Essex Joint Strategic Needs Assessment for Children s Emotional Well-Being and Mental Health EXECUTIVE SUMMARY
CONTENTS Page number 1. INTRODUCTION 1 2. OBJECTIVES 2 3. SUMMARY OF THE CONTENT INCLUDED IN THE FULL REPORT 3 4. SUMMARY OF MAIN FINDINGS 3 5. CONCLUSION AND SUMMARY OF RECOMMENDATIONS 6
EXECUTIVE SUMMARY This document provides a brief summary on the work that has been carried out to produce a new Joint Strategic Needs Assessment for Essex, together with information on the main findings, conclusions and recommendations from the work undertaken. For further details on the information outlined here, please see the full report. 1. INTRODUCTION In 2013 Essex County Council in partnership with health commissioned Mental Health Strategies, a national organisation specialising in mental health, to write a CAMHS Joint Strategic Needs Assessment (JSNA) for Essex, which includes Southendon-Sea and Thurrock. This JSNA report will replace the previous needs assessment completed in 2005. The JSNA will support commissioners in Essex to redesign and remodel emotional well-being and mental services to address the inequalities in current provision for children and young people. This work will help Essex to achieve its ambition to commission an integrated emotional well-being and mental health service for children, young people and their families to ensure that the best quality of care and outcomes can be achieved. Since April 2013 Clinical Commissioning Groups (CCGs), Essex County Council (ECC), Southend-on-Sea Borough Council and Thurrock Council are responsible for planning, designing and commissioning local health and well-being services on behalf of the Essex population. To develop a pan Essex approach, all commissioners need to be aware that Essex has a complicated infrastructure in that North Essex has three CCGs: Mid Essex, West Essex and North East Essex and South Essex has four CCGS: South East Essex, South West Essex, Thurrock and Southend-on-Sea. Local authority responsibilities lie with Essex County Council, Thurrock Council and Southend-on-Sea Borough Council. Essex County Council area also comprises of twelve district, borough and city councils. 1
In addition to the complex commissioning picture, there are a number of providers of CAMHS across Essex: Tier 1 provision is delivered through a range of universal services provided by the NHS (GPs for example), local authorities and the voluntary and community sectors Tier 2 provision, commissioned by the appropriate local authority, is delivered by SEPT in Thurrock and Southend. In the ECC area, some Tier 2 provision is provided directly by ECC (including Lionmede for example), Local Delivery groups and the Clinical Commissioning Groups The voluntary and community sectors provide Tier 2 services pan-essex focusing on early intervention and early help, largely commissioned through the Clinical Commissioning Groups, Family Innovation Fund and Local Delivery Groups CAMHS Tier 3 is provided by both NEPFT and SEPT A specialist LD and CAMHS service is provided by SEPT A Crisis Outreach Service is provided within both NEPFT and SEPT Tier 4 provision is commissioned from NEPFT and SEPT, which subcontracts specialist beds as required. This means that there is a need to work collaboratively across a whole range of organisations to deliver effective CAMHS provision which meets local need. 2. OBJECTIVES The objectives set out in the specification for this review were to: Identify the unmet mental health needs of children and adolescents in Essex Provide epidemiological information on the prevalence of mental health problems Make recommendations to meet those unmet needs. While the previous needs assessment conducted in 2005 focused mainly on the wider policy context surrounding CAMHS, this updated version was required to give insight into the broader spectrum of emotional health and well-being and service provision. 2
3. SUMMARY OF THE CONTENT INCLUDED IN THE FULL REPORT The work completed for this JSNA includes the following: A summary of national and local research on the importance of emotional health and well-being Local contextual information A summary of relevant national policy and legislation A summary of NICE Guidance on mental health and emotional wellbeing services for children and young people Current and projected populations Estimates of the prevalence of mental health disorders Mapping of the known CAMHS services in Essex An analysis of patterns of access to services The results of the consultation process to identify unmet need Analysis of workforce numbers 4. SUMMARY OF MAIN FINDINGS We have summarised here the main findings from the work undertaken to prepare the JSNA, but would like to emphasise these are only based on the work undertaken for this JSNA; most notably data analysis to identify current access to services, and a consultation process to identify unmet need, and do not result from any direct work with providers to review the operation, quality and outcomes of individual services. It is also important to note that feedback collected both as part of this JSNA, and from earlier consultations, does include many positive comments about individual services. The work required for this JSNA was specifically around identifying need and service gaps, and was not a review of service quality. Findings Our work for the JSNA has identified that there is a complex, fragmented and poorly understood set of services in place across Essex for children and young people with poor emotional wellbeing and mental health difficulties. There is a high degree of concern in many groups of professionals about existing access to CAMHS services for the children and young people with whom they work. This is evidenced by the high numbers attending the workshop in May, and others who have since been in contact to raise issues. In terms of service user experience, this complex picture of provision has resulted in differing access criteria and service delivery, with a lack of clarity on pathways between services. This is also difficult for professionals to navigate. 3
There is no overall coherent integrated strategy for Essex CAMHS services within which services are commissioned, and we found little evidence of wide spread use of care pathways across services. Although our role was not to review operational processes, there were obvious tensions between services, and a lack of clarity about the roles of the tiers, especially Tier 2. These are the most fragmented, yet seemingly cover a very broad range of need, with some elements of service delivery being from multiple professionals, and therefore more appropriately classified as a Tier 3 intervention. We have had significant difficulties in piecing together even a basic set of information about the numbers of children and young people accessing services. This is partly due to the fragmented approach to commissioning these services evident across the county. When data has been provided, the quality is generally poor, and several providers have resubmitted information to us following challenges about its accuracy. We have been unable to fully map the access to services for any particular group. The countywide consultation events did result in a consensus about the three key priorities for improvement in services. These were: The need for early intervention More support for schools in dealing with pupils emotional wellbeing and mental health difficulties The need to work more with families rather than just the child There are an increasing number of lower level mental health and emotional wellbeing services being commissioned by schools, but there is limited understanding of the extent of this provision. Statutory universal Tier 1 services are already well established as part of an integrated pathway, with appropriate referral, quality, supervision and governance arrangements, and the challenge now is to make sure these newly commissioned services are similarly incorporated in local CAMHS service pathways. The current fragmented picture of provision of Tier 2 services seems to cause the most concern amongst professionals, with inadequate clarity on the remit, availability and referral criteria of these services. There was a consistent message that staff struggle to gain access to Tier 2 services for the children with whom they work. It has proved very difficult to get a robust set of data from ECC Tier 2 services to use for this JSNA. The service does collect data, but this has included numerous errors, and we have been provided with several version of the basic data set. 4
Staff within the ECC Tier 2 service report pressures in providing large, but currently unquantifiable levels of time providing consultation to other services. The data collected shows a high number of recorded consultations. These do form a valuable preventative service, but there does need to be an evaluation as to whether this consultative role actually results in a reduction in the numbers of children and young people requiring direct CAMHS interventions. The information about the numbers accessing Tier 3 services is more complete than for Tier 2, but the providers collect slightly different datasets which has hampered the development of a full picture of service access. There does appear to be significant differences in the numbers accessing Tier 3 services across Essex, but it is difficult to establish from data alone whether these patterns represent true variation. The data we have received suggests that overall access to CAMHS Tiers 2 and 3 appears to be below expected levels, and the balance between Tier 2 and 3 services is not as expected for the tiered service model. However we are aware there are gaps in the available data. Although we have done some analysis of workforce numbers and workload, given the gaps in information, together with the difficulty in measuring caseload intensity across services, the results provide limited intelligence. This will be better performed within individual services. Given the difficulties in accessing the full data sets from providers, we had hoped to use data from the referral gateways. Problems were again encountered here too, as SEPT and NEPT who manage the services both collect slightly differing datasets, and there are some areas of poor quality recording. The gateway data does show that one fifth of all referrals across both trusts are for individuals who have already received interventions. This may well be good practice if they relate to individuals who have been discharged after a first completed intervention, and then referred back at a later stage, but this needs investigation. During the range of consultation meetings and events, there was not a single reference made by any professional regarding access to Tier 4 services. This might be because of the small numbers of individuals requiring Tier 4 interventions, meaning there would be very few in any geographic area, or it might be that those few staff who have any links with Tier 4 services did not attend any of the events. 5
CONCLUSION AND SUMMARY OF RECOMMENDATIONS The CAMHS JSNA now provides Essex commissioners with some of the key information required to ensure that appropriate services are in place to meet the mental health and emotional wellbeing needs of children and young people in Essex. This information includes: the national policies and legislation which set out what should be delivered best practice clinical guidance as published by NICE our best estimates, based on current research, as to the potential numbers of children and young people, both in total and in specific high risk groups, who might be in need of services. However, the JSNA currently provides an incomplete picture on the full range of services across Essex, and the existing numbers and demographic profiles of those children and young people accessing existing services. The significant difficulties that have been encountered in trying to complete those sections, and establish a profile of the current patterns of service, has in fact starkly illustrated the view of professionals elicited during the JSNA consultation. Existing CAMHS service provision has traditionally been complex and fragmented, and recent structural and governance changes both have, and will in the future, result in an equally complex profile of commissioning. This has resulted in a challenging environment within which professionals have to work, and most importantly results in difficulties in access to services for children and young people with emotional well-being and mental health needs. Tier 2 services currently appear to cause the greatest concern, with a multiplicity of providers, and a lack of clarity about many of the services roles, referral processes, and access criteria. However, there are also a lack of pathways from Tier 1 services, difficulties in movement between Tier 2 and 3 services, and a lack of understanding of interconnection with Tier 4 services. Feedback collected both as part of this JSNA, and from earlier consultations, does include many positive comments about individual services. Overall, the most significant concerns raised during our work have been about access to services, and not service quality and outcomes. However the current pattern of provision of CAMHS services across Essex does not appear to be a result of a coherent strategy, and there is an absence of common set of pathways and outcomes. Within such a framework, there then can be the 6
opportunity for local tailoring of services, but at the moment the service profile and existing, albeit incomplete, patterns of access illustrate considerable variation and inequity of service provision across Essex. The establishment of the new joint commissioning forum (JCC), together with the county wide stakeholder partnership provides the opportunity to develop that strategic focus. Commissioners report that there have been consistently expressed views on how to improve services which will shape the strategic review recommendations. Clearly active participation from all parties will be essential, and this engagement can now be secured through the new local authority public health responsibilities. We have made a number of recommendations which are as follows: 1. Commissioners need to put in place a full strategic review of CAMHS services across Essex, with the objective of delivering recommendations which will result in better integrated services and clarity on pathways of care. 2. The commissioners need to agree, potentially through the newly established JCC, an outline performance framework that enables a common set of data to be collected about individuals accessing service. This can be used to revalidate the data used in Section 11 on levels of access to services, and ideally, to start to map the access of some of groups identified as being at particular risk of developing mental health problems. 3. Following the development of the outline performance framework for data collection, the health and social care commissioners should review whether this should be further developed and implemented as a full shared performance management and contract management framework across all CAMHS contracts. This will enable the expertise of specialist CAMHS commissioners to be shared across all organisations. 4. Commissioners need to ensure that they have access to appropriate skills, and a robust process in place to routinely review and challenge information which is provided to them as part of the contract monitoring process. 5. Information on CAMHS services across the county needs to be more widely publicised to all professionals working with children, to help provide clarity on service provision, referral criteria and care pathways, and facilitate better access. In particular, those working in universal services need more assistance in navigation through CAMHS services. 7
6. Commissioners and providers need to put in place a process by which information on service gaps for specific groups can be collated to feed into the commissioning process. 7. Commissioners need to undertake a stocktake, and map all commissioned Tiers 1 and 2 mental health and emotional well-being services being delivered within schools and across the community by the voluntary sector, and work with those providers to ensure they are integrated into local CAMHS service pathways. 8. Review and clarify the role of the ECC Tier 2 service in the provision of consultation to other services, to ensure that it is effective in reducing the numbers of children and young people requiring direct interventions from CAMHS services. 9. ECC Tier 2 Commissioners and the provider should work together to improve the data quality for this service, and agree a basic dataset on users accessing the ECC Tier 2 service. This data should be regularly reviewed to better understand service performance and trends. 10. Commissioners also need to ensure that the gateway services, both existing and newly established, although operating differently, do collect a basic common data set which can support future service reviews, and build up a picture of unmet need via analysis of rejected referrals. 11. Commissioners need to fully understand the range of Tier 4 services now being commissioned by NHS England, and ensure that there is clarity around the role of home treatment which operates between Tiers 3 and 4. 8