Child and Adolescent Mental Health Service (CAMHS) - Bromley ...

The Trust BoardAgendaDate of Meeting: 23 November 200910Item No.Child and Adolescent Mental Health ServiceTitle:(CAMHS) Strategy Action PlanClive UrenContact Officer:Chief Operating Officerclive.uren@bromleypct.nhs.ukKaren Fletcher-WrightAssistant Director (Access and Inclusion)karen.fletcher-wright@bromley.gov.ukLead Partner:NHS Bromley and London Borough of Bromley1. SUMMARY1.1 This report updates the Children’s Trust on progress made in addressing theactions from the CAMHS review of July 2008.2. RECOMMENDATIONS2.1 The Bromley Children and Young People Trust Board are asked to:2.1.1 Note the progress made with Action Plan (Appendix 1).2.1.2 Endorse the proposal to combine CAMHS Tiers 2 and 3, and create a JointCommissioning GroupThe Bromley Children and Young People Trust is a partnership of the following organisations:Bromley Mytime, Children and Families Voluntary Sector Forum, Early Years Development and Childcare Partnership, London Borough of Bromley,Metropolitan Police Service (Bromley), NHS Bromley, Oxleas NHS Foundation Trust, Primary and Special Schools, Secondary Schools,and South London Healthcare NHS TrustVisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk

BROMLEY CHILDREN AND YOUNG PEOPLE TRUST BOARDCHILD AND ADOLESCENT MENTAL HEALTH SERVICE (CAMHS) STRATEGY ACTION PLAN3. COMMENTARY3.1 Bromley PCT commissioned a review of CAMHS services in Autumn 2007; theterms of reference and scope of the review were the subject of a report to theChildren and Young People Trust Board. The outcomes from this review werereported initially to the Local Authority’s Director CYP Services; given the particularfocus of this review and the relatively narrow evidence base, the Directorrecommended that a further phase of review was undertaken. It was agreed toprogress a second, more comprehensive review, jointly commissioned by BromleyPCT and the Local Authority. An independent external consultant, Dr MurraySmall, was appointed to undertake this review. Full account was taken of theevidence collated through the first phase of review together with evidenceassimilated through an earlier review commissioned by the PCT in 2004. Thereview process incorporated workshops with all key stakeholder groups includingclinicians, schools, local authority officers and interviews with Councillors.3.2 The report which was presented by the independent consultant to the Children’sTrust Board on 14 July 2008 together with the conclusions and14 recommendations. A joint agency working group under the chairmanship of thelocal authority’s Assistant Director (Access and Inclusion) prepared an action plan,which is at Appendix 1, to address the 14 recommendations, which was receivedby the Portfolio Holder on 17 March 2009. This report provides an update on theactions contained in the plan.3.3 A strategic project board has been established to oversee the development of theaction plan with representatives from the PCT commissioner and providers of theCAMHS service together with senior officers of the Local Authority’s CYP services.The Board has met on five occasions. The Board comprises.ChairClive UrenBromley PCT ProviderSue SouthonJanet EttridgeChief Operating Officer, Bromley PCTDirector of Community Provider UnitAssistant Director (Clinical Services and CareEnvironment)Bromley PCT CommissionerYee ChoLead Commissioner - Community and Children'sServices Strategic Planning and PerformanceDevelopmentNicola WilsonLead Commissioner, Mental Health and LearningDisabilitiesFor more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 2 of 14

BROMLEY CHILDREN AND YOUNG PEOPLE TRUST BOARDCHILD AND ADOLESCENT MENTAL HEALTH SERVICE (CAMHS) STRATEGY ACTION PLANLondon Borough of BromleyGillian PearsonDirector Children and Young People ServicesKaren Fletcher-Wright Assistant Director (Access and Inclusion)OxleasStephen WhitmoreDirector of CAMHS and Learning DisabilityServices3.4 Future Structure and Responsibility for CAMHS in BromleyThe overarching aim of recommendation one as described in the summary ofprogress previously presented to the Children’s Trust is to re-commission CAMHSusing a cost effective business model. To take forward this aim the Project Boardcommissioned a small study to look at the way in which CAMHS was currentlycommissioned and provided across separate tiers of work. Whilst a number ofother local authorities and Primary Care Trusts Commission Tier 4 separately itwas found to be very rare (ie only 2 out of 32 areas) to commission Tiers 2 and 3separately. The study showed that the services could be run more efficiently andprovide better value for money if Tiers 2 and 3 were combined and commissionedfrom a joint commissioning group. The board has requested that, subject to theprovision of a business case, Oxleas and the Primary Care Trust Provider Unitcombine to create a single CAMHS provider organisation. The details of this arecurrently being negotiated with staff with a view to a proposal being agreed inprinciple by the PCT and Oxleas Boards in December 2009.In order for the services to be as cost effective as possible whilst also reaching anincreasing number of clients, the Board has agreed that a robust set ofspecifications will be prepared to inform the commissioning of the new jointservice. The specifications may include improvement waiting times, thresholdcriteria, effective outreach and moves towards a single point of access, all of whichwere recommendations of the review. A joint commissioning group has beenestablished comprising the Assistant Director of Access and Inclusion, PrimaryCare Trust and Mental Health Commissioner and they will produce the specificationonce agreement has been reached in principle and in time for implementationfrom 1 April 2010.3.5 Governance ModelA further recommendation towards this overarching aim was to determine aneffective Governance Model. The Board has agreed that the CAMHS StrategyGroup will now be a Commissioner-led group and will receive regular reports onthe providers' progress in delivering to the specifications set out in the newcontract. The strategy group has begun to monitor activity data and budgetinformation. The CAMHS Operational Group will be provider-led and will ensurethat the providers are all working together effectively to deliver the specificationand make improvements to the service. Arrangements have been made to takeFor more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 3 of 14

BROMLEY CHILDREN AND YOUNG PEOPLE TRUST BOARDCHILD AND ADOLESCENT MENTAL HEALTH SERVICE (CAMHS) STRATEGY ACTION PLANforward separate discussion with Bromley Y about how its contribution to CAMHSwill be commissioned in future.3.6 Developing New Ways of Working and Maximise Current ResourcesAppendix 2 provides a summary update on progress in these areas. Since the July2008 review, professionals have been working together to successfully reducewaiting times for both assessment and treatment in both Tiers 2 and 3.Tier 2 now only has a one week wait for assessment and then 12 weeks before aservice is provided, making a referral to treatment 13 weeks. Tier 3, average 17weeks from referral to treatment for most services, although Family Therapy maystill be longer than this. All urgent referrals are progressed by both Tiers 2 and 3immediately. The NICE guidelines are for under 26 weeks from referral totreatment. All CAMHS services achieve this benchmark.Maximising Tier 1 resources to provide early intervention was also recommendedin July 2008 review. Tier 1 resources have been considerably increased sinceOctober and 2009 by the introduction of a new Targeted Mental Health in Schoolsproject utilising a £200k grant. The Tier 1 services provided by the PCT and LocalAuthority have been identified and are at Appendix 3.4. POLICY IMPLICATIONS4.1 Improving CAMHS is a key target within Bromley’s Children and Young People’sPlan.5. FINANCIAL IMPLICATIONS5.1 The CAMHS grant is an area based grant. In 2009/10 the funding for CAMHSService in the London Borough of Bromley is £469,010 in addition to mainstreamfunding of £114,580. The grant is used to support the delivery of boroughwideCAMHS Services with health and voluntary sector partners.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 4 of 14

CAMHS STRATEGIC REVIEW ACTION PLAN OCTOBER 2008 – APRIL 2010 Updated 09 Feb 09Future structure and responsibility for CAMHS in BromleyObjective Task & Actions Lead Person Timescale Comments/Updates1.1 CAMHS review projectboard to discuss andrecommend future servicemodel to be agreed byCouncil Members, PCTBoard, Children’s Trust andothers.• Review Action Plan• Monitor progress• Report to Children’s TrustResearch models from otherareas• Identify good practice incommissioning andproviding CAMHS report toproject boardClive UrenGillian PearsonNicola Wilson (NW)Karen Fletcher-Wright(KFW), Mick Russell (MR)Independent ConsultantJuly 2008-Oct 2009Oct 2008-Dec 2009Jan 2009 – Feb 2009Group established. Clive Uren (PCT)chairing. LBB: Gillian Pearson, KarenFletcher-Wright; PCT provider: SueSouthon, Janet Ettridge; PCTCommissioner: Yee Cho, Nicola Wilson;Oxleas, Steven WhitmoreResearch shows that less than 10% ofCAMHS are commissioned in Tiers.Independent consultant demonstratesmore efficient use of resources and Tiers2 and 3 combined.• Produce possible financialmodels based on goodpracticeIndependent ConsultantFeb 2009Findings reported to Project Board in July2009.• Report findings to projectboardIndependent ConsultantMarch 2009• Refine commissioningintentions and proposefuture structure• Agree new commissioningintentionsProject BoardProject BoardMarch-July 2009Oct 2009September 2009 - Board agreed PCT andOxleas to combine Tiers 2 and 3 subjectto the provision of a business case byDecember 2009.• Agree governance modelfor commissioning cycleProject Board Oct 2009 Board agreed to form commissioning groupto devise specification by December 2009.• Begin operating newmodelApril 2010Work still be done on how Bromley Y iscommissioned.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 5 of 14

Recommendation 2Financial arrangement to be agreed by CYPS and Bromley PCTObjectives Tasks/Actions Lead Person Timescale Comments/Updates2.1 Ensure transparency offinancial position• Improve financialinformation contained ininitial reportNicola Wilson (NW)Oct 2008Current model to be set out anddiscussed at strategic and operationalgroups to identify issues• Recommend to reviewproject board to furtherinvestigate costs ifnecessaryNWNov 2008Strategy group now monitor activitydata and budget.2.2 Agree future monitoringagreement with reviewproject board• Establish effective financialreporting mechanisms• Ensure financialmonitoring arrangementsare included in newgovernance modelNW/KFWNW/KFWApril 2009Dec 2009Strategy group to monitor regularlyAgreed by Project Board September2009 for implementation December2009.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 6 of 14

Recommendation 3Build on excellence through increased resources and/or limit service to available resourcesObjective Tasks/Actions Lead Person Timescale Comments/Updates3.1 Increase funding on Tiers 1and 2 to absorb greaternumbers• Explore further grantfunding opportunitiesKFW, Janet Ettridge (JE)By April 2009 andongoingTAMHS bid successful. TAMHS projectset up and providing supports in 15schools from Autumn Term 2009.• Re-examine thresholdcriteria• Benchmark criteria withother LocalAuthorities/PCTsKathy Morris (KM), MR,VR, MJ, RS, KFW, SueByronOct 2008 – Feb 2009Feb 2009Clinical group Bromley Y Tier 2 and 3but now agreed that Tiers 2 and 3 willbe combined.• Address capacity issues intier 3 as commissioningopportunities allow.Now commissioning framework to bein place by February 2010.3.2 Clarify roles of each tierservice(Decision now made tocombine Tiers 2 and 3)• Tiers 2 and 3 to devise ajoint description ofservices• Identify and describe Tier1 supportKM, MRJE, KFW, RS, KMOperational groupOct - Dec 2008Oct - Dec 2008Booklet aimed at referrers has beendeveloped and issued.Tier 1 services have been identifiedand estimates made for percentage oftime allocated to Tier 1.• Clarify Tier 4 criteria• Describe seamlessapproach through tiersNWJE/KFWDec 2008Dec 2008 - Feb 2009Need to identify link for Tier 4 –Behind schedule. Work carried outand new specification will addressTier 4 issues.This is covered in booklet.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 7 of 14

Recommendation 3Build on excellence through increased resources and/or limit service to available resourcesObjective Tasks/Actions Lead Person Timescale Comments/Updates3.3 Construct new models ofworking, including morework within schools andcommunity centres by Tiers1 and 2• Develop model for accessto CAMHS throughlocalised services.• Identify services to bedelivered in outreachsettingsRobert South (RS)/JEKM, JE, RS, MJOct 2008 - April 2009Oct 2008 - Sept 2009Pilot project begun in Biggin Hill areaproviding single point of access forGPs, Children and Family Centres,schools and health professionals.To be evaluated in Feb/March androlled out across Borough ifsuccessful.• Work with Tier 3 todevelop localised approachMR/RSApril 2009 – Sept 2009Commitment in increase local deliveryto form part of new specification.3.4 Role of Tier 3 to focus onmost severe and complexwith rapid access provision• Re-examine thresholdcriteria. See previous• CAMHS commissioner tojoin complex cases panel.• Ensure support from Tier3.MRMR, KFW, Merlin Joseph(MJ)MROct 2008 - Dec 2008Oct 2008Dec 2008Complex cases panel set up by LBB toconsider joint funding proposals and issuccessfully engaging.CAMHS Tier 3.3.5 Differentiate treatments forclient groups requirements• Identify patient groups• Articulate new treatmentmodel for each group andreferral pathway• Agree new treatmentmodels with operationsgroupKM/Valerie Foster (VF),Mick Russell (MR)KM/VF/MRKM/VF/MROct 2008 - Jan 2009Jan 2009 - May 2009May 2009 – operationsgroup. Prioritise areasto inform commissioningUsing needs analysis as basis forchoosing other groups to be prioritised• Identify resourcerequirements• Make recommendations tothe commissionersNW/KFWNW/KFWSept 2009Sept 2009Report to project board in time for redefiningcommissioning intentions.Report to be available for newcommissioning specification.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 8 of 14

Recommendation 4Improve communication about CAMHS to service users and stakeholdersObjective Tasks and actions Lead Timescale Comments/Updates4.1 • Ensure clearcommunication toreferrers, parentsand young people• Produce website• Develop joint booklet in printers• Develop newsletter• Train frontline and key staff• Develop locally based services (seeprevious recommendations)Martin Wilson/Rachel HusseyFiona GiffordKFW/MWDec 2008Work already begunAll tiers have agreed to review theirwebsites and set up links/signposts toother areas. On hold until Tiers 2 and3 combine. Tier 3 already haswebsite.Ensure Children’s Trust website haslinks.4.2 • Ensure understandingof the nature ofassessment andtreatment whenreferral is made• Develop description of care pathwayswhich are easily understood by otherprofessionalsVR/KM/MR June 2009 On hold now that Tiers 2 and 3 willcombine. This objective needs tofollow on from Objective 3 Task 5Evaluate through questionnaire4.3 • Ensure sufficient signposting in Childrenand Family Centresand other venues• Identify venues.• Monitor access and take upRSOct 2008 Apr201016 Children and Family Centresalready in operation when jointbooklet produced signposting canbeginInclude drug and alcohol abuse.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 9 of 14

Recommendation 5Improve access to CAMHS with special reference to vulnerable groupsObjective Tasks and Actions Lead Timescale Comments/Updates5.1 • Improve access forhard to engagegroups• Audit current access of hard to reachgroups• Develop more school based and otheroutreach work• Work more closely with social care• Consider using more home visits• Establish access arrangements for PRUsand respite centres• Liaise with hospital trust about childrenwith chronic illnessKFW/JE/RSKM/MJ/MRKFWMR/Mark O’Leary(MOL)Oct 2008 – Apr2009Actions for this objective will dovetailwith new models of working incommunity based locations.• Bromley Y working in respitecentres.• Children with behaviour problemsin school to be included in newcare pathways. New consultantpost helps better referral andaccess from hospitals.5.2 • Improve access forchildren of parentswith identified MHneeds• Improve liaison between CAMHS andAdult Mental HealthMR /NW By April 2009 Look at care pathway for this group.Young Carers social worker to besignposted to services.Adult Mental Health Services recordingwhere children are involved in theircases. Protocol for referrals beingdeveloped.5.3 • Improve service forchildren withsubstance misuseissues• Work with Bypass to develop serviceprotocolVR, Suzett Polson(SP)By Sept 2009Protocol in handNew referral pathwaysData now referred into strategy groupto monitor progress5.4 • Improve access forBME groups• Evaluate Somali Women’s Project at Tier 3Lulu Pearce (LP)(ethnic communitiesprogrammemanager)/MRDec 2008Evaluation reported to OperationalGroup.• Develop localised projectsRS/VROct 2008April 2010New work began with black adolescentboys.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 10 of 14

Recommendation 6Improve service for autism and ADHDObjective Task/Action Lead Timescale Comments/Updates6.1 • Establish level of needin autism group• Work with education service to establishincrease in autism numbers• Identify children with autism but not onSEN registerKM/Bromley AutisticTrustKFW/Linda Pae(LPo)/MOL/EvelynTseng (ET)Dec 2008Oct 2008Autism numbers established. PCT hasagreed to continue additional funding.Autism Standing Forum now chairedby Mental Health professional.6.2 • Develop care pathwayfor autism• Work with schools and educationalpsychologists to identify different MHneeds in autism groupKM/ETOct 2008 –Apr 2009Assessment already developed.Looking at how to move on to carepathway in delivering mental healthissues.• Develop pathway with Joint Services forDisabled ChildrenHelen Norris (HN)Apr 2009 –Sept 2009Staff seconded to teams or servicesbeing developed with Joint PCT/LBBsteering group. To be finalisedAutumn 2009.6.3 • Ensure ADHD pathwayfunctions effectively• Monitor ADHD strategyET, KM, MR, MOLOct 2008 –July 2009Regular report to strategy• Work with PCT on GP prescribing issuesJEOngoingFor more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 11 of 14

Recommendation 7Consider how to deal with the Court Assessments and Risk AssessmentsObjective Tasks/Actions Lead Person Timescale Comments/Updates7.1 Court Assessments • Develop model and commissioningarrangementsMJ/JS April 2009 Additional funding for public lawoutline will go to tender for this newservice.7.2 Risk Assessments • Specify types of risks assessments KFW/MJ/MR April 2009 Risk assessments currently requestedon ad hoc basis by schools. Requiresco-ordination protocol.Meeting set up.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 12 of 14

APPENDIX 2CAMHS REVIEW ACTION PLANSummary of ProgressOverarching aim: To re-commission CAMHS using a cost effectivebusiness model.Recommendations 1 and 2A project board has been set up including chief officers from PCT, LBB andOxleas.The strategy group monitors expenditure across Tiers from April 2009.The Project Board has agreed that Tiers 2 and 3 should be merged undera single umbrella organisation. A Joint Commissioning Group has beencreated.Recommendation 3Overarching aim: To develop new ways of working to maximise currentresources.A successful grant application was made to provide additional Tier 1services to schools (TAMHS) bringing in £150k-£200k. Project iscurrently being rolled out across 15 schools.A multi-agency single point of access through the Bromley Children andFamily Project localised service has been developed and began in theBiggin Hill area (Community Area 6) and gradually rolled out across theBorough if successful.A comprehensive needs analysis has been carried out by the PCT publichealth team and it is being used to prioritise client groups who requiredifferentiated treatment models ie LAC. This will be used to inform thespecification for a new commissioning framework across Tiers 2 and 3.Improve Access to CAMHS for vulnerable groupsA new project has begun for black adolescent boys in an area of theBorough.A care pathway has been developed for children with behaviour problems.CAMHS Support is being provided to the new respite service for childrenat risk of exclusion from school.For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 13 of 14

APPENDIX 3CAMHS Tier 1 Services - Emotional Heath and Mental WellbeingTier 1 Services are provided as part of universal services and delivered by a largenumber of professionals as a percentage of their role. For example, anEducation Welfare Officer may help a child who is fearful of returning to schoolafter a bullying incident. The following PCT and Council Children and YoungPeople Services have some input into a child's emotional wellbeing and thefollowing table estimate of the % time which could be allocated to the work. Theservices cover a spectrum of need and services respond as part of their genericrole.% Spent on EmotionalLocal Authority Children and Young People ServicesWellbeingPupil Support Services - Learning Support 30Pupil Support Services - English Language 30Pupil Support Services - Travellers 30Behaviour Support Services - Outreach Services 701-2-1 Tuition and Participation KS2 30Education Welfare Officers 20Behaviour Support Services - Pupil Referral 50Behaviour Support Services - Home and Hospital 50Primary Respite 60Secondary Respite 60Community Vision Nursery 10Children's Fund 60Bromley Transition Service 70Primary - Children Project 70Education Psychologists 10PCT Community Provider Unit ServicesLooked After Children/s Nurse 40School Nursing 40Health Visiting 40YoT Nurse 75Contraception and Reproductive Health 20For more information on the Bromley Children and Young People Trustvisit www.bromley.gov.uk/childrenstrust or e-mail childrens.trust@bromley.gov.uk Page 14 of 14