Written evidence submitted by South Staffordshire & Shropshire Healthcare NHS Foundation Trust (CMH0171)
Executive Summary
1 This submission is made on behalf of the CAMHS Services, Specialist & Families Directorate, South Staffordshire & Shropshire Healthcare NHS Foundation Trust. In providing a submission to the Committee we wish to share a summary of views, recent experience and expertise from a NHS provider perspective in response to the published Terms of Reference of the Inquiry.
2 The key points covered in our submission are:
Services are experiencing a wider demand of complex presentations and young people in crisis. ONS has started predicting an increase in prevalence of mental health problems for children and young people nationally which is likely to impact on the demand for services.
There has been an erosion of early intervention for young people’s emotional health and well being and this is contributing to young people presenting with more entrenched difficulties.
We are noting some of the trends highlighted in the inquiry terms of reference and we present examples where bullying and digital culture are clearly impacting on our young people’s mental health and emotional wellbeing.
Introduction
3 This response is from South Staffordshire & Shropshire Healthcare NHS Foundation Trust (SSSFT) which provides a range of healthcare services including: mental health (children and adult), learning disability, community paediatric and specialist nursing. We welcome the opportunity the inquiry provides to discuss the current challenges and risks that young people are facing within our nation and the impact on their emotional health and well being as well as the consideration of the provision of services and how these are commissioned and delivered. This response is structured around the questions posed within the Terms of Reference.
4 South Staffordshire has a population of approximately 628,000 (0-19 years approx 144,000 ONS 2011) across a broad geographical area including towns with high areas of deprivation and rural communities.
5 SSSFT provides Tier 2 and 3 community based CAMHS services for the residents of South Staffordshire, this also includes a dedicated Looked After Children’s CAMHS team and a tier 3 CAMHS team for a local Youth Offending Institute. There are additional CAMHS services within South Staffordshire provided by partners: ASD diagnostic and Intervention Service and CAMHS Youth Offending Service (10-19) by Midlands Psychology CIC; On line Services (Upside) Barnardo’s and a range of early intervention support and counselling services commissioned from the Local Authority Framework Agreement. However whilst there is a range of provision, as a whole CAMHS services in (South) Staffordshire remains one of the lowest benchmarked funded and lacks parity with adult services.
The current state of CAMHS, including service provision across all four tiers; access and availability; funding and commissioning; and quality.
Service provision across all tiers
6 SSSFT CAMHS services provide services at Tiers 2 and 3. We have two core teams covering the area and in addition to this have a small early years support service in the West of the county, looked after children/adoption CAMHS team; Tier 3 YOI team; Tier 2 youth team with drop in facilities in the East of the County; provide input into a local PRU and have a small team of Primary Mental Health workers. We also have Early Intervention in Psychosis teams based within adult mental health
Access and availability
7 Access to our services has remained consistent over the last years
We have successfully implemented CAPA (Choice and Partnership Approach) to manage capacity, demand and flow through the system of referrals. Locally we are working collaboratively with our Local Authority Support Teams and Community Paediatric colleagues to ensure that pathways into services are easier and that young people access the right service without delay rather than being referred from one service to another.
8 Access to Tier 4 inpatient provision remains an area of grave concern locally, regionally and nationally. Locally this is having an increasing impact on inpatient Paediatric and Adult Mental Health services. Young people often have to wait unnecessarily long periods of time from the point that a consultant psychiatrist has assessed that they require in-patient treatment. Demands then are placed on our local CAMHS teams to provide home treatment – something we are not resourced to or have the capacity to provide or to negotiate lengthy stays in acute paediatric wards which can be a risk for both the young person with mental health needs and the other physically poorly children on these wards.
Funding and commissioning
9 SSSFT continue to provide a range of CAMHS services within this limited budget and within the constraints of local CIP programmes.
10 In March 2013 SSSFT early intervention (EI) services were decommissioned by Staffordshire County Council. Following a review, the county commissioners determined that funding would be withdrawn from a number of EI schemes across the county due to the lack of evidence regarding outcomes and the geographical inequity of the schemes. Following this they have participated in the BOND national pilot programme. The focus of the BOND project is to stimulate the role of third sector providers within the delivery of EI services. Services are now being commissioned through this framework however there has been a delay from the original decommissioning.
11 Up until 2011 a CAMHS strategy was in place but organisational changes meant that the strategy has not been refreshed and work is currently being undertaken to address this. The all age strategy will provide the framework for agreeing the key priorities for children.
12 Unlike adult mental health, CAMHS is not subject to joint commissioning in Staffordshire. With the previous government’s initiatives regarding the delivery of a comprehensive CAMHS (and associated performance indicators) there was a shared approach to CAMHS between PCTs and Staffordshire County Council. The ending of the CAMHS Grant in 2010 however created immediate pressures for the local authority in maintaining their input into CAMHS. The CAMHS Strategic Commissioning Group ceased to function and recent decision-making has been less shared. However efforts are being made to ensure future decisions in CAMHS are made at least with an awareness of the impact on other commissioners.
Quality
13 We are a member of CORC and collate service user outcome measures plus service user experience feedback.
Trends in children's and adolescent mental health, including the impact of bullying and of digital culture
14 There is a concern amongst clinicians about the impact of the digital culture on children and young people. Comments have been made about how intrusive this can be for instance how bullying can now continue into the home without respite, the impact of young people playing online games with ‘virtual friends’ rather than building appropriate social networks with their peers, the impact on sleep and ability to function at school. We are witnessing a number of cases where children and teenagers have become depressed and suicidal due to cyber bullying.
Data and information on CAMHS
15 Over the last year we have seen a dramatic increase in the number of young people presenting in crisis. The number of admissions for assessment for young people who have self harmed and/ or suicidal ideation has doubled. These young people often require more appointments due to the nature of their crisis and may not be discharged quickly or transferred to an appropriate in-patient bed thus also placing greater demands on acute paediatric services. We recognise the impact that this is having on our paediatric colleagues and so have provided additional training for the wards to help them understand the needs of these young people.
16 It is difficult, from our data sets to determine whether cases are becoming more complex. However clinicians report that the nature of young people who are presenting to our services are more complex and often are not presenting until they are in crisis.
Preventative action and public mental health, including multiagency working
17 SSSFT traditionally had a strong ethos of early intervention and prevention work, much of this has been developed on a multiagency basis through initiatives such as ASPEN and 4-2-11s however these were decommissioned as stated above.
18 Currently our services have been working closely with the Local Authority Support Teams to provide a more integrated pathway for young people who have mental health needs. In doing so they are able to access a range of services and we are able to signpost referrals to more appropriate early support services rather than entering a ‘mental health’ provision.
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
Perinatal and infant mental health
19 CAMHS provide a limited early years support service to one area of South Staffordshire, however we recognise that the need for early support within these formative years is vital and currently is lacking. Without this support problems build and escalate and then young people and families are presenting when their difficulties are entrenched. If support could be provided earlier this would have a huge impact on their development, attainment at school and overall emotional health and well being.
Urgent and out-of-hours care
20 SSFT provide an out of hour’s services provided by the local CAMHS and Crisis (Adult Mental Health) teams. This provides advice out of hours and assessment of admissions for ‘deliberate self harm’ over the weekends. There is a clinical on call system which manages the out of hours cases (there is also a management on call in case there needs to be escalation). These services currently experience pressure when children and young people from surrounding areas present or when young people with severe clinical presentations require admission .
Use of S136 detention
21 SSSFT have three s136 suites in South Staffordshire and Shropshire. We have noted an increase in the number of young people who are being detained in these suites, which are also the s136 suites for adults who require a place of safety. In 2012/3 we had 15 under 18’s who were brought to the suites and up until the end of January 2014 there had been 25 admissions. Whilst these suites are preferable to detention within a police cell they are not the most suitable provision for young people.
Transition to adult mental health services
22 SSSFT has a transitions protocol which is currently being revised for young people who require a transition to adult mental health services. We have worked locally with our colleagues to develop a pathway for young people with ongoing needs due to ADHD.
Key Recommendations
We would hope that the Government provides:
19 April 2014