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 - Bolton CCG
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
Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - 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
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Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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
Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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
Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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

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Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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
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Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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
Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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
Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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
Bolton Local Transformation Plan (LTP) Children and Young People's Emotional Health and Wellbeing - Bolton CCG
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.
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