Agenda item

To review the accessibility of CAMHS in Hackney.

4.1 In March 2022, the Commission assessed the accessibility of local CAMHS through the Cabinet Q and A process.  At this meeting the Commission noted the acute pressures which services were under and which had resulted in lengthy waiting times for children to be assessed and to receive therapeutic support.  The Commission agreed to follow up this work in greater detail within the 2022/23 work programme.

4.2 The Commission therefore requested an update from local CAMHS on the accessibility of local services to include

·  Overview of service demand, waiting times and compliance with accessibility standards;

·  Update on the development of a single point of access (no wrong front door) across the CAMHS alliance;

·  Access to therapeutic services and who are waiting for therapeutic support; - Demographic analysis of disproportionalities in those children and young people seeking help from CAMHS;

·  Governance and oversight of CAMHS alliance - structures that oversee service demands, waiting times and the broader implementation of local priorities.

4.3 To support the scrutiny of this item it was noted that members of the Commission had:

1.  Undertaken a number of site visits to a range of providers within the CAMHS Alliance - including First Steps, Specialist CAMHS and Off-Centre.

2.  Held a focus group where 8 members of the Commission were able to discuss service accessibility with a range of  mental health practitioners from First Steps, Specialist CAMHS and Off-Centre and wider CAMHS Alliance.

4.4 The Chair thanked all those CAMHS services and CAMHS practitioners who gave up their time to speak to the Commission and for responding to all its questions.  The Chair emphasised how important it was for the Commission to be able to engage with front-line practitioners in the scrutiny process, as this provides additional insight and helps members to connect with and better understand the issues under scrutiny.  Importantly, it also helps members to understand what adaptations or changes that might be necessary to improve services.

Introduction by CAMHS Alliance

4.5 Officers introduced the report highlighting the following key issues:

·  The emotional health and wellbeing of children and young people was a top priority locally to which all local agencies were signed up to and which is reflected in local strategies and plans (i.e. Emotional Health and Wellbeing Strategy).

·  All authorities are required to have developed a CAMHS Transformation Plan, which in Hackney is delivered by the Emotional Health and Wellbeing Partnership (EHEBP) which is overseen by the Emotional Health and Wellbeing Board (Chaired by the Group Director for Children and  Education).

·  Post Covid demand for CAMHS services has increased significantly which has created demand pressures within the local CAMHS system.  A number of work streams have been developed to respond to these challenges including the reconfiguration of  neuro-divergent pathways of support and the ‘surge response’ of services.

·  In July 2023, seven Clinical Commissioning Groups merged which also provided an opportunity to take stock of local CAMHS provision and to refocus local priorities and galvanise efforts to improve integration and address inequalities.

·  The EHEBP have a number of local priorities:

·  Development of a single point of access (SPA) where work has already commenced and was delivering results in terms of more efficient referral of children across the system;

·  Eating Disorder service - there has been good progress in reducing waiting times to manageable and acceptable levels, but this remains a priority;

·  Crisis Service - a crisis response service had now been developed which was fit for purpose

·  Neuro-Divergent Pathway has been reviewed to reduce system blockages, increase capacity and reduce waiting times.

·  It was important to underline the shift required away from CAMHS services to broader early help and support of young people's mental health and emotional wellbeing.  Ensuring more children receive help earlier will prevent needs from escalating and avoid the need for more complex and costly interventions at a later time. WAMHS was a good example of this which focused on up skilling staff and schools to develop early intervention and support to children.

·  The local partnership was working toward the i-THRIVE model of CAMHS provision which would map out existing services and ensure that there were no gaps.  This model also moves away from the medical model of provision to ensure that there a wider range of emotional health and wellbeing needs are met.  This will lead to a diversion of resources to early help which will reduce pressures on acute services, but also make sure families get the help they need for children earlier.

·  It was noted that City & Hackney CAMHS service had been highlighted by a report of the Children's Commissioner as the 6th best performing service in England.

Questions from the Commission.

4.6 Officers were asked for an update on the refreshed Emotional Health and Wellbeing Action Plan?

·  Progress had been limited as a clinical lead for this work had yet to be appointed.  It was hoped that a new lead would be recruited by the autumn of 2023 and further work could then commence.

4.7Can officers indicate the number of children presenting to A & E with emotional health and wellbeing concerns, the nature of their needs and whether these needs required a medical intervention? What is being done to reduce A & E presentation for mental health concerns  by young people?  Is there data as to whether children have previously presented at A & E or another setting in the CAMHS system?

·  The Associate Director for Specialist CAMHS confirmed that there had been an increased number of children presenting in crisis, and there had been interventions to increase nursing support in A & E as well as other diversionary programmes.  The numbers of children presenting at A & E reflect broader system problems and the ability to safely discharge within the community.  Delays are also arising from the volume of young people presenting, the complexity of their needs and the limits on placement availability. It is an ambition of local services that a young person is not in A & E any longer than they need to be.

·  Data was not to hand as to children’s previous contact with A & E or contact with other mental health services, but ensuring children get the help that they need earlier, closer to home and where they feel more comfortable was a priority for the CAMHS partnership.  The crisis team (and broader alliance) was evaluating pathways to ensure that help can be provided earlier and away from A & E. The ICCS (Crisis Service) was working to develop interventions which can help keep young people at home, but receive the same level of intensive support as they might receive in more clinical settings.

4.8  Some children will require emergency admission for more clinical support.  Are services confident that there is sufficient capacity to meet local needs?  Are children presenting at A & E with a neuro-divergent diagnosis perhaps because their needs have not been identified or met through existing ND pathways?

·  Whilst there were undoubtedly challenges during Covid, there is now a collaborative response across NHS services across NE London to ensure that children presenting in crisis and need in-patient support are kept within the NE London region.  Crisis services are of the view that children’s stay in in-patient settings should be as minimally required as this is not the best setting for meeting their needs, and to help maintain access to acute clinical services where needed.

·  There are many intersections and there is a huge overlap in some of the conditions that children may present with (neuro-diversity, self-harm, eating disorder, gender dysphoria) and it was a challenge for clinicians to disentangle trauma from neurodiversity as they may present with similar identifying issues.  In reality, clinicians noted that very few children presented with a single need and most turn up with multiple and often quite complex needs which need to be unpacked with clinical support.

4.9  What are officers' perspectives of children not in school and who or who may be experiencing emotional avoidance?

·  In terms of emotional based school avoidance, the Psychological Therapies Lead responded that a recent audit of specialist CAMHS service revealed that these cases made up ? of the whole caseload and thus represent a significant local issue for mental health and emotional wellbeing services.  Practitioners noted that it was very difficult to get children back into school once they were emotionally avoiding school, and therefore it was important for early intervention to help parents and teachers to recognise these issues at an early stage and to signpost children for support as early as possible.

·  It was also emphasised that the solution was also not going to come from one service, but a wider systems based response.  Clinical services partnerships with schools and teachers and other community support was integral to this approach, and was associated with more successful outcomes in getting children back into school.  Practitioners present were of the view however, that the provision of clinical services within school was not the answer, as the focus should remain on non-clinical interventions provided at a much earlier stage. Practitioners present noted that good therapy does not ‘fix’ all children and does not help a majority of children to get back to school, so the emphasis must still be on prevention.  In some ways, therapy can be viewed as a failure as it is an admission that there has been some earlier omission of help and support for the child.

4.10 A member of the Commission connected to local schools highlighted a number of issues in relation to emotionally based avoidance and children not in education.

·  Firstly, there was limited oversight of those children who were avoiding school and whose parents may have opted to electively home educate them.  There was one member of staff who was tasked with the oversight of children not in education even though there has been a huge increase in the number of children who are educated at home. This is something that the local authority does have control over and should act accordingly.

·  Secondly, where schools had identified children who may need help at a relatively early stage to children’s social care, in many instances this did not reach the threshold for support.  Children were then referred back to the school for support but found difficult to provide alongside other priorities.

·  Whilst WAMHS was positive in that it sought to up-skill staff, it added to the daily responsibilities and growing tasks of teachers and schools.

4.11 The report submitted to the Commission highlighted that Off-Centre community therapy service had to close its waiting list for one whole year due to recruitment challenges.

·  Off-Centre is unique in that it covers children across the age range from 16-25 years.  The problem is that adult services threshold for care and support is generally much higher and younger adults find it difficult to access the care that they might need after the age of 18.  Off Centre is a voluntary sector organisation and although commissioned by the NHS is vulnerable to staff recruitment and retention issues as it is not able to offer levels of pay and benefits comparable to similar services in the statutory sector.  Off Centre is designed to support children and young people with mild to moderate conditions, but during and after the pandemic it was seeing children with moderate to severe conditions and it could no longer hold all these children safely whilst taking on new cases.  Without psychiatry or prescribing input and with increased staffing pressures, the service could not maintain the level of risk presented by the existing caseload and it was therefore agreed to close the waiting list to continue to offer support to existing clients and work through the backlog of cases.  The service has since reformulated and reopened the waiting list, and have agreed a risk sharing arrangement with the neighbourhood MAT team who work with children aged over 18.

4.12  Can officers expand on staffing issues further and perhaps explain the broader recruitment and retention issues across the mental health sector and how these are being addressed?

·  There were many thousands of vacancies across the NHS including in mental health services.  CAMHS services have faced recruitment and retention issues across the country and many local services are running a constant cycle of recruitment activity, many of which result in unsuccessful outcomes.  One service noted however, that many of the contracts on offer that were 12 month fixed-term contracts, which in the middle of a cost of living crisis were not appealing to many potential applicants.  Further work was needed to develop these into substantive posts.

·  Delivering CAMHS services through the pandemic has been difficult and challenging for staff involved, so the wellbeing offer to staff was also felt to be an important part of that retention strategy.  Local services were also under pressure from agencies which were recruiting staff as they were paying higher rates that might be available in established posts.

·  Retaining staff was key though as many staff were not staying on for a number of reasons, perhaps for better paid private work, to work more flexibility or to move away from front-line positions where work was more challenging.

4.13 In terms of drivers for increased demand for services, to what extent is ‘the context’ of children's conditions playing a role in creating additional emotional health and wellbeing needs, such as for example schools?

·  Practitioners acknowledged the enormity of the teaching role in keeping children safe, teaching them and supporting them to develop and achieve both personally and academically.  The Single Point of Access (SPA) was trying to match up support offered through WAMHS to the school concerned.  Secondly, there were plans to develop the consultation arm of the CAMHS service to further understand what resources teachers had and what they might need to support children's emotional wellbeing further i.e. are there collective issues which the school might need help to address i.e. bullying effects, attachment issues.  It was not possible to have clinicians in every school, and schools cannot be expected to pick up all emotional and wellbeing support themselves.

·  Many teachers were already doing very good emotional health and wellbeing work with children through their existing approaches, that is supporting them to build sound relationships. 

4.14 To what extent do school behaviour policies, some of which are known to be punitive and can lead to exclusion, impact on children’s mental health and wellbeing?  What is WAMHS encountering in this respect and how is it working with schools on this issue if it is problematic?

·  Although WAMHS has no authority to dictate the contents or application of school behaviour policies, it can of course work with schools when invited to do so.  All schools are different with varying ethos, student expectations, leaderships and staff and whilst some local schools have wellbeing as a priority in their action plan, others do not.  WAMHS offers a roadmap to a wellbeing model of operation through a self-assessment process which will help to reveal the schools own priorities which they can then prioritise and respond to. 

·  CAMHS practitioners are aware that there may be punitive behaviour policies in local schools which is leading to distress and anxiety amongst local young people but are not in a position to directly influence these.  Trusting relationships have to be built with schools to support change, and to ensure that behaviour policies are more positive behaviour affirming.

·  A case was cited where local CAMHS practitioners were able to influence the outcome for the child who was about to be excluded for persistent lateness.  The involvement of CAMHS workers had helped the school to understand the context of the pupils home environment and how this may be affecting her behaviour and helped to inform schools' response to not exclude.  This had to be a collective arrangement between schools and other wellbeing practitioners.

4.15 Understanding that many services across numerous local statutory and voluntary agencies make up the CAMHS alliance, where does strategic oversight and key decision making sit for the work of CAMHS in Hackney?  To what extent is the work of CAMHS data informed and led given that the focus group highlighted some of the challenges around data and the need for more interconnectivity across services?

·  The CAMHS Alliance takes decisions for the wider partnership and reports into the Emotional Health and Wellbeing Partnership which itself reports to the Integrated Care Partnership.

·  The NHS has long promised a fully integrated data system across health partners but has consistently failed to deliver.  Instead, the local CAMHS Alliance has developed its own key data set and set out the important data that it needs to manage the local emotional health and wellbeing system.  The Single Point of Access has really helped to start the process of creating system wide data which can inform current service delivery and future service planning.

·  Historically however, many services were commissioned by different organisations which required different information and supported different systems to deliver this information.  The strength of the CAMHS Alliance however, is that it allows services to work together on such issues as data and create locally based solutions. 

·  An example of the challenges of data collection was in relation to broader equalities work and ‘white other’ ethnic data collection category, which fails to identify the needs of the large Orthodox Jewish Community.  Similarly, more data is needed around the needs of neuro-divergent young people to help the services respond better and help address the long waiting lists which are experienced locally.

4.16 What are the key factors which you think the Commission should focus on in assessing the success of local mental health and wellbeing services?

·  The key issue is integration and there needs to be more cooperative working across local health and social care systems.  Whilst there has been good progress in developing a SPA for CAMHS, it would be more useful if there was a single point of access for a much wider range of needs in which children and their families could be directed for help or support.  There were moves to co-locate HCVS, social care and CAMHS to improve coordination and support for local families.  It was also important to help maintain diverse routes of entry into services.

4.17 The Chair thanked all officers for attending and answering members' questions.  The Commission would reflect on the focus groups as well as discussion held this evening and submit a brief summary with outline recommendations to relevant cabinet members.