CAMHS Transformation Plan Refresh - January Children and Young People s Mental Health and Emotional Wellbeing

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1 CAMHS Transformation Plan Refresh - January 2017 Children and Young People s Mental Health and Emotional Wellbeing 1

2 Contents Page 2 Lambeth Overview Page 3 South East Sustainability and Transformation Plan (STP) Page 4 - Our Starting Point in Lambeth Page 6 - Progress to date for 2016/17 Page 12 Challenges Page 13 Governance Page 14 Areas for Development Page 19 Details of Previous Spend Page 20 CAMHS Transformation in Lambeth Page 23 Risks and Mitigation Page 25 - Appendices Appendix 1 Young Lambeth Emotional Wellbeing and Mental Health Strategy Appendix 2 Eating Disorder Service Update Appendix 3 CYP IAPT Proposal for Lambeth Appendix 4 Update on key pilot projects funded in 2015/16 1

3 Following the publication of Future In Mind and the Young Lambeth Emotional Wellbeing and Mental Health Strategy, Lambeth CCG worked with partners to develop a Transformation Plan for our CAMHS services. This refresh of the plan is to provide an update based on the learning and progress throughout the last year, and to set out the plans for transformation over the next 4 years. Our original Transformation Plan can be found at Lambeth CAMHS Transformation Plan The Young Lambeth Emotional Wellbeing and Mental Health Strategy can be found at Young Lambeth Emotional Wellbeing and Mental Health Strategy The Transformation Plan was approved by the CAMHS Joint Commissioning Group and the Children and Maternity Programme Board (CMPB). Lambeth Overview The Young Lambeth Emotional Wellbeing and Mental Health (EWMH) Strategy produced in 2015 highlights 5 main priorities and work streams, in line with Future in Mind. The commissioning intentions and actions for Lambeth were developed under the following priority areas: PRIORITY 1: Prevention: Awareness, Knowledge and Training PRIORITY 2: Maximising Resilience and Self Sufficiency PRIORITY 3: Improving Access to Clinical Services PRIORITY 4: Transition: From Birth to Adulthood PRIORITY 5: A Public Mental Health Approach: The wider Environmental Factors The Lambeth Emotional Wellbeing and Mental Health Strategy 2015 and the supporting Transformation Plan set out Lambeth s ambitions and intentions over the next 5 years. The priority areas, identified needs and the required outcomes remain consistent throughout both documents and reflect the areas of need in the Lambeth Joint Strategic Needs Assessment. The Plan is intended as a live document and while Lambeth s horizon continues to change in regard to services for children, and the changes take place within CAMHS provision, the plan will be developed and adapted to reflect this. This plan is to sit alongside the Lambeth Strategy. Lambeth is currently updating its Joint Strategic Needs Assessment for children and young people which will highlight levels and areas of need for

4 This Plan has been developed in line with the local Sustainability and Transformation Plan (STP) and with the Collaborative Commissioning Plan being developed with neighbouring boroughs for March South East London Sustainability and Transformation Plan (STP) The Sustainability and Transformation Plan (STP) for South East London includes CAMHS as an area of focus for the next 5 years. Lambeth CCG has been involved with the development of the local STP and we ensure that the CAMHS plans are echoed in our local plans for change. The STP states that Transformation Plans are expected to result in a significant reduction in demand for Specialised CAMHS services within the next 5 years. The STP also reflects that current crisis care pathways are under-developed, particularly for children and young people with complex needs and behaviours related to learning disability (LD) and/or Autism and emerging personality disorders. The overall distribution of CAMHS inpatient capacity does not match Regional population needs and young people are being admitted far from their home, or to paediatric or adult beds; the NHS England National CAMHS Service Review aims to redress service deficits by redistributing/realigning beds to meet local needs. The clear expectation is that by 2020 there will be no inappropriate admissions to adult or paediatric beds and patients will be treated in local care pathways. The STP areas of focus are: To promote commissioning of consistent out of hours services for young people particularly to manage crisis and prevent escalation with clear ambition to manage demand effectively at community level and reduce inpatient admissions TCPs with engagement and support of NHS England to oversee consistent delivery of multi-agency pre-admission Care and Treatment Reviews for children and young people with LD, and/or autism to reduce inpatient admissions NHS England Specialised Commissioning Team to work collaboratively with CCG and Local Authority commissioners to design and commission effective community pathways with robust links to local acute inpatient services with ambition to reduce lengths of stay and inappropriate placements reflected in LTP and TCP NHS England Specialised Commissioning Team to continue to work with local commissioners to reflect ambition in LTP/TCP and STP plans to 3

5 - ensure Regional inpatient capacity meets requirements so out of region admissions become the exception - to reduce variation by introducing standardised access and waiting times - adopt consistent models of care based on best practice that reduce the reliance on inpatient care - deliver seamless age-related service transitions - to support the pilots within the New Care Models programme (NWL) Our Starting Point in Lambeth In the Young Lambeth Emotional Wellbeing and Mental Health Strategy, we set out the following outcomes we want to achieve by 2020; Significant increase in anticipated mental health population accessing treatment to 30%. 20% increase in uptake of parenting programmes and parenting support 75% of the children s workforce will have completed emotional wellbeing and mental health training Waiting time targets achieved and maintained. 10 weeks from referral to treatment for the Early Intervention service, 18 weeks from referral to treatment for all other CAMHS services 20% reduction in the number of children & young people accessing hospital based mental health services (inpatient and outpatient) Reductions in presentations to A&E Nationally recognised excellent eating disorder pathway, with reduced waiting times and improved access An established and comprehensive perinatal MH pathway. Increased number of women accessing mental health services Recommendations referencing the wellbeing and mental health of children & young people from the Black Mental Health Programme are fully implemented and evaluated Outcome monitoring and evaluation framework fully established and routinely informing service improvement Reduction in inequalities through explicit Equalities Objective which start with transition from child to adult mental health services Comprehensive clinical and referral pathways fully embedded for key presenting conditions; conduct disorder, self-harm, first on set psychosis, eating disorders, depression & anxiety (baseline and targets competed in 2015/16) 4

6 It is our ambition and intention to move from a crisis led model of care to an early identification and prevention focus. We are working towards reducing the number of children and young people who will require access to inpatient treatment, specialist Tier 3 and 4 intervention or attend A and E at crisis point. In the longer term it is our vision to create a more integrated model or alliance between providers from the voluntary and community sector to provide support at an earlier stage. Alongside early intervention programmes around building emotional wellbeing and resilience, we envisage a suite of services and provision at Tiers 1, 2 and 3 for children and young people in Lambeth by Robust pathways from this range of provision into our main CAMHS provider SLaM, Children s Social Care and Early Help team, will enhance the offer available to young people, families and referrers such as schools and GP s. The focus within Year 1 was to: Scope, cost and make recommendations for a comprehensive evidence-based parenting programme, early intervention and prevention programmes Undertake the mapping and scoping of emotional wellbeing and mental health training and skills within the children s workforce Develop a comprehensive eating disorder pathway Undertake a comprehensive review of current CAMHS provision within our clinical services Develop a comprehensive crisis care pathway Effectively implement IAPT Scope and Implement a comprehensive Perinatal Mental Health pathway Scope and identify gaps and needs in support for CYP that have experienced sexual abuse and/or exploitation 5

7 Progress to date for 2016/17 Throughout 2016 Lambeth has been working to begin to implement the changes as laid out in our original Transformation Plan. A number of our work streams in Year 1 focussed on the scoping and mapping of current provision and undertaking gap analysis to inform work and change over the next 4 years. Improving Access to Clinical Services Waiting times: The Five Year Forward Plan states that by 2020/21 at least 70,000 more children and young people should have access to high-quality mental health care when they need it. It was our immediate vision for 2015/16 to improve access to clinical services for children and young people in Lambeth, which has been realised through a number of initiatives. The priority for us in Lambeth, as well as nationally, was to reduce waiting times for children and young people to access our clinical services, especially our Early Intervention Service. Our waiting times had reached an average of 50 weeks in 2015 and we had started to work with our mental health trust to develop plans to bring these down to our target of an average 11 weeks. Table 1 - Waiting times for Lambeth CAMHs services Child and Adolescent Community Service Lambeth Lambeth CAMHS Early Intervention Lambeth CAMHS Neurodevelopmental Team Lambeth Children Looked After Lambeth Youth Offending The average waiting time of those assessed in the quarter is now weeks and we are working to continue to reduce this. We are also monitoring the number of accepted referrals for the Early Intervention Service as these have been lower in Quarter 2. Lambeth had committed an additional 180k per year to the service to initiate our waiting time initiative. The funding provided additional resources and capacity in the team, as well as the 6

8 Neurodevelopmental Team. We have continued to see a general decrease in the waiting times for the EI service, but continue to monitor this through our London Dataset quarterly reports and regular meetings with our Lambeth service lead. Table 2 Average waiting times for Lambeth Early Intervention Service Average Waiting Times (weeks) for Lambeth Early Intervention Service Quarter 3 15/16 Quarter 4 15/16 Quarter 1 16/17 Quarter 2 16/17 Table 3 Number of accepted referrals in Lambeth Early Intervention Service Number of Accepted Referrals in Lambeth Early Intervention Service Quarter 3 15/16 Quarter 4 15/16 Quarter 1 16/17 Quarter 2 16/17 Eating Disorder Service: We have seen the embedding of the community Eating Disorder Service and the implementation of a direct advice line for professionals. Through a piece of partnership working with our mental health trust SLaM and neighbouring boroughs of Southwark, Lewisham and Croydon, the advice line was funded and launched in February This was in response to feedback from schools and GP s 7

9 around accessing the eating disorder service and requiring advice for individual young people and their work to support them. Based on limited initial data, this has led to an increase in suitable referrals to the eating disorder service and has skilled up and supported professionals in the community to work with young people requiring support. Our highest area of Tier 4 specialist service/outpatient spend is for the eating disorder service and provision, hopefully leading to the reduction of inpatient placements required for Lambeth children and young people. Table 4 Numbers of referrals to Eating Disorder Service by borough CCG Received Accepted % Accepted NHS BEXLEY CCG % NHS BROMLEY CCG % NHS CROYDON CCG % NHS GREENWICH CCG % NHS LAMBETH CCG % NHS LEWISHAM CCG % NHS SOUTHWARK CCG % Grand Total % CAMHS Service Reviews and SPOA: September 2016 saw the start of our CAMHS service reviews in Lambeth. The aim of the review is to better understand the current provision in Lambeth, to ensure the services are meeting expectations and standards, to look at activity levels, to review resourcing and capacity and identify areas of good practice, learning and improvement. To date we have undertaken two reviews, the Looked After Children CAMHS service and the Youth offending CAMHS service, and have two more arranged for January As part of the reviews, we are also undertaking independent case file audits of a range of cases. The reviews have been useful for the service leads and staff as well as commissioners, working together to review the service and delivery. We have also gathered the views of partners and referrers to identify key areas of improvement in each of the CAMHS teams. As the review of CAMHS services progresses, the feasibility and effectiveness of a Single Point of Access (SPOA) will be evaluated and incorporated in the transformation of the service. 8

10 It is our aim to have completed the reviews by the end of May 17, with a report completed and taken to our CAMHS Joint Commissioning Group and Children and Maternity programme Board. Completion of the review will help us to identify gaps in provision, reorganise current team structures where needed and better allocate resource. The outcome of the reviews will be a pivotal step in understanding how to best transform CAMHS provision in Lambeth on a wider scale to meet presenting need with a very real focus on Early Intervention, Tier 2 support and pathways such as crisis care, transitions and ADHD. National data shows that 10% of our children and young people s population will be living with a mental illness, and these would benefit from support or treatment. Crisis Care: For our crisis care provision, we are confident that we will realise a 10% reduction in children and young people presenting in crisis by With the addition of 2 x Band 7 nurses within the Lambeth CAMHS team, working closely with the Emergency department and our Paediatric Liaison Service, we have added integrated capacity. We will continue to work closely with our South East Commissioners to ensure a robust and constant response to crisis care. We are working alongside SLaM, Lewisham, Croydon and Southwark to develop a plan for robust and consistent provision across the boroughs, responding to local need. In 2016 (month 3) Lambeth received a one off non recurrent payment of 215k earmarked for eating disorder and/or crisis care. This has been allocated to the Tier 4 outpatient treatment delivered by our main CAMHS provider SLaM. This work mainly includes treatment for Eating Disorders, as well as Obsessive Compulsive Disorder, and Dialectic Behavioural Therapy. By ensuring children and young people have access to the most effective treatment locally, we aim to improve outcomes for young people within just one treatment episode, and reduce the need for inpatient provision and repeat access. Transformation of the system Engaging with the Community and Voluntary Sector: A key aim and measure within Future in Mind and our Transformation Plans is to increase access to support for young people, whilst reducing the demand on specialist treatment. Therefore it is crucial that we improve our offer at an early intervention and tier 1 and 2 level. A great deal of work has been undertaken to engage with the voluntary and community sector working with children and young people in Lambeth. Our vision is to truly transform our CAMHS 9

11 provision and support our workforce to create a suite of options with intervention and support available at a Tier 2 level for children and young people. A high number of young people in Lambeth do not have a diagnosable mental health disorder and therefore would not meet the threshold for our existing CAMHS services, but require support and advice around emotional wellbeing and mental health. Our vision for Lambeth is to transform the current system to breakdown the Tiers and thresholds and ensure we are providing the correct level of service at the right time for the right young people. In 2016 we held a number of workshops and events to facilitate networking, promote a partnership approach to emotional wellbeing delivery, and to encourage co-production and collaboration. We are encouraging the collaborative approach to emotional wellbeing and to supporting young people and creating understanding that CAMHS is a wider system, rather than just centred on medical services. This has been a key step towards building positive relationships with our community and VCS partners and bringing them into the CAMHS provision. We are currently running a procurement exercise for organisations to bid in for funding for new and innovative projects addressing emotional wellbeing at this wider level. The projects and/or services commissioned will need to be evidence based and outcome focused, and will be evaluated for their impact and outcomes for young people. We hope to embed the effective services within our overall CAMHS offer over the next 4 years. The funded initiatives and projects both in 15/16 and 16/17 once evaluated and reviewed, will be a critical part of the wider CAMHS offer in Lambeth. We will continue to work closely with the community throughout this bidding process and to coproduce the development of our new CAMHS model in Lambeth over the upcoming years. Improving Prevention, Awareness, Knowledge and Maximising Resilience: We have worked closely with local partnerships such as the Children and Young People Health Partnership (CYPHP) to build our prevention and early intervention offer. We have jointly commissioned prevention programmes within schools across Lambeth and Southwark, to train and up skill staff in emotional resilience and self-sufficiency tools for young people. This was in response to a mapping exercise undertaken in Lambeth last year identifying the needs of children and young people and the support and provision schools were commissioning or delivering in house. We are currently tendering for a piece of work to be undertaken before March 2017, to scope out evidence based provision for early intervention, prevention, and parenting. This will help to identify 10

12 best practice and high impact programmes, and will support our co-commissioning plans with schools and our ability to share best practice. We are working with commissioning colleagues to align our transformation plans in this area with the Parenting Strategy for Lambeth and the development of parenting programmes delivered in the community. In Lambeth the LEAP and CYPHP programmes are currently running to improve health and social outcomes for children and young people. We will embed the learning from these initiatives and the effective services into future provision, both across CAMHS and the wider social system. In Year 1 a piece of direct engagement work was undertaken with young people and young adults across the borough, looking at what mental health means to them. We commissioned an experienced youth worker to interview individuals and groups a total of 40 young people - from a number of our identified vulnerable groups such as Looked After Children, BME communities, young offenders and the LGBTQ community. Findings from the interviews, group sessions and subsequent report will not only inform the transformation of CAMHS provision and how we target them, but also feed into our communications and awareness raising work. 11

13 Challenges The main challenges in Year 1 have been with recruitment of clinical staff within our clinical services. The delays in recruitment have affected delivery start dates and allocation of funding. We had hoped by this stage to have recruited to a Band 8a Prescribing Nurse, to increase capacity and response within the ADHD Service. The post has now gone out to advert and we are hopeful it will be recruited to in the later stages of Year 1. Staffing challenges within the Commissioning Team has also led to a number of delays within our delivery, especially the delayed start of the CAMHS service reviews and workforce skills development scoping exercise. We are currently re-recruiting to a Transformation Manager post within the children s commissioning team to ensure the needed focus and dedication for this work. In Year 1 baselines were identified for our key transformation work streams which have now been agreed. The issue of delayed baseline data has now mostly been resolved in collaboration with our mental health trust and we are able to update the baseline figures for our transformational work. Progress against these KPIs is monitored regularly; however we have struggled to gather robust data for a number of the work streams. We continue to monitor data against agreed benchmarks evidencing improvements in access for children and young people. NHSE informed CCG s of additional recurrent and non-recurrent funding between October and December 2016 from the 25m national allocation. Although the allocated funding is a positive, the last minute allocation of this allocation and criteria has often made it difficult to embed this within our plans and allocate accordingly. We are currently in discussion with Lewisham, Southwark and Croydon and SLaM as to how best to allocate this resource and how we can work jointly. As detailed in our Areas for Development there are a number of work streams that we will be looking at for a consistent approach across the south east, such as CYP IAPT training and delivery, and our crisis care models. With the key aim of the CAMHS transformation work being the increase of access to services for children and young people, whilst reducing the demand on specialist and inpatient treatment, we are faced with the financial challenge of current increasing spend for the CCGs for Tier 4 specialist services. With an initial increase in specialist spend at a local level, we are hoping to see a decrease in repeat admissions and repeat episodes in treatment. 12

14 Governance Formal governance and oversight of the Transformation Plan is in place via the CCG Governing Body, The Health and Wellbeing Board, The Children and Maternity Programme Board, and the YOS Management Board in Lambeth. These groups contain a wide range of our key partners at both a senior management and executive level, including the Children s Clinical Lead and Cabinet Member. The quarterly CAMHS Joint Commissioning Group ensures input and understanding at a more operational level and is one of the mechanisms in which our Cabinet Member contributes to this area of work. The Transformation Plan has been taken to additional forums and networks to engage with key partners for example the SENCO s forum, Local Care Network and Locality GP meetings. Our Eating Disorder Service will also be a member of the Quality Assurance Network to ensure best practice and transparency. 13

15 Area s For Development There are a number of key areas for development identified for Lambeth and on a south east sector level over the next 4 years. South East Sector Areas for Development: We are committed to working with our neighbouring boroughs to ensure a coordinated approach and therefore a better service for children and young people. Lambeth has facilitated south east sector meetings with SLaM, NHS England, and Lewisham, Croydon and Southwark quarterly and commissioners meet on a regular basis to tackle areas of work together. Our commissioning intentions for CAMHS have been aligned with other South East boroughs who commission SLaM to ensure this approach continues. All of the borough s commissioning intentions include the high level intention of a 32% increase in access to CAMHS provision by Eating Disorder Service Lambeth will continue to work with the south east boroughs and SLaM to develop the eating disorder service. We are fortunate to have a service that is regarded highly as best practice and has effective outcomes with young people. Please see Appendix 1 for a detailed update of the Eating Disorder Service. Crisis Care Provision We will build on our crisis care provision across Lambeth and the south east to ensure we have a full service for children and young people. We are working to develop the crisis care telephone line within adult s service to include CAMHS or signpost to CAMHS, and looking at how to compliment the Paediatric Liaison Service in Lambeth and Southwark. Service provision in this area needs to be out of normal office hours and may need to be provided in different locations to the other CAMHS services. We will be working with clinical leads within SLaM to develop an appropriate and effective model. Transforming Care In Lambeth we have updated our core contract with SLaM to include the development of At Risk registers for learning disabilities. We are currently working with our adult commissioning colleagues to develop this locally and will look to Croydon and Southwark for learning. These areas are further along the process and we will work together to ensure there is a systematic approach across boroughs. We are already seeing an increase in the number of children and young people within the LD/Autism cohort who suffer a mental health episode or are showing behavioural difficulties and may require inpatient support or treatment. We are undertaking Care Treatment Reviews and working closely with NHS England to ensure wherever possible more appropriate treatment is sought and provided in the community, and families are supported to support their child. Child Sexual Abuse and Exploitation (CSA/E) This area of development has been a priority within our transformation work and local focus. In Lambeth we are working with partners to develop a CSE and CSA strategy, action plan and robust pathway. In Year 1 we commissioned scoping and mapping work with the NSPCC to look at 14

16 prevalence and gaps in provision. Together with Southwark, Lewisham, Bromley and Lambeth we will look at evidence based provision, perhaps in the form of a child hub or a third sector specialist service offering therapeutic support and counselling. Lambeth and Lewisham have been very involved with the South East and pan London work taking place around the Child House model and will support Croydon as the identified area for the proof of concept house. We are currently working with our lead and designated doctor and nurse to develop a child hub for young people experiencing sexual abuse, especially historical. We have allocated a small amount of funding for therapeutic support and are identifying the best pathway and provider for this provision, hopefully with neighbouring boroughs. In the South East, we also need to ensure we are meeting the emotional and mental health needs of unaccompanied asylum seeking children which is an emerging issue for our area. CYP Improving Access to Psychological Therapies (IAPT) CYP-IAPT is a national qualification focused on the emotional wellbeing and mental health sectors. It sets out approaches to supporting children and young people through measurable outcomes. There is a number of staff within Lambeth CAMHS services trained in IAPT. This has previously been funded by NHS England however from 2017/2018 each CCG will be required to contribute to the cost of the CYP-IAPT programme of training. The national context for the workforce development is: To build capacity and capability across the system so that by 2020, 70,000 more children and young people can be offered an evidenced based intervention. Train 3400 existing staff in an evidence based intervention Train 1700 NEW staff in evidence based interventions Incorporate workforce development plans in refreshed Local Transformation Plans (October 2016) CCGs are expected to increasingly invest in the mental health workforce using year-on-year uplift in baseline allocations of Transformation Plan funding. In Lambeth we have decided to take the Psychological Wellbeing Practitioner (PWP) approach to training staff in CYP-IAPT. We intend to build on our current IAPT offer and have bid for 4 PWP practitioners which will enable us to link effectively with the GP localities and communities within Lambeth. It is our ambition to place 1 PWP in each of the localities based in the community. A bid for 4 PWP allows for some flexibility within this model giving an opportunity to provide added input in localities with an increase in demand. IAPT would be linked to local GP practices, which would be aligned to local schools enabling interventions to be delivered within the primary care setting reducing stigma and promoting a more flexible approach to care as the PWP could be contracted to work evening and weekends. This model mirrors CYP PPI engagement feedback which stated services should be located close to school and home whilst being flexible and easily accessible. This 15

17 fits with a model of care that is proactive, intervenes early and underpinned with clinical and evidence based interventions. We will be working with our providers to develop the model to ensure CYP-IAPT trained staff will work across a range of settings in Lambeth to maximise the reach of IAPT and the impact. It is key for us in Lambeth that our children s workforce is skilled and confident in working with young people and bringing about change and positive outcomes. Our aim is for the access to IAPT in community settings to help to decrease the level of need for Tier 3 intense intervention and therefore lower the cost attributed. Collaborative Commissioning There is continuing collaboration between Lambeth and NHS England (NHSE) Specialised Commissioning; we have been involved in the review of NHS England Specialised CAMHS (Tier 4) in London as part of Transforming Specialised Services in London (TSSL) programme and as such the case for change to look at how we can improve the model of care to provide the right care, at the right time, and in the right place. We have also started the discussions locally, within the Sustainability and Transformation Plan (STP) area and NHSE around transforming care for CYP in the Justice system. Lambeth commissioners have been directly involved in the Our Healthier South East London Partnership/STP work and have regular discussions with NHSE specialised commissioning in regard to South East sector and borough specific work. CAMHS services are provided across the spectrum of care settings with some of the most complex and/or high risk cases requiring admission to specialised (T4) inpatient care. There is the expectation that Local Transformation Plans lead to a significant reduction in demand for Specialised CAMHS services within the next 5 years. Community crisis care pathways that can provide robust and sustainable alternatives to inpatient care are under-developed particularly for children and young people with complex needs and behaviours related to learning disability (LD) and/or Autism and emerging personality disorders. The overall distribution of CAMHS inpatient capacity does not match Regional population needs and young people are being admitted far from their home, or to paediatric or adult beds; the NHS England National CAMHS Service Review aims to redress service deficits by redistributing/realigning beds to meet local needs, the clear expectation is that by 2020 there will be no inappropriate admissions to adult or paediatric beds and patients will be treated in local care pathways. Lambeth Areas for Continued Development: Transforming CAMHS medical provision In Year 2 we will see the completion of the CAMHS service reviews and will have gained a full understanding of the current pathways, treatment options, service structures, and routes of access. This will be the key tool for the transformation of Lambeth provision. We will be able to identify clearer routes of access for self-referral, and referral from GP s and schools. We aim to improve communication between the voluntary and community sector, statutory services and SLaM to ensure a smoother and more robust treatment journey for young people. We will continue to focus on the key areas of need as identified in our Lambeth needs assessment and the upcoming children s Joint Strategic Needs Assessment, such as transition periods, 16

18 transforming care, learning disabilities, behavioural disorders, ADHD and autism pathways, BME groups, and asylum seeking children. The Lambeth mental health core contract has been amended to include the regular reporting of outcomes to the CCG and CAMHS commissioners. Outcomes from CGAS have not been routinely provided as part of performance monitoring and are a key measure of impact of treatment and service provision. School Collaboration A key area for us to develop is our direct work with schools and bringing them in as commissioning partners. Schools are a key partner in delivering emotional wellbeing to young people and the CYPHP emotional resilience programme will be an effective facilitator in this process. We want to help to change the school ethos around embedding emotional resilience and self-sufficiency into children and young people from a young age. Children need practical coping skills and mechanisms to deal with issues and to understand who to speak to when they need help. We are looking to develop the links between our medical CAMHS service and schools by having school champions and link workers in place. We will work with school staff and our CAMHS workers to ensure two way communication is improved and CAMHS services are providing advice and guidance to schools wherever a child does not meet the threshold for provision or therapies. We are also planning to work with the Lambeth Youth Council to co-produce their project ideas for raising awareness of mental health in schools and to break down the stigma of talking about it. We will be looking at the PSHE content and delivery and key messages that we can develop for school staff. We are also joint funding with the council an Emotional Wellbeing and Healthy Schools Coordinator to provide the key contact and liaison between ourselves as commissioners and schools. Workforce Development and Training Our Year 1 and 2 plans include undertaking scoping work to look at the current level of training and skills within the young people s workforce around emotional wellbeing and mental health. We will initially focus on the skillset of social workers, schools, GP s and health visitors and identify good practice and effective training with the aim of rolling out a programme of training and awareness. We will work with partners to ensure the identified provision is effective, feasible and will bring the best outcomes for children and young people accessing these services and support. Embedding local schemes such as LEAP and CYPHP The projects within the Lambeth Early Action Partnership (LEAP) that have a synergy with the transformation of CAMHS will be further explored and built into our local offer. We will continue to work in partnerships with the Children and Young People Health Partnership (CYPHP) in a number of areas including the health and wellbeing of Looked After Children, those with long term conditions, and the delivery of the emotional resilience training programme in schools across Lambeth and Southwark. Co-production and Engagement 17

19 Children and young people o We will be working with the Lambeth Youth Council to develop their ideas around the PSHE curriculum and how emotional wellbeing should be embedded within schools. They propose to have a set of guidance for schools, informing them what young people need PSHE to cover including how to deal with issues such as exam stress, sound sleeping techniques and taking time for your mental wellbeing. This will also hopefully form our young people s Takeover Day. Parents and Families o We plan to work closely with parents and families to develop our parenting programmes around emotional wellbeing and mental health. In partnership with Local Authority colleagues we will ensure our parenting provision provides families with the skills and awareness to support young people at home and encourage discussion around these key issues. Digital Technology and Communication In Lambeth we are keen to improve our use of digital technology to promote services and access for children and young people, and to signpost those to help and support when needed. We are looking at evidence based approaches and will be working with young people and colleagues within youth engagement, communications, and the community sector to take this forward. We are developing a communications plan for children and young people and intend to work with young people as well as our Co-production Group to take this work forward. The communication plan includes national campaigns to link in with and promote locally, as well as working with Lambeth young people to develop local initiatives and approaches relating to local need and communities. We will promote nationally recognised digital tools locally such as NHS Go and the Health A-Z, but will also learn from our neighbouring boroughs who have invested in their own digital projects in this area of work. 18

20 Detail of Previous Spend In previous years, the focus of CAMHS spend has been on Tier 3 and 4 provision for treatment within our CAMHS services. 2015/16: Total budget for Tiers 1-3 CAMHS Total budget for Tier 4 OP Total budget for Tier 4 IP TOTAL CAMHS Budget 3.667m 574k (200k overspent against allocated budget) 1m (approx) 5.241m Of the 3.667m spent on Tiers 1-3 this consisted mainly of the block contract with our mental health trust ( 2.5m). It also included money for additional wellbeing services such as substance misuse, autism and early help led by the local authority. The levels of activity were summarized in the Strategy as below: The Young Lambeth Emotional Wellbeing and Mental Health Strategy sets out our current spend per child in Lambeth, as of 2015/16. Although there is limited data, the national average cost per contact with tier 1-3 (Community) CAMHS is a relatively crude benchmark and shows an average median cost of 240 per contact across 65 participating organisations. To calculate the average cost per contact in Lambeth, we looked at the 2267 young people seen by Lambeth CAMHS Tiers 1-3 in 2015/16 and used the national average of 6 sessions/contacts per patient giving us per contact, which is just above the national average. However, when we looked at spend per head compared with the neighbouring boroughs of Southwark, Lewisham and Croydon, Lambeth was investing approx. 25% less per head than Lewisham and Southwark, with Lambeth spending 48 per head compared with neighbouring boroughs both spending 61 per head. 19

21 CAMHS Transformation in Lambeth Our aim in Lambeth is to transform our provision for children and young people requiring support around their mental health and emotional wellbeing. We know based on national assumptions that 10% of the population have a diagnosable mental health need or issue, of which approximately 20% are currently accessing support or treatment. Our aim nationally is to increase this number to 35%. However our aim for Lambeth is to increase this access at an earlier stage and not at a treatment or crisis level, requiring Tier 3 and Tier 4 provision. We want to ensure young people are receiving the appropriate support and help at the right time, to prevent them needing to access higher level treatment at a later date. By improving and increasing our provision at a Tier 2 level, we hope to meet the needs of young people and increase the number able to access these services. Our aim is to flip the levels of activity to have more accessibility and provision at Tier 2 and less need for high level treatment services and inpatient provision. Specialist Mental Health Services (hospital) Community Mental Health Services Early Intervention (CAMHS) Resilience/Prevention Plans for between now and 2020 Future in Mind and NHS England confirm incremental funding allocations for each CCG area for five years ( ). This is in addition to the current CCG contract with the mental health trust in Lambeth. The national formula suggests an annual uplift of 2%. We are in discussion with our financial team as to the agreed uplift for Lambeth CAMHS provision. The projected five year financial commitment for CAMHS transformation in Lambeth is set out in Table 5. 20

22 Table 5 Funding allocation for CAMHS Transformation by Lambeth CCG Year 2016/ / / / /2021 Funding amount for 684k 684k 697, , ,867 Lambeth Uplift % 2% 2% 2% 2% 2% Uplift amount 0 13,680 13,954 14,233 14,517 Value (incl. Growth) 684k 697, , , ,384 The total Transformation funding allocated to Lambeth CCG annually was 195,000 plus 488,519 in Year 1 totalling 683, 519. In Year 2 we saw a CCG uplift of 3% uplift however this was not ring fenced for CAMHS so not allocated. However a commitment to ring fence the proposed allocation growth for Lambeth CCG has been made and reflected in the table above. Lambeth received an additional in year payment of 215k for eating disorder and crisis care in month 3 of This was allocated to our eating disorder specialist provision at Tier 4 level. We have been informed of an allocation of a recurrent 101k and non-recurrent 33k in 2017 for Health and Youth Justice. Lambeth are working with key partners in the criminal justice system to undertake a mapping exercise to identify areas of need and gaps within the health offer to young people coming through the criminal justice system or to the attention of police and courts. We have not included these additional payments in our main CAMHS table of spend above. Our detailed breakdown of spend for 2016/17 can be found in our original Transformation Plan as submitted in December 2015 and on the Lambeth CCG website. Table 6 gives detail of the allocation of underspend in 16/17. 21

23 CAMHS Transformation Funding 2016/17 Forecast spend against Priority 8% 2% 19% P1 Prevention:Awareness, knowledge and training P2 Maximising Resiliance and Self Sufficiency P3 Improving Access to Clinical Services 50% 21% P4 Transition from Birth to Adulthood P5 A Public Mental health Apporach: the wider Environmental Factors For the next 4 years of Transformation, in Lambeth we plan to re-evaluate our spend on our 5 priority areas above and ensure the correct effective balance against key outcomes such as workforce development of the wider children s workforce, the delivery of early intervention and prevention programmes, a range of services at Tier 2 community level, and the reconfiguration of our clinical and therapeutic CAMHS provision (Tier 3 and 4). Table 6 Allocation of 16/17 underspend Allocation of 16/17 underspend Priority 5 A Public Mental Health Approach Joint Strategic Needs Assessment (JSNA) Development Suggested Amount Public Health Approach: Wider environmental factors The CAMHS Needs Assessment was completed in 2014 and whilst we have continued to gather stakeholder s views and are carrying out the review of services, it is important that Lambeth has a comprehensive and up to date JSNA for children and young people, which includes information on emotional wellbeing & mental health. We have therefore allocated 10k towards the development of the Lambeth JSNA. 10k Public Health Approach: Wider Joint funding of the Healthy Schools Coordinator Post This post has been developed from the Healthy Schools post that 30k 22

24 environmental factors Public Health Approach: Wider environmental factors previously sat within the Local Authority. With partners it was decided that the role was pivotal but could be improved by adding a more structured emotional wellbeing and mental health element. This post holder would be our key contact with the schools in Lambeth, both to assist with the roll out of our emotional resilience programme and for the upcoming EI and prevention programmes we are looking to joint commission with schools. Contribution to the further evaluation and analysis of the Children and Young People Health Partnership (CYPHP) programme in Lambeth. The evaluation will give us further information and evidence around impact on young people s wellbeing and health, as well as the social care and environmental impacts on health and vice versa. The programmes around Looked After Children s health and wellbeing, children with long term conditions such as asthma and epilepsy, and mental health support for them. 20k Improving Access to Early Intervention services, Bidding opportunity for VCS to meet the Lambeth EWMH strategic objectives We will invite VCS partners within our co-production group and wider to submit a 2 page proposal for non-recurrent funding for a project or provision that supports our identified vulnerable groups such as LAC, BME, young offenders etc and meets our key strategic objectives. We will work collaboratively with the successful organisations, to co-produce outcomes and to identify innovative projects that address gaps in current provision. As part of the selection process The CAMHS Joint Commissioning Group will oversee the tendering process. It is our ambition that the successful organisations will enhance the local offer. 200k Risks and Mitigation There are a number of risks to our plan and to the general transformation of CAMHS in Lambeth; The risk of CCG not ring fencing CAMHS funding due to demands and overspend elsewhere Although NHS England can request ring fenced money for CAMHS services within CCGs, this does not seem to be enforced. Whilst Lambeth CCG has committed to the allocation of the budget, due to increasing pressure at a local level and with decreasing budgets and increasing cost, this may change in the future. We will try to mitigate against this by working closely with Chief Finance Officers and Children and Maternity Porgramme Board to ensure we have justification for ring fencing 23

25 this money and have given clear evidence for impact and outcomes, along with the risks of not ring fencing this money for CAMHS. The risk of overspend on CAMHS due to increasing overspend of the Tier 4 specialist budget We currently have overspent within our Tier 4 specialist budgets (outpatient) and this seems to be increasing year on year. Lambeth CCG are committed to matching our budget wherever possible, however with the plans of NHSE to reduce inpatient costs this will lead to an increase in specialist costs to the CCGs. We are working closely with our CCG finance team to ensure up to date predictions for spend are known, and we are working with our providers to ensure treatment and support is allocated correctly and appropriately. Unknown changes to the CAMHS pathways Inpatient provision and management coming back to CCGs We are currently working closely with NHSE to look at the options of moving inpatient placements back to a local level and the responsibility sitting with the CCGs. If this happens, the funding and cost will sit with CCGs. Local Authority decreasing budgets having an impact on the outcomes and feasibility of our projects and work areas. A number of our CAMHS ambitions and changes in delivery in Lambeth rely on partnership working, co-commissioning and implementation across the wider children s workforce. If the horizon continues to change dramatically across the local authority, schools, and the VCS sector, as we are already seeing, this will impact on not only funding but capacity to deliver. We will need to continue to work closely with all partners and stakeholders, and the community, to ensure we come up with innovative and high impact delivery for children and young people. 24

26 Appendices Appendix 1 Young Lambeth Emotional Wellbeing and Mental Health Strategy Young Lambeth Emotional Wellbeing and Mental Health Strategy Appendix 2 Eating Disorder Service Update Submitted alongside Transformation Plan Appendix 3 CYP IAPT Proposal for Lambeth Submitted alongside Transformation Plan Appendix 4 - Update as of October 2016 on key pilot projects funded in 2015/16 Funding for 24 places at Breathe Art, Lambeth With Year 1 underspend in 2015/16 we were able to fund places on a 6 month programme for Lambeth children and young people with Hemiplegia including an Easter Camp and monthly groups for 12 young people, and a Next Stage graduate programme for 12 young people. This programme uses an innovative and interactive programme of magic tricks to engage young people. The programme has demonstrated good clinical outcomes, with evidence of increased confidence and wellbeing. This project has already won an award in Lambeth for its work with children and young people. We will use 68k of underspend in 2015/16 to fund places for 24 young people. To date, the Breathe Art programme has delivered 2 foundation programmes for Hemiplegia patients in the summer of 2016 to only 2 Lambeth young people. The next stage graduate programme attracted 4 young Lambeth people. There have been challenges identifying a larger cohort of Lambeth children, therefore we are monitoring the uptake and may need to reallocate a proportion of the funding. A full evaluation of this programme is due in March To fund a support worker within the Gaia DA Centre for one year - for YP aged 11-17, affected by parents DA. And fund placements for young people for counselling In Lambeth Refuge deliver an excellent service to people affected by domestic abuse, through the Gaia Centre. Through the transformation plans, we were able to fund a young people s support worker in the Early Intervention Team for 18 months and allocate 20k for young people to access therapeutic services and counselling for domestic abuse or CSE, facilitated by the support worker. This work will be reviewed after the 18 months. As of July 2016; 9 children young people have been referred, 6 linked into The Gaia. Engaging with schools, 50/50 split between girls and boys. In recognition of the need to support high school aged children the age range will span We are working with the Gaia Centre in partnership with our Community Safety commissioning colleagues at London Borough of Lambeth to look at future funding of this post and embedding the work within the VAWG work streams. To fund evidence based Multi-Systemic Therapy for 10 families from the Brandon Centre 25