Report to: East Sussex Health Overview Scrutiny Committee
Report title: Child and Adolescent Mental Health Services (CAMHS) in East Sussex
Report
authors: Sussex Partnership Foundation NHS Trust and NHS
Sussex
1. Introduction
Following previous reports to HOSC in March and September 2022 detailing Child and Adolescent Mental Health Services, this report provides an overview of the strategic approach to improvement for children and young people’s mental health and well-being services and actions being taken to improve access and reduce waiting times for services.
This is within the
local and national context of an increase in the emotional and
mental health needs of our children and young people, which has
meant significant increases in people needing these
services.
The Foundations for Our Future Emotional Wellbeing and Mental Health Strategy launched formally in May 2023. This, together with the Children and Young People’s Emotional Wellbeing and Mental Health Local Transformation Plan (LTP), outline our shared priorities in Sussex. They are fully aligned in that the priorities and actions within the LTP form the basis of our strategy delivery plans going forward.
The vision of the strategy is: to support all children and young people to lead emotionally healthy lives, and within this there are the following key priorities.
Prevention
Prevention and early intervention are key to promoting and maintaining good mental and wellbeing in all people. This includes addressing some of the wider determinants of health including family and social circumstances, housing, income, education, and social isolation.
Early Help and Access to Support
Treating mental health issues in children early is crucial. Multi-agency partners across Sussex, including health and education, recognise that the earlier we can collaborate with evidence-based interventions, the better the outcomes we will see later on in people.
Specialist and Timely support to meet High and Complex Needs
Some children and young people will need more help and risk support, particularly those who are most vulnerable, such as those with multiple high needs and complex disabilities, and those who are looked after or who have experienced trauma or abuse. We will ensure our resources are targeted to be responsive towards children, young people and their families with the greatest needs and vulnerability.
Support for Life Transitions
We recognise that the transition to adult services is a focal point for improvement. We are committed to doing more to focus on supporting children and young people through points of change or ‘life transitions’ such as leaving school, home or looked after care. The aim is to reduce the numbers of young people who transition to adult mental health services, facilitate access to support within communities, and develop pathways of care such as 16-25 pathway to provide a different model of support.
In delivering these priorities across Sussex, we will focus our actions across three main areas: prevention; improving support across all parts of the pathway; and improving ways of working. Our plans for 2023/24 focus on maintaining the investment made in previous years, maximising productivity, collaboration, and addressing unwarranted variation across Sussex. A key focus is to ensure a mechanism for enabling investment over the longer term that supports prevention and earlier support as part of a system wide approach.
2.1 Sussex Delivery Plan Priorities 2023/24
Figure 1. Sussex wide workstreams 23/24
2.2 East Sussex Delivery Plan Priorities 2023/24
While this is a Sussex wide strategy, and with it an ambition to deliver the same best outcomes for all children and young people across Sussex, it is important that specific needs of local communities are considered. As such, the Sussex wide strategy has been translated into a local delivery plan for East Sussex that meet the needs of the local population, supporting local integrated working, whilst delivering the same agreed outcome framework across all areas. The local plan complements and supports the Sussex wide delivery plan.
The delivery plan for East Sussex focusses on four priorities;
· To develop a social prescription model for children and young people with mild to moderate Mental Health and Emotional Wellbeing difficulties and support subsidised access to community support and activities
· To provide accessible high-quality advice, guidance and self-help for children and young people, their families and practitioners
· To increase early help and access to support for mild to moderate mental health and emotional wellbeing difficulties
· To improve well-being through education, including early years.
2.3 Children and Young People's Mental Health and Emotional Wellbeing Local Transformation Plan.
The Local Transformation Plan is one of our core strategic drivers for the improvement of children and young people’s emotional wellbeing and mental health services across Sussex. First published in 2015, NHS England as part of the long-term plan, required local systems to demonstrate effective planning that will result in system wide transformation of children and young people’s mental health investment and resources, to result in improved access and service provision. This has been built on and published year on year.
Our refreshed plan was published in October 2022 and our key actions to support the delivery of our strategic priorities are:
· To fully implement the Single Point of Access (SPOA) model across the whole of Sussex. In East Sussex there is an established Single Point of Advice set up in partnership between Sussex Partnership NHS Foundation Trust CAMHS and East Sussex County Council.
· To continue our good progress with rolling out the National Mental Health Support Teams (MHSTs) initiative which will provide 52% population coverage of students in 2023/24. In East Sussex, recruitment is progressing well that will extend the MHST current offer in the Havens, Eastbourne, Hailsham, Bexhill and Hastings to include the Rother area from September 2023 (Wave 9). This will result in 5.5 teams in East Sussex (further update on progress is included in this report).
· To continue improving access to services, for example by providing face to face drop in as well as online drop in access to iRock Youth Hub in Eastbourne, Newhaven, and Hastings.
· To develop early intervention in psychosis to provide its service in line with evidence-based treatment (NICE compliance level 3, example including physical health checks, family intervention, employment support) for the expanded age group of 14 to 65 with early onset psychosis.
· To develop a system-wide and expanded all age eating disorder pathway.
· To improve urgent and emergency support by expanding our child and adolescent mental health services (CAMHS) Urgent Help Service and Home Treatment Team as well as our Paediatric Mental Health Liaison Service that are now based 7 days a week at the Conquest Hospital Hastings and Eastbourne District General Hospital.
· To support children and young people with complex needs, for example by trialling Personalised Health Budgets in East Sussex for care experienced 16–25-year-olds.
· To further develop Social Prescribing, including funded participation in positive activities, new schemes were implemented in East Sussex to support vulnerable children and young people. In partnership with Primary Care Networks and our third sector partners, social prescribing is a way to link anyone with non-medical support within their local community, to improve health and wellbeing. We have ensured that Ukrainian children and young people in East Sussex have access to Social Prescribing.
In East Sussex, Sussex Partnership Foundation Trust delivers specialist mental health services for children and young people (CAMHS); acute and urgent care; community specialist and early intervention (mild to moderate need) services. This includes the following:
Figure 2: Sussex Partnership Foundation NHS Trust: CAMHS services in East Sussex.
3.1 Community CAMHS
The Children and Young Peoples Mental Health Access Target is currently being met. This is a national target set by NHSE and measures the increase in the number of children and young people accessing mental health services and support. Although the access target is currently being met (2022/23) this does not reflect the level of demand, and challenge in meeting the presenting needs of children requiring support and this is an important priority for the system.
The numbers of referrals accepted into the service continues to be above pre pandemic levels as set out in Figure 3.
Figure 3: CAMHS East Sussex new referrals
|
Referrals Received per month |
Referrals Accepted per month |
|
|
2019 |
471 |
295 |
|
2022 |
467 |
454 |
|
2023 |
368 (average of Jan-May monthly referrals) |
368 |
The percentage of received vs accepted referrals accepted is 100% which indicates that the East Sussex Single Point of Advice (SPoA) continues to triage appropriately. Where children and young people may not be appropriate for CAMHS, they are offered information and advice or signposted to other suitable provision. Numbers of referrals accepted to the caseload on average per month remains at a higher level than 2019 whilst not reflecting the immediate post pandemic surge numbers. This can be a challenge for service capacity and the complexity of need has increased. In particular, there is increased need for ongoing treatment and monitoring of those in receipt of ADHD medication and the service needs to balance initial and ongoing treatment appointments.
Because of the ongoing levels of need and complexity, CAMHS East Sussex caseload has continued to increase (open referrals who have attended a treatment contact for their first episode of treatment).
Figure 4: CAMHS East Sussex caseload
This has resulted in the number of young people waiting between referral and first assessment and to first treatment being impacted.
In order to most efficiently manage the demand for both initial assessments and intervention the balance across the two are reviewed regularly and opportunities taken to, for example, hold initial assessment days to address a greater number of assessments.
3.2 Interventions
All children and young people listed for an intervention have received an initial assessment and are awaiting a specialist intervention. Children and Young people can be waiting for more than one intervention if deemed clinically required. This is most often young people waiting for neurodevelopmental or psychiatry assessment, whilst waiting for therapeutic input, for example cognitive behavioural therapy. In more complex cases, they may have already attended and completed other interventions, but further intervention is required. Once a young person has been accepted for CAMHS assessment and/or any intervention, the Duty and Liaison service maintains contact with the family to ensure they are aware of what to do if they are concerned about changes in their child's mental health.
A significant proportion of those children and young people are waiting for a neurodevelopmental assessment as a next step in their intervention. There is a sustained high referral demand for neurodevelopmental assessments and as a consequence, over 60% of people included in the caseload in East Sussex have neurodevelopmental needs.
· 1,250 young people are waiting to complete their ADHD assessment.
· 863 young people are waiting to complete their ASC assessment.
· 144 young people are waiting to commence Cognitive Behavioural Therapy
· 123 young people and their families are waiting to commence Family/Systemic Therapy.
Figure 5: Referrals to NDP by month and the cumulative waiting list numbers
3.3 Actions to manage increased need and reduce waiting times
3.3.1 Introduction of Stepped Care Model
East Sussex CAMHS have implemented ‘Stepped Care’ which aims to ensure young people receive the most appropriate service as early as possible. The aim is to offer young people and their family early intervention and support, with the intention of reducing the need without further input from CAMHS, as their needs have been met early. Early results from the evaluation of this new approach are that from the young people engaged in ‘stepped care’, 60% are discharged after ‘early’ intervention having met their goal-based outcomes.
This model offers family/carer information session to all new referrals, and thus information about mental health and wellbeing and how they can best support their young person. Additionally, following the initial assessment, most (not all depending on urgent need and complexity) young people will be offered a trans-diagnostic evidenced based group intervention or family work. In East Sussex, nearly all young people referred for mental health presentation will be offered treatment intervention within 6 months of referral thus reducing the risk of a prolonged wait for intervention.
3.3.2 i-Rock Youth Hubs in Newhaven, Eastbourne and Hastings
SPFT continues to deliver the three i-Rock services in Newhaven, Eastbourne and Hastings. Young people and their families are offered face to face and, as a development during the Covid pandemic, online ‘drop in’ is also offered. Each month, between 80-100 young people and young adults use i-Rock. The majority of young people using i-Rock have not accessed services previously and are supported to work with universal or third sector partner delivering early intervention services.
3.3.3 Further actions to address waiting times
· SPFT are collaborating with partner agencies (Mental Health Support Teams and NHS School Health) and schools to ensure young people, parent and carers and professionals understand how to access advice, and the services and support available for children and young people.
· Sussex CAMHS has implemented the ‘Child Not Brought’ (CNB) pilot. This pilot was designed to contact families and carers in advance of scheduled appointments to ensure they had all the information they need to support them in bringing their child to the appointment. This was in response to the service experiencing a high rate of appointments missed due to non-attendance. Early results demonstrate a reduction from historical 40% of people not attending to 0% in a ‘post pilot’ period. This contact is now continuing to ensure all appointments available can be optimised and more children can be seen.
· By increasing the attendance rate in initial assessments, and making the CAMHS offer more effective, it has been possible to work with people and their families who had been waiting the longest and agree alternative pathways if a CAMHS initial assessment was no longer indicated.
· SPFT are working on refining the CAMHS web-based information so that families are accessing clear information, and communication with families is improved. Examples are videos that will be shared with families when they are first accepted into CAMHS and the use of the MindDistrict online self-help modules for young people.
· SPFT commissioned a specialist provider to complete Autism Spectrum Condition (ASC) assessments for those on the intervention waiting list as of 30th April 2022. In East Sussex, 220 young people were identified and agreed to the assessment process. All 220 have now received the assessment and a diagnosis where clinically appropriate.
· A stock take of specialist CAMHS will take place in quarter two 2023/24, to inform a development plan to address unwarranted variation in support and outcomes for children and young people across Sussex. Aligned to this, SPFT is reviewing its model to enable transformation of existing services. This will support an improvement in waiting times for access and treatment and ensure a consistent core offer.
· Regarding actions in relation to the neuro developmental pathway and waiting times, please see 4.0 below.
3.4 Eating Disorders
Specialist Eating Disorder services are delivered by the Sussex wide Family Eating Disorder Service (SFEDS). There has been a sustained improvement to in-month delivery of Access and Waiting Time Standards (AWTS) for children and young people’s eating disorders. The standard is for treatment to be received within 4 weeks for routine cases and within 1 week for urgent cases.
Figure 6: East Sussex Eating Disorder referral to treatment in month
By way of illustration, in April 2023, East Sussex reported:
The number of young people with eating disorders (urgent cases) that were referred and waited no more than 1 week from referral to the start of NICE-approved treatment: 2 (100% achievement in East Sussex).
The number of young people with eating disorders (routine cases) that were referred and waited no more than 4 weeks from referral to the start of NICE-approved treatment: 4 (100% achievement in East Sussex).
This improvement has been supported by:
· Expansion of the specialist team.
· Implementation of new referral process to improve access for young people and their families.
· Expanded early support offer delivered by BEAT, the national eating disorder charity that has been commissioned locally. A new pathway launched in SFEDS in January 2023 to ensure families receive support to support their young person.
· Co-development of system-wide, all age pathway ambition for eating difficulties and disorders.
4. Neurodevelopmental Pathway Development
There has been a significant work programme that partners, stakeholders and experts by experience have undertaken together to develop plans for our future approach to all age neurodevelopmental care and support across Sussex. Investment in 2021/22 and 2022/23 targeted expansion within these services to support improved waiting times. This will support the delivery of a Sussex-wide plan that sets out how our services will be designed going forward to best support local people, together with potential solutions to support any remaining required reduction in waiting times.
Alongside this development, support for children, young people and their families has been increased in East Sussex through co-production with people who are Neurodivergent, and their families and carers:
1. Keyworkers East Sussex – in partnership with a third sector provider. Keyworkers provide individual workers for children, young people and adults up to 25 years old with a learning disability and or who are autistic, where they are a current mental health inpatient or there is a significant risk of hospital admissions due to lack of alternative preventative support. Our Keyworker programme provides person centered support engaging the child or young person in appropriate pathways and services not only reducing the risk of poor outcomes such as hospital admissions but also increasing the potential for positive and strength-based opportunities building on their neurodiverse profile. A Keyworker service has core functions such as advocacy, support and ‘unblocking’ when care and support pathways are unclear.
2. East Sussex Family Support Service - In co-production with parents and carers, a third sector partner in East Sussex provides a service for young people and adults (their family, carers, friends) up to the age 25, who suspect they are neurodivergent, are on an NHS assessment pathway, or have received a diagnosis (pre and post diagnostic support). The service includes:
· Family navigation service;
· Individual peer support service, including face to face befriending service;
· Training programme; example Insider's guide to ADHD; neurodiversity workshops for parent carers of children waiting for all neurodevelopmental assessments.
5. Mental Health Support Teams in Schools (MHSTs) Progress Update
From September 2023, MHSTs will be offered to 52% of school aged children and young people in Sussex, this includes 5.5 MHSTs in East Sussex. The latest implementation wave (Wave 9) will support the delivery of this target by adding an additional 4 MHSTs in Sussex (3 in West Sussex, 0.5 in Brighton and Hove and 0.5 in East Sussex), which will be targeted in specific areas of need such as rural areas with little infrastructure and areas of high deprivation. The service is called “Me and My Mind” as chosen by young people.
East Sussex County Council and Sussex Partnership NHS Foundation Trust jointly provide the MHSTs under a single management line within the council.
The key functions of our MHSTs are consistent with the national model as follows:
· Delivery of evidence-based interventions to support children and young people with mild to moderate mental health issues in schools.
· Supporting schools to develop a Whole School Approach to mental health and emotional well-being.
· Giving timely advice to school and college staff and liaising with external specialist services to help children and young people to get the right support and stay in education.
MHSTs employ a new workforce, that include (Trainee) Education Mental Health Practitioners (EMHP) who attend year-long training at the University of Sussex. EMHPs work alongside senior practitioners and clinical supervisors.
East Sussex MHSTs continue to develop and grow, which is evidenced by the growing number of referrals to the service to date are:
Academic year 2020/21: 536
Academic year 2021/22: 864
Academic year 2022/23 data collection is still ongoing and the East Sussex MHST individual session contacts continue to grow in line with the referral numbers.
Feedback from children and young people who have accessed a 1:1 intervention:
ü I felt like the care I had was something that has helped me out a lot through my tough times. The activity diary I was given was for me to write down my things I was going to do for that week, and I found that was really helpful and it showed me that I did not need to stress about with what I was going to do for that week. And the goal progress chart also showed me that things could get better if I tried.
ü I was able to get strategies that actually worked and helped me, and I was able to understand and recognise a lot more things about my anxiousness and stress. The person I got listened well and was able to take in everything I’d say and make everything more manageable. It made me motivated to try and fulfil my goals and I have been affected positively by this experience. The person I got was patient, kind, empathetic and always tried to help in any way possible.
Feedback from children and young people who have accessed a group or psychoeducation sessions:
ü All the strategies actually work- 5 finger breathing is one of the best ideas I’ve ever heard of for anxiety.
ü I like the Bear cards- their emotions look like me and are fun to pick out. Day dreaming (visualisation of calm space)- I created my own Candyland! I have sometimes used it outside of the group such as when I can’t sleep. Favourite activity was drawing the worried man as it made us all laugh.
Feedback from Parents and Carers of have received 1:1 intervention:
ü Generally given my child a smile back
ü The kindness and the help and support given to my daughter helped so much. The strategies given to her eased her anxiety and her confidence has reboosted. She is able to openly talk about her problems where before she might have struggled.
6.Conclusion
Children and young people’s mental health and well-being services are a key priority for the Sussex Integrated Care System. We are working together with health and care partners to improve the services and support provided to children and young people to help them to manage their emotional wellbeing and mental health. The importance of this has been reflected in increased investment into these services in recent years, and significant work to engage widely with stakeholders, including children, young people and their families and carers, in reviewing services and developing our priority areas for improvement.
We recognise there is much more to do to achieve our ambitions, and this is set against a trend of increasing need for services and support and a financial context that requires continued transformation within existing resources. The work that will take place in 23/24 will predominantly focus on improving emotional wellbeing and mental health support within our existing resource, with some limited expansion, for example further roll out of Mental Health in Schools Teams. Transformation is key to meet the needs of our children and young people and reduce the need for specialist support through early intervention. This will require all system partners to work together recognising that the emotional health and mental wellbeing of the children and young people of East Sussex is everybody's business.