UPDATE ON THE DEVELOPMENT OF A HIGHLAND IMPLEMENTATION PLAN FOR THE MENTAL HEALTH OF CHILDREN AND YOUNG PEOPLE: A FRAMEWORK FOR PROMOTION, PREVENTION AND CARE

Report by Sally Amor Child Health Commissioner/Public Health Specialist and Jan Baird, Director of Community Care

The Board is asked to:

  • Note the update and progress made in developing the Highland Implementation Plan for the Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care since February 2008.
  • Note the on going identified need and priority for investment in CAMHS across the NHS system for 2009/10.
  • Note the particular challenges regarding investment in Tier 3/4 specialist CAMHS services.
  1. Background and Summary

TheMental Health of Children and Young People: A Framework for Promotion, Prevention and Care, was published by the Scottish Executive in November 2005, with a ten year timescale for implementation. The Board will be familiar with the expectations of the Framework that NHS systems address, a range of mental health needs and difficulties for children and young people across the whole continuum of mental health, from mental health promotion, through preventing mental illness, to supporting, treating and caring for those children and young people experiencing mental health difficulties of all ranges of complexity and severity. The Board are also aware that the Framework acknowledges that the primary purpose of specialist NHS CAMHS services is to provide services for those children and young people with the greatest mental health need. Following swiftly, is the need for specialist CAMHS to provide consultation and training to partners providing services to children and young people with mental health needs and difficulties. These principles underpin the approach in the development of the Highland CAMHS Framework Implementation Plan.

The Chief Officers Group of the Joint Committee for Children and Young People and the Argyll & Bute Health and Care Strategic Partnership continue to serve as the project board while the bi-annual performance visits from the Scottish Government’s Delivering for Mental Health team ensure ongoing oversight of the process from the centre. CAMHS services in Argyll and Bute are now an integral part of the process.

This paper updates the Board on the work that has been undertaken since February 2008. The CAMHS Framework Implementation detailed in that paper detailed an ambitious work programme for the CAMHS Implementation Group and integrated children’s service partners. An updatedversion of the CAMHS Framework Implementation Plan to date is available on request.

  1. Progress and Highlights

Service Design

There has been good progress in developing an integrated specialist CAMHS service within the specialist CAMHS services based in Inverness. Clinical psychology and the Department for Child and Family Psychiatry are to co locate on the same site, utilising the CAPA patient management system to better route children and young people into specialist services best suited to addressing their needs. The first phase of CAMHS eHealth investment is underpinning these developments.

Priorities and Planning 2008/09

Resources have been secured through priorities and planning for the current financial year. This funding is welcome, and will support specific actions in the CAMHS Implementation Plan as follows:

  • The anticipated recruitment of a highly specialist dual trained learning disability and CAMHS Consultant working across children’s learning disabilities services and specialist CAMHS sited at Raigmore and adult services will support the development of mental health services for children with learning disabilities, adding much welcome capacity and expertise for related psychology and partners across integrated children’s services. This will go some way to address risks that have been identified for this very vulnerable client group and enable earlier interventions to support children who may be prone to very challenging adolescence and transitions into adult life.
  • Recruitment of a Tier 3 specialist post in the North Highland CHP. This post, a collaboration between specialist CAMHS in Inverness and the North Highland CHP, will explore and test out the service models for supporting very vulnerable young people with Tier 3, and at times Tier 4 need in community settings. The post will also provide invaluable support when a young person may be returning from in patient care. The post holder will be supported through a visiting team from Inverness on a monthly basis, with the provision of regular access with Inverness colleagues on an as needed basis in between. They will also be very closely linked with integrated children’s service partners locally and have a key role in implementing GIRFEC approaches to CAMHS service developments.

Mental Health Act Implementation Monies

Funding has also come on stream from Mental Health Act monies. This will be used for additional clinical posts within the Inverness based specialist services, with a mature dialogue across disciplines as to how these may be recruited to, given the well recognised challenge across Scotland as to how to recruit to specialist posts. Related development opportunities for training posts are also being secured so that Highland CAMHS services will be sustainable over time. These posts will begin to address some of the pressures and risks within specialist CAMHS across all of NHS Highland, support the development of pathways and best practice and support the QINMAC (standards for CAMHS) process as well.

Workforce and Financial Planning

A significant exercise has been undertaken to identify the work force needs for the Highland partnership for specialist CAMHS with a related exercise to be replicated in Argyll and Bute where service provision across two health systems and three CHPs is particularly challenging.

These exercises will inform a financial plan for September 2008, detailing how Highland will implement the CAMHS Framework by 2015, which is a requirement of the Scottish Government.

In the meantime, in order to address the significant service capacity and risk issues for specialist CAMHS based in Inverness a decision has been made to withdraw of the Highland visiting CAMHS consultant service to the Western Isles as the risks and pressures on the Highland service are too great. This has been jointly agreed between the two services.

Integrated Children Services Partners

Following a series of consultation seminars earlier this year a number of conclusionsand related recommendationshave been detailed. These are currently being discussed with senior managers and Chief Officers for both partnerships.

Delivering for Mental Health Targets

Reduce admissions for 16-18 by 50%

In addition to older adolescents within the CAMHS system whose transition needs into adult services are often a challenge to community services, there are also 16-18 year olds who will be presenting with significant mental health need to adult mental health services. The Delivering for Mental Health target to reduce 16-18 admissions to in patient provision represents a further challenge to NHS Highland system and has a built in assumption that there will be more community based provision for this cohort. There could be opportunities for addressing some of these challenges through investment in community mental health services through adopting a pro active approach to transition. In the meantime, work is in progress to develop a joint protocol for admission to adult services, informed by work undertaken in Argyll and Bute.

Mental Health Link Worker

The role has been discussed and explored with the Highland and Argyll and Bute partnerships and is due to be signed off at the end of the summer to allow a scoping exercise of gaps and capacity issues prior to the Scottish Government Delivering for Mental Health implementation visit in October 2008.

Training for Looked After and Accommodated Children and Young People

The additional posts in specialist Inverness based CAMHS services will enable staff to take on this function and begin to deliver training from January 2000. The emerging integrated children’s services training group have indentified the need to review the national training developed in support of this target

  1. Risks and Challenges

Tier 3/4 need in Highland

By definition, young people with Tier 4 mental health needs have a high and at times distressing level of need that represent a challenge to existing services which have not been historically funded to provide such a level of service and present risks to families, services and the corporate NHS. Within Highland, these circumstances and the related clinical decision making processes may be confounded by age, maturity, remoteness and rurality, family relationships and the capacity of specialist CAMHS, as currently configured and resourced to respond to such high levels of need and related risks.

There is an expectation from the Scottish Government that nationally, there will be an increase in patient beds for young people aged 12-18. This is to be achieved through regional planning, for Highland in the North and West regional planning groups.

Decisions to increase the number of in patient beds in the West of Scotland predated the Scottish Executive and subsequent Scottish Government expectations of an increase.

The North of Scotland Planning Group has been developing proposals to increase the number of in patient beds at the regional unit in Dundee for the last two years and is now at the point where it is seeking a formal sign up to such a development from NOS Boards. The NOS proposals have also recognised the need for NHS systems to invest in community based services.

A mini needs assessment (2008) was undertaken by the NOS CAMHS Project Board in Spring 2008. This was based on the current understanding of in patient use of the Dudhope facility and other in patient units elsewhere in Scotland which may be accessed for a young person from Highland if there is no bed available in Dudhope. For the 2.5 bed places a year that have been identified to address Highland’s needs there is an indicative annual cost of £600,000. This represents a significant financial pressure for the NHS Highland system and takes not account of the need to invest in community based services to support the care journey from in patient to community based services.

Since December 2007, the Department for Child and Family Psychiatry has been keeping a record of indentified Tier 4 need that they are seeking to meet within the existing service on a month to month basis. At any one point in time there have been 12 -15 young people with identified Tier 4 need: of these there are 5-7 young people receive community based services, whilst the rest are in a range of specialist provision (in patient units, residential school settings). One young person a month has been admitted to the paediatric ward, this despite a review in 2005 that recommended that this was not an appropriate environment for a young person to be admitted to. In order to better manage the risk that these young people may present to themselves, due to their symptoms and to the organisation, in the absence of funding to provide intensive community supports or the availability of an in patient bed, a protocol for identifying and addressing Tier 4 need in the community has been developed, found to be useful and is currently being revised.

The balance of investment required across community based intensive Tier 3/4 services and in patient beds will prove to be very challenging for the NHS Highland system and a range of options are currently being explored as to how this challenge might best be met. NHS Highland have confirmed to the North of Scotland that they are unable to commit funds at this stage to progress the outline business case for an increase in bed numbers at the regional in patient unit in Dundee. NHS Highland propose that funding should be prioritised with the allocation of funding to regional planning groups for specialist paediatric services.

  1. Conclusions

Specialist CAMHS across the NHS Highland system continue to work with considerable levels of risk and need.

The CAMHS Implementation Group is making progress with a challenging and demanding agenda of change.Opportunities that are both creative and innovative are being adopted, this in itself is challenging. The service is seeking to develop a specialist CAMHS service that will be attractive to prospective employees and deliver the highest quality care through a sustainable service model best suited to the population of Highland.

  1. Contribution to Board Objectives

The work programme detailed in this paper and the associated CAMHS Implementation Plan will address both direct improvements in health and build organisational capacity to enable direct improvements in health as follows:

  • Specific objectives and milestones from Delivering for Mental Health and Delivering a Healthy Future: An Action Framework for Children and Young People’s Health in Scotland will be met.
  • In addition, the following goals in Delivering for Health will be met: shifting the balance of care, long term conditions, service redesign, workforce strategy.
  • Additional Board objectives will also be addressed as follows: HEAT targets, health improvement, quality of service delivery, engagement with the public and users and carers.
  1. Governance Implications
  • Governance arrangements for staff will be addressed through engagement in the Review process and related service redesign and workforce planning developments.
  • There is a clear process for ensuring the involvement and engagement of users and carers to address the Patient Focus Public Involvement agenda
  • Clinical Governance issues will be identified and addressed through service redesign and work force planning developments
  • The process includes all Highland CHPs as equal partners
  • The process is embedded in both the Highland and Argyll and Bute partnership processes.
  1. Impact Assessment

An EQIA has been carried on previous Board papers on the CAMHS Framework Implementation Plan. The two key recommendations from the EQIA were: firstly ensuring effective engagement with relevant equality groups and secondly, ensuring that any service redesign is impact assessed as required. The first recommendation has been clearly evidenced through the consultation process detailed in the appended Implementation Plan. Further work will also be included in the NHSH LGB action plan. The second recommendation isa standing one for the CAMHS Implementation Group to be “mindful” of equality issues.This is an on going priority for the group.

Sally Amor
Child Health Commissioner
Public Health
22 August 2008 / Jan Baird
Director of Community Care

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