" recommended a number of changes under five broad themes:-

·       Promoting resilience, prevention and early intervention

·       Improving access to effective support – a system without tiers

·       Care for the most vulnerable

·       Accountability and transparency;

·       Developing the workforce

 

As a result of this announcement, NHS England provided an opportunity to bid for funding for CAMHS which met the proposals above, in addition to some further work streams on perinatal services, community eating disorder services and clinical training.  A Local Transformation Plan was submitted which identified the work to be undertaken with other agencies, including Schools, Police, CAMHS Provider and Public Health to use a multi-agency approach to improve outcomes.  The bid was written on behalf of Lincolnshire County Council and all Clinical Commissioning Groups in Lincolnshire and had progressed through the Women & Children's Board, Health and Wellbeing Board and East Midlands NHS Specialised Commissioning.  The bid was successful in securing £1.4m per year, over five years pending tracking, and would total a minimum of £7m additional income.

 

It was intended to commission an integrated new model of service delivery for Lincolnshire CAMHS based on a robust specification which combined the following:-

·       A non-tier system which included a Community Based Eating Disorder Service, Tier 3+ provision which would operate a 24/7 service for those in crisis and give particular support for vulnerable groups to reduce health inequalities.  This was expected to commence on 1^st April 2016;

·       A service built on NICE clinical pathways explicit in the number of interventions provided, frequency of contact and anticipated length of time in treatment incorporating at CAPA approach;

·       A model which focuses on empowering the voice of young people, delivering evidence based practice and improved outcomes utilising mechanisms such as Child Outcome Research Consortium (CORC), Outcome Orientated CAMHS (OO-CAMHS), Patient Related Outcomes Monitoring (PROM), Strength and Difficulty Questionnaires (SDQ's) and Child Experience of Service Questionnaire (CHI-ESQ);

·       Increased support for transitions and behavioural support through the development of multi-agency pathways;

·       Developing staff through Children and Young People's Improving Access to Psychological Therapies Programme Training (CYP IAPT).  This service was a transformation programme delivered by NHS England which aimed to improve existing CAMHS working in communities and would include identification of clinical and non-clinical staff for IAPT training;

·       Establishment of a Single Point of Referral (SPR) so all referrals were received into a daily triage function, prioritising referrals within stretching and ambitious wait times, including a four hour response time for emergency referrals;

 

To date, Lincolnshire had:

·         Undertaken stakeholder consultation with over 55 local groups;

·           Implemented a further Section 75 Agreement between the Local Authority and CCGs;

·           Revised the CAMHS specification;

·           Participated in East Midlands review of readiness to implement "Future in Mind", which resulted in an internal action plan which was shared with key stakeholders such as Chief Commissioners for Learning, LPFT and CCGs;

·           A gap analysis was undertaken between the existing and proposed service and areas of priority identified;

·           Commissioned Perinatal Specialist Teams to provide a specialised service for the prevention and treatment of Serious Mental Illness in the antenatal and postnatal period supporting Mother and Baby;

·           Started costing various options for Children and Young People's Improving Access to Psychological Therapies Programme Training;

·           Clarified the specific support to be given to vulnerable groups, including reduced wait times;

·           Identified how to deliver a community based Eating Disorder/Tier 3+ out of hours crisis service;

·           Developed self-harm, transition and behaviour pathways;

·           Commissioned a Behavioural Outreach Support Service for pupils displaying challenging behaviour, a Physical Disabilities Support Service with Autism and Learning Disabilities Service to support the needs of pupils across the county;

·           Commenced a review of the services which support Readiness for School and Child's Health priorities including Health Visiting, School Nursing and services delivered from Children's Centres as part of a holistic package of support for Children & Young People;

·           Applied for Schools Pilot funding which, despite being unsuccessful, showed engagement of schools to support mental health services and the commitment to the ethos within that bid remained;

·           Provided development and consultation days to support frontline practitioners through training days on mental health issues such as reducing stigma;

·           Started to develop a web-based universal access offer making it clear to service users and their families what services could be expected and how to access CAMHS.  The planned "go live" date was January 2016; and

·           Attained Local Transformation Planning money.

 

Other highlights of the new model were to include:-

·           Extended opening hours;

·           Crisis support;

·           A professional advice line between 9am and 5pm;

·           Training, consultation, support to Universal services and Professionals;

·           More robust support for transitions to Adult Mental Health Services with clearer optimum treatment journey;

·           Accessible locations;

·           Timely services to ensure that demand and capacity be proactively managed to minimise waiting; and

·           Flexible service delivered in line with views of young people.

 

Members were given the opportunity to ask questions during which the following points were noted:-

·       The new tierless service was to concentrate on the needs of the person rather than multi-agency services working in silos.  Focus had been on providing a service where both demand and capacity could be managed;

·       It was acknowledged that there were areas of deprivation in the county including the coastal ribbon and that was a key consideration when managing the demand in future.  Teams had already started to be moved to match the demand as the issue had previously been recognised;

·       There was still a process in place to follow for patients and performance management formed part of that process.  Some of the work undertaken in Lincolnshire in respect of performance management was being rolled out nationally.  Performance information was received from LPFT on a quarterly basis and one outcome had a stakeholder input.  Continuous improvement was included as was finance and productivity to ensure the service was managed efficiently within the budget available.  This information was then reported to the Chief Commissioning Officer on a quarterly basis;

·       Although schools had committed to primary care in respect of CAMHS, it was reported that some schools were not active in utilising the service.  It was acknowledged that further work would be required within these particular schools;

·       It was suggested that some high performing schools had correlation between self-harm and eating disorders, etc.  CAMHS were struggling to engage the schools acknowledgement and it was felt that because young people were academically able, these issues were overlooked;

·       Work had been ongoing over approximately two years to consider improvements to the service.  Additional money received by CAMHS was referred to.  It was explained that the bid submitted was a detailed report of the transformation to take place within Lincolnshire and was a joint vision of that service.  The bid had been well received by NHS England and one of very few who were successful without requiring submission of further information;

·       The Committee noted their concern that the report did not give assurance of seamless working between services;

·       The figures noted within the table on page 25 of the report included emergency assessments required to be undertaken within 24 hours and routine assessments within 72 hours.  It was suggested that the emergency figures be removed and reported separately as the figures were not accurate at present;

·       The Committee requested how many routine assessments were meeting performance deadlines without including the emergency figures;

·       The difference between CAMHS and Adult Social Care services was considerably different as children and families received a more intensive service with CAMHS which was not provided by Adult Services.  The transition pathway was being reviewed nationally as it was acknowledged that there was a gap in service.  Integrated team meetings within Adult Services had been implemented to handover casework as the transition process started at 17.5 years.

·       Concern was raised about the families and their anxieties during this change.  They had come to trust their support workers so the transition and re-engagement with a new team was encouraged to be done in a sensitive manner;

·       NICE guidelines included pathways for suicidal thoughts and self-harm with the Adult Crisis Team seeing 16 year olds in liaison with CAMHS.  It was explained that despite some medical consultants occasionally struggling with suicidal thoughts these young people still required help.  The more often young people presented with suicidal thoughts or self-harm the more they were at risk.  It was also stressed that young people who were more vocal than others or caused issues at school were often as much at risk as those who withdraw.  United Lincolnshire Hospitals NHS Trust (ULHT) had made good progress with their pathways in this area and CAMHS had provided out-of-hours on-call assessment services to assist with safe discharges more timely;

·       Self-harm issues within A&E were also being addressed with qualified self-harm nurses on duty working alongside ULHT staff;

·       Concern was raised that a lack of clear service areas, without a tierless system, would not highlight where performance targets may not be met or any gaps in service;

·       Certain measures were required to be monitored within national guidance.  In relation to clinical measures a decision was required on what the key measures should be.  Sufficient training to ensure staff had good levels of understanding in these areas was essential.  It was agreed that patients should have the ability to rate their service as their mental health was so important;

·       Clarity of the table on page 25 of the report was requested with a clear explanation of the content of that table.  The Committee were unhappy that the report was not clear enough to enable them to scrutinise it sufficiently.

 

The Chairman thanked Officers for their attendance.  Although acknowledged that this report was an introduction to CAMHS, the Chairman expressed the Committee's disappointment at the lack of detail within the report.  A request was made that a further, detailed, report be presented to the Committee at its' meeting in June or July 2016 to provide performance information following the commencement of the contract for a tierless service on 1 April 2016.

 

RESOLVED

1.    That the report and comments made be noted; and

2.    That an update and report on progress of performance since the commencement of the tierless service on 1 April 2016 be scheduled for a future meeting of the Health Scrutiny Committee for Lincolnshire.