Written evidence submitted by the Oxford Health Foundation Trust (CYP0067)
Oxford Health NHS Foundation Trust is a mental health and community trust providing services in Oxfordshire, Buckinghamshire, Bath and North East Somerset (BaNES), Swindon and Wiltshire. It relates to the Berkshire, Oxfordshire and Buckinghamshire (BOB) ICS and BaNES, Swindon and Wiltshire (BSW) CCG, which have an estimated under 18s population of 481,914.
The Trust provides a full range of Child and Adolescent Mental Health Services (CAMHS) across this footprint, with some variations based on local commissioning. Community CAMHS services are organised around the iThrive model, with Getting Help, Getting More Help, Outreach and Crisis Teams, as well as specialist eating disorders services and Neurodevelopmental Clinics. The trust provides Wave 1, Wave 2 and now also Wave 4 MHST teams.
Oxford Health is also the host of the Thames Valley Tier 4 Provider Collaborative, which provides inpatient psychiatric beds for young people in BOB, BSW and Gloucestershire from Willow House in Berkshire, Highfield Unit in Oxford, Marlborough House in Swindon and Huntercombe in Maidenhead. The Trust is also lead provider for 2 nationally commissioned regional forensic CAMHS teams (covering our Tier 3 catchment and wider areas: South Central (Thames Valley, Hants/IoW and Dorset) and South West (North) covering BSW, Gloucestershire and adjoining areas).
With regards to CAMHS inpatient services, OHFT provides:
2a) Factors which are contributing to the increase in children’s mental health needs.
During this period children’s mental health needs have increased due to several contributing factors. These include:
- The recession
- The pandemic
- Cuts to universal services
- Cuts to social care and education
- Parental mental health and wellbeing deterioration
2b) Where need has increased the most
Increased need is highest for:
2c) Additional investment into children’s mental health services is welcome but has often required working to rushed deadlines and has not provided additional funding to Core CAMHS to reflect the increase in demand.
2d) The ability to identify suitable inpatient beds for children and young people continues to be an area of difficulty, with the system under a lot of pressure
The national and regional bed capacity has been significantly depleted over the last 2 years, with no replacement provision planned. The Thames Valley footprint has lost the following capacity:
The South of England has significantly lower numbers of beds per capita. There are no beds in the South for young people with moderate/severe ASC/LD. Our PICU, planned to be opened this year, will contain the first NHS PICU beds in the South.
Referrals for young people with complex eating disorders and ASC have significantly increased. The provider collaborative has reduced the inappropriate use of out of area beds by 74%, but waiting time for access to beds has increased due to bed closures
2e) Stigma in relation to mental health remains
A lot of work has been done to promote awareness of mental health for young people, resulting in increased demand on services. However, stigma remains (including in services, such as amongst acute sector and social care colleagues). This is a barrier which stops people from accessing the help they need. There is also an expectation that mental health services are the only route to addressing mental health issues, rather than the support being jointly owned by social care, families, the voluntary and community sector and universal services.
2f) Transition continues to be a challenge
There are ongoing issues with transitions for young people. This is being addressed through the 16 – 25 work, but funding for this new pathway is at such an early stage that it is not yet possible to tell whether funding is sufficient or whether the planned transformations will have significant impact. Support tends to be low-level (e.g. from the Mental Health Academy) and some University mental health services are not linked to NHS services, causing fragmentation and discontinuity.
There is some feeling that the issue of difficult transitions is getting worse during the Covid pandemic. This is because mental health staff have been redeployed (reducing available resources in core adult mental health services) whilst acuity has increased (meaning that resources are disproportionately used for a small number of patients, leaving those with lower levels of need with a lower level of service.
There remain key differences between the support you can get in CAMHS and in Adult services. CAMHS services tend to be more systemic and work with schools, families and social care. The thresholds for admission to community and inpatient services are much higher for adults. Many young people have difficulties accessing IAPT services as they have to instigate the contact and their issues with social anxiety make this difficult for them. Early intervention / low level support provided by services such as the Mental Health Support Teams for children and young people do not have equivalents for the college-age population.
Young people also experience difficulties when transitioning from children to adult services in social care. Service provision is either insufficient to provide continuity, or thresholds are so high that it is impossible for some young people to access support.
In Oxfordshire, the CAMHS Partnership consists of several VCSE organisations integrated into the service provision which has positive outcomes for young people. However, it is challenged by differences in commissioning as CAMHS are commissioned to 18 but the VCSE organisations work with young people up to the age of 24.
2g) Eating disorder services are experiencing a lot of pressure
These services have been experiencing significant growth in demand without corresponding increases in capacity (and funding) for several years. This trend has continued and increased during the Covid pandemic due to a variety of issues including a lack of social contact, the increasing pressure from social media, anxiety about school and difficulties with parental mental health. Please see data section for more detail about increasing demand.
New investment is just beginning, so it is too early to see its impact. Additional investment has also been modelled to meet only pre-Covid growth in demand. There is also a concern that under-funding in Adult Eating Disorders Services means that young people who would benefit from continued treatment from an eating disorders service in adulthood may not meet criteria for these services. There is some funding for the First Episode Rapid Early Intervention for Eating Disorders (FREED) model across the country, but access to this funding is not universal. Young people who have already been in a CAMHS service do not meet the criteria for the FREED pathway.
There is a requirement to provide a specialist pathway for children and young people with Avoidant and Restrictive Food Intake Disorder (ARFID), but this is not possible to do without dedicated additional investment over and above the investment which has been provided to meet demand in eating disorder services. Young people with ARFID also experience a lack of commissioned pathway when they transition to adult services.
2h) Access to NHS-funded services is improving, but more needs to be done to make this meaningful
We have increased access to CAMHS through creating Single Points of Access (SPAs – these are small teams of administrators and clinicians who coordinate all incoming referrals into CAMHS) and delivering MHSTs, but this has led to an increase in demand (e.g. for NDC assessments).
2i) There are advantages and disadvantages to re-focusing the system to work more with early intervention in children and young people’s mental health, to prevent more serious illnesses from developing
2j) Tackling self-harm and suicide
There are more measures which we could be taking to tackle self-harm and suicide. However, trying to prevent suicide entirely is not possible as some suicides are unaccompanied by warning signs.
2k) There is a need for a dedicated workforce strategy for children and young people’s services
This is essential if CAMHS services are to increase in capacity, as recruitment and retention are an ongoing area of difficulty.
2l) Best practice / innovation we are delivering
We are regularly using the following apps across CAMHS:
We have dedicated teams providing high standard neurodevelopmental assessments and treatment which are consistent with NICE guidance. During the pandemic these teams have developed assessment tools and treatment protocols so that this work has continued. We have shared these developments with other areas who stopped this work during the first lockdown.
The teams are multidisciplinary with efficient use of skills for example Non-Medical Practitioners work with psychiatrists to maximise the number of young people seen and ensure appropriate high-quality care. The parent groups (educational, parenting, anxiety, challenging behaviours) have been developed so that they are delivered virtually and with videos that can be watched independently.
The service experiences pressure from the fact that demand frequently exceeds capacity. The service is often the only provision offering interventions for young people with non co-morbid NDS (for example, in Buckinghamshire there is a lack of Educational Psychology and Early Help provision for this group of children and young people)
The outreach and crisis teams have had to adapt to deal with increased frequency and complexity of presentations, alongside the current pandemic restrictions. This has included:
However, the out of hours offer is very thinly spread as one duty worker covers two counties.
Staff across CAMHS have adapted well to delivering digital interventions. Productivity has increased but the evaluation of digital interventions on the outcomes for patients is yet to be completed.
We have increased the range of self-help materials available to young people and their families. These are on our website and include anxiety, low mood and sleep advice and particular resources for parents of young people with neurodevelopmental disorders.
We have a strong ethos of children and young people’s Participation Teams being involved in shaping services.
Our community FCAMHS provision provides an accessible and authoritative service for children with high risk behaviours whether in the youth justice system or elsewhere. The service model developed by the Trust within FCAMHS in the Thames Valley has been recently adopted and applied to the national development of FCAMHS provision and there are now 13 such services covering the whole of England. OHFT now provide two FCAMHS services. The OHFT FCAMHS team is now actively involved in consideration of further services for children with complex needs in line with the NHSE Health and Justice Long-Team Plan.
There has been a sustained doubling of referrals to the Horizon service (Supporting Children and Families after Sexual Harm). Most of these young people have also experienced other forms of trauma and adversity, especially domestic abuse, peer on peer abuse or other forms of child maltreatment. A substantial number are presenting with abuse experiences that have occurred during the pandemic.
Horizon aims to have a highly flexible approach to meet the complex needs of our patients in the way that works for them. We intentionally have no fixed criteria for offering consultative support to other professionals other than that sexual harm has occurred and offer advice to professionals worried about broader issues outside our consultation remit such as suspected sexual harm, perpetrators within the family, or childhood trauma.
We have worked hard to build capacity and confidence through extensive regular training to multiagency professionals through Oxfordshire Safeguarding Children’s Board, within CAMHS, to junior doctors. We recently introduced a new 2-hour complex trauma lecture into the first day of the Oxford medical student Brain and Behaviour course, which has generated multiple requests to visit our team for learning. We host visitor meetings around twice per month and adapt the pace and content of our discussions to maximise learning for visiting professionals and students. We have recently trained staff in EMDR (eye movement desensitisation and reprocessing) so we can now offer four different types of psychological intervention, tailored to individual needs and increasing patient choice.
There are an increasing number of highly complex young people presenting to mental health services who are either Looked After Children or are families at risk of breakdown. They often combine complex family situations with significant risky behaviours, are open to multiple services with complex webs of care and intensive resource to support. When their mental health difficulties are not best treated by an inpatient psychiatric provision, but they cannot return to their family or placement, there is a lack of non-inpatient provision that can support these young people. This often leads to placement out of county, breaking links with family and with services that have cared for these young people. Improving multi-agency provisions for these young people is vital. Resolving this would require commissioning of a new provision, with a radically different model of care to what is traditionally provided by social care, or within the Tier 4 CAMHS inpatient network. This work would be led by our colleagues in Children’s social care, but CAMHS and other agencies involvement would be vital.
These situations often place significant strain on relations between mental health services and social care providers- the lack of appropriate provision can create conflict over which inappropriate provision should be used- a social care placement with inadequate ability to manage risk or a tier 4 inpatient provision that may cause iatrogenic harm. This inhibits a collaborative approach which vital in these cases
Our In-reach team offers consultation, liaison, advice, support and reflective practice for Families and Children’s Services professionals as well as interventions focused on complex trauma and attachment issues (where there is also a mental health or significant wellbeing need identified). The team is informed by the needs of the young person and their family rather than using strict access service criteria, using the terminology of the THRIVE Framework. This group of young people also receives considerable input from the FCAMHS teams.
Through consultation, screening and joint assessment the team will identify the most appropriate intervention. This could be:
It is important to note the significant impact that the pandemic has had on young people’s mental health.
3a) Reduced referral numbers but increased acuity. There have been fewer referrals for most disorders. However, there has been a significant increase in eating disorders referrals and these presentations tend to be at lower weights which increases the risk to physical health and the need for paediatric admission, as well as more entrenched illness and as a result a higher need for inpatient use.
3b) Increased need amongst children and young people with autistic spectrum conditions. We have seen a significant increase in young people presenting with autistic spectrum conditions and mental health disorders and/ or challenging behaviour. This group of young people are particularly difficult to treat as a lot of the evidence-based treatments need modification for those who have ASC and the uncertainty and changes in routine has had a significant impact on their mental health and wellbeing. These young people are presenting with more extremes of behaviour and self-harm that under usual circumstances would cause significant anxiety amongst social care and acute sector colleagues, as well as in CAMHS. This is coupled with a lack of alternative prevision such as respite care, social care or foster care placements.
3c) Increased anxiety due to change and unpredictability. i.e. loss of control and lack of predictability for the immediate future, loss of peer support contact, loss of daily routine/purpose, health anxiety for self and family, unpredictability regarding GCSE’s and A Levels leading to increased exam/future plans anxiety, less protection from/time away from unhealthy/unsafe family relationships or parents with deteriorating mental health.
3d) The advantages and disadvantages of more digital working by mental health services. Due to the significant change as a result of Covid to digital working this is harder to assess. Some young people have found digital working very helpful. The number of appointments not attended has reduced increasing productivity. However, there are concerns about the fact that young people may not be able to have a confidential appointment with their therapist as their parents or siblings may be able to overhear. Some young people are reluctant to be seen on camera and there are concerns that they cannot be properly assessed. Some people need to be seen face to face but this brings its own difficulties due to social distancing and use of PPE which can affect the therapeutic relationship. Engaging young people with ASC and delivering Multi-Family Therapy has proved surprisingly successful.
4a) Access target data
Currently services are only funded for up to 35% of young people who need a service, but we are currently achieving 54% in some areas. (Please note data quality issues for BSW and Getting Help in Swindon is commissioned differently which is not captured in this report). This was for pre-Covid levels of mental health need. The estimate is that this has now increased to 1 in 6 young people having a mental health need.
The Access performance data highlights the increasing demand for CYP MH Services where an expectation has been set that only 35% of young people with mental health needs can access services. This is not ethical or equitable to meet the complex and distressing needs of young people. We are not funded for the over performance (cost pressures) and without funding we are not able to staff to appropriate levels to meet demand.
4b) Eating Disorders – increasing need data
During 2020/2021, the BSW CAMHS service has seen a significant increase in the number of young people presenting with an eating disorder compared to previous years. Compared to a 3-year average, the service saw an increase of 39% between April and December 2020. Referrals for eating disorders during and after the first national lockdown, between April and May 2020, were significantly lower than 2019, but quickly picked up in June. Between June and December, the service has experienced an increase of 69% when compared to the previous 3 years.
The data in BSW mirrors the national picture, which shows a 65% increase in eating disorder referrals in quarters 2 and 3 in 2020/21 (Figures 2 and 3).
Oxfordshire and Buckinghamshire
Data from Oxfordshire and Buckinghamshire mirrors this pattern.
The level of increasing demand is not reflected in the uplift applied to CYP MH services and block funding allocations, so waiting times will continue to increase.
As an organisation we are engaged with the national NHSE I CYP MH team on the CAMHS Waiting Time Standards programme, working on appropriate waiting times, tools to support patient tracking and standard rules to determine access and waiting times. There is huge variation across services nationally on how access, first appointment and waiting times are measured and recorded.
The table below shows the MHST provision by the Trust:
No. of Teams
Investment per annum
No. of Schools
Oxfordshire- Oxford City
34 schools (5 Secondary, 29 Primary)
Oxfordshire- North Oxfordshire
45 schools (7 Secondary, 38 Primary)
BaNES and Wiltshire
BaNES and Wiltshire
North Bucks and South Bucks (Wave 1 and 3)
49 schools (23 secondary, 23 Primary and 3 colleges)
5a) Advantages of MHSTs
5b) Challenges to the MHST model
[i] There is some evidence from the ‘open-dialogue’ approach (Seikkula et al 2011) which has been used in services in other parts of the world that ensuring a highly skilled workforce is more effective. The open-dialogue approach places an emphasis on (1) a highly trained universal workforce (2) first contact with professionals to be led by highly trained staff amongst and (3) other practice considerations. Reported evidence has since been reviewed and trialed elsewhere since but indications were that having more trained staff led to more effective services – in terms of costs (reduced input needed / less social costs) and better patient outcomes. Whilst used in adults, this approach holds clinical sense.
The Comprehensive Open-Dialogue Approach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Jaakko Seikkulaa*, Birgitta Alakareb and Jukka Aaltonena