Issue - meetings

Following the conclusion of the programme of extraordinary meetings of the Scrutiny Committee to consider the Child and Adolescent Mental Health Services (CAMHS) Review, the Scrutny Committee is invited to give consideration to any conclusions it has drawn and possible recommendations to be included in the final report which will be submitted for consideration in the New Year.

Officer contact: Jonathan Vali, 0161 474 3201, jonathan.vali@stockport.gov.uk

The Chair gave a brief overview of the work undertaken to date in relation to the CAMHS Scrutiny Review, including highlights from the three extraordinary meetings held in the Autumn. The Chair identified headline issues that could form recommendations in the Final Report, including:-

·         Integration of Tier 2 and Tier 3 services and specialist services

·         Promoting mental wellbeing among young people

·         ‘Plugging gaps’ in services, particularly in the transition from children to adult services.

It was also suggested that a further recommendation be considered to request that the issue of children and young people’s mental wellbeing be included in future Joint Strategic Needs Assessments.

RESOLVED – That the Democratic Services Manager be requested to circulate a draft of the CAMHS Review Final Report, with the provisional title, ‘Mind the Gap’, to members of the Scrutiny Committee in advance of Christmas to allow for feedback prior to its submission to the Scrutiny Committee in January 2014.

To consider  a report of the Director of Public Health.

The report sets out ideas for promoting mental wellbeing amongst children, young people and families, in particular through school, and the role of the Public Health Team in these efforts.

Officer contact: Duncan Weldrake/ Catherine Johnson,  0161 474 2443/ 2446, Duncan.weldrake@stockport.gov.uk / Catherine.johnson@stockport.gov.uk

A representative of the Director of Public Health submitted a report (copies of which had been circulated) summarising activity undertaken by the Public Health service in promoting wellbeing of children, young people and families and where there was scope to enhance and support work already being undertaken by partners.

The following issues were discussed:-

·         Importance of prevention, and the role of the health visitor in supporting parents when issues first presented. There was only so much any school could do if their efforts were not supported/ undermined at home. The work at an AGMA level on troubled families may assist for those with very high need.

·         The role of parent support advisers in schools was discussed and the scope for schools to buy-in such services, perhaps jointly to minimise the cost to each school.

·         Training was key to ensure staff in schools and other settings involving young people were able to refer and signpost appropriately and early.  Discussion earlier in the meeting to increasing the amount of training on pastoral support as part of the teacher training programme was welcomed.

·         The relatively low levels of young people from Stockport in Tier 4 services was an indication of the good work being done at Tier 3 and enhancing this through integration with Tier 2 should bear further fruit.

RESOLVED – That the report be noted.

Representatives of partner organisations have been invited to the meeting to provide a summary of their work in so far as it relates to children and young people’s mental health and work in educational settings. These organisations include:-

·         Beacon Counselling

·         Educational Psychology Services

·         Jigsaw Service

·         A representative of secondary schools

·         A representative of Pupil Referral Units

·         Stockport College

A copy of report by Beacon Counselling on their engagement with Service Users and copy of their latest schools newsletter are enclosed as background information.

The Chair welcomed to the meeting representatives from a range of organisations and invited them to provide the Scrutiny Committee with an overview of their work in relation to children and young people’s mental health and wellbeing.

Beacon Counselling - James Harper, General Manager

The following issues were highlighted:-

·         Beacon had been operating for 30 years, focussing mainly on adult counselling, but in 1996 started to work in secondary schools.

·         The organisation worked with approximately 450 young people, mostly in educational settings, but also through outreach work.

·         Support was provided to those with low level needs and those struggling with challenging life events.

·         Beacon had a focus on developing coping skills for young people and ensuring they had resilience.

Primary Sector (High Lane Primary) – Judith Morris, Head Teacher

The following issues were highlighted:-

·         A whole school focus on developing basic life skills through Personal, Social and Health Education (PHSE) and Social and Emotional Aspects of Learning (SEAL) and embedding this within a broad range of curriculum areas.

·         The school employed a number of initiatives to support this work, such as ‘worry wallets’, ‘safety maps’ peer support, ‘Buddy Bus stops’, as well as ensuring pupils felt empowered and confident to raise concerns.

Secondary Sector (The Kingsway School) – Jane Maxey, Head of Lower School

The following issues were highlighted:-

·         Personal wellbeing was given the same priority as learning.

·         Important to engage parents.

·         Provision of onsite counsellors, aligned to need and not time limited. Waiting lists were managed and no pupil was turned away.

·         Close work with Behaviour Support Unit and dedicated social workers to respond quickly to emerging problems.

·         Student mentoring and peer monitoring used, particularly around transition.

Further Education Sector (Stockport College) – Susan Hartley, Mental Health Support Coordinator

The following issues were highlighted:-

·         Dedicated team to support student wellbeing, including counsellors, wellbeing practioners, to address a range of physical and mental wellbeing issues.

·         A responsive service with short waiting lists due to dedicated team.

·         Wellbeing agenda embedded within student services and close work with other support areas to provide assistance with issues such as housing and benefits.

National Health Schools Standard - Tanya Cross, Operational Leader, Stockport Council

The following issues were highlighted:-

·         Work with schools to train staff and develop resources to help embed wellbeing in the curriculum and in particular to enhance PSHE.

·         Emphasis given to equipping young people with skills to cope and be resilient.

Behaviour Support Service – Janette Braithwaite, Head Teacher

The following issues were highlighted:-

·         Approximately 1500 referrals ‘on the books’ at any one time for the Service. Inevitably a high proportion of those will involve mental health issues.

·         Use the Social and Emotional Aspects of Learning (SEAL) tool. This was no longer a government priority and so there was concern that the agenda would lose its impetus.

·         Success with developing restorative approaches in schools to change the ethos to focus on repairing harm rather than focussing on punishment and blame.

·         Primary Jigsaw Service was an education based multiagency team who took referrals from schools and CAMHS panel. In 2012-13 there were 298 referrals, 150 from schools, 137 from CAMHS and 11 from other agencies. They did 221 assessments and interventions, representing a 22% increase from the previous year.

·         Gaps and areas of concern included pressures on resources and funding; difficulties in engaging with hard to reach parents; lack of interventions for attachment issues.

Pupil Referral Unit (Pendlebury Centre) – Janice Cahill, Head Teacher

The following issues were highlighted:-

·         Service involved with those pupils at risk of exclusion and who had been excluded.

·         The Centre provided mental health interventions through its Cedar Unit, which were more intensive interventions for those with Tier 2/3 mental health need.

·         Work was also undertaken with those pupils with medical conditions that kept them out of school and in hospital.

·         There was an increasing awareness of mental health issues connected to young people involved with the  ...  view the full minutes text for item 3

To consider a report of the Public Health Specialist

The attached documents provide information requested at the last meeting on the level of need for CAMHS in Stockport and a demographic profile of children and young people in the borough.

Duncan Weldrake, Public Health Specialist, submitted a report (copies of which had been circulated) providing additional data on prevalence of mental ill-health in young people in Stockport, and demographic data for the borough. The information had been provided in response to questions raised at the last extraordinary meeting. It was emphasised that providing accurate data was a challenge and extrapolation from national data had been necessary to establish some of the prevalence data.

The following comments were made/ issue raised:-

·         Over 6000 young people in Stockport were expected to have a mental health need, with the highest prevalence of disorders amongst boys.

·         The greater prevalence of mental health disorders was amongst older children, and the disorders often changed over time. The higher prevalence amongst older children may be due in part to different approaches to behaviour in primary and secondary schools.

·         There was no clear evidence that focussing resources on early years would prevent demand later in adolescence, although there may be benefit in targeting resources at under-5s with attachment issues. There were discussions taking place between partners on developing an attachment service.

·         Was children’s mental health sufficiently embedded within the neighbourhood management approach to tackling inequalities? Was the focus of work through Children’s Centres on parenting contributing to mental wellbeing? There was insufficient evidence at this stage. It may be that interventions skewed toward making children ‘ready to learn’ may not be addressing mental wellbeing adequately. It was important to ensure all partners and deliverers of services made mental health and wellbeing ‘their business’. Linking specialist mental health services into local service delivery mechanisms would assist with this.

·         There was not always a clear link between deprivation and children/ adolescent mental health disorders.

·         There was a gender bias in favour of females in respect of eating disorders although there were an increasing number of younger boys presenting.

·         Referrals were fewer from those from ethnic minority groups, although the scale of the issue was difficult to quantify. The lower rates may be because differing social groups managed problems differently, or it may be due to stigma. The Pennine Care NHS Foundation Trust had undertaken work to try to address possible stigma concerns amongst specific ethnic groups within its footprint.

RESOLVED – (1) That the report be noted.

(2) That the Democratic Services Manager be requested to invite a representative of Beacon Counselling to the next meeting of the CAMHS Review to discuss their work in schools.

To consider a report of the Joint Commissioning Manager.

This report presents some information about the need for CAMHS in Stockport and the current provision and highlights the challenges in ensuring universal access.

A report of the Joint Commissioning Manager (Children and Young People) was submitted (copies of which had been circulated) providing some additional statistical information requested by the Committee, information about the need for CAMHS in the Stockport, the current provision and particular challenges in ensuring universal access.

Alison Caven (Joint Commissioning Manager, Children and Young People, Stockport CCG), Dr Prathiba Chitsabesan (Consultant Child and Adolescent Psychiatrist, Pennine Care NHS Foundation Trust), Gina Evans (Joint Commissioning Lead, Mental Health, Stockport CCG), Donna Sager (Service Director (Commissioning & Transformation), Stockport Council) and Duncan Weldrake (Public Health Specialist, Stockport Council) attended the meeting to answer councillors’ questions.

Councillors asked questions and made comments on the information contacted in the report. The following issues were raised:-

·         A number of service users with Tier 4 conditions were being managed as part of Tier 3 Services as this often involved less severe interventions. There were a number of pathways in Tier 3 that were home-based/  non-in patient treatments.

·         Members expressed surprise at the numbers of referrals being made. In response it was stated that this partly reflected increased interventions and early identification. There had been a significant increase in diagnosis of neuro-developmental disorders (including ADHD, autism, Tourette’s syndrome). This in part reflected increasingly early interventions and identification, and parents who were increasingly willing to champion take-up of services. The additional pressures on services through greater referrals did not necessarily reflect increasing prevalence but may be because of increased awareness. The discrepancy between expected prevalence and referral should be explored further.

·         There was significant pressure on services to assess autistic spectrum disorders where assessments were taking up to 20 hours. There were a number of contributing factors, including a high number of repeat referrals because of continued concerns, despite no diagnosis. Compared to other local authorities, Stockport did not have a stringent referral threshold so there were significant numbers of referrals across the spectrum, many of which do not meet the diagnostic threshold and so could not access services they might need. Services were provided to meet a diagnosis, not need. Many of the most important interventions were not specialist mental health services but were needed long term from a range of partners. These services needed to be delivered in more co-ordinated and cost effective ways to ensure sustainability and improved outcomes.

·         Parents and carers often provided significant challenge to negative diagnoses, which accounted for many of the repeat referrals. In some cases a diagnosis of a learning disability was preferred by parents rather than the stigma associated with a mental ill-health diagnosis.

·         Where referrals did not meet the diagnostic criteria, parents would be advised to adopt some of the strategies and elements of the pathway (excluding medication), but there was often a reluctance or difficulties on the part of schools to commit resources to these interventions without a diagnosis. The Parenting Service also provided support in trying to resolve care issues.

·         Stockport had the highest level of special educational need statements in Greater Manchester, but changes to the schools funding regime would replace this with the introduction of High Needs Funding. These changes would relieve pressures on some services involved in supporting the statementing process, but was likely to cause confusion in the short term.

·         There was already work underway to address the problems with the autistic spectrum disorder assessments to streamline the process and reduce the time taken through the introduction of guidelines etc.

The Chair invited professionals and officers to identify those areas where improvements in service configuration and delivery would have the greatest impact on outcomes. In response, it was stated that integration of Tier 2 and 3 services into a single service would provide greater flexibility in delivery to make it more responsive to need, although there remained difficulties in achieving this because of clinical governance concerns.

It was also stated that a greater promotion of mental wellbeing  ...  view the full minutes text for item 4

To consider an information note of the Joint Commissioning Manager and CAMHS Co-ordinator.

The attached information note provides the Scrutiny Committee with background information to inform their discussions on mental health service provision for 16-18 year olds. The report also identifies gaps in service and opportunities for improvement.

A joint report of the CAMHS Commissioning Manager and the CAMHS Co-ordinator was submitted (copies of which had been circulated) detailing provision of Mental Health Services in Stockport for 16-17 year olds, identifying gaps/shortfalls in service and opportunities for service improvement. The report also detailed information on service provision from partner organisations.

Alison Caven (Joint Commissioning Manager, Children and Young People, Stockport CCG), Mark Chidgey (Director of Provider Management, Stockport CCG), Gina Evans (Joint Commissioning Lead, Mental Health, Stockport CCG), Dr Heinke Otto (Consultant Adolescent Psychiatrist, Pennine Care NHS Foundation Trust) and Donna Sager (Service Director (Commissioning & Transformation), Stockport Council) attended the meeting to answer councillors’ questions.

The following issues were highlighted:-

·         Difficulties for 16+ who were no longer able to access tier 2 school based services trying to access adult services.

·         Lack of community based services for those stepping down from tier 3.

·         Difficulties in responding to the volume of referrals to Central Youth.

·         For those with Learning Disabilities, the age range covered was only up to 16. Those with neurological issues were becoming increasingly prevalent within the service.

·         In relation to care leavers, the KITE service was only provided up to 18, although mental and emotional vulnerability may continue well beyond this.

·         Unlike adult mental health services, the criteria of risk assessment for children was not as robust so where a young person had a diagnosis of a mild condition they may nonetheless be at high risk of harm as conditions may escalate quickly.

·         Fragmentation of services was more pronounced in children’s services. There were often a range of smaller, specialist services being provided but changes in need would mean a referral to a further service and the disengagement by a young person. A more integrated, centralised service may be beneficial in reducing this problem.

·         Young people’s mental health problems were often caused by vulnerability factors rather than medical conditions, which was often the case with adults. This meant that diagnoses were less stable and support more complicated to provide.

Members asked a number of questions and made comments in respect of the following:-

·         The idea of a centralise hub for service users to reduce the number of referrals between smaller, specialist services. There was a danger that smaller teams were more protective of their resources and referrals. It was acknowledged that there was already a single point of referral into the system that was managed by the Pennine Care NHS Foundation Trust.

·         The different age threshold for service users was a cause of concern, and wherever possible this should be standardised to 18. This would then help improve transition from children’s to adult services which could be complemented through more centralised and co-ordinated provision.

·         Services would often continue to see users even if their problems changed rather than risk them being lost to a service and not getting support. However, this created problems with service capacity.

·         Diagnosis of mental health problems in adolescence was problematic as was often socially caused and linked to a traumatic episode. Early intervention in these circumstances was important. Those with mild to moderate conditions can often cope with their problems while at school because of the more structured environment but their conditions can escalate on the transition to college etc.

·         There was often a greater prevalence of mental health problems for people with learning disabilities. There was an upward trend and the interventions required were becoming increasing significant, often being pharmaceutical. In many cases these young people would be identifiable through the SEND register.

·         A number of schools in Stockport bought in services from Beacon Counselling. Statutory partners were very supportive of and encouraged this kind of 3^rd sector activity. Many colleges also made provision, but there was no way to ensure this happened in all settings.

·         There was no nationally targeted resource to support young people during the transition from one educational setting to another (secondary to college etc.), and  ...  view the full minutes text for item 2