Written evidence submitted by Hospital Trusts (CYP0106)

A Holistic, Collaborative Approach to CAMHS Crisis 1

The White paper (Integration and Innovation, 2021) sets out two forms of integration which will be underpinned by new legislation: integration within the NHS to remove boundaries to collaboration, and greater collaboration between the NHS and the local government, to deliver improved outcomes to health and wellbeing for local people. The government intends to support integrated care systems play a greater role, delivering the best possible care, with different parts of the NHS joining up- and the NHS and local government forming dynamic partnerships to address some of society’s most complex health problems .

The experience of the pandemic has made the case for integrated care even stronger. We want to showcase an example of successful collaboration, where different parts of the system came together, and organisational silos were overcome, facilitating flexible and innovative work.

CYP Mental health services in North Central London (NCL)

Children and Young People’s (CYP) Mental Health (MH) services in North Central London (NCL) are provided by Barnet, Enfield and Haringey Mental Health Trust, Whittington Health, The Royal Free NHS Foundation trust, UCLH and The Tavistock and Portman NHS Foundation Trust. NCL CYP MH services deliver a range of services to children and young people with moderate and severe mental illness. There is local variation in the provision of crisis support and in- reach into acute hospitals by CAMHS services, with services in the south (Whittington, Royal Free and UCLH) having access to more resources than north (Barnet and North Middlesex University Hospital). The Whittington Health Paediatric Liaison Service provides paediatric liaison function to hospital inpatients and crisis support to children and young people who present at A&E or require short admission onto the paediatric ward.

The NCL Out of hours CAMHS crisis service was launched shortly before the onset of the pandemic and is delivered across NCL. The service provides crisis assessments for young people presenting in acute settings between 12 noon and midnight, 7 days a week. The service also covers the North and South Hubs.

The North and South hubs were set up as a response to the first wave of the pandemic, when paediatric A&Es and wards across the sector were closed/ converted into adult wards. They were established as a mechanism to prevent unnecessary attendance at A&E departments, and as a site to direct young people from A&E departments at the earliest opportunity. They are staffed by clinicians

1 Dr Aspa Paspali, Consultant Child & Adolescent Psychiatrist, CAMHS Clinical Lead, Whittington Health NHS Trust; Dr Sally Hodges, Chief Clinical Operating Officer, Tavistock and Portman NHS FT; Dr Neeta Patel, Consultant Paediatrician, Whittington Health NHS Trust; Sarah McKerracher, NCL Children and Young People’s Mental Health Programme Lead, North London Partners in Health and Care, & Senior Strategy and Transformation Manager, Tavistock and Portman NHS Foundation Trust; Dr Georgina Fozard, Darzi Fellow, ST6 in Child & Adolescent Psychiatry, Tavistock & Portman NHS FT; Sheron Hosking, Associate Director of CAMHS and Mental Health, Whittington Health NHS Trust. 26 February 2021

from the NCL Out of Hours CAMHS crisis teams, and at times staff redeployed from CAMHS or paediatric mental health services.

The South hub is collocated with Islington CAMHS, a short walk from the Whittington hospital, and has allowed for flexible moving of staff to see young people where most appropriate. As part of the COVID 19 response, the system has also expanded the 24/7 CAMHS crisis telephone line across all NCL.

Young people in mental health crisis presenting to acute hospitals has increased during the COVID 19 pandemic, both in numbers and in acuity/ complexity. The reasons for this increase are multifaceted, and to a large extent preceded the pandemic. There is a large unmet need for CAMHS , long waiting times to access services, high variability in the provision of services locally, incentives to be reactive rather than proactive – for example, to respond to short term funding cycles over long term strategy. True parity of esteem between mental and physical health has not been achieved. Very few hospitals have established paediatric liaison teams2. Services are set up primarily for treatment, not for prevention, and there is not enough co- production with parents and young people. Crisis can often be a means to access services, and children and young people are signposted to A&E departments as a way to access services faster. There are inadequate links between CAMHS and social care. Social problems are often treated as health problems, in the context of underfunded social services and breakdown in support systems around the child. This was particularly evident during the pandemic. School closures led to social isolation, lack of daily structure and increased levels of stress in parents and children.

Children and young people in mental health crisis; evidence from activity data

Capturing accurate activity data on mental health presentations of children and young people, especially across acute presentations (A&E and paediatric inpatient beds) is challenging, largely due to coding limitations. Quantitative data has been collated across 10 different sources in NCL to inform the below.

- In comparison to the same period in 2019-20, CYP MH presentations between March – September 2020 across NCL have increased.

- The proportion of mental health related A&E presentations have increased compared to the same period last year, despite overall paediatric A&E activity still being below 2019-20 levels.

- Comparison of admissions data from April – September 2020/21 with 2019/20 across breadth of crisis related services provides some evidence that mental health presentations have increased by c.15%.

- Since the crisis hubs were established, the October activity shows growth by approximately four times the amount in April, continuing to divert pressure away from A&Es.

- The number of CYP referrals for eating disorder services have increased by 35%, compared to July-Sept in 2019/20.

2 Woodgate M.& Garralda E. (2006), Paediatric Liaison Work by Child and Adolescent Mental Health Services. Child and Adolescent Mental Health 11: 19–24. doi: 10.1111/j.1475-3588.2005.00373.x

- Community referrals increased by 12% and community contacts by 10% in 2019/20, based on data from Barnet, Enfield and Haringey, Tavistock & Portman, and Whittington. Monthly performance data across previous years demonstrates a steady increase in proportion of CYP accessing MH services (community and crisis).

- For 20/21 NCL has already exceeded the revised access target. However, despite the number of referrals growing every year, the level of predicted unmet need in terms of CYP MH prevalence vs total referrals is c. 65%.

- Tier 3 and tier 4 demand and capacity modelling has been undertaken in May 2020 with ICS analytics, based on national growth assumptions and local activity data from previous years. This modelling projected an increase in demand of 25% and spikes of up to 30% have already been experienced.

- Nationally there are frequently no tier 4 beds available. Local delays to discharge from Tier 4 settings also continue to place blocks to patient flow across inpatient settings and many of which are associated with inadequate access to social care support/placements. Work is in progress with social care partners to better understand and address these issues.

- Nationally, mental health demand in children and young people is projected to grow by 20- 30%, as a result of suppressed and unmet demand, lock down and COVID 19 impacts, and population growth.

COVID 19 response

All NCL acute and community partners came together, under strong leadership, to respond to the COVID 19 pandemic. An NCL- wide crisis pathway was developed at pace in April, and reconfigured during June and September to adapt to changing paediatric acute service provision across NCL, in the context of closure of paediatric departments (UCLH and Royal Free hospitals) to increase COVID capacity. Communication and collaboration was facilitated by the creative use of technology; for example, weekly NCL- wide crisis calls were established; demand and capacity data modelling via ICS analytics supported an evidence- based estimation of demand and consequent allocation of resources. On call rotas were merged to increase resilience if clinicians fell ill or needed to self- isolate. Resources were used flexibly – eg taxi services to safely move patients between sites as needed, reduced bureaucracy to allow staff to work flexibly across organisations.

We increased the capacity within the NCL nurse- led out of hours CAMHS crisis team from 4.3 WTE to 12.2 WTE (meaning 5 people on shift 12-12 everyday 7 days a week across NCL). This allowed for faster assessment and discharge of young people presenting to the acute sites and reduction in the time spent in hospitals.

The 24/7 crisis line provided by Barnet, Enfield and Haringey MHT, expanded to Camden and Islington . The North and South hubs demonstrated increasing activity and successful diversion out of A&E departments, which was vital in the context of increasing demand.

Community teams RAG rated all open cases and diverted resources to the most vulnerable young people to try to avert the need for crisis services.

The system has now 3 acute sites (plus 2 diversion hubs) for children and young people requiring urgent or emergency care. Psychiatry liaison workforce in acute sites provide cover to A&E and inpatient wards, and are supported by the Out of Hours crisis team and the psychiatry oncall rota.

Examples of good practice: working together

Psychiatric emergencies for young people can cause significant pressure on hospital staff and must be dealt with promptly and effectively, to avoid blocking beds and breaching targets. Out of hours availability of CAMHS is necessary to support paediatric and nursing staff who admit young people in mental health crisis. There is no other resource as responsive as an NHS emergency department4.

Collaboration and integration between disciplines providing liaison services is crucial. From the patient’s point of view, mental and physical problems are not separate; nor should services be5

Despite the many national policy recommendations and research in the past decade recommending dedicated paediatric liaison services in general hospitals6 , true parity of esteem remains an aspiration in most areas. Whittington Health NHS trust, an Integrated Care Organisation, has a longstanding history of commitment to recognising the importance of aligning physical and mental health. A well- established multidisciplinary paediatric mental health service is co-located in the acute hospital site, and is part of the paediatric team. Co- location creates opportunities for joint learning and support, and reduces stigma around mental illness, as young people who present to hospital with mental health needs are under the care of both paediatric and mental health teams.

As the Whittington hospital and the South Hub became key sites in the NCL CAMHS crisis pathway after the COVID 19 outbreak, collaboration between CAMHS and paediatric teams was essential to respond to the increasing numbers of children and young people presenting in mental health crisis. The closure of the Royal Free Hospital paediatric A&E and ward , where our specialist Eating Disorders service is located, meant that young people with eating disorders who needed medical stabilisation were now admitted at the Whittington. The reduced availability of tier 4 CAMHS beds meant that young people remained in paediatric beds at the Whittington for longer periods, while waiting for a tier 4 bed. In January and February 2021there were instances when the paediatric team had to support unusually high numbers of young people in mental health crisis at the time, some presenting with acutely challenging behaviour in the context of self- harm or severe mental illness. Paediatric staff needed to quickly develop skills and confidence in managing eating disorders and psychiatric emergencies. Having a well-established paediatric liaison team allowed to quickly set up simulation training, mental health and medicolegal training, and regular staff support and reflective practice sessions. Good working relationships between CAMHS and paediatric teams meant that young people presenting with complex mental health needs received safe and good quality care while in the acute setting.

4 RCPsych Paediatric Liaison network (2014) Parity of mental and physical health in hospitals Submission to the Parliamentary Health Select Committee inquiry into Child and Adolescent Mental Health Services

5 RCPsych Paediatric Liaison network (2014) Parity of mental and physical health in hospitals Submission to the

Parliamentary Health Select Committee inquiry into Child and Adolescent Mental Health Services

6 See National guidance on paediatric mental health http://www.sebastiankraemer.com/docs/Kraemer%20National%20Guidance%20on%20Paediatric%20Mental

%20Health%20Liaison.pdf

System implications and next steps

CYP mental health demand trends are growing as per national trends. Complexity and interface across specialist and social care placements continue to cause significant challenges to patient flow.

The investment in staffing during COVID 19 has been small in proportion to the increase in demand and acuity. There are continuing concerns around current resourcing and investment allocations across the breadth of NCL services to ensure children and young people receive safe, equitable care, regardless of where in the system they present. Pre-existing gaps in investment and variation in resourcing across NCL CAMHS mental health providers has resulted in a current inequity. Resourcing implications to ensure safe and equitable care to stabilise crisis pathway in the north and south of the sector and address historic gaps need to be addressed.

Capturing accurate CYP mental health activity data, especially across acute presentations (A&E and paediatric inpatient beds) is challenging, largely due to coding limitations. As such the dashboards collated by the paediatric review implementation team significantly under report the CYP mental health crisis activity across NCL. We need to build capability of CAMHS data analytics capabilities and shared evidence base, including appropriate governance to oversee this across the multiple providers in NCL and system reporting.

Investment to strengthen and stabilise the community services capacity is critical to ensure children and young people continue to be supported in community settings where appropriate, and that crisis prevention and step-down care is sustainable. This includes addressing inequities in service models, cross-sector investment and population health needs.

We need to establish support mechanisms to better integrate with social care and education sectors.

We need to shift investment towards community while at the same time stabilise the current acute pressures. The NCL system is not currently compliant with the mental health concordat and long term plan ambitions for 24/7 emergency crisis and treatment7. With the closure of acute hospital settings and a significant increase in acuity, the system has had to develop A&E diversion and 24/7 crisis response services. With a deficit in bed capacity there is an even higher need to keep people out of hospital.

The impact of COVID 19 meant we tested the local pathways across a wider area developing community hubs where young people could be diverted from acute hospital sites, to support the wider system during the pandemic. We have seen the emergence of an integrated system recognising the importance of aligning physical and mental health, and the need for flexibility along the interface of community, acute and tier 4 adolescence services. This is a testament of the benefits of an Integrated Care Organisation delivering services across community and acute settings, and of a model that works. We welcome the government plans as set out in the White Paper for more integration and collaboration, and hope for sufficient investment to make this happen.

7NHS Long Term Plan (2019) Children and Young People’s Mental Health https://www.longtermplan.nhs.uk/areas-of-work/mental-health/children-and-young-peoples-mental-health/

59.8% Acute hospitals

13.2 % Mental Health

NICE guidance to admit

Social media exposure to self harm

High variability = increased chaos

Funding cycles lead to rapid response to problems over long term strategy

Long term underfunding esp BEH

Large unmet need for CAMHS

Downbanding/division of labour may not be more efficient

Has skillset of Tier 3 adjusted to DSH prevalence?

Is staff mix correct?

Eg could we do with more MH nurses?

Barnet

In BEH community teams providing crisis /liaison

Vacant posts in BEH due to no

Need more in Community / 3rd sector / schools services

Funding unequal across Thrive categories Social present as health

Inadequate links between social

Social isolation and loneliness Parental anxiety

Deaths/bereavement

Job losses/poverty

Treating social issues as health problems

Services set up for treatment rather than prevention

Individual work rather than group work

*https://www.england.nhs.uk/wp-

content/uploads/2020/02/nhs- allocations-infographics-feb-2020.pdf

** Incidence, clinical management, and mortality risk following self harm among children

and adolescents: cohort study in primary care

care and CAMHS

Front door/ waiting lists Signposting to A&E

eg 111? CAMHS?

Reduced activity and leisure

Patient must fit to professional/modality

rather than the other way around Not enough co-production with patients

BMJ 2017; 359 doi: https://doi.org/

10.1136/bmj.j4351 (Published 18

October 2017)

Analysis resulting from Dr G Fozard, Darzi Fellow NCL-wide stakeholder

The NHS Long Term Plan commits to increase access to mental health services for children and young people significantly. The chart below shows the number of children and young people in NCL who have received mental health treatment in the prior 12-month rolling period to each month.

Treatment is defined as a minimum of two contacts within that period. Since March 2019, an additional 2,000 children and young people have received treatment, and, as at August 2020, 39.7% of the estimated total number of children with diagnosable mental health disorders in NCL have received treatment.

The original NCL Long Term Plan for 20/21 expected that 12,814 CYP would be treated; this was reduced to 10,251 as part of the post-COVID Phase 3 planning round to take into account the uncertainties around recovery.

Whittington hospital Paediatric mental health referrals

Tier 3 acute hospitals mental health admissions

OOH crisis activity

■ OOH Crisis Team ■ North Hub ■Sout h Hub

May-20 Apr-20 Mar -20

Fe b- 20 -

Jan-20

Dec- 19 -

Nov- 1 9 -

Oct- 1 9 -

Sep-19

Aug-19 ■

Ju -l 19 -

0 50 1 00 15 0

References

Department of Health and Social Care (2021) Blueprint launched for NHS and social care reform following pandemic https://www.gov.uk/government/news/blueprint-launched-for- nhs-and-social-care-reform-following-pandemic
Department of Health and Social care (2021) Integration and innovation: working together to improve health and social care for all https://www.gov.uk/government/publications/working-together-to-improve-health-and- social-care-for-all/integration-and-innovation-working-together-to-improve-health-and- social-care-for-all-html-version
Kraemer, S. 2010 Liaison and co-operation between paediatrics and mental health

PAEDIATRICS AND CHILD HEALTH 20:8

National Guidance on paediatric mental health http://www.sebastiankraemer.com/docs/Kraemer%20National%20Guidance%20on%20Pae diatric%20Mental%20Health%20Liaison.pdf
NHS Long Term Plan (2019) Children and Young People’s Mental Health https://www.longtermplan.nhs.uk/areas-of-work/mental-health/children-and-young- peoples-mental-health/
RCPsych Paediatric Liaison network (2014) Parity of mental and physical health in hospitals Submission to the Parliamentary Health Select Committee inquiry into Child and Adolescent Mental Health Services

March 2021