Agenda item

The Director of Operations & Transformation (CAMHS and Learning Disability Services) Tees, Esk and Wear Valley Foundation Trust was in attendance to deliver a presentation on CAMHS Waiting Times (for copy of presentation, see file of minutes).

 

The presentation provided Members with Key Areas of the Work Programme; Details of the i-Thrive framework of care; Response to CQC Concerns; Waiting Times including the Crisis Service and Eating Disorders; Case Example and Next Steps.

 

The Director of Operations and Transformation advised members that they had a 97% success rate of ensuring that service users and their carers were being kept in touch from CAMHS and other support services. She also advised that CAMHS were unable to cap caseloads as this was determined by the type and intensity of the work, but they were working with clinicians about this and reassured members that staff did receive the right training. The Trust were also looking at more creative ways of filling staff vacancies.

 

The Director referred to the work programme key areas and explained that the five areas highlighted in the presentation were intrinsically linked. Waiting times and staffing remained the main areas and if they could get these right than the others would fall into place.

 

In relation to the i-Thrive model members were advised that this was a national recommended multi-agency framework that considered four areas; getting advice; getting help; getting risk support and getting more help. In relation to getting advice and help this did not need to be delivered by mental health staff and were children and young people in these groups did not need to interact with CAMHS. Those who received risk support or more help required specialist mental health support. However, in County Durham all children and young people whether they required advice and help, or risk support and more help went through the CAMHS system, and this needed to be managed as those who require advice and help could receive the support they need from other services. Only 5%-10% of children and young people need specialist treatment, but if children and young people seeking advice and help were not seen quickly their mental health could deteriorate and they may require specialist help.

 

Members were also advised that 90% of schools were part of the Mental Health Support Teams to provide school-based support, early help and prevention and meet young peoples need at place.

 

The Director advised that in the Teesside area also within the Trust, CAMHS only signposted those who were seeking advice and help and the waiting times in this area were lower than in County Durham area. She advised that a pilot was planned for North Durham but had no further details.

 

Information was given on waiting times for non neuro referrals where a triage assessment would take place prior to full assessment and members learned that TEWV calculated the wait from the triage assessment whereas nationally this was calculated from the start of treatment. In relation to specialist neuro assessments CAMHS do not carry out treatment unless there were mental health needs too. The nature of autism requires that assessments are carried out face to face and COVID and lockdown had impacted on the Trust’s ability to carry out these assessments.

 

Members were also advised that there was a dedicated Crisis Team in County Durham, which was not available in all trusts. The Crisis Team were meeting their targets and providing a wrap around care at home so that the patient did not need to be admitted to hospital, this was similar to the service operated by Adult Mental Health Services but with better support.

 

The Director then referred to eating disorders and advised that this service experienced a peak in referrals as we came out of lockdown as parents did not realise their children had an issue and the schools were closed. She went on to advise that children and young people with eating disorders are usually admitted to hospital and they always had one young person in Durham or Darlington in hospital that took resources away from the community. She advised that Avoidable Restrictive Food Intake Disorder (AFRID) had always been around but now had a name and was given a code by NHS England that would link to the eating disorder code, and this would show an increase in their numbers when this code went live in September. The Trust were lobbying NHS England to see if this code could be changed so that it did not impact on the eating disorder code, as people with AFRID were usually avoiding food because of a sensory issue or having had a bad experience with food.

 

Following the presentation, the Chair asked Members for their questions.

 

Councillor C Bell referred to a particular case and how their appointments were often cancelled, and the parent had to contact CAMHS to arrange a further appointment and asked if there was a reason for this.

 

The Director responded that she was unable to comment on particular cases but if Members wished to contact her direct with the details, she was happy to look into these.

 

Councillor C Bell then referred to assessment times and asked how long from the initial contact did it take for an assessment to take place and how many posts were currently vacant.

 

The Director indicated that it was dependent on what the child was being assessed for it could be hours or days and advised that they currently had vacancies in North End House.

 

In response to a question from Councillor C Bell about what help was available for families who had a child under CAMHS, the Officer responded that they carried out family therapy to ensure that no one falls through the gaps, however there was a difference between challenging behaviour and mental health issues.

 

Councillor Hunt referred to the waiting list and asked if those who were not deemed as severe if they were getting pushed back for severe cases. She also referred to the referral system in Durham been different and if this was something that needed to be looked at and if Autism patients were being treated before the assessment. She then asked if a child had been on the waiting list for some time, then become an adult what would happen to their case.

 

The Director responded that in the NHS urgent cases were dealt with as a priority and gave an example that if someone was suicidal then they would take precedence as they had to manage risk, but it would not impact too much on the waiting list. With regard to referrals, Durham had a single point of access where anyone could be referred even as a self-referral but until that initial assessment had taken place, they were unaware what help was required and which service could provide that help. Undertaking referrals was taking time away from seeing patients so they needed to think about this differently in view of the numbers. She then advised that they did not carry out treatment for Autism but would refer patients to other places while they were waiting for their assessment. With regard to patients transitioning from a child to an adult they had an Autism waiting list for adults but the numbers on this list were lower and that person would be transitioned across to that list. This process would start when they were 17 so that the transition would be seamless as possible.

 

In response to a question from Councillor Currah, the Director indicated that clinicians carried out the Autism diagnosis and they had nearly 3,000 children currently within the system and they monitored cancelled appointments. They were currently carrying some vacancies that could impact on the service.

 

Councillor Currah then referred to the waiting list and asked if they had undertaken an analysis of how many staff, they would need to recruit to reduce the waiting list. The Director advised that the vacancies were not always in the Autism assessment as it was a small team, and the vacancies were more generic in the CAMHS team. They had looked at outsourcing some of the assessments to reduce the waiting list.

 

Councillor Currah then asked if the information could be presented on how many staff would be needed to reduce the wailing list so that Members could talk to people such as MPs.

 

Councillor Sterling referred to the i-THRIVE framework of care and asked if they measured the impact of waiting times so if there was an escalation of need from one advice through to risk how was that measured. She then referred to those needing advice and help and signposting to others such as voluntary groups and asked how this was measured and followed up. She then asked if voluntary groups had sufficient resources to properly work with these children and how was it assessed and it was uncomfortable that they were relying on volunteers for important work.

 

The Director indicated that it was the voluntary sector and not volunteers and staff were qualified paid to work in the organisation.

 

Councillor Sterling then asked how staff caseloads were monitored and how often were the keeping in touch sessions. She then referred to Autism and while they were waiting for an assessment, they should be working with other agencies such as schools, but they hear from schools that there was no funding for support without an assessment, she asked how agencies worked together on this and where did they obtain the funding.

 

In relation to the i-Thrive model the Director advised that it was too early to give an indication the respective areas of the model were not monitored but the initial assessment would calculate the risk which would be given a RAG rating, where red is urgent amber and green non-urgent, and this was monitored on a weekly basis.

 

The Director then referred to the keeping in touch process that had different tiggers and was dependent on the initial rag rating. It could range from keeping in touch on a daily basis or a monthly to six weekly bases. Members were advised that the keeping in touch phone call which was followed up with a letter that included the details of different local organisations and if there was a significant or immediate change in the mental health of the child contact details for the crisis team. If the child was stepped up from green to amber than the keeping in touch days would intensify. They currently had 7500 children and had to employ someone to help keep them on track and this was monitored every day to make sure they were on track. This was also scrutinised frequently by the Trust Board.

 

Councillor Sterling commented that it was reassuring that the keeping in touch was monitored on a daily basis.

 

The Director referred to the voluntary sector and advised that the team would still provide some supervisory support; however, this would be a commissioning decision but presently they were commissioned to provide the services. The money would follow the children and organisations would have to bid for the work and ensure due diligence was in place.

 

With regard to caseloads these were reviewed every month, but they had also undertaken deep dives in each of the teams to ensure the caseloads were appropriate and this would continue.

 

Councillor Gunn suggested that in view of the importance of the issue a further meeting be arranged to ensure that everyone had the opportunity to speak and identify their issues and add to the discussion.

 

In response to questions from Councillor Walton, the Director advised that the waiting lists were monitored electronically but were now linked to electronic patient records and were more accurate. The definition of urgent was not a mandate framework for children crisis referral but they monitored against the adult framework that was within four hours and it was a clinician that they would speak to.

 

Councillor Walton referred to the ARFID figures and was concerned that this would impact on the figures and what could they do as a committee to lobby.

 

The Director responded that they were lobbying as an organisation and other organisations were doing the same as they recognised that they needed a different code for ARFID so that it did not impact on figures.

 

Councillor Walton indicated that that there needed to be a distinction between a child that suffered from anorexia or bulimia to a child that struggled to eat.

 

The Director indicated that they could provide a distinction in the figures internally, but this would need to be reported externally as a general eating disorder.

 

Councillor Walton asked if the committee could be provided with the details of the number of appointments that were cancelled. The Director would obtain this information and circulate to the Members.

 

Mrs Gunn referred to the length of the waiting lists which were an issue, but it was important to recognise that some of the issues come pre CAMHS as well and were not purely a CAMHS issue. There were some really good long-term strategies starting to be implemented but wanted to see more of a short-term plan to address the length of the waiting list. She went on to ask what Full Time Equivalents were available to work on treatments and assessments and what were the gaps.

 

The Director responded that the long-term strategies were put on hold to deal with current issues. It was a systemwide issue and was everyone’s responsibility and they needed to do quicker. In relation to behavioural problems the first three years of a child’s life were very important and support for parents could help. The Director stressed the time it takes for clinicians assess children through the system and if a few hundred children were removed from the lists who had come to CAMHS with challenging behavioural issues rather than mental health those clinicians could be working with someone who had recognised mental health problems. They were currently being reactive, and they needed to get away from this and every time they took a step back the waiting list had increased, and the waiting time was not an acceptable level.

 

In response to further questions from Mrs Gunn, the Director indicated that they were focusing on the five key areas and provided details of actions. She then advised that the waiting lists had reduced in the last year, so they were going in the right direction and things were improving. Their work with partners was their longer-term vision for the next 12 months. She would confirm if it was working or calendar days but suspected it was working days and the figures were for Durham only. She indicated that Teesside’s figures were better but had lower numbers, Darlington’s wait assessment was 16 days as opposed to 23 for Durham but again their numbers were smaller. The national clock stopped at the assessment stage, but they also measured it internally and lots of children were open to lots of teams and no two children were the same and had different needs. Some children may be on a waiting list for Autism but were currently having some other assistance so numbers were helpful but there was lots of activity going on behind the scenes.

 

Mrs Gunn indicated that it would be helpful for Members to understand the current risks and where monitoring did not take place and the length of time it was taken to complete treatment. and the average number of treatments per child?

 

The Director responded that they monitored everything, but it was difficult to give an average treatment per child as this was variable as children all had different needs but would ask the question.

 

Mrs Gunn asked if they were considering the use of technology to try and reduce some of the processing times such as virtual appointments.

 

The Director responded that COVID helped with this process but now that restrictions had been lifted it would be rare not to see a child at least once as it was dangerous to see a child electronically all the time, but they had the technology in place.

 

In response to a question on the conversation rate for neuro figures the Director advised that this was 70% for a diagnosis. Demand was going up and was about streamlining people into the right pathway and to ensure that people were getting the right help they needed. They needed to get assessments such as in schools so that they were not going onto lists that they did not need to be on.

 

Mrs Gunn then referred to eating disorders and asked how many were currently on the lists and how many were new and were these increasing and the severity due to other waiting lists.

 

The Director responded that it was a completely different waiting list for eating disorders and was monitored differently. It was schools and families who could catch these disorders earlier.

 

Ms Evans commented on the advice and help areas of the i-THRIVE framework of care and at the last meeting they received a presentation on ‘Young Families Strategy’ that mentioned a social subscribing pilot and she asked for details of the North Durham pilot to be circulated to Members. She then referred to Young People and Families Partnership Board and asked about interface and how the commission was carried out and how voluntary sectors could help alleviate some of the advice and help sections. She then indicated that at the last meeting members observed how the voluntary sector was struggling and how it didn’t have enough capacity and struggled with funding and asked that some cross check be carried out and those conversations be had and have a direction that was consistent and realistic and was going to work.

 

The Director indicated that she worked closely with commissioners and would get some further details on the North Durham pilot that was looking at the infrastructures around North Durham. If they did go down the voluntary sector route that would be recommissioned and the money would follow to deliver the service safely and effectively and commissioned properly through the appropriate channels.

 

Councillor Townsend asked about neuropathway and autism pathway and asked if this was the pathway for both Autism and ADHD. The Director would check on this and advise members accordingly.

 

Councillor Townsend then referred to the crisis team being available 24 hours a day, seven days a week and that the average wait time was 1.68 hours, but she had just seen a report of someone waiting 10 hours for a crisis team and some being told to ring the police. She asked when the crisis system was not working what would the Director advise members to do when they were contacted. She then commented that schools would not provide support to children until they had a diagnosis, but this was incorrect and should receive support in schools.

 

The Director referred to the crisis team and that they did have a 24 hour, 7 days a week crisis team but it was a small resource and due to staff shortages have had on occasions had to link it to the adult crisis team to keep the team going. She was happy to look at specific cases and indicated that in some cases it was appropriate to tell people to call the Police due to the immediate risk to the person.

 

Councillor Gunn indicated that they had to recognise that around some of the levels of this service there were national issues and commitment by organisations locally was one thing but commitment by government nationally for NHS spending and special education disability funding and for the increasing number of children with mental health issues and how this was dealt with had to be recognised. She wanted to look at the next steps and already mentioned was the North Durham Pilot and asked that details of this pilot be provided to Members at a future meeting. She then referred to communication plans for schools and the public regarding service developments and how to access support this was crucial and asked that scrutiny look at these communication plans. They had heard about casework and how difficult it was, but parents were desperate for the care and support for the child and the family and would like to see the plan. When looking at embedding mental health practitioners and primary care network again this was crucial to the system and asked if they could hear more about how this was going to happen, and the detail and the next steps were the crucial issues now. She again referred to a workshop to look at the issues in more detail or a paper briefing around some of the issues raised.

 

The Chair responded that the work programme would be discussed later in the agenda, but he could not see any issues with arranging a workshop.

 

The Director asked if the workshop could be system wide as they needed to move forward together.

 

The Chair referred to the NHS digital data analysed by the Royal College of Sociatrists that came out in March for routine cases waiting for an assessment that was 63 days nationally, the presentation stated 23 days for Durham, treatment nationally was 91 days and 203 days in the presentation for Durham and asked if this could be taken away and given some context.

 

The Director indicated that she would provide some data on a quarterly basis so that the statistics could be monitored.

 

Resolved: That the presentation be noted.