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Commissioned Joint Committee - Children, Education and Communities Policy and Scrutiny Committee and Health and Adult Social Care Policy and Scrutiny Committee |
28 February 2022 |
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Joint Report of the Director of Prevention, Commissioning and Education and Skills and the Director of Mental Health and Complex Care for NHS Vale of York Clinical Commissioning Group Children's Services |
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Emotional and Mental Well-Being of Children and Young People
Summary
1. Members have requested a report outlining the current factors that influence the emotional and mental well-being[1] of children and young people[2] (to age approximately 19) in the City, and how the local system can jointly support a high level of emotional and mental well being in the younger population.
2. This report covers:
· National and local policy
· Mental health disorders in children and young people
· The Covid-19 pandemic
· What is on offer locally
· Local concerns and challenges
· What the future might look like
Background
3. National and local policy framework
Future in Mind (2015)[3] set the direction of travel for the well-being of children: taking five key themes the report sought to secure focus on:
1. Prevention and promotion: particularly in early years (first 5 years)
2. Early intervention
3. Ease of access to the right support at the right time
4. The right support for vulnerable groups of children
5. Good workforce planning across the whole workforce, not simply within standard CAMHS services
4. Future in Mind came with some funding to the CCG: locally, a
proportion of the funding was mandated into a community eating disorder service, and the remainder was invested jointly with the Council into the School Wellbeing Service.
5. In 2019, the NHS published its long-term plan[4] (LTP) for England, with targets for 2024:
· 35% of pupils have access to an NHS funded mental health support team
· 35% of children with a diagnosable mental health disorder can access NHS funded care
· Digital offer for all children and young people
6. The LTP expects that local systems will work together and jointly commission whenever possible and reflects a shift in thinking around commissioning in mental health from a service structured approach, to a needs-led system known as iThrive which is well adapted to systems working across agencies. One of the aims of the iThrive model is to ensure the system is giving sufficient focus on young people who are ‘thriving’ or benefit from the ‘getting advice’ and ‘getting help’ segments of the model.
7.
The diagram below illustrates the iThrive
system. Essentially the model considers the needs of the
child at any given point and offers the appropriate response, which
could be form within local authority, health or third sector
services: the role of schools, families and community organisations
are recognised.
8. Locally, the leading policy is the All-Age Mental Health Strategy 2018-2023[5] which has two relevant themes:
· Getting better at spotting the early signs and intervene early
· Improve services for mothers, children and young people
9. The Mental Health Partnership Board has been more focused on adult mental well-being as NHS funding has been made available for adult initiatives since 2020. Partly in consequence and also to refresh the Yor-Ok Board, a new partnership group was established in 2021 to focus on children's health and well-being, including emotional and mental well-being: this group reports to the Health and Wellbeing Board
10. The plan for children's emotional and mental well-being was revised in 2021: it is structured around the iThrive model, setting out an ambition of supporting children and young people as early as possible from primary through secondary school. The iTHRIVE model approach support a social model of supporting individuals and families through getting help and getting more help reducing the need for longer term MH service input.
11. Mental health disorders in children and young people
A mental health disorder is one which significantly affects daily functioning and is of long duration; these are disorders for which specialist CAMHS (Orca House) is commissioned. Short term or predictable difficulties, for example exam nerves or loss/bereavement may be less severe and are appropriately treated in school or the local community and would generally not be appropriate for referral to specialist CAMHS: see below for further discussion regarding this.
12. Of lifelong mental health disorders, 50% begin to be seen between the ages of 14 and 18 (it is ‘50% by the age of 14 and 75% before their mid-20s’ according to No Health Without Mental Health (2011) Such disorders include ADHD, psychosis, eating disorders, and personality disorders. Death due to eating disorder is a leading cause of death in women aged under 34, whilst suicide rates are highest among men aged 24-45 years.
13. We know children in care and those who are cared for by a parent with mental illness are more likely to require support. We are also seeing an increasing number of young boys requiring eating disorder services
14. Since 2018, our knowledge of the prevalence of all mental health disorders in children has improved with more regular publication of national prevalence surveys:
|
Year of National Survey |
National Prevalence (5-19) |
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2004 |
10% |
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2018 |
12% |
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2021 |
14% |
Source: NHS Digital
15. Prevalence is used for planning purposes and is not a statement of actual numbers, which are more difficult to analyse as the incidence of risk factors, such as deprivation, in the local population has an impact on the numbers with diagnosable illness.
16. The current NHS Long Term Plan performance targets state that providers should support at least 35% of children with a diagnosable mental health condition (see above), less than the predicted 75% requiring some form of support and noting that the target of 35% is based on the 2004 prevalence rate from 2004, of 10%. TEWV's performance is at 45%, well in excess.
17. The leading disorders recorded locally have since 2004 been low mood (depression) and/or anxiety (within the definition of emotional disorders). These disorders wholly accounted for the national overall increases in prevalence in 2018 and 2021. The distribution of increased prevalence is not even across all age groups, for example, the largest age group to be experiencing these difficulties is the 17-19 group of young women, of who some 22% are predicted to have a diagnosable emotional disorder. Other disorders, such as ADHD or conduct disorders have remained stable in terms of prevalence, although their incidence has increased because of population growth.
18. Autism is not of itself a mental health disorder, but may be associated with anxiety or obsessive behaviours which are mental health disorders. Likewise, trauma, in the sense of childhood trauma arising from poor attachment or neglect/abuse is also not a mental health disorder, but the correlation between adverse childhood experiences and mental health disorder or illness is high. The numbers of children locally falling into the higher categories of child protection, such as being looked after or carrying significant risk under a child protection plan is therefore an indicator of need.
19.
The Covid-19
pandemic
Locally,
the pandemic has led and is predicted to lead to an increased
demand for support to improve emotional and mental
well-being. Demand for the School Well-Being Service and its
response has been disrupted by school closures during the
pandemic.
20. We are now seeing a 50% rise in young people accessing school support and an increase in absenteeism as young people are trying to come to terms with life changes following the pandemic. Schools are noticing higher levels of acuity and need for young people in school in regards to emotional regulation leading to challenging behaviours; more schools are moving to trauma informed approaches to understand the underlying causes of adverse behaviours and changes in young people whilst at school.
21. The Well-Being in Mind service (funded through NHS England) has commenced (January 2022) in 8 schools and colleges: demand for support is already high, indicating it is meeting a need.
22. The local authority commission York Mind to support young people and equally the demand in service has increased and the level of input required due to levels of distress has also increased
23. Specialist CAMHS has also seen a reduction in referrals, probably due to reduced access to primary care and reduced school attendance during the pandemic, although data for 2021/2022 to Quarter 2 indicates a strong upward trend in referrals and acceptances. Quarter 3 (December 2021) data will eb available for the scrutiny meeting.
24. Tees Esk and Wear Valleys Trust (TEWV) also noted the increase in acuity for those whose needs should be met by specialist CAMHS services with potential additional demands on service, notably for eating disorders and anxiety disorders: this is evidenced on the above chart through the reduction in the proportion of referrals signposted and diverted.
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2019-20 |
2020-21 |
2021-22 (Q2) |
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Number of Referrals into CAMHS |
1710 |
1539 |
1022 |
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Rate Discharged Less Than 2 Contacts |
48% |
40% |
31% |
25. The figures do not include crisis team referrals
26. The majority of referrals signposted out relate to anxiety or low mood and are appropriate for lower level intervention in community services in school or other setting.
27. TEWV forecast in 2020 that by 2025, in consequence of the COVID-19 pandemic there would be a 50% increase in the number of children requiring some form of intervention to support their emotional and mental well-being; the majority of these needs are predicted to be short term, and a combination of whole system (school, home and community) reassurance and short term interventions would suffice. This demands a whole system response to children's emotional and mental well-being and cannot be dependent on specialist CAMHS services alone to provide support: schools, public health, third sector and the community more generally have roles to play.
28. Initially, in 2020 and through to 2021 there was a significant increase in the demand for inpatient beds, which are commissioned by NHS England: the position is still of concern, but as restrictions have lifted demand has reduced somewhat and currently there are fewer than 5 children from York in an inpatient bed.
29. The pandemic has accelerated some of the developments envisaged in the NHS long term plan, particularly in relation to the development of digital services: for example the specialist CAMHS offer is now fully blended between face to face and virtual, depending on clinical need and the preferences of children and young people. However, a full analysis is required to understand the impact
30.
What is on offer
locally
The
commissioning map for services that contribute to children's
emotional and mental well being in York is below:
|
VOY CCG |
NHSE |
ICS |
TEWV |
Vol Sector |
Schools |
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· Specialist CAMHS (TEWV) · CAMHS in-reach to York Youth Justice Service · Autism assessment service (TEWV) · Mental Health Support Team York (Jan 2022)
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Forensic CAMHS/ Sexual Assault Referral Centre
CAMHS inpatient beds
Speech and Language in-reach to Youth Justice Service |
Keyworkers for complex autism
Kooth online advice and counselling (to March 2022) |
CAMHS
Community eating disorder service
Learning Disability nurse for complex autism
Early Intervention in Psychosis
Crisis support
Safe Haven (16+) |
IDAS
The Island
York Mind
NSPCC
National websites and self help forums |
Locally determined support, eg family workers, counsellors
This support is not mapped across the City |
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CYC
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· Counselling service 16-23 (York Mind) · Healthy Child Service (school nursing and health visiting) · Early Help · Educational psychology (advice only) service · Emotional Literacy Support Assistants
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Jointly commissioned
· School Well-Being Service · FIRST service for complex autism · Safe Haven
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31.
Local demand
The specialist CAMHS caseload
figures indicate increasing demand.
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Caseload 2019/20 |
Caseload 2020/21 |
Caseload 2021/22 (Q2) |
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Number on Caseload (waiting or in treatment) |
2256 |
2456 |
2085 |
32.
The leading conditions as indicated
by the caseload and referral figures for specialist CAMHS are
neurodevelopmental disorders (these exclude autism once assessed as
requiring a full assessment, but do include ADHD), anxiety and
depression.
Those conditions with more than 60 patients on caseload as at Q2
2021/2022 are:
|
Row Labels |
Caseload 2019/20 |
Caseload 2020/21 |
Caseload 2021/22 (Q2) |
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ANXIETY |
533 |
540 |
442 |
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CONDUCT DISORDERS |
198 |
244 |
202 |
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DEPRESSION |
323 |
359 |
279 |
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EATING DISORDERS |
10 |
47 |
60 |
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IN CRISIS |
102 |
140 |
108 |
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MENTAL HEALTH |
120 |
88 |
64 |
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NEURODEVELOPMENT EXCL AUTISM (includes ADHD) |
491 |
680 |
735 |
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NEURODEVELOPMENTAL CONDITIONS (includes autism waiting list) |
275 |
207 |
106 |
33. The figures for patients on pathways have remained largely stable, with notable exceptions for eating disorders and neurodevelopmental disorders both of which have increased significantly, but note this figure includes children referred for an autism assessment waiting for an initial decision as to whether a full autism assessment should be undertaken. There have been notable decreases in numbers on the autism waiting list due to more efficient assessment pathways, but the overall number of referrals has increased significantly and assessments are running at double the number in 2017/18. The number with anxiety disorders due to earlier access to group therapy has reduced waiting lists, but again masks an increase in demand.
34. TEWV performs well against the national target of treating seeing 35%of children with a diagnosable mental health disorder: as at Q3 (December 2021) performance is at 45%
35. The data relating to the school well-being service during an academic year disrupted by Covid-19 shows increasing demand. The service's remit is to work with children experiencing anxiety and low mood: we have seen an increase in requests around emotional regulation, undoubtedly driven by the pandemic, and particularly an increase in levels of work in primary schools.
36.
Local concerns and
challenges
Across
the local system in York, the following are seen as the leading
concerns in relation to children's emotional and mental
well-being
· Gaps in provision for prevention and early intervention
· Increase in levels of school avoidance generated by anxiety (a Covid response)
· Percentage of referrals to specialist CAMHS that are signposted and diverted, indicating unmet need elsewhere
· Increased complexity of referrals into specialist CAMHS evidenced by a reduction in referrals not accepted
· The significant increase in eating disorders
· The scope of the offer for children in care of the Council with complex needs (eg autism and mental health)
· The whole pathway of support for autism, although average waiting time for assessment has reduced, the offer for support pre-assessment and post-diagnosis is limited.
37. These concerns are set out in more detail in the Annex.
38.
What the future might look
like
The list below
offers an indication of opportunities for further joint work
through pathway redesign or commissioning into either the statutory
or voluntary sectors. It must be noted that there is minimal
funding available for new investment from either the Council or the
CCG beyond the NHS Mental Health Investment Standard, which has
increased the CCG funding for specialist CAMHS for the past 4
years. The reorganisation of NHS commissioning in 2022 means
that future commissioning arrangements within health will be
through the Integrated Care Board for Humber Coast and Vale with
possible devolution for some elements.
39. Many of the suggestions are framed within the principle of an integrated whole pathway approach as envisaged by the York Mental Health Strategy. These potentially include a single gateway model, more active commissioning into the third sector, a formally adopted graduated pathway, a revised neuro pathway (autism and then ADHD) and use of the principles of the SEND Inclusion Review and sufficiency planning.
40. Using the iThrive model:
· Getting advice:
o Improved web based offer for advice and self help
o Single gateway into all emotional and mental health support to identify needs
· Getting help:
o Integrated Counselling offer
o Third sector led or provided information, advice and support at levels below specialist CAMHS
o Clear step down/alternative offer should a referral to specialist CAMHS not be accepted
o Early offer for suspected autism
· Getting more help
o Specific offer for looked after children and child protection plans linked to the wider CAMHS offer.
o Specialist teachers for SEMH (ADHD)
· Getting high risk help
o home treatment offer for those awaiting tier 4 provision and for those experiencing high levels of distress,
o Revise the FIRST offer within the neuro pathway
41. On 14 February 2022 a summit of system leaders across North Yorkshire and York was convened to consider the challenges facing children's emotional and mental well-being and tasked with identifying and committing to transformational change. The challenges for York set out in this report were discussed, and, in line with the Mental Health Strategy aim of integrated systems, a commitment made to the development and piloting at pace of a multi agency hub in York including voluntary sector colleagues in one of the areas in the City with high levels of need across the system. The hub's role will be to undertake early assessment of the needs of the child to ensure the right support is provided and that the child can be followed up. Further information regarding this proposal will be provided at the Scrutiny Committee meeting.
Consultation
42. This is a joint report from children's services and the clinical commissioning group, and has involved consultation with council services and external health partners.
Options
43. Please see above.
Analysis
44. Please see above.
Council Plan
45. Not applicable.
46. Implications
· Financial There are no relevant implications
· Human Resources (HR) There are no relevant implications
· Equalities There are no relevant implications
· Legal There are no relevant implications
· Crime and Disorder There are no relevant implications
· Information Technology (IT) There are no relevant implications
· Property There are no relevant implications
· Other: There are no relevant implications
Risk Management
47. There are no relevant risks
Recommendations
48. Members are asked to consider the report.
Reason:To enable the committee to note the findings, the work that is ongoing and the further next steps.
Contact Details
Author:
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Chief Officer Responsible for the report: Denise Nightingale Director of Mental Health and Complex Care NHS Vale of York CCG |
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Co-Author Jamaila Hussain Director of Prevention, Commissioning and Education and Skills Dept Name People Directorate |
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Report Approved |
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Date |
14 February 2022 |
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Jamaila Hussain Director of Prevention, Commissioning and Education and Skills |
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Report Approved |
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Date |
14 February 2022 |
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Wards Affected: |
All |
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For further information please contact the author of the report
Annexes: Annex 1 - Level of referrals signposted by specialist CAMHS
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Abbreviations:
LTP: the NHS published long-term plan to 2024
CAMHS: Specialist Children and Adolescent Mental Health Service
ADHD: Attention Deficit Hyperactivity Disorder
TEWV: NHS Tees Esk and Wear Valleys Foundation Mental Health Trust
CCG: Clinical Commissioning Group
NHS: National Health Service
FIRST: Family Intervention Rapid Support Team
SEMH: Social Emotional and Mental Health Needs
CBT: Cognitive Behavioural Therapy
EHCP: Education Health and Care Plan