Written evidence submitted by 5 Boroughs Partnership NHS Foundation Trust (CMH0067)
1.1 The 5 Boroughs Partnership NHS Foundation Trust is a specialist mental health trust, in the North West of England, providing community and inpatient services to the Boroughs of Warrington, Wigan, Halton, Knowsley and St Helen, alongside generic community services in Knowsley. The Trust is situated between Liverpool and Manchester and represents a large geographical area with a total population of 938,000. Each Borough has a different demographic profile and need. The Trust has a long history of working collaboratively to address the health inequalities of the population served.
1.2 In 2012 we celebrated 10 years as the ‘5 Boroughs Partnership NHS Trust’, gaining Foundation Trust status in 2010. During this time we have successfully brought together five CAMHS teams who initially worked in very different ways. All services now achieve the same quality standards and outcomes for children, young people and their carers.
1.3 We provide a range of CAMHS services from Tier 2 through to Tier 4.
1.4 Over the last four years, we have extended our services up to 18 and introduced a dedicated 24/7 on call model, with the formation of a CAMHS Urgent Response Team. This service provides a 24 hour response to those who have an urgent need for assessment. It operates 365 days per year and includes CAMHS Consultant Psychiatrist cover. In September 2014 we introduced a Trust Wide Single Point of Access Service [SPoA]. Fairhaven, our Tier 4, 8 bedded adolescent unit, celebrates its 5th year in May 2014.
1.5 We believe that the 5 Boroughs Partnership NHS Foundation Trust has a proven track record delivering high quality CAMHS services. We have experience of working across a large geographical area, planning, researching and delivering exciting, innovative ways of working.
1.6 Our vision is to promote good mental health and wellbeing in children, young people and families through the development of competence and skills across the whole workforce.
1.7 Over recent years we have seen an increase in referrals to all aspects of our services. In particular we have noticed a sharp increase in 16 + presentations and a correlation with greater numbers of risk and crisis assessments.
1.8 The following submission of evidence will pay particular attention to the impact on our Tier 3 and Tier 4 services.
Single Point of Access Service [SPoA]
2.1 The rationale for the introduction of this service was in response to the increase in demands both on numbers referred and the change in presentation. The rise in referrals was having an impact on our waiting times and accessibility. This was resulting in bottlenecks within service for specialist treatments; staff morale was significantly affected as specialist clinicians were pulled into crisis work, and consequently not able to deliver specialist interventions.
2.1 The aim of the Single Point of Access service was to meet our increasing demand using existing resource in the most efficient way.
2.3 Over the course of 2013 the CAMHS Tier 3 services underwent a major transformation. We combined and streamlined our borough service delivery into three area teams as opposed to the previous 5 teams. The aim in doing so was to ensure equitability in service delivery across all our service areas.
2.4 At the same time we formed a SPoA service to support the locally based therapeutic teams and enhance the delivery of a comprehensive seamless CAMHS service. The SPoA comprises of two arms: the response team and the assessment team.
2.5 The response team provide the 24 /7 emergency care, undertaking emergency appointments both in community and ward based settings. The service operates during the hours of 9.00 am to 9.00 pm, 7days a week, with a waking night shift at one of our acute hospital sites and an on call rota for psychiatric emergencies.
2.6 The assessment team action all referrals to CAMHS and undertake initial appointments under the Choice and Partnership Approach [CAPA] for CAMHS delivery. Currently this service operates during the hours of 9.00am and 5.00pm Monday to Friday. However more recently we have needed to implement Saturday clinics to meet our ever increasing demand.
2.7 Since the commencement of the SPoA service, in the Autumn of 2013, the following comparison of referrals have been collated;
2.8 Response Team
September 2013 – January 2014 inclusive total referrals accepted = 523
The same period during 2012 – 2013 total referrals accepted = 308
September 2013 – January 2014 - S136 responses = 8
2.9 All these referrals meet the criteria of the 24 hour emergency response time.
2.10 Assessment Team
September 2013 – January 2014 inclusive total number of referrals accepted = 925
The same period during 2012 – 2013 total referrals accepted = 830
2.11 Based on the above figures we forecast an increase of 1042 referrals in the year to our CAMHS services.
2.12 99% of cases were seen within 6 weeks. However, the target for the assessment team is 10 working days for a routine appointment. The majority of all appointments are within 10 days. During the same period last year 72 % of all cases were seen within 6 weeks.
2.13 All cases that require the therapeutic input of tier 3 community teams are transferred into the local area team for a partnership appointment as per CAPA. The average wait for a partnership across all areas is 4 – 6 weeks.
Tier 4 service – Fairhaven Young Peoples Unit [ FYPU]
3.1 We currently provide an 8 bedded mental health inpatient unit for young people aged 14yrs – 18yrs. Initially the unit was spot purchased by specialist commissioning.
3.2 In April 2013 we were commissioned to assess for admission young people who reside within the 5 Boroughs geographical area. This has meant easier access to local services for young people and their families who would have previously been admitted to Chester, Manchester and occasionally beyond.
3.3 Fairhaven Young Person Unit has been at full occupancy for the last 12 months. There is a Tier 4 national review currently being undertaken in 2014. The lack of capacity for Tier 4 beds is making national headlines.
3.4 As a Trust we have not admitted any under 18 year old to an adult bed for 3 years. We fear that the continued pressure on capacity will require us to consider admitting young people to our adult beds in the future, at a time when our adult colleagues are experiencing capacity issues and there is an increase in usage of private beds in the region.
3.5 We envisaged the regional and national bed shortage will remain an issue. As such we are now proposing to increase our bed capacity by a further 2 beds. In addition, we are also considering the further development of our Tier 4 support to community tier 3 services.
3.6 We are planning to develop a Fairhaven Day Service which will provide a specialist assessment, treatment and rehabilitation service to young people. The primary function of the Day Service is to provide specialist care to adolescents who present with symptoms relating to severe mental illness and often present as complex cases. The day service will work in close partnership with Tier 3 CAMHS. The service will be accessible seven days a week. With the addition of the 2 extra beds we are keen to consider the development of 2 specialist eating disorder beds.
3.7 In January 2014 NHS England began a 3 month review of Tier 4 services to map out the provision and capacity across the country. Early indications have confirmed our experience that there is an overall increased demand for Tier 4 beds.
Challenges facing CAMHS in 2014
4.1 Demand – The significant increase in the referral rate has placed staff under pressure to achieve waiting time targets. If this trend continues we will be unable to meet the same response times without an increase in workforce capacity. The current situation does not allow adequate flexibility for any reduction in resource, such as sickness or maternity leave. Any absence of staff within the workforce results in subsequent impact on service delivery.
4.2 Changes in crisis presentation – we have noticed as a service that there has been a change in young people’s crisis presentation. Previously the majority of cases presenting at A&E were as a result of overdose. However, more recently our information would suggest that young people’s acute presentation of mental illness/distress has changed.
4.2.1 Increasing numbers of young people are presenting with more violent suicidal ideations such as thoughts of hanging and jumping, and impulsive risk taking behaviours. There has been a significant increase in self-harming behaviours; young people are routinely reporting the use of self-cutting as a normal coping strategy.
4.2.2 Nice Guidance CG016 on self-harm refers predominately to overdose, with recommendation to present at A&E with an admission to a paediatric ward over night for both medical treatment and to await specialist medical health assessment. This guidance does not address these changes in presentation and can often result in challenges around the use of paediatric beds with no perceived medical reason. We would value a review of the NICE Guidance to support the significant change in presentations to service.
4.3 Reduction of targeted service provision- recently there have been cuts in local services both within the Local Authority and 3rd sector providers. The increase in our referral rates may reflect the lack of early intervention and support for both our service users and for professionals. As a specialist service we are also finding there are fewer services we can sign post on to, which may result in an increase pressure at Tier 3.
4.4 Recruitment and Retention- The changes in young people’s presentation has resulted in significant changes in case mix. CAMHS staff are now care co-ordinating large numbers of cases where self-harming and risk taking behaviour is a feature.
Staff burn-out and work related stress may increase if measures are not put in place to support staff with this higher risk caseload.
4.4.1 With the challenging economic climate of recent years, our services are no longer expanding. Consequently, there is less opportunity for movement and career development within services. We need therefore to think creatively about how we retain our staff and reward good practice, if staff are to feel valued, in what is an extremely demanding job.
4.5 Cost Improvement Plans- are a constant challenge to services. We are always reviewing how we can best utilise our existing resources to ensure best value. As an organisation we are advocates of ‘Pan-Borough’ services, pooling our staff and ensuring specialist resources are available across all areas. For example we have a Pan Borough Personality Disorder service, Pan Borough Eating Disorder service and we are developing a Pan Borough Autistic Spectrum Disorder specialist service.
Future developments
5.1 CYP-IAPT
5.1.1 CYP-IAPT is a real opportunity for us to transform our services and demonstrate our value. It enables us to develop strong local partnership arrangements at a time of economic challenge and increased pressures. The involvement of young people, in both their own care and in service delivery, is key to the success of sustaining high quality service provision.
5.1.2 In 2013 we were successful in our application for CYP-IAPT in one of our boroughs and we are seeking to re-submit this year to support the transformational change across all areas.
5.2 Eating Disorder Service
5.2.1 Our Pan borough Young People's Specialist ED service offers an evidence based, integrated care model with a multidisciplinary clinical care pathway. The care package is multimodal and based on NICE guidance (2004 - not revised yet), national commissioning guidance (joint commissioning panel for mental health - 2013) and MARSIPAN/ junior MARSIPAN (2012) national guidance for severely unwell anorexia nervosa patients
5.2.2 The team offers a specialist multi-disciplinary case assessment and treatment in line with the Maudsley model. The team consists of a Consultant Psychiatrist, Paediatrician, Dietician, Family Therapists and CBT therapist developing a multimodal package of care.
5.3 Shared Decision Making
5.3.1 Shared Decision Making aims to empower children and young people (and their families) to play an active part in decisions about their care by focusing on the detail of interactions between individual practitioners and the children and young people they work with.
5.3.2 We are currently undertaking a SDM project within our depression care pathway and have just submitted a bid to AQuA to support a project on SDM in the transition of young people to adult services. We feel this offers us an exciting opportunity to use the key principles of shared decision making in our service transformation.
5.3.3 The key areas of shared decision making involve agreeing goals, discussing options, agreeing treatment choice and reviewing progress.
5.4 Staff wellbeing group
5.4.1 As an organisation we are keen to promote a positive approach to improving CAMHS Staff Health and Wellbeing The focus is to promote health and wellbeing in the workplace with greater job satisfaction and quality of care, given current increased pressures.
5.4.2 The aim of the group is to help to develop systems for early identification of work related problems and provide early intervention to reduce absences from work. This work will ensure that systems are in place for managers and front line staff to work collaboratively for a healthy workplace and relationships are based on trust and shared values.
5.4.3 We aim to encourage innovative and creative ideas as well as training to establish a healthy- motivational environment.
6.0 In summary, we live in a time of increasing CAMHS service demand and reducing human and financial resource. Services have to draw on creative and innovative ways to adapt service delivery to cope in the shifting landscape, making CAMHS services fit for future needs.
2 April 2014