National Assembly for Wales
Children, Young People and Education Committee
CAM 23
Inquiry
into Child and Adolescent Mental Health Services
(CAMHS)
Evidence from : Betsi Cadwaladr University Health Board
1) The availability of early intervention services for children and adolescents with mental health problems
o Increased ease of access to specialist CAMHS by introducing CAMHS Single Point of Access in each county. This is established in all counties, currently at different stages of implementation. February 2014 Team Leads are agreeing an action plan at the monthly Mental Health Measure Operational Group for county launches
o Equal access for GP and non GP referrers to minimise the number of conversations young people and their families need to have before accessing the service, and to continue to promote good detection skills in community settings.
o Increased access to timely matched care by introducing Initial Discussion with mental health professionals when seeking help from specialist CAMHS, the goal of which is to significantly enhance the dialogue with referrers at the point of referral. This will determine the next best step at the point of access, based on clinical discussion. Daily access to Initial Discussion in five of six county teams. Action plan required for remaining team to ensure work towards daily availability
o Clear framework for outcomes from ‘Initial Discussion’ in place in all teams
o Advice and Information, including bibliotherapy, training, information for professionals and families
o Signposting
o Universal or targeted group work
o Professional consultation as intervention
o Primary mental health assessment
Regional plan for developing and delivering standardised early and preventive interventions within core specialist CAMHS (Part 1) across the BCUHB region:
o Bibliotherapy Book Prescription Scheme for Children and Families in all counties. The scheme is currently available in five out of six counties, Gwynedd have recently committed funding and the scheme is currently being introduced. All counties will have the scheme available by June 2014. Implementation/sustainability plans are needed in all teams, and links to national developments are in place
o Mental Health Matters website resources will be available in all secondary schools and colleges. This is work in progress and requires continual update and content review. A key message that the site is conveying to young people is “don’t feel invisible, find your voice and talk to someone”. School and community workshops are delivered in some counties to promote the message, increase understanding and provide clear information about mental health and well-being, risk and resilience and reduce stigma associated with ‘mental health’. Plans are in place to include the 5 ways to well-being for children, young people and parents into this resource
o Targeted group work for the prevention of anxiety and depression – “Friends” suite of cognitive behavioural programmes[1] this is progressing slowly with the long term goal of building capacity for delivery in community settings, and by staff from a range of agencies.
o Suicide prevention skills including ‘Connecting with People’ training – regional pathway for supporting front line professionals in early-stage risk assessment is currently in development alongside Local Safeguarding Children’s Board
o Parent interventions targeted at children age 0-5 years. A regional strategy is in development for very early intervention for children and their families, working across service boards and in partnership with local authorities and children and young people partnerships. This will highly likely include targeted group work for parents of children with behaviour problems – “Incredible Years” parent programmes[2] as well as joint initiatives with adult mental health to increase access to interventions for parent mental well being
o Training in topics and skills relevant to emotional, behavioural and mental health problems delivered by each county team, to enhance capability of universal services. Topics include mental health awareness, self harm, depression, eating problems and disorders; regionally and locally agreed skills training on specific targeted interventions
o A future goal is to deliver targeted and universal groups/workshops for young people to promote positive mental health and coping skills. Specialist CAMHS aims to support and where appropriate jointly facilitate effective groups and workshops, in collaboration with partner agencies e.g. to whole classes/year groups/youth clubs to promote emotional well being and coping such as peer support; stress management; mental health awareness; coping with exams.
Risks to achieving Part 1 in specialist CAMHS
Goals of the Part 1 scheme for children and young people are ambitious. We aim to manage demand in the long term via easy, rapid access to consultation about referrals, building capacity in universal services, increasing input for children 0-5 years, and timely access to mental health assessment and intervention to those who need specialist input.
Key challenges in achieving Part 1 scheme in BCU CAMHs is that the required pace of change is quick, and the amount of change is significant. A shortage of management capacity at the local team level across the region slows down progress. Clinical capacity allocated to the early intervention and prevention/primary mental health function across teams varies, set against pressures to meet the 28 day target for mental health assessment. There is risk that capacity will be diverted further down the stream in a context of trying to work further up, which will compromise the delivery of early and preventive functions sustainably over time. This is particularly risky in teams where there are greater numbers of staff in post who are not eligible to carry out mental health assessments under the Measure. A further risk to achieving Part 1 includes not being able to achieve Trained Trainer accreditation for the “Friends” suite of programmes.
2) Access to community Specialist CAMHS at Tier 2 and above for children and adolescents with mental health problems, including access to psychological therapies
In BCU we have worked to develop a Access and Eligibility criteria work stream which will assist to identify which patients fall within Part 1 and those that fall in to Part 2 of the Mental Health (Wales) Measure 2010.
There is a lack of capacity in driving access times down from 28 weeks to 28 days in line with the mental health measure requirements. In BCU we deliver training in CBT, DBT and Family therapy but there is a gap in the provision of child psychotherapy and therefore we cannot fully respond to the NICE guideline for depression. We work well collaboratively with post graduate deaneries e.g. Family Therapy in Derby University, CBT and DBT modules jointly with Bangor University and with other such establishments in the design and delivery of therapies for children and young people with CAMH needs however capacity is required within CAMHS to enable the release of staff for training and development and in light of new and emerging therapeutic interventions.
The often non-recurrent nature of funding allocated for CAMHS means that often posts are short term as opposed to long term that enables tangible service development.
3) The extent to which CAMHS are embedded within broader health and social care services
Conwy Local Health Board (LHB) hosted via funds from the Welsh Government for the North Wales Specialist CAMHS Planning Network from it’s inception in September 2006 but with the amalgamation of the 6 former LHB’s in the North Wales region BCU now hosts the former CAMHS network board. In order to align with the Clinical Programme Group model of service delivery the service board was renamed the Emotional Health and Well Being (EH&WB) service board and terms of reference and membership were revised to ensure it was and remains fit for purpose with robust governance arrangements in place and fully inclusive of all partner agencies. Membership of, and attendance at Children and Young People’s Partnership groups across North Wales, and joint projects funded by Families First are in place in some counties.
4) Whether CAMHS is given sufficient priority within broader mental health and social care services, including the allocation of resources to CAMHS
Within broader mental health services BCU secured additional funding for additional posts in primary mental health care in line with mental health measure implementation. BCU is committed to the preventative agenda. All too often pressures in acute mental health and other health specialties often detract from providing an appropriate level of investment in community/Specialist CAMHS.
5) Whether there is significant regional variation in access to CAMHS across Wales
When BCU was formed there was significant variance in CAMHS provision regionally but through the Emotional health and well being service board (formerly the CAMHs network) we are working towards consistency and equity in access for children and young people.
6) The effectiveness of the arrangements for children and young people with mental health problems who need emergency services
BCU CAMHS are clear regarding their responsibility responding to emergencies both in and out of hours and polices have been developed and are in use across the region.
There is a BCU policy for DSH clearly indicating that young people should be admitted following DSH and assessed the following working day.
If there is an urgent mental health issue or emergency it is CAMHS team’s responsibility to urgently respond on the same day if required, this remains a matter of clinical judgment and may on occasion lead to other clinical activities being cancelled at short notice.
Out of hours mental health emergencies present a serious problem; currently they are dealt with initially by Adult mental health for 16 and 17 yr olds and Pediatrics for 15 years and below. There is telephone advice available from consultant Child Psychiatrists on call with the intention of sharing responsibility for any clinical decisions. Collaboration with adult mental health services is becoming more difficult with an increasing expectation from Adult Mental health services that CAMHs should provide a full out of hours service.
All A&E departments may very occasionally require urgent CAMHS advice and assessment within the working day. The overarching principle is that CAMHS are responsible for leading on Mental Health for all emergencies up to eve of the young person 18th birthday. As CAMHs is a small specialty the provision of out of hours assessment is heavily dependant on support from Adult Mental health and pediatric colleagues.
AIMS accreditation – a working group has been set up and has identified a ward in each of the DGH’s seemed suitable for admissions to adult wards for those under 18. Robust data of admission is collected in BCU and between Jan 2013 and December 2013 there were 3 admissions, length of stay has also reduced from the previous 12 months data.
7) The extent to which the current provision of CAMHS is promoting safeguarding, children’s rights, and the engagement of children and young people
The office of the Children’s commissioner interfaces with the designated lead nurse and this is factored in to service development and provision.
Advocacy – children receiving mental health services have a right to independent advocacy services. This is under review with our partners to ensure that we meet WG requirements to enable all young people to access advocacy services. Safeguarding;
Clear robust safeguarding mechanisms and reporting structures are in place. Safeguarding training at all levels is delivered across the region as a priority in all CAMHS.
Safeguarding and appropriate disclosure checks on newly appointed staff are in place via the North Wales Shared Business Partnership.
Some examples of engagement in Specialist and community CAMHs;
o Service user groups locally via CAMHS teams, Suggestions board is present in waiting rooms in most clinics, Routine use of young people in interviewing for staff appointments across the tiers, Young people involved in the design of the waiting areas for CAMHS, Consultation with Conwy Youth Council regarding information about CAMHS and development of website. Young people are actively involved in the QNCC peer review process.
Tier 4 Unit; North Wales Adolescent Service;
o Young people are always present at interviews for staff and are supported in the process, The new Intensive Community Support Team (ICST); young people across North Wales and service users were and remain involved in the design and development of this new service for those with the most complex of emotional / mental health needs, The courtyard area at the unit has been a design project for service users, Artwork at the unit when first built was created by service users, T4MH strategy – a group of service users at the unit provided a consultation response to the strategy via a fully facilitated workshop.
o ‘Inspire’ is a youth work in hospital project that aims to support young people who present at hospitals with self-harming behaviours including drug and alcohol misuse and other mental health problems, based in Wrexham but also serves the counties of Flintshire and Denbighshire aims to increase and improve coping skills, provides diversionary activities and supports the non-medical needs of the young people’s emotional development individually and via group work, linking to mainstream and specialist services.
8) Any other key issues identified by stakeholders:
Need to drive forward the setting up of a CAMHS national service board. Since CAMHS networks have been fragmented and some not functioning, this has been a major problem. Communications need streamlining, often there is a blurring of policy requirements amidst too many groups and too many meetings thus causing duplication. We are working hard to reduce Out of county placements to neighboring English counties and therefore it would be beneficial to increase provision in BCU particularly for those young people with complex needs, co-morbidity and an identified gap in services in BCU for those with sexually inappropriate behaviours. Transition planning from CAMHS to AMH starts well in advance of the young persons eve of 18th birthday and work continues to progress in the relationship between Adult mental health and CAMHS. Eating Disorders service development – we have a lack of dietetic provision in BCU and are looking to improve this. Information sharing by professionals across Agencies needs to improve. BCU has been working with the APB to secure funding for a regional Substance misuse services via the newly awarded regional allocation of funds.