Written evidence submitted by Essex County Council (CMH0078)

1.1   Essex County Council (ECC) is pleased to submit evidence to the Select Committee’s enquiry into children and adolescent mental health services (CAMHS).

The current state of CAMHS, including service provision across all four tiers; access and availability; funding and commissioning; and quality

1.2   CAMHS is a vital support service to children and young people and their families, but is often over-looked in the context of national and local priorities.

1.3   Children’s and adolescent mental health is an important issue with negative long term consequences if not addressed early. An estimated 50% of all mental illnesses arise by the age of 14 and an estimated 10% of all 5-19 year olds (nationally) have a diagnosable mental health condition. Intervening early is crucial if this is to be addressed.

1.4   The prevalence of mental health problems is even higher among vulnerable groups:

•         45% of children in care.

•         At least 40% of young offenders.

•         36% of children and young people with learning disabilities.

1.5   Access to services can be fragmented and difficult to understand for young people and their families. Our own work for the Essex Joint Strategic Needs Assessment (JSNA 2013) identified that there is a complex, fragmented and poorly understood set of services in place across Essex for children and young people who have poor emotional wellbeing and mental health difficulties.

1.6   In the Greater Essex area (comprising Essex County Council and the unitary authority areas of Southend and Thurrock) the responsibility for commissioning is split across 11 different organisations: 7 clinical commissioning groups (CCGs) plus 3 local authorities (ECC, Southend and Thurrock) plus NHS England. This makes it difficult to develop an integrated approach. We found little evidence of wide spread use of care pathways across services. Essex partners are working hard to overcome these challenges.

1.7   Essex is not alone. A survey undertaken by YoungMinds revealed that one third of children and young people do not know where to turn to get help when they feel depressed or anxious.

1.8   Across Southend, Essex and Thurrock, partners have been engaged since 2011 in reviewing the response to children and young people’s emotional wellbeing and mental health needs and commissioners, providers and wider stakeholders (including users) have recognised for some time that the current model is not providing sufficient integration.  Consultations with partners, children and young people focused on the experience of CAMHS Tier 2 and Tier 3 have identified the following key themes:

•         Supporting parents/carers and the whole family

•         Having local or community based services and engaging with young people

•         Improved access to support, advice with quick and easy access/referral to appropriate services.

•         Workforce training (including universal staff)

1.9   The three Local Authorities (Southend, Essex and Thurrock), the seven Clinical Commissioning Groups (CCGs), current providers and a wide range of stakeholders have been working in partnership to develop a service model that integrates the Tier 2 and Tier 3 Services (which are currently separate), reflects good practice and addresses the gaps and approaches identified in these consultations.

1.10          The new Essex model will aim to deliver an improved response to children’s emotional wellbeing and mental health needs and improve their emotional wellbeing and mental health.  Essex partners are seeking to design a new system that will:

• provide easier and swifter access for children and young people with emotional wellbeing and mental health needs and their family/carer to appropriate interventions by introducing a single point of access with signposting to advice and support
• ensure more children/young people and their family/carer are appropriately supported within universal and other services through early advice and support.
• introduce an easier access  route and ensure referrals are directed to appropriate services and that feedback is given
• ensure more children/young people and their family/carer receive timely and appropriate evidence based interventions
• ensure more children/young people and their family/carer have improved emotional wellbeing and mental health as a result of receiving evidence based effective interventions
• use resources effectively and efficiently by integrating Tiers 2 & 3 delivery across health and the LAs
• deliver a more holistic service for professionals and users with fewer “hand offs” between services by integrating Tiers 2 and 3 and ensuring coordination with other services
• avoid and reduce the inappropriate use of A&E to access Emotional Wellbeing Mental Health Service by quick screening and direction to appropriate service, and ensuring that crisis services are effective and adopt an assertive outreach approach
• ensure children and young people 14-25 needing long term mental health support receive appropriate support and have a smooth transition to adult mental health services

1.11          Essex partners are therefore working locally to better integrate services. But ECC also believes that the Government needs to be clear where responsibility for driving the CAMHS agenda should sit. ECC believes that Health and Wellbeing Boards have an important system-wide role in promoting CAMHS as an important health issue with long term consequences for the local health economy if not addressed early, and also in promoting the shift in spend from crisis intervention (tier 4) to early intervention and prevention. NHS England also has an important co-ordination role in promoting greater collaboration between CCGs and local authorities.

1.12          ECC is confident that greater integration between health and social care, and moves towards joint commissioning and pooled budgets, can transform the CAMHS system. Effective interventions at each tier of CAMHS can help save money at the next higher tier of CAMHS services. Early intervention and prevention not only makes sense for the individual in terms of better mental health outcomes but will also deliver better value for money.

Trends in children’s and adolescent mental health, including the impact of bullying and of digital media

2.1  As stated above, 50% of mental illnesses have arisen in a person by the age of 14. An estimated 25,000 children aged 5-19 years have a diagnosable mental health condition in Essex and a further 25,000 have an emotional or behavioural problem requiring targeted support. These children have a wide range of conditions including clinically significant conduct disorders, self harm, depression, hyperactivity and less common disorders such autistic disorders and eating disorders. Many young people suffer from multiple problems such as bullying and learning difficulties. Prevalence rates are higher among boys than girls and amongst 11-15 year olds compared to younger children.

2.2  It is estimated that 8% of pupils (aged 7-16) in Essex, or nearly 15,000, have poor emotional wellbeing. The proportion of pupils with poor emotional wellbeing shows a steady increase with age, from 6% in Year 4 to 12% in Year 11.

2.3  But problems are becoming more complex and severe. Data and reports from our service providers, GPs and schools show that there is big growth in eating disorders and self-harm, while schools are also reporting more cyber bullying. The digital era and cyber bullying (facebook, twitter etc) also provide new means and forums for bullying that can create stress and mounting mental health disorders in young children – problems which may not have even existed even a decade ago.

2.4  Research by the Samaritans (see Samaritans Suicide Statistics Report 2013) suggests that suicide is the second biggest cause of death worldwide among 15-19 year olds. Moreover, it is generally acknowledged that suicide is estimated to be under-reported for reasons of stigma, religion and social attitudes. Some suicides maybe hidden among other causes of death, such as road traffic accidents and drowning.

2.5  With limited resources and statutory and moral obligations to respond to high level / crisis interventions, it is not always easy to give early intervention and prevention the priority it needs. We are addressing this by ensuring CAMHS is closely linked to and working well with our early offer of help provision.  We are also seeking to facilitate and encourage partners through our CAMHS Stakeholder Partnership and other arenas (including School Forums and local Children’s Partnerships) to work together and promote positive messages about emotional wellbeing; to support universal services to build resilience and self-esteem and to identify and address emerging needs appropriately themselves and refer on when necessary.  Schools have a particularly important role to play in identification, early support and prevention, given the amount of contact and time they have with children and young people. However, we would also welcome a national focus on this with national support and awareness raising.  

2.6  Schools play a crucially important role in building self esteem and identifying and responding to early signs of emotional and mental health need.  Changes to the curriculum requirements of schools have meant that many schools no longer give emotional wellbeing the attention it needs.  National encouragement to schools to take a greater focus on building emotional wellbeing, resilience and self-esteem would help us as children and young people cannot achieve good academic results without this.   Nationally produced resource materials and national campaigns could assist with promoting wellbeing and addressing the rise in eating disorders and self-harm and would prevent each area having to develop its own.

Data and information on children’s and adolescent mental health and CAMHS

3.1  There is a need for better information sharing between different tiers and there should be a presumption for sharing information between partner organisations, unless somebody opts out. Data is currently locked within the system.

3.2  Essex partners have had significant difficulties in piecing together even a basic set of information about the numbers of children and young people accessing services. This is partly due to the fragmented approach to commissioning these services between different organisations but also because when data has been provided, the quality is generally poor, and several providers have resubmitted information to us following challenges about its accuracy. We have been unable to fully map the access to services for any particular group. It is therefore difficult to get a whole system picture of activity.

3.3  ECC also believes that while the national CAMHS dataset is helpful it would be good if it was accompanied by a set of national key performance indicators which could be used locally.  At present we are all expending considerable effort on developing our own. 

3.4  More broadly, it has become increasingly hard to find out about best practice since the abolition of the CAMHS national support service. Chimat and NICE both highlight some evidenced interventions and data about costed activities but national facilitation about sharing of good practice and benchmarking is no longer available.  Consequently in developing our redesigned Service Model we have expended considerable effort in contacting other areas for information – this could have been reduced if there were national opportunities for this.

Concerns relating to specific areas of CAMHS provision, including perinatal and infant mental health; urgent and out-of-hours care; the use of S136 detention for under 18s; suicide prevention strategies; and the transition to adult mental health services

4.1  There is a growing trend of people going to A&E out of hours to get a quick mental health service. This is evidence that we need to be far more effective at early intervention and prevention if demand on crisis provision is to ease.   While local relationships and protocols between the various local providers is undoubtedly crucial in addressing this, national guidance would assist as the issue spans tiers of service and involves different Commissioners.

4.2  There is also concern that psychiatrists insist on people seeking them out and visiting them in clinics, rather than being an out-reach service going to their homes. Psychiatrists need to be encouraged (including through their Royal College) to hold more consultations in localities.

4.3  As in areas, there are challenges in Essex in ensuring child development centres, paediatricians and other services work together with CAMHS to ensure an integrated approach to behaviour and emotions/mental health.  Increased numbers of children with complex behaviour needs and autistic spectrum conditions mean that services are challenged to develop and train staff to take a whole system approach and respond to the needs of those children.  Additional support and training developed and provided nationally, such as is currently undertaken for children’s IAPT would support us with this.  Royal Colleges can play a helpful role in encouraging their members to take a holistic approach and work in a more joined up way with other professionals and services.

4.4  Similar challenges exist across our services in responding to the emotional wellbeing and mental health needs of children with a Learning Disability.  We are embedding CAMHS as a key element of the Local Offer and the integrated Education, Health and Care Plans.  However further national support, advice and training would assist.

4.5  Joint planning and working between tier 4 and tier 3 mental health and children’s social care is not as good as it should be. This is now complicated as the Commissioning responsibilities are spread across different organisations. We are experiencing a growing number of situations where inpatient beds are not available locally and situations where parents feel they cannot take a young person home, Tier 4 need to discharge even though mental health needs are still high and it is not appropriate for Social Care to take the young person into care.  More “half-way” support is needed, but the resourcing of this is not easy.

4.6  We welcome the recent increase in numbers of Health Visitors.  It would be very helpful if it was made a requirement that a number of these focus on, are trained on and champion perinatal and infant mental health – looking for early signs of problematic attachment between parent and infants and being skilled and tasked to address that by providing direct therapeutic and supportive interventions to the parent and infant.

4.7  A key challenge for us is ensuring smooth transitions for those who need it from CAMHS to adult mental health servcies.  Given the difference in thresholds this is especially challenging now that the Children and Families Act rightly highlights the need to support young people with vulnerabilities and those leaving care through to 25.  In Essex we are seeking to address that and many other areas will also be doing this.  A national working group to support us with this would be very helpful.

4.8  Within the wider health and adult mental health system, CAMHS still feels that it is a small and poor cousin.  It would help greatly for central Government to provide an assertive and strong lead on raising awareness of the importance of CAMHS with close working and sponsorship between both the Department for Health and the Department for Education.

2 April 2014

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