National Assembly for Wales
Children, Young People and Education Committee

CAM 49

Inquiry into Child and Adolescent Mental Health Services (CAMHS)
Evidence from : Cwm Taf Local Health Board

 

This response is for the Children, Young People and Education Committee who are undertaking an inquiry into Child and Adolescent Mental Health Services (CAMHS).

 

1. The availability of early intervention services for children and adolescents with mental health problems;

 

Specialist CAMHS currently provide a limited contribution to early intervention services as the funding for primary care services generally sits outside CAMHS and is provided by staff with direct access to children and young people such as teachers, school nurses, school counsellors and GP’s.

 

The contribution that CAMHS make to early intervention would be though the Primary Mental Health Service who provide training and contribute to early intervention with Tier 1 Professionals. There are however differences in each area and with the introduction of the Mental Health Measure that has a focus on providing support for GP’s, these early intervention services are being further stretched and diminished.

 

One of the major challenges that has been faced by CAMHS services over the past 2 years has been changes in funding streams. Due to the partnership nature of CAMHS activity across the NHS and Local Government (Socials Services and Education) some of the non-recurrent funding provided by Local Authorities to support early intervention services has been withdrawn. This has led to a reduction in some services in some areas.

 

This means disparity of provision of some services between local authority areas both within and across Local Health Boards.

 

The consequence of reduced community-based services is that some of the services associated with Part One of the Mental Health Measure are needing to be provided through outpatient services to achieve economies of scale in provision recognising that best practice would indicate these services should be community based via GP surgeries and other non-hospital settings.

 

2. Access to community specialist CAMHS at tier 2 and above for children and adolescents with mental health problems, including access to psychological therapies;

 

The definition of what constitutes a Secondary level CAMH services has been prescribed by the Mental Health Measure. Secondary level services are defined as for those with more complex needs, requiring more specialised services. The service is provided by multi-disciplinary teams or by teams assembled for a specific purpose on the basis of the complexity and severity of children’s and young people’s needs or the particular combinations of co-morbidity found on specialist assessment.

 

Secondary level services are mainly accessed by a referral from a GP, or other Health professionals such as Paediatricians. Referrals are also taken from external partners such as Social Workers and Educational Psychologists. Tier one professionals can also access primary mental health services where available.

 

The diagram below shows how the tiers map across to the levels of service:

 

 

 

 

 

In regards to access to psychological therapies, there is an all Wales Policy for the development of the psychological services. All Health Boards have been required to set up a committee, CAMHS are part of that Committee.

 

CAMHS have traditionally provided a level of psychological work however there are a limited number of workers who are trained with specialist qualification. It is therefore rare that we can be fully compliant with the NICE guidelines for common conditions.

 

There is a variation in the provision of psychological therapies in each of the LHB’s which needs to be addressed through a more joined-up commissioning process and will inevitably have resource implications moving forward.

 

3. The extent to which CAMHS are embedded within broader health and social care services

 

The Welsh Government Strategy – Together for Mental Health is an inclusive strategy that recognises that the provision of Mental Health Services is a shared responsibility. There have been multiagency boards set up in each Health Board area that should enable closer working between Health & Social care and other partner agencies. It has been decided in each of the Health Board areas that there will be a  CAMHS partnership board development as a subgroup of the age inclusive Together for Mental Health Partnership Boards. These groups are at different stages of development in each of the Health Board areas.

 

4. Whether CAMHS is given sufficient priority within broader mental health and social care services, including the allocation of resources to CAMHS;

 

We have benchmarked against both NHS benchmarking that provides National averages and against the recently released Royal College of Psychiatrists document ‘Building and Sustaining Specialist CAHMS’, as in Table 1.

 

Table 1: Cwm Taf CAMHS comparison against NHS services Benchmarking report 2012

 

Benchmarking Data Area (per 100,000)

National Averages

Cwm Taf, C&V & ABMU CAMHS Averages

No. staff

17

5.5

Budget

£1.1m

£583k (excluding T4)

New seen (per team)

239

266

Follow Up (per team)

1,650

1,734

 

As is evidenced in the above table the Cwm Taf CAMHS Directorate (CTUHB, C&VUHB, ABMUHB) has approximately 32% of the national benchmarked averages for numbers of staff and approximately 50% of the average budget. Despite these low figures however the teams deal with more than the benchmarked average numbers of both new seen and follow ups as highlighted in Table 2 below;

 

Table 2: Royal College Psychiatrists Guidance - Building and Sustaining Specialist CAMHS (2013)

 

Number of WTE clinicians

in a team serving a

100 000 total population

Number of new referrals per

WTE per year

Total maximum new referrals

per team per year

20.0 (four-star service)

24.2 – Teaching Trust

40

800

10.0 <40 (referral base with a higher

percentage of severe/complex

cases, small MDT)

<40

<400

5.0 (25% psychiatrist time) <40 (referral base with much

higher percentage of severe/

complex cases, smaller MDT)

<40

<200

Cwm Taf Service 6.0

44

266

 

As illustrated in Table 2 the number of staff recommended by the Royal College of Psychiatrists for a 4 star service is 24.2 for a teaching hospital and we currently have an average across our teams of 6 – this is 25% of the recommended numbers.

 

Despite these shortfalls when compared with national benchmarks, the Cwm Taf CAMHS service sustains numbers of new seen and follow up appointments above the average numbers normally seen with much more staff.

 

As is highlighted in the tables above there has been significant additional investment in England. In addition to this the implementation of the Mental Health Measure was intended to focus on Adult Services and older age, and not children, although this age group was brought in later.

 

5. Whether there is significant regional variation in access to CAMHS across Wales;

 

Historically the funding arrangements for CAMHS are different throughout Wales; this has lead to different models being developed due to different funding streams. There has also been a withdrawal of some dedicated funding streams e.g. Cymorth

 

In the Cwm Taf CAMHS Directorate (CTUHB, C&VUHB, ABMUHB) there are the same referral routes but the amount of Primary Mental Health workers in each area varies so there is a difference in Primary Care.

 

There are Community Intensive Therapy Team’s in operation in the Cwm Taf Network area and however these types of teams are not in place across all of Wales. This situation impacts on Tier 4 inpatient services especially as there is a knock on effect on admission and discharge planning in the areas where there is no intensive support available.

 

For neurodevelopmental disorders, historically in Cwm Taf there are no shared care arrangements and pathways are also not developed.  In Cardiff & Vale we are improving shared care and have a partial pathway development. Similarly in

ABMU there are pathways in place but operationally different across the areas because of historical arrangements.

 

Neurodevelopmental assessments have historically been undertaken in the Health Boards covered by Cwm Taf CAMHS Network area, however in other Health Boards providing neurodevelopmental services for children they are not seen as part of a specialist CAMHS team. In addition to this, with the implementation of the Mental Health Measure, neurodevelopmental disorders were not taken into consideration as for the most part they would be classed as Part 1 and subject to a 28 day waiting time, under secondary CAMHS for the more complex cases with they would have a 16 week waiting time or if they are under paediatrics they would have a 26 week waiting time target.

 

6. The effectiveness of the arrangements for children and young people with mental health problems who need emergency services;

 

In the Cwm Taf CAMHS Network area CAMHS is available 24 hours a day, out of hours this is supported by Adult Mental Health.  The generic CAMHS teams respond to emergencies within office hours and out of hours there is an on-call rota that is accessible through Health Services out of Hours.

 

During working hours there are differences between the different LHB areas. In ABMU there is the Doctor of the day and there is disparity about access to liaison services which include 16-18 year olds – not taking out any services up to 18th

In Cwm Taf there is  patch based limited community response, with limited community based on Clinical prioritisation throughout working day, that way impact on normal clinic function if / when demand outstrips availability within limited resource of CAMHS.

 

There are only 14 tertiary CAMHS beds available in South Wales and there is no specialist provision for Children and young people who present in a crisis needing a secondary level bed (i.e. they don’t need a specialist inpatient bed). Adult services in each LHB area are required to have a dedicated bed for young people who present in crisis needing a mental health bed in line with Welsh Government Guidance (attached) and the Mental Health Act Code of Practice (attached).

 

We also attach a letter from WHSCC confirming the Tertiary commissioning arrangements for Ty Llydiard in light of the change in policy.

 

7. The extent to which the current provision of CAMHS is promoting safeguarding, children’s rights, and the engagement of children and young people;

 

There is an expectation of all clinical staff to be trained and updated in all safeguarding procedures and policies. In addition to this there are Senior Nurses in each area and a Head of Nursing to advise of safeguarding and report to Head of Safeguarding in Health Board

 

There have traditionally been Advocacy services available in the Tier 4 inpatient unit and under Together for Mental Health this has been broadened so that it is now available to all community services.

 

In Together for Mental Health there is an emphasis on greater engagement with patients and carers, this applies equally to children and young people. It is hoped that the Children and young people’s subgroup of the Together for Mental Health Partnership boards will include representation from Young People.

 

8. Any other key issues identified by stakeholders;

 

One of the major issues presently faced by CAMHS is that when the age range was increased to the 18th birthday there was no funding transfer from Adult Mental Health Services to reflect the transfer of provision that they had always given to this age group. Very limited funding was provided centrally for this key policy change in 2011/12. This change in the age range has led to a significant increase in the presentation of serious mental illness and crisis presentations. These have impacted significantly on service and we have evidence from the generic teams who have conducted audits and found there has been shown to be an increase in the number of 16-18 year olds referred to from 41% in April to September 2012 to 70% in the same timescale in 2013. This has presented a significant strain upon current limited resources in the Cwm Taf CAMHS Directorate (CTUHB, C&VUHB, ABMUHB).

 

There have been concerns raised about the Mental Health Measure requirements. Part One of the measure requires that primary mental health support staff are available to GP and this conflicts with the previous Welsh Government Targets for CAMHS Primary Mental Health workers. CAMHS do not get the majority of their referrals to primary mental health via the GP,  and there is a risk that the valuable services that are provided by our existing primary mental health workers will be lost due to pressure to meet a Tier One target that is not appropriate for children and young people. The Mental Health Measure also does not take into account historic nature of workforce development in CAMHS e.g. Paediatric nurses are not eligible to carry out a central part of either Part one or Part 2 of the Mental Health Measure and there are very experienced nurses with this speciality in CAMHS who can no longer Care-Coordinate under Part 2 of the Measure,

 

The Royal College Psychiatry has recommended that there should be 24-40 beds per million population. In South Wales (2.3 million population) there are currently 14 beds commissioned for a general inpatient unit (Ty Llydiard) that has no emergency and limited out of hours assessments. In addition to this there are no commissioned beds in Wales for learning disability or forensic secure placements which means that admissions when necessary are in England.

 

It is important to note that the current commissioned CAMHS in the Cwm Taf network is a specialist and mainly secondary care service. It is designed and resourced to provide expertise in assessment, treatment, care and advice for children with mental health problems. It is not currently resourced to deal with all low level emotional, behavioural and developmental disorders. These are the domain of tier 1 service such as school councillors, health visitors, GPs, educational psychologists, local authority social workers, etc. Unfortunately there are unrealistic expectations that the special CAMHs service is set up to deal with any form of non-physical disorder in childhood, in particular conduct disorders, and we feel that this may reflect a lack of general resources, training and sign-posting at the tier 1 level over the years.

 

This is described well by the Royal College of Psychiatrists in the attached report (CR182) Building and sustaining specialist CAMHS to improve outcomes for children and young people. (please refer to page 15, 27,28 & 29). We do of course provide an important advisory role where needed and an on-going role where there is co-morbid mental health issues.

 

Eating Disorders are more prevalent in children and at the severe end of the spectrum it is the main reason for admissions to Ty Llydiard representing about 50% of all admissions. The Cwm Taf network has responded positively to this rising prevalence and at a ward level our doctors and nurses have a high level of skill to address the needs of children with eating disorders. The ward is also supported by a specialist CAMHS dietician with additional support from the Princess of Wales Hospital where Ty Llydiard is sited. We are currently working with WHSCC to commission Tier 4 eating disorder services across south-Wales with Ty Llydiard as the hub for this service improvement, utilising 250k provided by Welsh Government. This will play a key role in admission avoidance and retaining the care and treatment programmes within Wales.

 

Evidence to demonstrate the quality of care at Ty Llydiard regarding eating disorders was presented to Welsh Government in September 2013 (Appendix 1).

 

 

 

APPENDIX 1

 

Eating Disorder (ED) Training at the Ty Llydiard Unit

 

Nurses complete the following post graduate training;  

 

 

We also have an on-site Dietician. The unit has a long history of treating eating disorders in the inpatient setting and there are many elements of the service that are adapted for this:

 

·         Specialist therapy team including family therapy, psychology, art psychotherapy, psychotherapy, music therapy – the type of therapy can be adapted to the patient’s needs

·         Specialist CAMHS Dietician with expertise in eating disorders

·         Specialist CAMHS OT with expertise in eating disorders

·         Ward protocol for management of eating disorders including meal times, management of food refusal, management of poor physical health

 

The junior MARSIPAN document discusses different care settings for the management of Anorexia nervosa, and makes a distinction between a generic CAMHS bed and a Specialist Eating Disorder Bed (available within a generic CAMHS unit). It states:

 

“A unit offering SEDBs for children should be able to provide:

 

·         expertise in nasogastric feeding (insertions may be performed off-site)

·         daily biochemistry

·         frequent nursing observations, up to and including one-to-one

·         observation when indicated

·         prevention of anorexic behaviours, e.g. water-loading, excessive

exercise

·         ECGs, daily if needed

·         management of the resisting child – including safe holding techniques,

and the acute and medium-term paediatric psychopharmacology of

children with eating disorders

·         use and management of the Mental Health Act 1983 (and its 2007

amendments) in those under 18, with particular reference to the

zone of parental control in children with eating disorders – the Mental

Capacity Act 2005 in 16- to 18-year olds and the Children Act 2004 in

those under 18

·         assessment of tissue viability in emaciated patients and treatment of

pressure sores

·         immediate cardiac resuscitation by staff trained to administer

resuscitation

·         access to advice from paediatricians and paediatric dieticians in a

timely and flexibly responsive manner, ideally in the form of a ‘Junior

MARSIPAN’ group.”

 

Ty Llidiard has access to every one of these points and our Dietician reports that nurses are adequately trained in all of these or can access expertise via links to the Princess of Wales Hospital or Cwm Taf services.

 

 

 

 

 

 

 

 

Description: WHSSCoutline

Your ref/eich cyf:

Our ref/ein cyf: DP/NJ/DD

Date/dyddiad: 11 April 2012

Tel/ffôn: 01443 443 443 Ext

Fax/ffacs: 01443 860297

Email/ebost: Daniel.phillips@wales.nhs.uk

 

 

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Dear all

 

Tier 4 CAMHS - Change in policy with regard 16 and 17 year old patients

 

The Welsh Government published the ‘Breaking the Barriers’ action plan for CAMHS in 2010.  This plan outlined a change in policy regarding the treatment of 16 and 17 year old young people requiring mental health services.  The policy states that from 1 April 2012 CAMH services should have primary responsibility for assessing and treating all children and young people up to the age of 18 years. Previously, the policy position was that only young people in school accessed CAMHS, and all other 16 and 17 year olds accessed services provided by adult mental health teams.

 

In order to support this change in policy, WHSSC has been working with the Tier 4 teams in North and South Wales to assess the impact on services.  Discussions are ongoing about the impact on capacity in inpatient services in South Wales and the possibility of investing in a consistent community intensive support model across South Wales to ensure the best use of the facility at Ty Llidiard. 

WHSSC will be setting up joint meetings with the Tier 4 service,  ABHB, Powys and Hywel Da Health Boards to discuss these proposals in the near future.  In North Wales discussions are also ongoing about a community intensive support model within the BCUHB area.  The intention is that a recommendation on these proposals will be put to the WHSSC Joint Committee in June.  

 

In the meantime WHSSC has been working with both Tier 4 services to amend the admission criteria for Tier 4 CAMHS inpatient services and the existing community intensive treatment teams.  These have been amended to reflect the policy change and also to ensure consistency across Wales.  The criteria have been agreed jointly by WHSSC, the Tier 4 services in Wales, and the CAMHS Advisor to the Welsh Government and are attached.

 

To reflect this work regarding the service models and admission criteria, the Tier 4 CAMHS Specialised Services  Policy will also be revised and this will be sent out for consultation in May.  The Policy will include further clarity regarding gatekeeping arrangements for Tier 4 services. 

 

Short term and crisis admissions

 

Across Wales we acknowledge that many services have already incorporated the change in policy regarding age into the operation of their CAMH services and that these arrangements are the subject of further local discussions between adult and CAMHS.

 

Both of the CAMHS inpatient units in Wales were planned as tertiary level units for children and young people who have already been assessed as requiring inpatient treatment and/or who need longer term inpatient assessment.  In North Wales the policy change regarding age will not affect the operation of the Tier 4 services as the unit at Abergele has taken patients up to the age of 18 since it opened.  However in the South there is concern that there may be an expectation that the unit could be used for all children requiring admission, including all short term and crisis admissions. The limited capacity and specialist nature of this tertiary provision means that there will be a requirement for joint working, and access to short term inpatient care at a Local Health Board level and we would be grateful for confirmation that arrangements are in place to provide this.

 

Thank for your attention to the issues raised in this letter and please do not hesitate to contact me if you have any comments.

 

Yours sincerely

 

 

 

Daniel Phillips

Director of Planning