Mindsight Surrey Children s Mental Health and wellbeing: Next Steps. Communication brief for our stakeholders. Surrey CCGs.

Transcription

1 Mindsight Surrey Children s Mental Health and wellbeing: Next Steps Surrey CCGs Communication brief for our stakeholders October 2018

2 Foreword In early 2018 a number of concerns were raised about some of the Mindsight Surrey CAMHS services by young people, parents, schools, GPs and CAMHS staff. The Surrey Clinical Commissioning Groups, Surrey County Council and Surrey and Borders Partnership NHS Foundation Trust would like to apologise to the children, young people and families who experienced distress due to the unacceptable waiting times and the lack of a routine service. We came together as a system and responded to the immediate concerns by implementing an Interim Plan that prioritised assessments for children who have been experiencing unacceptably long wait times. We also jointly commissioned an independent review of Mindsight Surrey CAMHS to identify areas that would help us improve the service going forward. We are committed to working in full partnership with primary care, schools, children and young people and parents to transform our children s mental health services. The Government s Green paper highlights the important role of schools and we will be engaging with all our stakeholders including GPs, schools, children and young people to shape a new strategy for Surrey. 2 ATTAIN

3 Contents In this document you will find: Context of the Independent Review Executive summary of the Review and its findings The Independent Review what did we want to know? What strengths of Mindsight Surrey were identified? A summary of the findings for the KLOEs A summary of the learning so far and recommendations A outline of what next for CAMHS in Surrey 3 ATTAIN

4 The independent review The review took place between June and August 2018 and is the learning so far. We are committed to understanding and working with schools; children and young people to inform the development of a new model. The review focused on six key lines of enquiry The review included analysis of data and input from around 200 people The review report set out a series of findings and recommendations for the future 4 ATTAIN

5 Executive Summary: What are the key messages from the Independent Review? There is a universal commitment to delivering high quality CAMHS services to children and young people in Surrey and to working in full partnership to develop a new model The Mindsight Surrey model is innovative, a number of the services are high performing and clinical interventions are perceived as high quality. There are some areas of excellence for example, Haven and Eating Disorder Service The vision for Mindsight Surrey is not being wholly delivered, nor is it deliverable in the current context. Challenges faced by the service include: multi-agency relationships are not working to provide consistent early help to children and young people (especially schools and GPs) Demand across the system for early help is rising the CAMHS service is not sufficiently robust the complexity of commissioning structures for CAMHS front-line teams are under pressure with significant vacancies Demand on the service has been 53% higher than predicted, however, the number of referrals is only marginally higher than the national average. Funding is slightly above national average when benchmarked against other CAMHS services in England although slightly below the top 21 performing services. Arguably, services should be able to be configured to deliver demand currently experienced by the service. Core funding represents 80% of total CAMHS funding, circa 20% of CAMHS funding is transformation funds Recommendations for the transformation of CAMHS are significant as many of the challenges faced by the service require structural and cultural change neither of which is quick or easy In the short-term, the review proposes a focus on building a more robust system for early intervention, supporting referrers and adapting elements of the CAMHS service In the long-term, the review proposes aligning agencies to simplify the system, reduce complexity, co-design a model of care that promotes ownership, accountability and early intervention, community development and family engagement Outlined on the following slides are the more detailed findings of the review. There is a lack of historic data relating to CAMHS in Surrey. Data capture and quality is improving, but still requires significant improvement. The lack of data has inevitably impacted our ability to answer all of the questions we would have liked to answer as a part of this review. 5 ATTAIN

6 The independent review what did we want to know? The following services were in scope of review: The Targeted CAMHS contract (formerly known as Tier 2) is managed by Surrey County Council) on behalf of the Surrey CCGs The Specialist CAMHS contract (formerly known as Tier 3) is managed by NHS Guildford and Waverley CCG on behalf of the Surrey CCGs The six key lines of enquiry (KLOEs) of this review are: 1. Is what we commissioned being delivered? Is the commissioned service deliverable in the current context? 2. What are the key reasons for increased demand in the Mindsight Surrey CAMHS service? 3. Why is there a variation in the Behavioural Emotional Neurodevelopmental (BEN) and CAMHS Community Teams waits? 4. How could we intervene earlier? 5. How effective are our pathways in meeting the health and wellbeing needs of children and young people? 6. What are your recommendations for all of the above questions in order to deliver a safe and sustainable service within the resources available? Footnote: Benchmarking data should be used as a guideline only due to the nature of variation across systems and 9,200 referrals is the approximate number left from 12,500 referrals when multiple service users and non-referrals are removed 6 ATTAIN

7 What strengths of Mindsight Surrey were identified? Universal commitment to delivering high quality services to children and young people in Surrey Relationships, leadership and service management that are evolving and improving across the system Services are high quality at point of delivery A number of high quality services which meet access and quality targets (e.g. Hope and Extended Hope and Eating Disorder Service) Locality working is building local teams around the needs of individual populations and linking local partners Concept of Single Point of Access and BEN pathway Committed workforce, with supportive delivery team culture working across professional and organisation boundaries to deliver services to children and young people Improving relationships and integration between SABP and its partners in Mindsight Surrey Services are being designed, where possible, with service users, families and carers 7 ATTAIN

8 KLOE 1: Is what we commissioned being delivered? The vision for Mindsight Surrey is not being wholly delivered All services that were commissioned are being delivered, with activity being marginally above Plan 53% more referrals that convert to treatment pathways were received by the service than commissioned The number of referrals is only marginally higher than the national average. See response to KLOE 2 for more detail What was commissioned? Targeted CAMHS services Specialist CAMHS services What is being delivered? All services commissioned are being delivered, but not all at the scale required (e.g. PMHT) and with significant waits for some services. All services commissioned are being delivered. 6,500 referrals per annum Over 9,000 referrals are being accepted per annum No wrong door and system navigation System leadership and multi-agency partnerships Consistent timely provision of high quality and safe services Focus on early intervention Working with children and young people and their families to co-design and review services Delivered by Mindsight Surrey CAMHS by Beacon Not working to unite the system and deliver early help and intervention Timely access to services is mixed, quality and safety are being compromised by long waits for particular services Agencies and partners are not consistently working together to provide early help. Primary Mental Health Teams are significantly under-resourced A number of the services are actively co-designing with children and young people 8 ATTAIN

9 KLOE 1: Is the commissioned service deliverable in the current context? It is our view that the commissioned service is not deliverable in the current context and that longerterm transformation is required. The major challenges are outlined opposite. Lack of a vision for a coherent system of services that support the emotional wellbeing and mental health of children and young people Lack of commitment from different agencies to take responsibility for the emotional wellbeing of children and young people and invest in early help and interventions Complex and fragmented commissioning structure Lack of coherent system governance that unites everyone to deliver a whole system approach to meeting the emotional and wellbeing needs of children and young people Mindsight Surrey CAMHS is not working together as a group of partners as well as it needs to, including evidence of a fragmented approach to the planning and management of the service and a lack of consistent and demonstrable clinical leadership Persistent workforce vacancy rate in Mindsight Surrey CAMHS that is presenting day-to-day challenges, impacting the motivation of staff and preventing a positive change to the service 9 ATTAIN

10 KLOE 2: What are the key reasons for increased demand in the Mindsight Surrey CAMHS service? Reported referrals for 17/18 included a large number of referrals that did not convert to a pathway (circa 2,500). There were also a number of duplicate records that have been removed for the purposes of this analysis. Demand projected by the commissioners and provider was too low with 53% more referrals converting to pathway than anticipated in 17/18. What are the key reasons for the increase in demand? The key reasons for the increase in demand for Mindsight Surrey CAMHS are: National uplift in awareness of children and young people s mental health Availability of a single point of access and no wrong door policy for referrers Early underperformance of the single point of access (subsequently improving) However, at 9,200 in total, the number of referrals converting to pathway tracks only marginally higher than the national average. 10 ATTAIN

11 KLOE 3: Why is there a variation in the Behavioural Emotional Neurodevelopmental (BEN) and CAMHS Community Teams waits? Activity for BEN continues to grow month on month with a year on year increase of 130%. Waiting times exceed both the national average and those reported by third sector organisations. Children, young people, their families and carers, clinical teams and provider partners experience the confusion being experienced by the service and therefore feel stressed. It is difficult to identify the root causes for the high demand and long waiting lists as there is little data or national benchmarks. Complexity in presentation it isn t always clear what the child or young person needs and it takes a lot of time and resource to accurately assess children in this pathway There is a lack of clear multi-agency and multi-provider partner pathways or clinical leadership (especially for ADHD), and therefore confusion amongst referrers Early intervention for these children and young people is impacted by services around BEN The teams that works across both BEN and CAMHS Community Teams do so without appropriate job planning or management Lack of opportunity for multi-agency, multi-provider partner and multi-disciplinary assessments and shared learning among professionals Data on activity and the service is not adequately captured and therefore isn t available to support the active management of the service 11 ATTAIN

12 KLOE 4: How could we intervene earlier? There is universal commitment to early intervention and a lot of opportunity to mobilise early help for children and young people in Surrey. More can be done. Early intervention in Surrey could be enhanced by: Investment in primary mental health team resource both in filling vacancies, but also in the size of the team. There are only nine PMHT workers covering c400 schools this is significantly less than the team of 21 pre April 2016 Building resilient families - working with parents and carers and siblings Building communities that support emotional wellbeing and early intervention Building communities where all are welcome, respected and valued Strengthening formal and informal and county-wide and neighbourhood relationships with agencies (e.g. primary care and schools) to forge a true wholesystems approach to early intervention Uniting the universal services to support emotional wellbeing in children and young people Full utilisation of Mindsight Surrey CAMHS provider partners 12 ATTAIN

13 KLOE 5: How effective are our pathways in meeting the health and wellbeing needs of children and young people? Mindsight Surrey is implementing a new approach to understanding their impact and outcomes. At present, however, there is a lack of significant quantifiable evidence to support an analytical answer to this question. Feedback from service users suggests service high quality when accessed. Life transforming services High impact service, when people are seen The challenges aren t about capability Good services, once seen Direct quotes from service users and service user representative groups Children and families pick up on stress levels of staff 13 ATTAIN

14 The summary conclusions from the review KLOE 1-5 The summary and wider findings of the review were: Commissioning of CAMHS is fragmented and not aligned to wider services that support children Projected demand by commissioners and the provider partnership was low (53% more referrals than anticipated were received in 17/18). The demand that has transpired almost matches national benchmarks for demand by 100,000 population The service is strong in parts, but under significant pressures in others Mindsight Surrey (including One Stop) was configured to manage too few referrals, especially for BEN Evidence that early performance of the triaging function was poor, but also evidence that current performance is beginning to address these historic issues There are long waits and high case loads and a focus on assessment and not treatment especially in BEN and CAMHS Community Teams (the latter having an impact on the broader service e.g. the Hope service) Evidence of slow mobilisation and communication of the Mindsight Surrey service model, lack of clear pathways, poor integration with wider agencies and provider partners (although the latter is slowly improving), lack of operational data and non-medical clinical leadership have contributed to the underperformance of the service and the high waits and case loads Funding is slightly above national average when benchmarked against other CAMHS services in England although slightly below the top 21 performing services. Arguably, services should be able to be configured to deliver demand currently experienced by the service Core funding represents 80% of total CAMHS funding, circa 20% of CAMHS funding is transformation funds Workforce issues are significantly exacerbating operational issues Data is historically and remains poor, SystmOne doesn t support the capturing of the information required to manage the service 14 ATTAIN

15 KLOE 6: What are your recommendations for all of the above questions in order to deliver a safe and sustainable service within the resources available? (Summary) The recommendations from the Independent Review fell into two categories short and long-term. Short-term now until the end of the current CAMHS contract term Continuation with delivery of Interim Plan for remainder of the 16 weeks (up to 21 st September 2018) Ongoing and rigorous evaluation of Interim Plan impact (including any routine referral and treatment waits, impact on vulnerable families and urgent and crisis presentations and capacity challenges for provider partners) Development of an agreed Interim Plan (perhaps called something different!) up to the end of current CAMHS contract to include: those elements of the Interim Plan that are having an impact * additional elements, as proposed in this report *excluding the refusal of routine referrals Mid to long-term Our recommendations for the transformation of CAMHS are significant. Many of the challenges will require structural and cultural change neither of which are quick or easy to achieve. The recommendations in this report are designed to address both of these elements We have not made a recommendation on timescales for implementation of the longer-term transformation because we are keen to avoid cutting across conversations that are taking place on this within the system. We suggest, however, that an extension to the CAMHS contract of at least a year is required (i.e. above core three years) to allow sufficient time for design, planning and mobilisation of a new service The capability required to deliver the transformation is significant and varied and should be drawn from national resources, and from across the local system to ensure a system-response and to develop a sustainable de-medicalised, whole-system, early intervention model If the system has the capacity to absorb the changes, some of the longer-term recommendations can be moved into the short-medium term 15 ATTAIN

16 KLOE 6: What are your recommendations for all of the above questions in order to deliver a safe and sustainable service within the resources available? The Independent Review proposed a series of recommendations regarding STRATEGY, building on the momentum of the Interim Plan to make the service safe in the immediate term and to harness the commitment of all those involved in the mid to long term. Shorter-term Mid to long-term Strategic context Clear and visible leadership and communication of findings of review and next steps System operational group / governance for integrated delivery to include SABP and provider partners and commissioners to actively manage and evolve the service Targeted communication and workshops with schools, primary care and stakeholders (e.g. CYA) to build relationships and understanding of CAMHS service and to listen to challenges, needs and feedback Strategic context Continued focus on aligning services that impact children and young people Continued co-design of an Emotional Wellbeing & Mental Health Strategy across health, social care and wider agencies Aligned and simplified commissioning, contracting and governance arrangements for children and young people and CAMHS Further development of an aligned lead provider model for integrated service delivery Review of governance of design and delivery of services to children and young people and establishment of a governance structure that unites the agencies involved in the care of children and young people 16 ATTAIN

17 KLOE 6: What are your recommendations for all of the above questions in order to deliver a safe and sustainable service within the resources available? The Independent Review proposed a series of recommendations regarding CAMHS SERVICE, building on the momentum of the Interim Plan to make the service safe in the immediate term and to harness the commitment of all those involved in the mid to long term. Shorter-term Mid to long-term CAMHS service CAMHS service Mindsight Surrey should further embed a clear management routine for the close and reactive management of services day-to-day and monitor performance Refresh risk strategy and risk plan for managing children on waiting lists for assessment AND treatment, and high case loads Detailed and speedy review and evaluation of any waits accumulating in any part of the system including treatment or assessment, impact on vulnerable families and crisis, urgent and routine presentations Improve integration with One Stop (consider re-co-location) Clear clinical leadership of and access criteria for all pathways (especially ADHD) Re-establish primary care medicines line to provide advice and guidance Sharpen, confirm and socialise psychiatry duty rota (under development) Scale up implementation of Shared Care across the wider Surrey geography Co-design of a whole system, de-medicalised model that promotes ownership, accountability and early intervention, community development, navigation and case management and parental and family engagement and: a children s services-wide single point of access clear leadership of pathways early intervention Specific recommendations on: A children s services-wide triage service not just CAMHS BEN pathways with clear leadership, increased management time, a clear pathway, whole system model involving all provider partners and agencies and children and young people and their families in care provision Bolstered PMHT provision Early intervention Universal implementation of shared care across Surrey Dynamic provider management and leadership and strong partnerships 17 ATTAIN

18 KLOE 6: What are your recommendations for all of the above questions in order to deliver a safe and sustainable service within the resources available? The Independent Review proposed a series of recommendations regarding RESOURCES, building on the momentum of the Interim Plan to make the service safe in the immediate term and to harness the commitment of all those involved in the mid to long term. Shorter-term Mid to long-term Resources Continue to improve data collection and reporting Job planning and SystmOne and CYP IAPT training for staff Prioritised PMHT recruitment Job planning Review of KPI and contract management regime between commissioners and providers to consolidate (in the short-term) and focus on the key indicators of performance, quality and safety Identifying champions and resources to ensure the delivery of CAMHS transformation Resources Agreement of a resource envelope for CYP care that will enable the delivery of the vision / model particularly focusing on the sustainability of transformation monies as it represents 21% of current spend Improved data collection protocols Workforce cultural change and de-medicalised leadership and delivery to drive up recruitment and retention; leveraging variety of skills and capabilities from wide ranging workforce, breaking down organisational and professional boundaries The capability required to deliver the transformation is significant and varied and should be drawn from national resources, and from across the local system 18 ATTAIN

19 What next for CAMHS in Surrey?

20 Process chart with four phases Improve outcomes for children and young people by improving the service tly own the plan and delivery Join Listen to, understand, engage and communicate with all stakeholders, particularly children and young people Build a culture of evaluation, reflection, learning and evolution local provision of services early help and prevention flexible and consistent access (through primary care and schools (state, private, home and no schooling) clear thresholds to and pathways for access (e.g. routine, urgent and crisis) appropriate referrals, assessment and intervention working with parents, carers and families joint ownership of the plan and its delivery strengthening the system in its widest sense (e.g. with adult services and wider children s services) sharing accountability for risk and success across the system fostering and use shared language actively care for our workforce understanding each other s pressures continued openness putting the voice of children and young people at the heart of co-designing, evaluation and assuring services clear and consistent and accessible communications with all stakeholders (particularly for vulnerable young people) on evaluation and the provision and analysis of good data including service user outcomes, quantifiable metrics and impact (e.g. on vulnerable families) 20 ATTAIN

21 How will we work together as a community? We are committed to building on existing relationships to work together as a community to improve outcomes for children and young people and to co-design the service of the future. Surrey & Borders Partnership Trust Surrey County Council, social care and schools Mindsight Surrey partners Health commissioners, GPs and wider health services Families and carers Children and young people 21 ATTAIN