Level of referrals signposted by specialist CAMHS

We have seen the numbers of children referred into specialist CAMHS, but not accepted

	2019-20	2020-21	2021-22 (Q2)
Number of Referrals into CAMHS	1710	1539	1022
Rate Discharged Less Than 2 Contacts	48%	40%	31%

This indicates potentially a lack of understanding at system level of the alternative avenues of support to specialist CAMHS, or a gap in provision to meet needs in relation to advice and getting some short term help.

There are a range of factors that influence the continued demand on specialist CAMHS:

· Need for a more clearly articulated pathway and process for accessing support to ensure early access and avoid handoffs.

· Expectations and assumptions regarding need for support, which may over-medicalise concerns and encourage inappropriate referrals to specialist CAMHS.

· Insufficiently broad offer for lower level needs.

· Thresholds and barriers to some services, e.g. the commissioned counselling service and the Safe Haven crisis service are for children aged 16 and over.

· Historical lack of investment into services, driven mainly by the national funding settlements in local authority and health despite significant investment from the CCG under the NHS Mental Health Investment Standard since 2018.

· Increasing numbers of statutory Education Health and Care Plans since the new SEND Code of Practice (2014) has diverted some local authority services, such as Educational Psychology, into predominantly statutory roles or traded work.

Gaps in provision for prevention and early intervention

An ambition of Future in Mind was to prevent problems escalating to the point where specialist services would need to be engaged "We need to value the importance of recognising and promoting good mental health and wellbeing in all people, not just focusing on mental illness and diagnosis. There is evidence that supporting families and carers, building resilience through to adulthood and supporting self-care reduces the burden of mental and physical ill health over the whole life course, reducing the cost of future interventions, improving economic growth and reducing health inequalities"^{^[1]}

The local offer for prevention and early intervention, mapped to the iThrive quadrants of Getting Advice and Getting Help

Getting Advice

Getting Help

Self-guided online access: national organisations such as Young Minds, Beat, Childline that can be accessed 24/7, and offer information, advice (including goal setting and workplans) and some chat, depending on the organisation

School nursing service: offers advice and signposting

Emotional Literacy Support Assistants (ELSAs): these staff work mainly in primary school, their role is to work preventatively with individual children experiencing lower level social and emotional needs.

School Well-Being Service: works into all schools, offering whole school approaches, consultation and advice to staff and direct 121 work using CBT informed approaches

Well-Being in Mind: a new schools based service (January 2022) in 7 schools and York College working on whole school, consultative and CBT work 121. The service is funded for at least 2 years, and a second team may be funded from 2024.

Schools commissioned provision: schools and York College commission their own arrangements, these include in house counselling. These offers are not mapped across the City

Educational Psychology service: offer advice and training to schools under a traded offer, but do not work 121

Family Information Service/early help

School Well-Being Service: works into all schools, offering whole school approaches, consultation and advice to staff and direct 121 work using CBT informed approaches

Counselling service: commissioned by CYC from York Mind working with 16-23 age group.

Inreach to Youth Justice Service: a CAMHS worker is embedded in the service and a psychologist works across the North Yorkshire and York services.

There is an emphasis on advice and support provided through schools, which does not reach into all schools and may exclude access for those children not able to be in school (noting the increase in school avoidance, below), those excluded or electively home educated or those in schools who are unable to purchase staff training. Also, the offer does not automatically provide support during holidays.

The structure of support to meet levels of need below specialist CAMHS appears fragmented, reducing robustness and disguising lack of sufficient provision to meet demand at the appropriate level: noting that anywhere between 31% and 48% of referrals are signposted out of specialist CAMHS, most of which could readily be addressed through an easy access offer structured around a CBT/CBT-informed approach.

The structure of support also suggests a reactive approach which favours support from an 'expert' or a clinician: self-help approaches have not been well marketed at system level as a valid and sufficient offer: the evidence of low take up of Kooth indicates this to be the case and led to its de-commissioning by the Integrated Care System from April 2022.

Further, school budgets are constrained, many schools are unable to purchase and/or prioritise additional pastoral support, although some have family support workers and other staff as part of their pastoral support or attendance approach.

There is missing any offer for infant mental health other than the TEWV service for mothers with significant mental health problems during pregnancy and for around one year after the birth. There are known links between poor maternal mental well-being and the later development of emotional and mental health problems for their children.

Emotionally Based School avoidance

This encompasses those children with heightened levels of anxiety, who become unable to attend full time and frequently are unable to attend school; the offer from the specialist teaching team cannot fill the place of a fully structured school timetable, and an increasing number of children are at risk of losing significant education and with it opportunities for attainment. Schools struggle to provide staffing to work intensively with young people to re-integrate them back into their educational settings.

The pandemic has seen an increase in numbers of children unable to access a full time school timetable. A task and finish group is looking at the issues involved; analysis of data for the current academic year indicates 59 instances of referrals for an EHCP since September 2021which reference school avoidance or significant anxiety. Social, emotional and mental health grounds are the fastest growing group within the SEND groups.

Education services have seen an increase in the percentage of Education Health and Care Plans (EHCPs) for Social and Emotional Mental Health (SEMH) and an increasing number of parental requests for statutory assessment for EHCP where anxiety impacting on school attendance is part of the presentation.

EHCPs by primary need	Number 2021	Percentage 2021	Compared to Percentage 2016
SLCN	126	11%	10%
ASC	428	37%	32%
SEMH	192	16%	12%

The scope of the offer for children in care of the Council with complex needs

Currently there is limited psychological or positive behaviour support specifically commissioned for children in care and who have experienced significant trauma that has affected mental health and emotional wellbeing. We have seen an increase in acuity for this cohort of young people and the council is working with health colleagues to look at specific service to support young people in care. For children looked after or on a child protection plan whose needs are complex there is currently no bespoke commissioned offer; we are seeing more children requiring intensive support in the community with consequences for educational attainment, increased number of placement moves, and with less likelihood of finding a foster placement.

The increase in eating disorders

An eating disorder is an indication of heightened levels of anxiety, which children attempt to control though their food intake.

Covid has heightened anxiety levels, particularly among high achieving pupils who have developed serious concerns around their school work and performance, and brought some previously hidden disordered eating into the spotlight as families have been together much more since March 2020. The service has also seen an increase in acuity, with several children being admitted to paediatric wards to stabilise their physical condition before work can be started to address the mental health disorder. As a result, the caseload for eating disorders has risen by 500% over three years, and the specialist service is struggling to manage the demand. This upward trend is similar across the UK during the pandemic.

Whilst the numbers accessing the eating disorder service are small overall, the effects on their physical mental, long term mental health and the well-being of their families is significant. Death from an eating disorder, frequently due to associated physical health problems, is a common cause of death in women under 34.

There have not been resources within the service to undertake early preventative work which could assist schools in spotting early signs and seeking help and advice. The CCG has this year commissioned some training from the national charity Beat which is being offered to all secondary schools in the City, but currently there is no available investment to broaden the scope of the service to those children who have not reached the thresholds for formal diagnosis of an eating disorder.

The whole pathway of support for autism and neurodevelopmental conditions

The current commissioned offer for autism in York covers the assessment and diagnosis services commissioned from York Hospital (under 5 age group); TEWV (5-18 age group) and The Retreat (over 18s). All providers have a limited offer for advice and support associated with the assessment and diagnosis.

The demand for assessments and numbers diagnosed have increased in recent years. The capacity in the under 5 assessment service is 48-50 a year, with a conversion rate of around 95%. Demand is now running at around 50% above capacity and a review of the internal referral and assessment approach is under way.

TEWV has doubled its assessment capacity in the last 4 years: in 2020/2021 the service diagnosed 190 York children, representing 72% of assessments. The diagnostic 'spikes' were in school year groups 5, 8 and 10, which correlates to increased in demand for EHCPs. Boys comprise the majority of diagnoses at a ratio of 3:1.

The autism specialist teaching team works with children and schools where a children has been diagnosed, offering general advice for children who are awaiting an assessment.

There is considerable scope to expand the autism pathway of support to include a structured offer for children where autism might be present and for those who have been diagnosed. There are a number of models available, which generally involve third sector organisations and a project to review and recommend options will start in February/March 2022.