Birmingham Specialist CAMHS: Service Redesign This is a big piece of work involving substantial service reorganisation Engineering this change is a complex process, and this is a work in progress But… We are excited about it…. And we hope that you will be too

Strategic Context NSF Every Child Matters Brighter Futures Birmingham Commissioning Strategy Key messages around integration of services, improved access, partnership working, focus on outcomes

Strategic Context Programme of organisational development Improve Access to Excellent Services Develop a transformational culture Improve relationships with partners Developing CAMHS as a flexible learning organisation, capable of adapting to the demands of a changing landscape. A lot of work has had to be undertaken to get us to the point where we are able to move forward with service development and redesign (including a sorting out of transactional elements eg financial position, but also beginning a program of organisational culture development. TL programme Ties in to our 3 high level strategic goals. First goal, captures our aim that we deliver on access targets but not at the expense of quality. Service design has to contribute to the sustainability of timely access, and we are committed to doing this, but we do not want to be preoccupied with targets at the expense of quality issues Need to be adaptable, to be flexible and to be a learning organisation. A transformational culture is necessary to achieve our aims, and manage change creatively. I believe that it is cultural change rather than structural change by itself that will transform services. Similarly, Partnership working is not just about sharing capacity, but is something that is good for children and families, and delivers better outcomes

Developmental Programme Transformational leadership programme Engagement with staff around organisational change 18 week reference group: capacity analysis and benchmarking Dialogue with partners Developing a shared vision Speak briefly to each of these. TL building leadership capacity throughout the organisation (not just at DMT level. Engagement with staff – tap into pool of skills and knowledge. Staff ownership of change 18 wk Critical work stream, both in clearing up the backlog, but also the work of capacity analysis, and transparency of measurement systems, to facilitate forward planning. Ongoing re-iterative process

Consultation Process Service Design Group Integration of service user views Whole Staff Group Away Days “Tiger Teams” Professional groups/disciplines Locality MDTs LAC and LD MDTs Partner agencies and commissioners The tight time scales mean that some of this work of multi-stakeholder engagement is still in the pipeline SDG links back to respective groups they represent as well as internal dialogue Think about how changes play out at professional/disciplinary and locality/specialist levels (horizontal and vertical integration)

Critical Issues threshold and demand structure and internal capacity segmentation partnership working equitable access. The service model needs to address the challenges posed by these key areas. Provide a service that is coherent, understandable to referrers and partners, and families, consistent and equitable, and can sustain the access targets we are required to meet. The consultation process has also raised some challenges that need to be addressed in relation to some key groups that use the service, both in terms of the strain on capacity, and in terms of the quality of service that we are able to offer to these groups.

Additional Key Issues Neurodevelopmental disorders: ASD ADHD Access systems Effective Communication Some further specific questions have been raised as part of both our capacity work and the work on service design which require consideration in a strategic context. These have a common thread in that they are issues which concern not only BCH CAMHS but also a number of other partner agencies. They are issues where the boundaries between specialist, targeted, and universal CAMHS services are unclear, and where solutions will require a creative approach to partnership working: Autistic Spectrum Disorder (ASD) There are large numbers of children in Birmingham who have an Autistic Spectrum Disorder. It has been acknowledged for some time by front-line staff that, whilst there are a range of resources in place, there is no clear differentiation of roles and coherent multi-agency care pathway. One possibility might be to explore creative alternatives to a referral driven system that tends to create a “yours or mine” mindset, such as joint clinics and consultation. Another possibility would be to consider whether the current absence of a dedicated neuro-developmental service at the hub of a multi-agency care pathways represents a “hole” in current commissioning. It is difficult to envisage how we can create an adequate multi-agency service for these children without further investment or significant contraction of some other part of the service, or a radical rethinking of how we reconfigure services for this group. Looking at other services for benchmarking, there is some variation, but certainly a number of specialist CAMHS services nationally stipulate that they will participate in multi-agency management of children with an ASD, but not as the lead agency, unless there are serious concerns about the child’s mental health Attention Deficit Hyperactivity Disorder (ADHD) Large numbers of children are referred to CAMHS with ADHD. In the majority of cases, medication or a mixture of medication, therapeutic interventions and behaviour management advice and programs for parents has proved to be the most successful treatment package. Once behaviour is stabilised, for many of these children there is no need to remain as CAMHS patients, other than for medication reviews, which can be done by GPs. However GPs do not currently accept this responsibility (with a very few exceptions) and valuable CAMHS medical time is taken up in writing repeat prescriptions and providing physical check-ups for large numbers of children, who often continue to be seen until their 16th birthday. GP prescribing would potentially spread the load between a relatively large number of GP’s rather than, as currently, a very small number of Child Psychiatrists holding large caseloads of such children. I do not feel that we have cracked this one yet. We really need to come up with a model that meets the needs of this group, whilst being sustainable in capacity terms. This will require a shift in thinking, different models, and a genuine partnership approach to the problem, with the development of joint working protocols.

Key Features of the emerging model: Integration of specialist community CAMHS into a single system into support to universal services, targeted services, specialist services, emergency and high intensity services (inpatient services) staff may engage in a range of clinical work that includes complex cases, early intervention, and consultation work. Single waiting list for specialist CAMHS organised by area. (Likely area configuration six hubs – 2 per locality) (T2 and T3 not separate services with own W/Ls etc). Capacity segmentation organised around a functional division of work (not personnel) Vertical integration combined with smaller area base. Although not all staff will be evenly distributed in terms of which bits of the functional system they work in, specialist CAMHS clinical staff will not work exclusively in only one area, and in principle Much thought and debate has gone into this, aimed at balancing the critical mass and range of clinicians necessary to handle the range of problems tasks and clinical risk inherent in specialist work, with a wish to develop more effective local relationships with partners, and the feeling that locality areas are too large for this as a single entity.

Emerging model (cont.) Hub and spoke model. Need to develop alternatives to a pure referral driven reactive model. Reduction in the number of registered cases, and more children and families seen in appropriate settings. Hub and spoke model. Central accommodation to house the MDT and provide generic and specialist clinical space. Additional access for families via “spoke” sites for local delivery of appointments (where clinically appropriate). Families routinely offered choice (not all services and appointment times will necessarily be available at all sites). There is room for debate as to whether BEN and South as large geographically dispersed localities should retain two “hubs” as currently. Need for alternatives to a pure referral driven reactive model. This is both in the sense of contributing to Early Intervention and preventative work, and consultation to the broader “comprehensive” network, but also developing a model of shared management of more complex cases in a variety of ways. (e.g cases may be simultaneously actively open to more than one agency – to a greater extent than happens currently – with a shared multi-agency plan, where specialist CAMHS contributes a specified limited role, not necessarily as lead agency. This might be via referral or consultation/joint clinic working models, link to development of neurodevelopmental services). This activity should aim to reduce the number of cases being referred in by enabling them to be appropriately supported and held outside the specialist CAMHS system. It is intended that much of the targeted work will be delivered without need for a system of written referral, formal assessment and case management. Streamlined access.

Development of clearer integrated multi-agency care pathways Development of a clear consistent set of criteria specifying the range of specialist assessment and treatment services, and targeted services Development of clearer integrated multi-agency care pathways Incorporation of a stepped care model – progression from less intensive to more intensive treatments. There needs to be clear criteria specifying the core business of assessment and treatment services, and targeted services. Incorporation of a stepped care model (including some expectations of what steps will have been taken prior to referral before a case will be accepted by us), and standardised evidenced-based interventions for specific presentations, but integrating with a more bespoke “care package” approach to more complex cases (e.g. co-morbidity and diagnostic ambiguity) and a risk management framework that overrides stepped care expectations to deliver clinical safety.

Standardised evidenced-based interventions for specific presentations, integrating with a more bespoke “care package” approach to more complex cases, and a risk management framework that overrides stepped care expectations to deliver clinical safety. Redesign of access system to streamline processes and deliver clarity for referrers. Currently some very unlean processes which are also not good in terms of clinical engagement and service user experience. Avoid multiple “hoops”. Don’t need bureaucratic systems of formal referral, extensive information gathering, screening appointments etc, to then sign post elsewhere or pass to a targeted service.

Birmingham Specialist CAMHS: Service Model Inpatient and Regional Specialist Resource Services: Specialised Inpatient provision dovetailing services to need e.g. age and presentation Range of specialist resources, assessment, consultation etc Emergency and High Intensity Services: Self harm assessment and emergency urgent access systems to manage high risk cases Out of hours on call service High Intensity community support aimed at reducing the need for inpatient admission and facilitating early discharge Specialist CAMHS Services: Provision focussed on children and young people with moderate to severe mental health problems Emphasis on assessment, formulation, diagnosis and intervention Coordinated multi-professional resource Care packages built around individualised assessment of need Targeted Services: Highly accessible targeted interventions Provided in partnership with community services, schools voluntary organisations etc Universal Services: Ensuring all services have good awareness of the impact and contributors to child mental Health Provision of accessible information for children, young people, parents, and professionals Information regarding specialist and targeted services, and how to access support

Services Inpatient Services “Tier 4” Teams Emergency and High Intensity LAC LD Specialist services Partner Agencies Schools, comm paeds, BCC, Children’s centres, Health Centres, primary care, voluntary organisations etc

Thresholds and Referral Criteria Specialist Services: Emergency Deliberate self-harm Current suicidal behaviour within the community Acute psychotic presentation Severe mental health trauma Priority Risk management framework (Rapid Access) Expressed suicidal ideation/intent Severe depressive psychotic symptoms Eating disorders Recent trauma In addition a multidisciplinary assessment and treatment service will be offered to the following groups: Moderate to severe OCD Bipolar disorder Moderate to severe depression Post-abuse or trauma (with associated mental health difficulties) (“timely access”) PTSD Severe anxiety Moderate to severe disturbances of attachment and emotional development Complex neuro-developmental disorders (ASD and ADHD) presenting with co-morbidity or mental health difficulties meeting the criteria for a specialist intervention. Timely ie meet 18 weeks, but 18 weeks not the limit of our ambition for routine cases Specialist services will operate through a referral based access point There is currently a gap around provision of services for this group – diagnostic and parent support services for ASD, and ongoing management of medication issues for ADHD. There are a number of possible options: We can seek funding for the development of a neurodevelopment service (which could be part of our service or positioned elsewhere). We can seek to develop partnerships and joint-working protocols with partner agencies to create a virtual service, to which we contribute expertise and training, and assessment diagnosis and treatment, but with capacity added by greater multi-agency input. We can tighten our threshold criteria in line with our core business as a specialist mental health service. This means that some families who currently get a specialist service will not (though they may be able to access targeted services such as parent support, but those we offer specialist services to should get a better service. Still an issue around post-5 diagnosis We can offer a truncated more limited service for this large group that is tailored to capacity rather than offering a more comprehensive service, for example offering assessment only, or limited interventions. We can maintain the status quo, in which case it is difficult to see how we can sustain access targets without a major reduction in other parts of the service on a large scale. In addition due to burden of numbers the current provision for ADHD is already sub-optimal in terms of multidisciplinary involvement.

Targeted Services highly accessible, non referral driven services for children with early concerns / risks re: mental emotional health e.g. anxiety, behaviour / anger problems / developmental concerns Emphasis on partnership working: facilitating, collaborating, and providing evidence driven packages many of which would be high volume and would be delivered in partnership with other organisations e.g. voluntary organisations, schools, community services.  High volume Streamlined Greater emphasis on partnership working i.e. PW is embedded in the whole system, but particularly at the forefront in targeted services

Examples of targeted interventions: Parenting support: Triple P Early Bird Nurture groups Schools based interventions: staff support and targeted therapeutic groups Some targeted interventions may be delivered direct to children and families by specialist staff, some may be delivered by partner agency staff with support or training from specialist staff.

Further models of targeted services: Frankley Early Intervention Project: co-ordinated packages of support targeted at high deprivation difficult to reach populations. Development of Infant Mental Health Services as distinct strand (link with identified strategic priorities) as part of under 5’s services. Role of PMHWs. primary mental health workers integrated within the new structure. Role includes some direct clinical work as part of the job. Frankley: innovative early intervention project, in an artea of high deprivation with a difficult to reach group. Currently evaluating to explore potential for further developments based on the same principles. Developed from the ground up in partnership with local community services (health centre schools etc) Infant mental health: links with strategic priorities. East MHG funded pilot. City wide developments. PMHWs

Targeted services have the potential function, within the stepped care framework, of collecting information regarding children / young people who were more at risk and therefore more likely to require a higher level of care if targeted interventions were unsuccessful.  Targeted Services delivered largely in the “spoke” sites and community settings Emphasis away from this being CAMHS case work and therefore less emphasis on formal assessment, less detailed correspondence and  no expectation to attend case conference IEPs etc. Part of “lean” processes. Streamlined access for children, young people and families. i.e. can facilitate appropriate access to specialist services [note that targeted services may involve highly sophisticated specialist skills] Need to think about the skill mix issues for each of the service areas, but it by no means follows that the more specialist services have the higher level skill mix.

Contribution to Universal Services Consultation and Training Mapping the range of current consultation and training work offered: need to ensure this work is linked to the overall strategic model, including the function of enabling cases to be appropriately held outside the specialist CAMHS referral system. Will include infant and child mental health awareness, and awareness of services (specialist and targeted) and how to access them).

Implementation: Big piece of work Implications for accommodation strategy and interim accommodation arrangements Refining the detail Development of service specification and care pathways Retaining the partnership approach Culture change Phased process Lots of work has gone into the service design process to get us to this point, but the work still to do is substantial. Although we share a sense of urgency and a wish to progress change, it is crucial that we don’t rush things and get sloppy, we have to get each stage right as we go (or pay the price later) Structural change is not enough needs to build culture change and transformational approach to deliver real improvements