Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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Bolton Local Transformation Plan (LTP) Children and Young People’s Emotional Health and Wellbeing 2019/20 Refresh Authors: Sarah Whitehead, Commissioning Manager, NHS Bolton CCG Joanne Higham, Head of Strategic Commissioning for Children & Young People, NHS Bolton CCG
Children and Young People’s Emotional Wellbeing and Mental Health Local Transformation Plan Refresh 2019/20 1. INTRODUCTION 1.1. The Bolton Children and Young People’s Emotional Health and Wellbeing Local Transformation Plan (LTP) forms part of the overarching Bolton Health and Care Locality Plan1 which sets out the local vision and aims which directly support the development and delivery of the Greater Manchester (GM) Devolution programme. 1.2. Mental health difficulties in children and young people are associated with educational failure, family disruption, disability, offending and antisocial behaviour, placing demands on social services, schools and the youth justice system. Untreated mental health problems create distress not only in the children and young people, but also for their families and carers, continuing into adult life and affecting the next generation. Devolution has enabled Greater Manchester to collectively respond to the challenges outlined within Future in Mind (2015) 2and in doing so, make a step change in transforming mental health services for children and young people living in Greater Manchester. 1.3. Bolton’s LTP has now been in place for four years and is required to be refreshed in order to describe and reflect on local progress, confirming that funding has been spent in accordance with the original plan. The refresh provides a high-level overview of the future ambition of the locality to fully achieve whole system transformation in order to improve outcomes for children and young people with mental health problems. 1.4. The LTP reflects the strategic vision of Bolton Clinical Commissioning Group (CCG), Bolton Council, Bolton NHS Foundation Trust (FT), Bolton Community and Voluntary Services, Bridgewater Community Healthcare NHS FT, Greater Manchester Mental Health NHS FT (GMMH) and North West Boroughs NHS FT. The plan has been developed with Children and Young People (CYP) with lived experience of emotional health and wellbeing difficulties in addition to other key stakeholders such as Bolton Healthwatch who are pinnacle to system-wide engagement across the Borough. Delivery of the outcomes is only possible with significant joint working between all these partners and at scale across GM. 1.5. The NSPCC complete a review of all Local Transformation Plans3 with a focus on assessing the inclusion of therapeutic support/services for children who have experienced abuse and neglect. The following elements were used to review the LTPs and therefore will be taken into account for our LTP refresh: To what extent LTP’s recognise that mental health issues can be attributed to abuse and neglect Whether the needs analysis incorporates abused and neglected children The information contained within each plan relating to existing or proposed new services for children who have experienced abuse or maltreatment. 1 http://www.boltonccg.nhs.uk/media/3027/bolton-locality-plan.pdf 2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/ Childrens_Mental_Health.pdf 3 https://www.nspcc.org.uk/globalassets/documents/research-reports/transforming-mental-health-services- children-experienced-abuse.pdf Page 1 of 49
1.6. In March 2018, NSPCC released a Local Transformation Plan Toolkit4 which provides guidance to localities on how to design and deliver mental health services for children who have been abused. Bolton will use the information provided within the toolkit, in addition to examples of good practice from 16/17 and 17/18, to enhance the provision across Bolton for our most vulnerable children and young people. 2. STRATEGIC CONTEXT 2.1. The NHS Operational Planning and Contracting Guidance 2017-2019 5set out the requirements for CCGs to deliver and implement the Mental Health Five Year Forward View6. For children and young people, the three requirements include: By 2020/21, at least 35% of Children and Young People with a diagnosable mental health condition receive treatment from a NHS-funded community mental health service. Commission community eating disorder teams so that 95% of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases Increase access to evidence-based specialist perinatal mental health care, in line with the requirement to meet 100% of need by 2020/21, and ensure that care is in line with NICE recommendations 2.2. An overview of Bolton’s current position against the three requirements is detailed below: At least 35% of Children and Young People with a diagnosable mental health condition receive treatment from a NHS-funded community mental health service 2.3. Improving Access to Children and Young People’s (CYP) Community Mental Health Support and Treatment is a key priority for Greater Manchester (GM) and Nationally. The Five Year Forward View for Mental Health states that by 2020/21 there will be a significant expansion in access to high-quality mental health care for children and young people. Nationally this means that 70,000 more CYP are accessing treatment each year. This equates to almost 4,000 additional CYP in GM being treated over the 2014/15 baseline (applying 2004 prevalence rates). 2.4. In order to model current activity levels the tier 3 population base for 5 – 19 year old have been taken into consideration. 4 https://www.nspcc.org.uk/globalassets/documents/publications/local-transformation-plans-toolkit.pdf 5 https://www.england.nhs.uk/wp-content/uploads/2016/09/NHS-operational-planning-guidance-201617- 201819.pdf 6 https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf Page 2 of 49
Figure 1: Children and Young People’s Access Targets from the Five Year Forward View for Mental Health. 2.5. Below details a snapshot picture of Bolton and Greater Manchester’s progress to delivering the access target set within the Five Year Forward View for Mental Health. As at October 2018, Bolton were on track to deliver the 2018/19 access target of 32% Actual Number of Total number of CYP Percentage access CYP Receiving with a diagnosable rate (2018/19 treatment (YTD) mental health forecast outturn). condition 2018/19 Target 32% NHS Bolton CCG 1,470 6,484 32.5% Greater Manchester 14,605 59,099 35.5% Figure 2: Total number of Children and Young People receiving treatment as at October 2018 (defined by 2 or more contacts). Source - NHS Digital (MHSDS) Commission community eating disorder teams so that 95% of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases 2.6. Across GM there are currently three community eating disorder services operating out of four different sites for young people. Work is taking place to ensure all services achieving the national access and wait time targets by 2020, which current trends would indicate that is on track, although not currently being achieved. CYP Eating Disorder Waiting time - Urgent (rolling 12 months - quarterly for national & regional) Mar-18 Jun-18 Sep-18 ENGLAND 78.9% 74.7% 81.3% NORTH OF ENGLAND 78.8% 73.5% 81.6% GREATER MANCHESTER (ICS) 74.5% 81.0% 90.0% Page 3 of 49
Figure 3: Children and Young People’s Eating Disorder waiting times for urgent appointments as at Sept 2018 (Source – NHS Digital) CYP Eating Disorder Waiting time - Routine (rolling 12 months - quarterly for national & regional) Mar-18 Jun-18 Sep-18 ENGLAND 79.9% 81.2% 80.2% NORTH OF ENGLAND 85.7% 84.2% 83.4% GREATER MANCHESTER (ICS) 80.4% 82.8% 86.6% Figure 4: Children and Young People’s Eating Disorder waiting times for routine appointments as at Sept 2018 (Source – NHS Digital) 2.7. Building on learning each service has developed since being established, the GM CEDS Steering Group working to support the services to deliver care in a more consistent way across the conurbation. The aim is to amplify aspects of the services that are working well, and continue to reduce unwarranted variation between the services. Clinical and operational staff are meeting monthly, along with commissioners and VCSE representatives to further develop a GM’s CEDS service specification for autumn 2019 in advance of commissioning intentions being agreed. Increase access to evidence-based specialist perinatal mental health care, in line with the requirement to meet 100% of need by 2020/21, and ensure that care is in line with NICE recommendations 2.8. Future in Mind (2015) published by the Department of Health prioritised the enhancement of Perinatal Mental Health Service as a key step to promoting, protecting and improving children and young people’s mental health and wellbeing. 2.9. NHS England has committed to fulfilling the ambition in the Five Year Forward View for Mental Health so that by 2020/21 there will be increased access to specialist perinatal mental health support in all areas of England, allowing at least an additional 30,000 women each year to receive evidence-based treatment, closer to home, when they need it. 3. GREATER MANCHESTER (GM) COLLABORATION 3.1. As the Greater Manchester Health and Social Care Partnership has established it is clear that a considerable amount of Future in Mind transformation planning and commissioning is best done to scale across the GM footprint rather only at a single LA/CCG footprint. 3.2. As part of devolution, Greater Manchester made a clear commitment to develop the current provision of mental health services, working towards parity of esteem. This includes taking collaborative action in making full use of the targeted Children and Young People’s mental health investment in localities, clusters and across Greater Manchester; supporting activity Page 4 of 49
linked to refreshed Local Transformation Plans (LTPs) devised to deliver the ambition set out in Future in Mind (FIM) . This guidance emphasises the need for joined-up commissioning and provision. To support this system alignment, a Greater Manchester Future In Minds Delivery Group has been instigated as a consortium of all 10 x Greater Manchester Clinical Commissioning Groups (and will include 10 Local Authorities), with representation from the Strategic Clinical Network, NHS England Specialised Commissioning and Public Health. 3.3. A number of groups oversee and deliver the required changes (with representation from Bolton CCG and Bolton Council): • Greater Manchester Children’s and Maternity Commissioning Consortium • Greater Manchester Future In Mind (FIM) Delivery Group • Greater Manchester Mental Health Strategy - Children and Young People’s Mental Health Board • Association of Directors of Children’s Services (GM Children’s Services Review). 3.4. This collaborative approach across the 10 Local Authority footprints is enabling the sharing and implementation of good/best practice, development of consistent care pathways and quality standards, leading to improved quality and equitable services across Greater Manchester. 3.5. Working together CCGs/LAs are delivering more efficient use of resources by commissioning and delivering some services at scale. The costs of Specialist CAMH Services are unlikely to be reduced, but efficiency will improved as a result of an implementation of THRIVE informed service delivery which will result in increased throughput. Additional efficiencies will be delivered by reducing the numbers of professionals involved in complex families for whom managing risk is the primary support/intervention. 3.6. The announcements of extra funding to transform mental health services contained within the autumn statement (December 2014) and Budget (March 2015) were designed to help areas build capacity and capability across the system so that, by 2020/21, they can make measurable progress towards closing the health and wellbeing gap and securing sustainable outcomes for children and young people’s mental health. 4. CAMHS WORKFORCE 4.1. In order to sustain delivering increased access and improved outcomes for children and young people’s (CYP) mental health – as per the national must do - a significant expansion in the workforce (and associated investment) is required. Following publication of the Five Year Forward View for Mental Health (FYFVMH) and more recently Stepping Forward to 2020/21: The mental health workforce plan for England (July 2017)7, Greater Manchester (GM) is required to hold plans how it will grow the mental health workforce to enable us to deliver the FYFVMH objectives. 4.2. In addition, GM and its localities have recognised the potential risk to effectively delivering our ambitious children and young people mental health transformation plans are largely centred on the workforce. 7 https://www.hee.nhs.uk/sites/default/files/documents/Stepping%20forward%20to%20202021%20- %20The%20mental%20health%20workforce%20plan%20for%20england.pdf Page 5 of 49
4.3. In response a £1.4 million investment through GM transformation funding has been secured to ensure a clear strategy and associate plans are in place to mitigate the known risks. The Greater Manchester Children and Young People’s Emotional Wellbeing and Mental Health Workforce Strategy has been developed through consultation and engagement with a variety of stakeholders that included NHS Providers, Clinicians, CCGs and the GM Strategic Clinical Network – to name a few. 4.4. The scope of the strategy focuses on the specialist element of CYP Mental Health workforce – CAMHS. Over time and through the work GM transformation funded GM i-Thrive programme strategic planning will seek to develop strategies for the wider CYP workforce. The purpose of the strategy is to outline principles and solutions across four key domains: - Improving supply and retention Building skills and knowledge Talent development and system leadership Improve workforce welfare and wellbeing 4.5. To date all specialist GM NHS CAMHS services have undergone the Self-assessed Skills Audit Tool (SASAT) to map their existing provision in order that a clear understanding of both local and GM gaps are understood. The assessment provides full information on staff numbers including whole time equivalents, skills and capabilities. 4.6. Building on the SASAT and in order to meet the requirements and those of the Five Year Forward View for Mental Health and Stepping Forward to 2020/21: The mental health workforce plan for England, GM as an STP area has to submitted returns to NHS England on how we are planning to grow the CAMHS workforce to enable us to deliver increased access and better outcomes. Allied Total CAMHS Workforce Expansion Medical Nursing Health Clinical Greater Manchester (100%) 9 65 37 111 Bolton (10.1%) 0.9 6.6 3.7 11.2 Bury (6.5%) 0.6 4.2 2.4 7.2 Heywood, Middleton & Rochdale (8.0%) 0.7 5.2 3 8.9 Manchester (21.1%) 1.9 13.7 7.8 23.4 Oldham (8.1%) 0.7 5.3 3 9 Salford (9.5%) 0.9 6.2 3.5 10.5 Stockport (10.0%) 0.9 6.5 3.7 11.1 Tameside & Glossop (8.3%) 0.7 5.4 3.1 9.2 Trafford (7.4%) 0.7 4.8 2.7 8.2 Wigan (11.0%) 1 7.1 4.1 12.2 TOTAL 9 65 37 111 Figure 5: Greater Manchester CAMHS workforce expansion (2016-2021) Note: Workforce expansion by service area in Full Time Equivalents (FTE). The numbers provided are based on Public Health weighted capitation formulas to apportion the nationally agreed figures across Greater Manchester STP 4.7. The enhancement of an additional 111 CAMHS clinical staff across Greater Manchester, outlined above, will be supported by Greater Manchester Transformation funded uplift of 39 Page 6 of 49
additional clinical posts working within the Greater Manchester Crisis Care Pathway (REACH-IN). This combined growth sets an ambitious target to grow the workforce by a total of 150 clinical posts by 2021; ensuring a comprehensive CAMHS (up to 18yrs) to meet the population needs Bolton CAMHS Workforce Trajectory 4.8. Bolton CCG and Bolton CAMHS have been working collaboratively to address the proposed CAMHS workforce expansion targets. The following tables detail a piece of work undertaken by Bolton CAMHS in January 2019 to describe the current and expected workforce situation by the end of the Local Transformation Plan funding in 2020/21. Year One (18/19) Role WTE Allied Health Professional 2.8 Admin & Clerical 1.0 Nursing & Midwifery 1.4 Year Two (19/20) Role WTE Medical 0.40 Allied Health Professional 0.50 Admin & Clerical 1.00 Nursing & Midwifery 2.00 Year Three (20/21) Role WTE Allied Health Professional 3.00 Admin & Clerical 0.30 Nursing & Midwifery 1.00 Figure 6: CAMHS workforce expansion trajectory from 2018/19 – 2020/21 4.9. Based on the information above, a summary of Bolton’s expected workforce increase is detailed below: Role* WTE Medical 0.90 Nursing & Midwifery 4.90 Allied Health Professionals 7.50 Admin and Clerical 3.10 Total 16.40 Figure 7: Bolton CAMHS expected workforce increase by 2021. *All roles include the additional workforce from the Community Eating Disorder Service (CEDS). Page 7 of 49
5. BOLTON CHILD POPULATION 5.1. Over the next five years Bolton’s total population, currently 283,115, will increase by 7,400 people (2.6%), and by 2027 there will be around 12,800 more people (4.5%) resident in the Borough. The year 2031 is the first year our population will reach 300,000. This is a notably slower increase than we see nationally (6.9%) but is similar to the changes predicted for the Greater Manchester conurbation8. 5.2. In general, over the next ten years Bolton’s pre-school and secondary school populations will reduce slightly while there will be a small increase in the older teens group. The primary school cohort will remain fairly stable. Over the next five years the only significant change will be an increase in the secondary school population9 Population change between 2017 and 2030 for 0-19 year olds 2017 2022 2025 2030 Pre- School (0-4) 19,036 18,977 18,862 18,490 Primary School (5 – 10) 23,339 23,415 23,016 23,022 Secondary School (11 – 15) 17,277 19,474 20,108 19,442 Older Teens (16-19) 13,737 13,717 14,861 15,692 Total 73,389 75,582 76,848 76,647 Figure 8: Bolton’s population change between 2017 and 2030 for 0-19 year olds 5.3. The proportion of BME children is growing at a much faster rate than the adult population. This means that today 27.5% of Bolton’s children are from BME backgrounds. The ethnic profile of births has also seen a change in recent years with an increase to mothers born outside of the UK. Latest official data (2014 births) shows that 25.7% (966) of Bolton’s live births were to mothers born outside the UK (this is similar to Greater Manchester (25.4%) and lower than seen nationally (27.8%). Of these, the greatest number were to mothers born 8 ONS (2016) Subnational Population Projections, ONS 9 ONS (2016) Subnational Population Projections, ONS. Page 8 of 49
in the Middle East and Asia (525), followed by the EU (203), Africa (203), and the New EU (174)10. 5.4. As at March 2018, there were 615 Looked After Children (LAC) for whom Bolton Council has responsibility. This is 91 children per 10,000. The Looked After Children figures peaked in Dec 2017 when there were 630 children in care (93.5 per 10,000) This is an increase from March 2017 when the numbers were 580 (87 per 10,000 of the population) and is in line with an upward trend over the past 15 years 5.5. The figure below compares Bolton 2018 data with Bolton and North West 2017 data and highlights that Bolton has similar numbers of Looked After Children to other local areas (86 per 10,000) but the rates are higher than the national average of 62 per 10,000 children under 18 years. Figure 9: North West Comparison for Looked After Children per 10,000 population 5.6. A total of 155 of Bolton Looked After Children (25%) are placed out of area which compared favourably to the national average of 40% and is a reflection of Bolton’s commitment to placing children closer to home (see figure below). Bolton CCG retains responsibility for commissioning and monitoring health services for those children who are out of area. Figure 10: North West Comparison for the percentage of Looked After Children based out of Borough 10 The New EU. Joined in 2004: Estonia, Latvia, Lithuania, Czech Republic, Hungary, Poland, Slovakia, Malta, Cyprus (EU), Cyprus (not otherwise stated), Slovenia, Czechoslovakia not otherwise stated. Joined in 2007: Bulgaria, Romania. Joined in 2013: Croatia. Page 9 of 49
5.7. As at March 2018, there were 230 children and young people placed within Bolton by other authorities of whom health organisations have a duty to provide care11 5.8. Between 2016 and 2017, 187 children have received a Child Sexual Exploitation (CSE) service; this is an 8% decrease on the previous year. 10% of the young people who received a service were male; this is a 6% decrease on 2016 but remains percentage points higher than the 2014 baseline. 5.9. Bolton’s 2018 – 2020 Strategy12 for Child Sexual Exploitation was endorsed by Bolton Safeguarding Children’s Board and aims to: Reduce the likelihood of children becoming victims of child sexual exploitation Ensure action is taken to safeguard children at risk of sexual exploitation Target, disrupt and prosecute the perpetrators of child sexual exploitation 5.10. Further information can be found in Bolton Safeguarding Children Board’s (BSCB) Annual Report 2016 – 2017 (Appendix 1). An updated report will be published by March 2019 5.11. As at January 2018, a total of 24,347 children were classed as living in poverty in Bolton13 5.12. At the end of March 2018, Bolton had 3439 open Early Help Assessments (EHA), of which, 1898 EHAs started in the year and equates to 281 per 10,000 children 5.13. 265 children were the subject of a Children Protection Plan: 50% of Child Protection Plans are in place to reduce the risk of harm from neglect 34% of Child Protection Plans are in place to address emotional abuse 6.4% of Child Protection Plans are in place to address physical abuse 5.6% of Child Protection Plans are in place to address sexual abuse 3.8% of Child Protection Plans are in place for multiple reasons 6. NEEDS ASSESSMENT AND ACTIVITY ASSUMPTIONS 6.1 Within Bolton approximately 15,050 young people (aged 5 – 19 years old) may be eligible for CAMHS services at tiers 1 and 2 (services for more common (less severe) mental health needs). This is a very inclusive figure which covers children and young people accessing mental health support in mainstream services (e.g. school nurses) and may include children with emotional distress but below the threshold for a diagnosable disorder. 6.2 It is anticipated that at any one time around 80-90% of the total population of children and young people will fall into the needs-based grouping of thriving (based on Green et al (2005). In order to model the EHWB activity this assumption has been applied to the population of Bolton; 11 Source – Bolton Council noting this figure is reliant on notifications from other local authorities 12 http://boltonsafeguardingchildren.org.uk/wp-content/uploads/2018/04/Child-Sexual-Exploitation-Strategy- 2018.pdf 13 https://mss.carto.com/viz/064da52a-2edc-4b7b-a709-f3697a5928b0/public_map Page 10 of 49
Objective 2018/19 2019/20 2020/21 80% of the needs based group is thriving and 64% 72% 80% would benefit from EHWB support only. Bolton Activity Projections 9,632 10,836 12,040 6.3 There are 4,400 Children and young people (aged 5 – 16) in Bolton who are eligible to be seen by a NHS funded community mental health provider. Greater Manchester Mental Health NHS Foundation Trust (GMMH) in partnership with North West Boroughs Healthcare NHS Foundation Trust (NWB) provide Bolton’s community mental health service for children and young people aged up to 18 years. A further 1,990 16-19 year olds suffer from a common mental health problem. Within Bolton there are three community mental health providers Bolton CAMHS (0 – 18 year olds), IAPT (16 – 18 year olds) and Early Intervention in Psychosis 14 years old +. 6.4 The Five Year Forward View for Mental Health states that by 2020/21 there will be a significant expansion in access to high-quality mental health care for children and young people14. At least 70,000 additional children and young people each year will receive evidence-based treatment – representing an increase in access to NHS-funded community services to meet the needs of at least 35% of those with diagnosable mental health conditions. 6.5 CAMHS activity for 2017/18 averaged at 942 CYP per month and currently averages at 1986 per month based on 8 months of data for 18/19*. Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total 2016/17 1091 951 929 874 845 877 956 1086 913 963 966 1072 11523 CAMHS Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total 2017/18 Activity 774 973 961 944 797 892 991 994 846 1050 949 1141 11312 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total 2018/19 (Incomplete) 1460 1823 2053 2309 1858 1944 2141 2302 15890 Figure 11: Bolton CAMHS activity per month for 2016, 2017 and 2018. * Data from April 2018 onwards details the total number of contacts and includes multiple contacts with the same individual 6.6 The Did Not Attend (DNA) rate for 17/18 new CAMHS appointments averaged at 4.6% which was a significant improvement from 16/17. DNA rates for 16/17, 17/18 and Year to Date for 2018/19 are below the national average DNA rate. Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Average 2016/17 Did Not 8.5% 4.0% 5.7% 5.8% 8.0% 8.9% 5.0% 7.1% 3.4% 3.6% 2.6% 5.6% 5.7% Attend Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Average 2017/18 (DNA) - 4.1% 5.3% 4.0% 5.0% 4.9% 2.9% 8.7% 5.0% 5.8% 2.5% 3.5% 3.0% 4.6% New Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Average 2018/19 (Incomplete) Appts 6.0% 2.8% 3.9% 4.8% 6.2% 3.7% 2.3% 3.0% 4.1% Figure 12: % of appointments which resulted in a Did Not Attend outcome for 2016, 2017 and 2018. 6.7 The introduction of a text-based appointment reminder service continues to benefit children and young people who are supported by CAMHS. Approximately 95% of children and young people are signed up to this automated service. 14 https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf Page 11 of 49
6.8 Additional work needs to be undertaken to further clarify and develop whole-system pathways. The work plan for 19/20 includes: Continue to monitor data to ensure that CAMHS referrals are appropriate and that children and young people access IAPT and Early Intervention in Psychosis (EIP) age appropriate services. Develop whole system pathways for Anxiety, Depression, Self-Harm and ADHD Continue to implemented the recommendations from the Thematic review of young suicides in Bolton 7. GOVERNANCE 7.1 The governance structure to oversee the implementation of the CYP Emotional Health and Wellbeing transformation plan has recently been strengthened to include the wider children’s agenda. The LTP transformation will now be driven through the Emotional Health and Wellbeing Transformation Steering Group comprising of representatives from partners, stakeholders, provider, parents and young people from across the locality. This group will support the development and provide oversight with scrutiny to those schemes identified to deliver the CAMHS Transformation Plan. This group meets on a monthly basis and feeds directly to the newly developed Integrated Children and Families Steering Group with reports submitted to the Mental Health Strategy and Planning Group. Figure 13: Bolton’s governance structure for children and young people’s mental health 7.2 The Integrated Children and Families Strategic Group (formerly Children’s and Maternity Strategy and Planning Group) also meet on a monthly basis with senior representation from the whole system including commissioning, NHS providers, Voluntary and Community Page 12 of 49
Sector, Children’s Social Care, Education and parents, and feeds directly into the Bolton System Accountability Meeting. 7.3 The overarching outcome for the Integrated Children and Families Strategic Group is: “Giving our children the best possible start in life, so that they have every chance to succeed and be happy” 7.4 Key objectives of the Strategic group include, but are not limited to: To ensure fair and equitable access to services To ensure clinical sustainability To ensure services are focused on early intervention and prevention Commissioning and delivery of high quality, evidence-based services and interventions Developing sustainable and consistent service provision Providing care closer to home where clinically and financially possible Streamlining pathways to ensure seamless delivery of care and positive patient experience Working with patients and the public to co-produce future service models to meet the needs of the Bolton population Support financial sustainability Feed into the wider Greater Manchester and Bolton transformation work programmes 7.5 The Bolton System Accountability Meeting comprises of chief executives and senior representatives from Bolton health and care organisations. The role of this meeting is to provide system oversight of finance, performance and outcomes in order to drive the changes through to the Health and Wellbeing Board. This framework of oversight and scrutiny continues the theme of continuous improvement by leadership members from each organisation providing the transparency and governance at each stage through to Health and Wellbeing Board. 7.6 Appropriate Governance documentation including clear terms of reference, risk registers, action logs and reporting templates are in place to support the continued scrutiny of this work programme ensuring that the focus on outcomes for children and young people remains a key priority. 7.7 Bolton’s refreshed LTP has been further strengthened by its continued commitment to the alignment governance and transparency processes detailed within the Greater Manchester (GM) Mental Health Strategy15. This GM Strategy forms part of the GM shared Health and Social Care Partnership (HSCP) which is derived from the 10 GM CCG’s and Councils and is strengthened further by representatives from NHS England Specialised Commissioning and Public Health. 7.8 The Greater Manchester strategy focuses on: Prevention - with an understanding that improving child and parental mental health and wellbeing is key to the overall future health and wellbeing of our communities. 15 https://www.greatermanchester- ca.gov.uk/downloads/file/161/greater_manchester_mental_health_strategy Page 13 of 49
Access – improving our ability to reach all the people who need care and to support them to access timely and evidence-based treatment. Integration - many people with mental health problems also have physical problems. These can lead to significantly poorer health outcomes and reduced quality of life. Through the strategy we will aim to achieving parity between mental health and physical illness. Sustainability - In order to effect change for the long term the strategy will build on evidence from the innovations which have proven to have impact either in Greater Manchester or elsewhere, to challenge the way we plan and invest in mental health 7.9 Bolton is committed to inclusion both at a local level with our Bolton partners but similarly within the shared values of the framework of the GM HSCP Health and Wellbeing Strategy who have incorporated a whole system approach to meeting the individual needs of each member of the GM community; with the mental health needs of children having key priorities. 7.10 We will collaborate with GM’s other local transformation partnerships to further develop and implement a single performance and outcomes framework. The planned GM framework will draw from the best practice already developed by local transformation partnerships, and will be informed and shaped by the voices of children and young people. (Patient reported outcome measures). 7.11 The GM outcomes framework and overall work programme will also be informed by learning from the children and young persons’ IAPT programme and through continued work with local transformation partnerships to peer review and challenge implementation progress, spending and impact of transformation ambitions. 8. CHILDREN AND YOUNG PEOPLE INVOLVMENT AND ENGAGEMENT 8.1 Bolton continues to be committed to the involvement and engagement of children, young people and their families in the development and implementation of the transformation work plans that form our LTP. Engagement with Children, Young People, Parents/Carers and Stakeholders forms the basis of our need for change, development and continuous improvement. 8.2 Recognising that further work was required in our approach to engagement with children and young people we have listened and been active in our commitment to further develop this area of the work programme. This has included, for example, commissioned engagement projects through our Voluntary Sector Providers to engage children and young people who experience mental health difficulties to actively “tell us”, through a variety of methods. 8.3 During its initial stages, the CAMHS transformation plan was co-produced as a result of the Building Health Partnerships programme which ran during 14/15 – 15/16. Four events were held during this period and representation was sought from: Children and young people with lived experience of mental health services Bolton VCSE Local authority CCG NHS providers 8.4 The action plans from the Building Health Partnerships were presented to Bolton’s Youth Council who prioritised the actions which were then transposed to the Bolton’s LTP. Page 14 of 49
8.5 Children and young people continue to be central to our engagement process; ensuring we have a robust transformation plan; we have led on a number of projects including: Procurement of a new CAMHS provider for Bolton with a young person representative on the panel Thrive small investments allocated by children and young people Development of an Anti-stigma campaign Development of a mobile app which supports action planning with CAMHS Describing the vision of the new CAMHS pathways through a variety of forums One young person has been filmed explaining his involvement with Building Health Partnerships and this film was showcased on the Building Health Partnerships national roadshow during 16/17. Children and young people have contributed to the development of an investment panel to review ideas and innovations from a range of voluntary sector organisations and supported agreement for funding of small investment opportunities aimed at improving outcomes for children, young people and their families across the borough 8.6 We have also and continue to sought evidence from our partner agencies about how Bolton children and young people view our services; Bolton Young Voices group based at Bolton CAMHS meet regularly and their opinions are shared with the CAMHS Steering Group through the CAMHS Participation Lead. 8.7 A comprehensive consultation of Bolton CAMHS took place during 2016 by our partner Healthwatch Bolton; who identified themes for improvement which have formed the basis of our refresh of the Local Transformation Plan. Bolton CVS were commissioned to facilitate engagement with the community and voluntary sector in Bolton and spoke to a range of partners including groups working with young people with experience of mental health services to inform the new CAMHS Model. 8.8 In 2017, Healthwatch Bolton also produced an engagement report on Young Carers in order to provide an insight into their day to day lives and the challenges they face16. Following this, two events were organised in January 2018 for Young Carers Awareness Day to showcase the engagement work, celebrate the support that Young Carers offer in Bolton and to encourage key stakeholders to work together to improve the emotional health and wellbeing support for Young Carers. This work is driven by the Young Carers Partnership Group which reports into Bolton’s Carers Partnership Board. 8.9 Through the development of robust engagement processes, aligned reporting and joined up governance processes the outcomes of Bolton children and young people’s remain a key strategic priority. The increasing level of quality monitoring processes and systems which both recognise and affect change such as ROM (routine outcome measurement) which is embedded within CAMHS quality monitoring and reporting, continues to reflect the vision of constant quality that Bolton continues to strive for. 8.10 Whilst we have incorporated schools and colleges within our engagement for CAMHS re- design and re-development we recognise that active engagement within schools, colleges and early learning establishments is a process of continuous engagement, review reflection an change in order that we can support the emotional wellbeing needs and children and 16 http://healthwatchbolton.co.uk/wp-content/plugins/download- attachments/includes/download.php?id=1654 Page 15 of 49
young people alongside children and young people who may have these needs alongside mental health needs. 8.11 In December 2018, a collaborative CYP Emotional Health and Wellbeing Stakeholder Engagement Event was delivered by Bolton CCG, Greater Manchester Mental Health Foundation Trust and North West Boroughs Foundation Trust. This event was based around Thrive Principles and aimed to provide an opportunity for all staff across Health, Social Care and Education to understand the strategic landscape around Children and Young People’s Mental Health. A key piece of feedback from the CAMHS re-procurement was that stakeholders did not know what provision was available across Bolton to support the emotional health and wellbeing of children and young people; therefore, the event aimed to showcase a variety of organisations who are funded through Bolton’s Local Transformation Plan. Further information can be found on page 31. 8.12 The Greater Manchester Health and Social Care Partnership (GMHSCP) have agreed to an overarching engagement framework which makes the commitment to securing expertise by experience into each of the Greater Manchester (GM) based programmes. 8.13 In February 2018 the Youth Combined Authority (YCA) was established; the YCA is part of the Greater Manchester Governance structure and gives young people under the age of 18 years, the opportunity to shape, influence and scrutinise Greater Manchester’s practice, policy and plans. The YCA is made up of two representatives from each of the ten Local Authority Youth Councils and two representatives from each of ten additional selected organisations from across Greater Manchester all of whom are committed to youth voice and social action. The YCA is supported by the Mayor’s office and co-ordinated by Youth Focus North West. 8.14 The YCA has elected a Health Working Group made up of members of the YCA and additional interested young people from the constituent groups and localities. The priority theme of the YCA Health Working Group is Mental Health with the following work streams: Stigma, challenging perceptions and raising awareness Quality, making services young people friendly, both those provided within the NHS and other agencies. Training for professionals and young people on supporting young people (i.e. Mental Health First Aid training) within the NHS and other agencies. Spreading good services across Greater Manchester and addressing the postcode lottery. 8.15 Children and Young People from January 2019 are represented as members of Greater Manchester Children and Young People’s Mental Health Board (GMCYPMH Board, which seeks to support the young people’s priorities as far as possible through coproduction principles. 8.16 Members of the GMYCA and the Health Working Group will consider the needs of the diverse nature of young people and consider accessible methods to gather views of young people who may not feel comfortable in a meeting environment by: Identifying stakeholders and people who have contact with young people; youth workers, organisations Use the information gained from their host organisations and by speaking to other young people Page 16 of 49
Conducting surveys and focus groups Keep young people updated via the GMYCA Communications Strategy Social media Use a range of different platforms to spread information, because not all young people use social media Twitter – live chat hashtags Link in with Health-watch champions Presentations in schools and colleges 8.17 In addition work and training has been initiated to improve shared decision making by empowering young people voice’s in their own treatment decisions about their individual mental health and care and treatment. Shared decision making is a central element of the GM i-Thrive programme. 9. BOLTON AMBITION 9.1 Bolton is committed to the needs of all children and young people and notably those who may experience mental health difficulties; we have considered our original Local Transformation Plan and in light of the views of our children, young people and their supporters and we have recognised the further development required. There is a clear expectation that through the delivery of our LTP, we will achieve a significant expansion of provision and access to high quality mental health and wellbeing support for our children and young people and those who care for them. This means we must put them at the very heart of all that we do and remain focused on ensuring better outcomes, experiences and delivery of services that meet their needs. 9.2 As described above, we are working in a collaborative, integrated system that has and continues to require a comprehensive system wide approach. The key to delivery of the Bolton Vision 17to significantly improve outcomes with a far greater emphasis (including investment) in prevention and earlier intervention. This programme of system change will continue be delivered through a phased approach that addresses whole scale system changes and the development of a culture which encourages sustainability. We also acknowledge that this approach holds a number of challenges and as such we are aligning, driving and supporting changes at a Greater Manchester level. 9.3 We have worked with our colleagues in GM Crisis Care Partnership steering group and have been committed to making the necessary changes to how we support young people and children with mental health needs experiencing crisis. The developments in the Rapid Assessment, Interface and Discharge (RAID) process are one area that Bolton has sought to be committed and offer leadership. Bolton was integral to the development of a new On Call Mental Health Liaison Service for children and young people (previously CAMHS on call); ensuring that safe crisis care is provided for Bolton children and those in Greater Manchester irrespective of what day, time of day or place that the child or young person presents in crisis. 9.4 Through Bolton’s whole service audit and refresh along with its commitment to a Greater Manchester vision for children and young people with mental health need; Bolton is committed to ensuring that the services we commission seek to empower and strengthen the experiences of Bolton children. Ensuring that Bolton children and young people have a positive experience of childhood and develop a strong sense of person, resilience and wellbeing. 17 http://boltonvision.org.uk/ Page 17 of 49
9.5 Bolton has sought to eliminate the boundaries and challenges that the current mental health service tiered care service model has embedded, This current tiered care systems has at times restricted and limited the ability of a child or young person being seen by the most appropriate person or service; at the most appropriate time or suitable place. 9.6 Bolton has adopted the THRIVE Model of developing an emotional well-being and mental health service for children, young people and those who care for them that is supported by locality wrap around service. Figure 14: Thrive model of emotional health and wellbeing 9.7 The THRIVE framework18 was developed through research by the Anna Freud National Centre for Children and Families and Tavistock and Portman NHS Foundation Trust as the basis of their redesign approach to establishing a system to support CAMHS transformation; and is embedded in the NW North West (NW) Strategic Commissioning Network (SCN) which we are committed to. 9.8 The THRIVE Model will replace the tiered model of care and support with a comprehensive therapeutic model which aims to be reflective of need and reactive to a child or young persons need in Bolton as summarised below; THRIVING – Global Emotional Health and Wellbeing (EHW) sessions within community venues. Developing specific tailored EHW packages for the most vulnerable within the community for example BME, Not in Education Employment and Training, youth offenders and Looked After Children. To support this work it is anticipated that 15 – 20 % of specialist nurse/consultant support would be required. GETTING ADVICE (COPING) - Prevention services across 7 days accessible through a range of mediums and in a range of settings including the utilisation of the voluntary sector youth clubs. One off low level intervention and signposting to other services. GETTING HELP - Early Intervention and improved and timely access to support for a young person in distress. Aimed at reducing risk and enhancing early interventions. This evidence based approach will be underpinned by enhanced training and support for multi-agency teams who may be first responders or who are already engaged with the young person. Training will be via utilisation of MindEd within group sessions supported 18 http://www.implementingthrive.org/about-us/the-thrive-framework/ Page 18 of 49
by CAMHS professionals, supervision will be accessed via CAMHS and adult mental health voluntary sector providers. GETTING MORE HELP – Access to specialist services for example Eating Disorder. Follow up and prevention of future crises through effective multi-agency care planning, improved access to evidence informed interventions and increased delivery of help in community settings including a young person’s home. GETTING RISK (INTENSIVE) SUPPORT – A flexible crisis response with access to risk assessment, advice and support 24:7 from a confident and well trained multi-agency workforce with access to appropriate hospital and community based places of safety and/or intensive home treatment teams who can support young people in crisis in their own homes. 9.9 We will use the THRIVE framework to develop an emotional well-being and mental health offer for children, young people and those who care for them that is supported by locality wraparound services and provision that seeks to prevent a journey of escalation and/or increasing severity and complexity 10. THE BOLTON JOURNEY – 2018/19 10.1 Utilising the local transformation funding, Bolton has made progress and invested in expanding the capacity of CAMHS to ensure appropriate access for CYP in a timely manner. In addition, investment and service development have commenced within our community and voluntary sector provision as well as early help and intervention within other settings such as schools. A summary of the main work stream areas from 2018/19 is detailed below. 2018/19 Emotional Health and Wellbeing Training 10.2 Our partnership, like all across Greater Manchester, is continuing to promote the MindEd e- learning platform as a training resource for the whole workforce. MindEd is an educational resource for children, families and professional produce by the Royal College of Psychiatrists website19: MindEd has been included in the approved training programme for Bolton local authority funded schools. This approved training programme will also be shared with independent schools within Bolton. 10.3 Plans are to be developed to commence the systematic roll out of the MindEd tool to all children’s services in Bolton by utilising Local authority and voluntary sector links. A continuous rolling training programme will be developed to ensure that skills are kept up to date and that training needs are being met. 10.4 Bolton continues to progress the development of a mental health competency framework for all staff working with children and young people. The aim of this will be to ensure that all organisations can identify the level of training required for each staff group and also know where to access the training. The competency framework will allow us to identify gaps in training provision and assist with collaborative working across Bolton to commission new training opportunities. 10.5 Due to the enormity of a full CYP Mental Health training framework, Bolton’s Children and Young People’s Emotional Health and Wellbeing Transformation Group have agreed the following training priorities: 19 https://www.minded.org.uk/ Page 19 of 49
Suicide Prevention and Self Harm Adverse Childhood Experiences (ACEs) – Trauma aware and Trauma informed Wider workforce training on Children and Young People’s Mental Health 10.6 Within our Workforce Development Work Stream, assumptions have been made on the demand within Bolton. The resulting local workforce plans will be fed into Bolton's Strategic workforce group via the Integrated Children and Families Strategic Group. The workforce development programme is currently being developed which includes Develop and enhance the skills and knowledge of Bolton’s community voluntary sector workforce Promoting CAMHS and assisting in the recruitment and retention of staff Promoting the CYP IAPT model and recruiting a wider community workforce Development of an all age liaison psychiatry model Feeding into the wider GM workforce development Development of a GM IThrive hub. 10.7 Bolton have utilised the following Greater Manchester Training initiatives to support the local workforce: GM i-THRIVE Training Academy o 6 staff members attended the Shared Decision Making training which took place in January 2019. Transforming Care for Children and Young People o Greater Manchester have been chosen to become an accelerator site for Transforming Care for Children and Young People. o As a result GM has been allocated some money from NHSE to support implementation of the Transforming Care model and one of the key aspects of this is embedding a risk support model for CYP with LD and autism in every locality o A total of 20 staff have signed up to this training across Health, Social Care and Education Children and Young People – Increasing Access to Psychological Therapies 10.8 The Children and Young People’s Improving Access to Psychological Therapies programme (CYP-IAPT) is a change programme for existing services delivering CYP mental health care. It aims to improve outcomes and experience of care for children, young people and their families by increasing access to effective services and evidence-based therapies through system-wide service improvements. In order to deliver the improvements in access to effective care for at least 70,000 children and young people, CCGs and provider organisations will need to continue increasing the skills of existing staff and develop a new workforce, embedding the CYP IAPT principles and ways of working across teams Page 20 of 49
Below demonstrates Bolton’s CYP-IAPT contribution since 2016. Bolton have met the 20/21 CYP-IAPT target of 9.4 Figure 15: Bolton’s CYP-IAPT contribution 5–19 Children and Young People’s Integrated Health and Wellbeing Service 10.9 The 5–19 Children and Young People’s Integrated Health and Wellbeing Service provided by Bridgewater Community Healthcare NHS Foundation Trust and commissioned through Public Health has been operational since December 2015 and brings together a range of teams to deliver a cohesive package of care for children and young people in Bolton. 10.10 The service provides the following support teams to children and young people within Bolton: School Nursing Immunisation and Vaccinations Healthy Schools Looked after Children & Safeguarding Family Health Lifestyle 360˚ Young People and Families Substance Misuse The Parallel 10.11 The 5-19 service will continue to develop a programme of work promoting emotional wellbeing through the school-aged years working alongside Children and Young People to identify and support those with emotional and mental health difficulties with clear referral process to CAMHS where appropriate. The key areas of this developing work include; Processes, support and training to identify any mental or emotional health issues and develop appropriate Brief Interventions and onward referral as required. Development of training for Children and Young People focusing on improving emotional Wellbeing, resilience and survival of life events and access to appropriate emotional/mental health support. Further enhance provision of emotional/mental health support in Educational Settings for those Children and Young People identified as ‘thriving’ ‘getting advice’ and ‘getting help’ under the Thrive model, but not requiring a referral to the CAMHS service. 10.12 CAMHS nurses have also been recruited to provide school support with mental health education and training and providing a link into the specialist CAMHS service. It is anticipated that these nurses will also provide support to staff who deal with the most vulnerable children for example Looked after Children, pupils referred to the pupil referral unit (PRU) and excluded children. 10.13 As part of a fully integrated Children’s Health and Wellbeing Service, the 5-19 service commissioned through Public Health went out for procurement in September 2018. A collaborative service specification based upon Thrive principles was developed between Bolton Council and Bolton CCG with wider multi-agency contribution to ensure whole-system emotional health and wellbeing pathways are further strengthened. Page 21 of 49
10.14 The contract for the 0 – 19 Integrated Children’s Health and Wellbeing Service was awarded in January 2019, with service transfer set to take place in April 2019. GM Children and Young People’s Crisis Care Pathway - REACH-IN 10.15 Bolton CCG have and continue to be actively involved in the GM Crisis Care pathway 20 development programme around access to 24:7 Mental Health provision and 7 Day Community Provision for Children and Young People (CYP). A Greater Manchester Transformation Fund £ 13.3m proposal was approved in December 2017, which held the vision to develop a GM-wide whole system crisis care pathway which will provide a high quality and timely response to young people in crisis and their families, accessible across 7 days. The pathway will be fully inclusive, have open access, be holistic and multi-agency and provide a timely and proportionate response based on need. In 2018/19, extensive work was undertaken to begin to operationalise the model, engaging with partners across GM, recruiting staff and designing clinical pathways and protocols. For 2019/20, the overarching aim is to launch of all elements of the pathway, completing recruitment and beginning to accept referrals. By the end of this financial year, Rapid Response Teams will be available 24/7 across GM, reducing demand on A&E and community CAMHS and improving the experience of young people and their families. As a key partner we will continue to support this vital work as it progresses. For further information please go to: https://www.penninecare.nhs.uk/gmccp/ Figure 16: The components of GM Crisis Care Pathway for Children and Young People 20 https://www.penninecare.nhs.uk/gmccp/ Page 22 of 49
10.16 To deliver this priority, a whole system approach is required that includes bringing together commissioning, simplifies the provider system, includes involvement from the independent and third sector and holds children and young people and those who care for them at the heart of change. This whole system change has already started and will continue into 2017/18. All Age Mental Health Liaison Service (Formerly Rapid Assessment Interface Discharge (RAID)) 10.17 As of 9th April 2018, Bolton were the first locality in Greater Manchester to go live with an All Age Mental Health Liaison service to assess and support Children and Young People under the age of 16 who present to Bolton Children’s A&E department in mental health crisis. 10.18 Bolton All Age Mental Health Liaison Service, delivered by Greater Manchester Mental Health NHS FT will also undertake initial assessments on the Paediatric Wards at Royal Bolton Hospital when it has not been possible to undertake the assessment in the A&E department. 10.19 The table below shows the total number of assessments which took place for children and young people aged 16 and under presenting at A&E in mental health crisis Number of Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total completed RAID assessments for 16 20 29 26 28 12 20 26 37 198 years and under Figure 17: Total number of RAID assessments taking place for children aged 16 and under 10.20 Bolton continues to support the rollout of All Age Mental Health Liaison across Greater Manchester including the development of a set of GM standards to ensure consistency of provision across each of the 10 localities. Greater Manchester Tier 4 (inpatient) CAMHS 10.21 The NHS England National Commissioning Committee approved the delegated responsibility of CAMHS Tier 4 General Adolescents (GA) and Eating Disorders (ED) Services to the devolved Greater Manchester Health and Social Care Partnership (GMHSCP) Chief Officer. 10.22 This enables Greater Manchester (GM) the ability to make key decisions around specialised Child Adolescence Mental Health Services (CAMHS) that will deliver cohesive pathways across the full spectrum of general mental health and eating disorders. Also enable creative solutions to service design to be pursued – in keeping with the national direction for specialised mental health services. 10.23 In this context, the GM delegated responsibility of CAMHS Tier 4 GA and ED commenced on 1st April 2018 and work is being undertaken to develop clear commissioning objectives that maximises the effectiveness of the GM New Care Model and the efficiencies within the areas of responsibility. 10.24 In support the GM CYP Crisis Care Pathway – REACH-IN pathway aims to dramatically improve the overall experience and outcomes for children and young people in crisis with mental health issues, along with those who care for and work with them. The work includes a new Tier 4 Assessment centre for managing referrals into specialist CAMHS inpatient bed. Page 23 of 49
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