Title of Proposal: Improving community mental health services for children and young people Programme Area: Children, Young People and Maternity CSU Lead(s) CCG Lead/Clinical Lead: Timescales What are the key milestones/ deadlines? Case for change None Kate Mansfield Re-procurement of community children s health services contract implementation April 2016 Implementation of Children and Families Act requirements September 2014 The impact of mental ill health 50% of life-long mental health issues start before the age of 14, and 75% by mid 20s. 1 in 10 children aged 5 16 has a clinical significant mental health problem, rising to 1 in 4 in adulthood. Mental health disorders in childhood can have high levels of persistence. In a national study, 25% of children with a diagnosable emotional disorder, and 43% with a diagnosable conduct disorder, still had the problem three years later. Young people experiencing anxiety in childhood are 3.5 times more likely than others to experience depression or anxiety disorders in adulthood. Demographic change Population growth since CCHP contract awarded in 2008 has been significant, and will continue to impact on demand for services in the next two years and beyond. o Number of 0-19 year olds projected to increase by over 6,500 over the next 16 years. o 28,000 new homes to be built by 2027. o Over the next 4 years, the Council plans to provide an average of 400 additional Reception school places per year. 1
SEN data 3 Special Schools provide specialist education for children with complex and severe learning difficulties and a new school for children with behavioural, emotional and social difficulties opened in 2011. A service for the delivery of Education Other Than At School is provided at three main sites across South Gloucestershire. The EOTAS service provides education for some very complex young people and requires regular consultation and liaison from paediatric and mental health services in order to manage children with behaviours that challenge. South Gloucestershire is a net importer of Looked After Children, many of whom have significant emotional and social difficulties. In January 2012 there were 1,016 pupils with a Statement of Special Educational Needs (2.6% of the entire school cohort). This is a higher percentage of children with a Statement of Special Educational Needs than in other local authorities. Analysis of the specific primary categories of Special Educational Need indicate that in 2011/12, 21.5% of children with SEN had behavioural / emotional and social difficulties, and 11% were on the autism spectrum. Current provision of services Community children s health and CAMHS services are provided under a single contract 2009-16. Some gaps, particularly in respect of targeted and specialist services were noted by the PCT when the contract value was agreed. There has been no additional investment in these services since 2009. The contract value needs to be reassessed in order to address these service gaps, demographic growth since 2009 and projected further population growth in future years. A realistic contract value will be crucial to successful re-procurement of these services for 2016. The CCG has committed, through the Children s Trust Board and the Health and Wellbeing Board, to work with the Local Authority to commission services which provide earlier intervention in support of vulnerable children and families. In particular in South Gloucestershire we need to ensure that we have emotional wellbeing services which can 2
intervene early and prevent escalation to longer term mental illness. This gap is squarely identified in the JSNA, the Health and Wellbeing Strategy and in feedback from member practices and from service users. The tiered model of care CAMHS services in the UK are described using a stepped or tiered model of care, as illustrated below: NICE guideline CG28 in relation to the management of depression in children and young people recommends a stepped care configuration of services, with support, consultation and early intervention available at an early stage, and clear channels of communication and flow between universal, targeted and specialist services. South Gloucestershire s community CAMHS service operates almost exclusively at Tier 3, accepting referrals for children and young people who have severe, complex and enduring emotional, behavioural and mental health difficulties. The service is frequently overwhelmed with referrals, and dissatisfaction with the service is high, despite significant reductions in core service waiting times due to the introduction of the Choice and Partnership Approach. The service consists of 11.2 wte and is the smallest of the 4 CAMHS teams across Bristol and South Glos. It receives a higher number of referrals than other teams (874 in 2012/13 - twice as many as the Bristol East Central team) and accepts a smaller proportion (62% in 12/13, compared to over 80% in East Central). 3
These significant numbers of rejected referrals cause other services, including schools and GPs, to feel that in some cases they are left holding risk around very vulnerable young people without specialist advice and support. In most other areas there are robust services at Tier 2, comprising a workforce of Primary Mental Health Workers, together with counselling services provided either within or outside statutory services. In South Gloucestershire at Tier 2 there are two Primary Mental Health Specialists one generic and one focused on infant mental health. An additional 1.6 Mental Health Workers are funded by South Gloucestershire Council, but are specifically focussed on Looked After Children, First Point advice and the ASD Unit at Chipping Sodbury School. These posts do not contribute to generic capacity of the team. For several years there have been no services to which GPs or schools can refer young people experiencing emotional distress. This is regularly flagged by schools and primary care teams as a significant gap in local services, and this was reflected in a recent CCG survey of the membership, which strongly supported investment in this area. Work between the CCG and the Local Authority has identified strengthening Tier 2 CAMHS as a priority service development. Tier 3 specialist issues and resources The recommended Psychiatric provision within a Tier 3 multi-disciplinary CAMHS team is 1.5 per 100,000 total population. For South Gloucestershire this would equate to 4.0 wte. The South Gloucestershire team currently has 2.1 wte funded posts. CAMHS input is extremely important in the diagnosis and management of children with Autism, particularly for higher functioning young people who may experience acute anxiety. Identification of Autism in South Gloucestershire children is rising. Some support services, such as the Early Bird and Cygnet programmes of specialist training for parents, require children to have been through the assessment pathway and been given a formal diagnosis before families can access them. There are currently over 80 children waiting for an Autism assessment, with some families waiting a year or more for assessment. Where young people cannot be educated in local schools 4
due to the severity of their needs, and due to the lack of intensive or specialist support available through CAMHS or LD services, the CCG contributes alongside the Local Authority to very expensive out of area residential school placements. This is in many cases an inefficient use of resources, to say nothing of the impact on individual young people and their families. Outline of proposals Project 1 Tier 2 expansion a) To pilot a South Gloucestershire young people s counselling service through the expansion of the contract of the existing provider of IAPT services for younger adults (Off The Record) so as to accept young people from age 11. OTR will establish a daily presence in South Gloucestershire, with a central point for acceptance and triage of referrals through a Youth Support Worker. Referrals will be accepted from General Practice, schools, and self-referral. Initial capacity 250 young people per year. This pilot will allow commissioners to determine the level of need for this service within South Gloucestershire, and to make future proposals on the size, scope and delivery method for counselling for young people. OTR is an existing accredited IAPT provider in South Gloucestershire, and provides an equivalent children and young people s counselling services in Bristol. Full year cost to CCG 15,000 (plus investment from Public Health of 25,000 see below). b) To develop Tier 2 CAMHS services by investing in two additional Primary Mental Health Specialist posts. To be employed through the CAMHS service (NBT) but embedded within Youth Intervention Support Services (South Gloucestershire Council) in the Children s Hubs, providing support and consultation to those teams and to schools/other agencies, together with undertaking specific interventions with young people, including young people who would not meet the traditional Tier 3 threshold. This proposal is in keeping with the future direction of Integrated Children s Services within the Council. The Council aims to add further capacity to this tier of provision and will in the Autumn consider a business case for a Mental Health Specialist within the Families in Focus service (Troubled Families) to be funded from Payment by Results income. Full year 5
cost to CCG 109,000. What outcomes will this support? (please embolden as many as relevant) Stage of the patient pathway supported (please embolden as many as relevant) What will success look like? Financial implications summary Project 2 increasing capacity of Tier 3 To increase capacity in the Tier 3 specialist CAMHS service in order to keep pace with demand. NBT as the current provider has identified Consultant Psychiatry time as the priority for investment. This will in particular help to reduce waiting times for specialist assessment and diagnosis. Proposal is to introduce additional 0.5 wte Consultant Psychiatrist. Full year cost to CCG 64,000. Quality ED Attendances Emergency Admissions Occupied Bed Days Emergency Elective admission Occupied Bed Days Elective Outpatient Activity (new or follow up) Service Change/ Infrastructure Other (please state) Prevention/ Early Intervention Access to Care Diagnostics Care Management Complex/ Crisis Aftercare/End of life Other (please state) Children and young people will have access to comprehensive, timely and effective mental health services which can meet their needs, and which prevent further escalation of their difficulties. Schools, GPs and social care teams will be supported in the care of children and young people experiencing emotional distress, with easily accessible consultant and advice from Tier 2 services, and access to face to face counselling services for those young people who need them. Project 1 Tier 2 expansion a) Counselling pilot full year cost to CCG 15,000 per annum. 25,000 per annum investment has been offered by South Gloucestershire Council Public Health as part of the mental health programme. This investment is dependent on matching investment from the CCG, and collective progress towards a more comprehensive model of children and young people s mental health services. Estimated costs for 14/15 (based on 7 months implementation) CCG 9,000, Public Health 15,000. 6
b) Primary Mental Health Specialists - 109,000 per annum. Estimated costs 14/15 (based on 6 months implementation) 54,500 Project 2 increasing capacity of Tier 3-64,000 per annum. Estimated costs 14/15 based on 6 months implementation 32,000. Total CCG investment required 188,000 per annum. Estimated costs 14/15 assuming all three proposals progressed, 95,500. Benefits realisation Engagement / Key Stakeholders Top 3 Risks and mitigation What resources will be required? Impact on other service areas Performance monitoring and KPIs Improved mental health. Greater satisfaction with services. Earlier intervention in mental health problems preventing escalation, and reducing use of adult mental health services in later life. More efficient use of CCG resources 2014-16. Fewer residential school placements. Successful re-procurement of community children s services in 2016. Local Authority Schools Children and young people Families GPs Voluntary sector Available investment insufficient to allow successful reprocurement of community children s services. Mitigation continue benchmarking work and review service models as part of re-procurement process. Creation of counselling service separate from other community health services increases fragmentation of care pathways. Mitigation explore inter-relationships between services during pilot phase and make recommendations for re-commissioning. Additional investment as outlined above. Commissioning resource from CYPM Team. Local Authority Public Health and commissioning resources. Development of primary mental health services for children needs to link with other family support services and be able to operate within local Safeguarding processes Potential for positive impact on adult mental health and criminal justice services in the future Children s Trust Board and SOG 7
Any Other Comments: QIPP Proposals - Business Case Template KPIs re parent satisfaction, response times, referral acceptance, goal attainment, reduction in out of area spend. Please note that assessments in the following areas will be required before final agreement that this project can go ahead: Prioritisation tool review and financial impact please complete Appendix 1 embedded below (both worksheets please) Equalities impact assessment Environmental impact assessment 8
South Gloucestershire CCG Operational Plan/QIPP Proposal Assessment Framework Title of Proposal: Improving Community Mental Health Services for Children Score 0-10 Parameter Scale (pick from drop down Weighting list) Low (0-3) Medium (4-7) High (8-10) Fit with CCG strategic aims and framework, 2014/15-2018/19 Little or no direct fit. Strategic priority already met. Fits with strategic framework but not a priority for 2014/15 Close fit with strategic framework and action required for 2014/15 TOTAL 10 25 250 Obligation to Commission Good practice. NICE interventional procedural guideline NICE clinical guideline, National Strategy, Improving Outcomes Guidance. Significant risk of litigation. Statutory obligation 8 25 200 Outcomes Health Inequalities Support from Strategic Commissioning Partners Strength of Evidence of Effectiveness Quality Improvement No link to priority outcome(s) defined in the JSNA. Links to national or regional or local outcome which is already being achieved. No or little impact on identified health inequalities identified in the JSNA. Little or no support from strategic partners Contrary evidence. No or limited evidence of quality gain. Unmet local or regional (SHA) or shared LA JSNA outcome. Impact on key health inequalities identified in JSNA and affecting quality of life Supports integration of services with the Local Authority or is supported by neighbouring CCGs for shared services where differential priorities are not operational possible / viable Evidence of benefits based on local or national pilot / service that proposal will be successful in achieving suggested targets / outcomes. Credible research evidence. Reasonable evidence of impacts on quality of life. Achieves key quality improvement indicators within top quartile nationally. National mandatory outcome as defined by the Commissioning Outcomes Framework. Area within the JSNA where current performance falls below expected standard. Impact on key health inequalities identified in the JSNA and affecting life expectancy Strongly supported by the Local Authority and neighbouring CCGs as a shared priority. This includes facilitating the integration of services. NICE TAG or grade one research evidence of benefits. Strong evidence of quality improvement equivalent to or greater than NICE threshold. Improves life expectancy, offers a cure or supports self management. 8 25 200 8 20 160 10 20 200 8 20 160 9 25 225 Promotes Independence Does not promote independence or reduce demand for other services. Contributes to independence and reduces demand for additional services. Strongly contributes to independence and reduces demand for additional services. 9 20 180 Affordability and cost effectiveness No or limited evidence of cost effectiveness or currently unaffordable for the CCG. Reasonable evidence that the proposal provides a cost effective return on investment and is currently affordable to the CCG. Strong evidence that the proposal provides a cost effective return on investment and is currently affordable to the CCG. 7 25 175 Consideration of Alternatives Alternative options / treatments available which achieve equivalent outcome and are more cost effective. Limited alternative options / treatments available which achieve equivalent outcome and are more cost effective. No alternative available. Significant risk (clinical, financial, litigation or reputational) in not proceeding. 7 15 105 Timescale Benefits will not be delivered within the period of the 5 year strategy. Benefits will be delivered in 3-5 years. Benefits will be delivered within two years. 8 10 80 Patient Experience / Public Engagement Number of People Who Will Benefit (not numbers treated) Risk Supports CCG statutory functions No or little evidence of public support or that proposal resolves area of significant public concern Evidence that proposal meets area of significant public concern (e.g. significant area or complaint or where access is problematic) Identified as priority based on formal public consultation / NHS national surveys 10 20 200 0-500 500-2500 2500+ 10 15 150 The probability of a successful implementation is low. Little impact on CCG performance or meeting statutory functions The probability of a successful implementation is medium. Directly improves CCG performance The probability of a successful implementation is high. Impacts on key statutory functions and / or business viability 8 20 160 8 15 120 TOTAL: 2565 Key to colours: Maximum: 3000 9 Significant criteria - consider rejection of proposal Significant criteria - consider approval of proposal unless more effective alternative exists