Transcript Slide 1

Re-commissioning of Community
Health Services for Children and
Young People
Stakeholder Workshop
Re-commissioning of Community
Health Services for Children and
Young People
Stakeholder Workshop
2
Introduction & Welcome
Richard Bailey, Deputy Head Joint Commissioning,
NHS Nene CCG and NHS Corby CCG
3
Purpose of the Day
• Provide a briefing on what is being re-commissioning
and why
• Explain the re-commissioning process
• Set out the opportunities to participate in the recommissioning process
• Share with you information and data derived
• Offer the opportunity to delegates to share some
early thoughts
4
Agenda – 1
• 9.40.
Why Re-Commission?
Dr Emma Clancy
• 9.55.
Re-Commissioning Process
Judith Cattermole, Alison Shipley, Stephen Marks
Summarise; Questions
• 10.15. Demographics; Needs Assessment
David Loyd-Hearn, Sian Heale
Summarise; Questions
• 11.00. Tea/Coffee
5
Agenda – 2
• 11.15. Table Top Tasks - Please ensure Tasks written
Judith Cattermole
• 12.15
Feedback –Verbal: one key message to assist
re-commissioning
• 12.35
Next Steps & How You Can Get Involved
Richard Bailey
• 12.40
Panel Q&A
• 12.50
Closing Remarks
Dr Darin Seiger
6
Why Re-Commission?
Dr Emma Clancy
Children and Young People Clinical Lead
NHS Nene CCG
7
No Change – Not An Option
• Growth in Need; Staff running to stand still
• Frustration from Young People and Parents
• Variability
– Access & Coverage across Northamptonshire
– Understanding (Clinicians; Service Users; Parents)
• Inability to align local authority and NHS Services
• Ultimately need to Service Fragmentation;
– Lessons from Victoria Climbie & “Baby P”
• But Change also brings opportunity
8
Imagine a joined up approach with a
locality flavour with services delivered
in a place convenient for children,
young people and families…
9
…Health & Local Authority Services
Together in Children Centres, Schools
and Communities…
10
So That…
• Families could access GPs, Health Visitors,
community nurses, mental health support etc. in one
place
• Promotion of community involvement and activities
• Health is more family friendly:
– It’s easier for patients to integrate into community and
social schemes
– There is a reduction in isolation, fostering good support
networks and promoting physical, emotional and mental
wellbeing
11
What Could We Do?
GPs could:
• do child surveillance clinics
• immunisations for pregnant women and new-born babies
• drop in clinics for mums needing GP advice
Hospital and Children Community Health services
could:
• Run children’s outpatient clinic running
• Base community children’s nurses locally to help with
admission avoidance work
12
What Could We Do Together?
• Offer a multi-disciplinary network including:
– Everything that children centres already offer
– Breast feeding support & midwives
– Learning Disabilities and special needs, community
paediatrics, secondary care, GP, Health Visitors, CAMHS,
social services, voluntary sector
• Streamline and integrate health & wellbeing and so
– Meet all needs for families from pre conception to late teens
and beyond
– Use the model to support the work we are doing to improve
the care currently being given to Looked After Children (LAC)
13
Where Do We Start?
• Look at current services, infrastructure and estate
• Get feedback about what works well and where, and
what could be done better/differently
• Use that to devise a centrally commissioned service
using the best models and recreating them to fill
gaps (e.g. community paediatric nurses in the North
might be useful in the South)
• Flexing approaches to suit local circumstances
• Today is the start of that journey…
14
Our Vision
“Children and Young People’s Community Health Services within
Northamptonshire will put the voice of children, young people and
their families at the centre of everything we do. Over the next 3
years and beyond, we will continue to improve community health
services to ensure they are responsive, equitable and inclusive.
Services will be available where and when they are needed the
most. By working together we aim to ensure children and young
people are happy, healthy, safe and resilient, enabling a positive
transition into adulthood.”
15
The Re-Commissioning Process
Judith Cattermole
Children and Young People Commissioner
NHS Nene CCG, NHS Corby CCG, Northamptonshire County Council
Lead for Re-Commissioning Programme
16
Why are we doing this now?
National and local drivers
• Legislative Changes - Pupils with Special Educational Needs (SEN) new
Education Health and Care Plan (EHC) with effect from September 2014
• Drive for Personalisation and Personal Health Budgets (PHB)
• NCC- Review of Designated Special provision (DSP’s)
• NCC- Devolution of funds to schools
• Safeguarding requirements to develop Early Help strategies and services.
• Recent OFSTED inspection of NCC and partners regarding Adoption and
Fostering, Safeguarding and Looked After Children (LAC) services
17
Local Health Provision
Children’s Community Health Services
• Two main providers - Northampton General Hospital (NGH) and
Northampton Healthcare Foundation Trust (NHFT)
• Inequity and inconsistency and gaps - in terms of pathways and ease of
access to specialist services
• Rising demand for specialist services
• High demand A&E services (children under five, self-harm rates)
• Rise in the number of long term ventilated babies
• Rise in the number of inpatient mental health admissions
• Pressure on Home Care support/packages -children remaining in hospital
once medically fit for discharge
• Impact upon the quality of life for our most complex children and their
families
18
Financial challenges
• Cost of A&E and inpatient admissions are tariff based and
high
• Financial challenges impacting upon all organisations- need to
develop more effective and efficient local services across
agencies which
– avoid duplication
– ensure streamlined pathways
– improve outcomes
– value for money
• CAMH services were subject to a tender exercise and need to
be re-tendered no later than 1st October 2014
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Joint Commissioning Opportunities
• NCC currently carrying out 2 major areas of reprovisioning
– SEN & Disability – Designated Special Provision (DSP) review,
EHC plans
– Re- commissioning Early Help and Prevention ServicesChildren’s Centres and Support Services to over 5’s
Opportunities to fully align commissioning activity now..
20
EHC Plans and SEN Provision
Review SEN Changes and
Designated Specialist Provision
DSP Review
Alison Shipley
Northamptonshire County Council
EHC Process & Plans
• EHC process supports child/family/schools with
Local Offer if assessment or plans not agreed
• Greater personalisation
• Shorter process (20 weeks) externally
facilitated
• Co-ordination of education, health and care
needs & provision as required
• Reviewed annually
• Possibility of notional or real personal budgets
• Can be in place 0-25 if required
EHC Roll Out
• Roll out for NEW requests for statutory assessment
• EHC process currently being offered to new applicants in
Kettering, Corby, Wellingborough & East Northants.
• EHC process will be offered to other areas on:
• - 1st November 2013 - Daventry & South
• - 1st January 2013 - Countywide
• Rowan Gate Special School trialling transfer of
Statements to EHC Plans from November 2013
SEN Provision Review - Scope
• The review was commissioned to evaluate:
• the diversity of provision in the county’s Resourced
Provisions (RPs) and SEN Unit provisions (Ups)
• the impact of the special/specialist provision on
developing inclusive practice and improving
outcomes for all children as well as those supported
in special/specialist provision
• the cost of current special/specialist provision and
its sustainability in the light of changes in funding
mechanisms and current financial restraints
SEN Provision Review –
implications for all
• Children and young people should access a wider range
of opportunities locally, and a more personalised
education offer, through the partnership working of
schools with other schools, alternative providers and
special/specialist services
• Review the Speech and Language Resourced provisions
in partnership with the Nene and Corby Clinical
Commissioning Groups
• Ffacilitate the provision of an all through Special School
in the south of the county for ASD, SLD and PMLD
SEN Provision Review –
implications for all
• commission bridging places for secondary aged young people
for
– the LA to use for Day 6 provision/assessment for permanently
excluded pupils and
– for schools to commission, places for the assessment of pupils at risk
of permanent exclusion or in need of specialist support for reintegration
• develop a continuum of provision across the county for BESD
and Autism promoting partnership working between special
schools, SEN Units and mainstream schools
SEN Provision Review –
implications for all
• establish satellite units who will work with an
agreed number of primary school children at
any one time to implement, under the
supervision and guidance of the special schools,
a range of provision and programmes for
primary pupils at risk of permanent exclusion or
permanently excluded
SEN Provision Review
Central services re-design
• NCC in partnership with other stakeholders to
• review and re-configure the capacity of centrally managed
education services
• regain central responsibility for receiving direct notification from
schools of permanent exclusions and arranging Day 6 provision
for them
• commission, from a range of providers, packages of education
tailored to meet the needs of each permanently excluded
secondary pupil, as close to their home as possible
• re-commission/de-commission special/specialist provision
where necessary
Central services re-design
• review the funding arrangements for
special/specialist provision
• ensure all provision is of high quality and value
for money
• re-commission speech and language provision
for children to establish an equitable county
wide service (with Nene and Corby Clinical
Commissioning Groups)
SEN Provision Review timescales
• Informal consultation held 7th June 2014
• Formal consultation with stakeholders October –
December 2013
• Cabinet – January 2014
• Implementation – May 2014 onwards
Early Help & Prevention for
children and families in
Northamptonshire
Stephen Marks
Northamptonshire County Council
Purpose
To enable children and families to access
appropriate support as early as possible, to help
them maintain their quality of life, prevent any
problems getting worse and reduce the demand
for high cost, specialist support services .
Outcomes for Children & Families
• All Families are able to maintain healthy and stable living conditions.
• All families are strong enough to manage stress over money, poverty &
unemployment.
• All families can give and receive support from friends, neighbours and the wider
community.
• All children and young people do well in education and this gives them the skills
they need to find work.
• All families maintain good health and well being for happier, healthier lives.
• All parents support their children’s healthy physical, emotional, learning and social
development.
• All families maintain stable and good quality family relationships.
Prevention and Demand Management
Current
Helping You
when you
can’t help
yourself
Future
Costs savings
generated by
reduction in volume
(Stock and Flow)
Specialist
Specialist
Targeted
Targeted
Prevention
Tier
Helping
You to
Help
yourself
Early Help
Universal
Prevention
Prevention / earlier
intervention
(Stage not age)
Early Help
Universal
Early Help
Forum
Areas:
Statutory and priority services for
NCC Early Help and Prevention
Commissioning
• Children’s Centre Services (under 5s)
• Supporting Services
–
–
–
–
Interpersonal Violence Services
Youth Provision
Services for young people with challenging behaviours
Parenting
Key Target Dates – Supporting
Services Tender
• Launch of Invitation to Tender – Mid October 2013
• Tender will close – late November 2013
• Tender evaluation and moderation – December 2013
to January 2014
• Award of tender – late-Jan 2014 to mid-Feb 2014
• Mobilisation, transition and implementation – Mid Feb
to May 2014
• Services commencement date – June 2014
Key Target Dates – Children’s Centre Services
Tender
•
•
•
•
•
Pre Qualification Questionnaire opens - Late Oct 2013
PQQ closes - Early Dec 2013
Launch of Invitation to Tender - Mid Dec 2013
Tender will close - Early Feb 2014
Tender evaluation and moderation - Mid Feb / Early March
2014
• Award - Late March / Early April 2014
• Mobilisation, transition and implementation - April to late
July 2014
• Services commencement date Late July / early August 2014
Other joint commissioning opportunities
• Regional Specialised Commissioning – neonatal pathways,
High Dependency, Acquired Brain Injury (ABI) specialist
rehabilitation and Tier 4 Inpatient CAMHS etc.
• Public Health – Renewed focus on emotional well being as
underpinning poor health outcomes
• Further opportunities to align approaches with Alcohol and
Substance misuse, sexual health etc.
• Police and community safety initiatives – focussing on
prevention- opportunities for closer collaboration
• Safeguarding improvement plans – opportunities to consider
a more joined up approach………
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Service Redesign Areas
Key Interfaces
A&E and Acute Hospitals
NCC- Social Care
Acute Paediatric Services
CCG’s Community Services
Emotional
Wellbeing &
Mental Health
Acute,
Complex &
Continuing
Care
SEN and
Disability
Key Interfaces
NCC- Early Help
NCC- Social Care
NCC – Educational Psychology
Clinical Commissioning Group’sAdult Mental Health
Commissioning
Youth Offending Service (YOS)
Key Interfaces
NCC- SEN and Disability –
EHC/Provision Review
CCG’s- Adult LD commissioning
CCG’s – Community Services
(Long Term Conditions)
What services will this involve?
Universal & Targeted Emotional Wellbeing Services
• Youth Counselling services
• Post sexual abuse counselling services
• Lesbian Gay Bisexual Transgender (LGBT) support service
• Psychology support for children with medical needs
• Support to schools for Behaviour Emotional and Social Difficulties (BESD) services
• Support to Hospital and Outreach Education (HOE) services
• Educational Psychology support for mental health
• Talk out Loud anti stigma programme
• Workforce reform
• Children’s Centre baby room project
• Domestic abuse – support to parent/ child
• Parent/Carer participation
• Video Interactive Guidance (VIG) and Theraplay services
• Sleep services
• Bereavement service
• Homestart
Linked (NCC funded)
TAMHS
ADHD support service
Youth counselling
services
Homestart
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What services will this involve?
Specialist CAMHS
•
Crisis and Home Treatment
•
Community Tier 3 CAMHS
•
Primary Mental Health Workers (PMHW)
•
Services for children and young people with Learning Disability
•
LAC service
•
Social Worker in CAMHS
•
Youth Offending Service Community Psychiatric Nurses (YOS CPNs)
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What services will this involve?
SEN and Disability
•
Special School Nursing
•
Physiotherapy
•
Occupational Therapy (OT)
•
Speech & Language Therapy (SLT)
•
Continence service
•
Paediatric Audiology
•
Child Development Centre (CDC)
•
Community Team for People with Learning Disability (CTPLD) - up to the age of 25
44
What services will this involve?
Acute, Complex & Continuing Care
•
Children’s Community Nursing
 Admission Avoidance
 Generic Community Nursing
 Specialist Community Nursing
•
Community Paediatrics
•
LAC health services
•
Complex and Continuing Care – home support packages
Recommissioning areas do not include Health Visiting and Mainstream School Nursing
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What is the timeline ?
Timeline
Activity
July– October 2013
Needs assessment and service review
Phase 1
1st October 2013
Current Providers service 1 years notice
October – December 2013
Service re-design – Inform and engagement
events- market testing -future specification
developed
Phase 2
January 2014 –June 2014
Procurement process begins
June 2014
New provider identified
Phase 3
June – October 2014
Transition to new provider
1st October 2014
New provider operating
Phase 4
1st October – 1st April 2015
Post transition implementation
1st April 2015
Post transition review and lessons learnt
46
Change Process
• Services currently delivered are valued and will continue to be
required- build upon the areas of good practice and an
opportunity for new models of delivery
• Staff will feel anxious and unsure – we do not want to lose
staff - ensure effective communication throughout the
process
• TUPE transfer conditions will apply. Provider organisations will
have a responsibility to ensure staff are fully briefed about
what this means for them
• Parents will feel anxious – this is an opportunity ensure
equitable and consistent service delivery- new service models
should be responsive to parent and child's needs
47
LSCBN
CYPBB
Health &
Wellbeing
Board
Programme Governance
Corby CCG
Children and young
people’s recommissioning – Project
steering group
Nene CCG
Children and Young People's Re
Commissioning Clinical Board
SEN and Disability key stakeholders
EWB&MH key stakeholders
Young Healthy Minds Partnership
Disabled Children and Young People
Partnership
Joint
Commissioning
Board
Children
and young
People Coproduction
Confirm &
Challenge
Parent/Carer
Coproduction
Confirm &
Challenge
Acute complex and continuing care key
stakeholders
Healthier Together
Stakeholder Groups
48
Summary
• Need to Re-Commission Services
• Opportunities from Re-Commissioning Services
• Large Agenda with Tight Timescales
• Committed to An Open Process
49
Questions?
50
Demographics & Needs Assessment
David Loyd-Hearn, Commissioning Lead Children & Young People
Emotional Wellbeing & Mental Health
Sian Heale, Commissioning Lead Children & Young People SEN,
Disability, Acute, Complex and Continuing Care
51
Demographics of Children and Young People
in Northamptonshire
52
Needs Analysis - Demographics
• The following figures are taken from various sources across
the NHS, County and District Councils, Provider Partners, and
Central Government Agencies.
• Where prevalence figures or indicators of need are sourced,
these are taken from national and international research
papers and applied to the population as at the 2011 census.
• These figures change on a regular basis dependent on
demand for services and are therefore intended to give a
perspective on the key trends affecting children and young
people services across Northamptonshire.
53
Needs Analysis - Population Demographics
• Northamptonshire has a population of 691,952 of which
171,736 (24.8%) are children and young people aged 0 to 19
years
• We can expect 1000 more children living in Northamptonshire
each year up to 2020
• There were 9,229 births in 2011 of which 21% of births were
to mothers born outside the UK
• Around 24,000 children in the county live in poverty, which is
approximately 1 in 6 children, ranging from 21% in
Northampton to 6% in South Northants
• 75% of the children in poverty live with a lone parent
• 50% of families in poverty have a child aged 0-4
54
Needs Analysis- Population Demographics
• Education: % of pupils achieving 5 A* to C GCSE grades:
Northamptonshire 55.0% (Corby 47.0% to South
Northamptonshire 71.2%)
• Employment: % adults in employment: UK (70.1%) and
Northamptonshire (76.8%)
• Physical activity: Adult participation in 30 minutes, moderate
intensity sport:
 England 36.0%
 Northamptonshire 34.0% (Wellingborough 23.1% to
Northampton 37.1%)
55
Starting Well – promotes wellbeing of both
parents and infants
• Programmes to support secure attachment with parents and
carers
• Breastfeeding support
• Supporting good parenting skills
 1930 parents accessed parenting programmes including 379
parents of children with special education needs and 1243
parents with particular needs (1000 of who accessed Service
Six)
 46,012 children aged 0-4
Pre-school and School Programmes
• 44.8% of 3 and 4 year old children benefit from early education
places in Northamptonshire (England 47%)
• 97% of under 5’s attending pre-school programmes (for
Northamptonshire (England 86%)
• c108,000 children attend school
• c4000 children and young people have statements 3.4%
compared to England average of 2.8%
• Variable local provision of school based social emotional learning
programmes which result in net savings of £84 for each £ spent
(DH, 2011)
• 105 pupils 0.1% were permanently excluded (2011/12)
Children and Adolescents – Vulnerable Groups
• Looked after children (by the state) - 5 fold increased risk of
mental disorder (Meltzer et al, 2003) (768 in
Northamptonshire)
• Children with learning disability - 6.5 fold increased risk of
mental illness (Emerson and Hatton, 2007)
• Special educational need (OR 3.7) (Parry-Langdon et al, 2008)
• Young offenders: 18 fold increased risk of suicide for men in
custody age 15–17 (Fazel et al, 2005)
Children and adolescents – Vulnerable Groups
Children with Disability
Within Northamptonshire there are approximately 3500 - 4500 children with
a disability
•
•
•
•
•
Approx. 2000 could be estimated to have a moderate learning disability
Of the 2000 with other disabilities, there are:
Approx. 72 with Profound and Multiple Learning Disability (PMLD)
Approx. 400 with Severe Learning Disability (SLD)
Approx. 700 with Autistic Spectrum Disorder (ASD) - although local
estimates put this nearer 1000
• Approx. 400 with Physical Disability (PD)
• Approx. 225 with Sensory Impairment (SI)
• Approx. 30 with Acquired Brain Injury (ABI)
59
Needs Analysis - Vulnerable groups
Looked After
Children
Safeguarding
Concerns
Post Adoption
Poverty
c145
1 in 6
Homelessness
Exclusions
Conduct Disorder
Drugs and Alcohol
undeclared
c7.8%
*5299
*5040
Learning Disability
Physical Disability
Young Carers
c2472
c400
*17,500
Single Traumatic
Events
Children in Need
Unaccompanied
Asylum Seekers
Lesbian Gay Bisexual
Transgender
c106
*10,304
c728
c3901
*Prevalence estimates based on national figures.
c667
(Complex)
Neurological
Developmental
Delays
*2968
60
Risk factors: Child Protection Plans in Northamptonshire
• There are 667 Children with a Child Protection Plan
• 15,020 of 11-17 year olds estimated to experience severe
maltreatment during childhood
• Sexual abuse single largest risk factor for mental disorder
• 3081 under 18 year olds experience sexual intercourse
Conduct disorder Northamptonshire
• Conduct disorder affects est. 5299 aged 5-16 year olds
• £795 million - lifetime cost of each one year cohort of 5-16 year
olds with conduct disorder in Northamptonshire
• Parenting interventions - NICE (2013) first line
• Prevents antisocial personality disorder in adulthood (NICE, 2009)
• 2.1% (154) parents accessed parenting groups in relation to
managing behaviour
• Note £632 million annual cost of crime by adults in
Northamptonshire who had conduct disorder and sub-threshold
conduct disorder during childhood and adolescence
• Note an estimated savings of £71m if parenting interventions
supported all the children with conduct disorders
Emotional Wellbeing and Mental
Health
63
Why is Emotional Well Being and Mental Health so
important for children and young people?
• 50% of life long mental health issues
start before the age of 14, 75% by mid
20’s
• 1 in 10 of children and young people are
affected with emotional wellbeing and
mental health issues, this increases to 1
in 4 in adulthood
• Good mental health and emotional
wellbeing improves physical health
(including life expectancy) and socio
economic outcomes
• 23% of burden of disease in UK
compared to 16% for cancer and 16% for
cardiovascular disease and costs England
at least £105 billion each year
• Local economy: £1347 million wider
annual cost of mental illness (this is a
combination of costs to the NHS, County
Council, Police, Benefits system or lost
time at work in sick pay)
• More susceptible to alcohol and
substance misuse, smoking and risk
taking behaviour (inc. crime)
64
Impacts of emotional and conduct disorder in children
and young people in UK (Green et al, 2005)
Risk Behaviour
Emotional
Disorder (6%)
Conduct
Disorder (4%)
No Disorder
Smoke Regularly
(age 11- 16)
19%
30%
5%
Drink at least twice
a week (age 11- 16)
5%
12%
3%
Ever Used Hard
Drugs (age 11- 16
6%
12%
1%
Have ever self
harmed (self report)
21%
19%
4%
Have no friends
6%
8%
1%
Have ever been
excluded from
school
12%
34%
4%
School based prevention interventions
Variable evidence that following cost effective approaches are
provided in Northamptonshire:
• Prevention of conduct disorder through school based social
emotional programmes (£84)
• School based bullying prevention (£14)
• School based violence prevention programmes
• Note Northamptonshire’s higher number of fixed period
exclusions 7.8% (England 6.5%) and permanent exclusions 0.12%
(England 0.08%)
Emotional Well Being and Mental Health
Needs Assessment and Service Review
The review consisted of:
- 167 Stakeholder meetings
- Document and procedure review
- Questionnaire by 775 children, young
people and adults
• The services jointly commissioned by the
NHS and Northamptonshire County
Council, benchmarked nationally
• The services delivered by partner
agencies e.g. Schools Targeted Support
• The informal and formal support
networks in the community
• Services that are provided outside of the
county and why we use them
• The changes to services, devolved
funding, and their impact on access to
services
• Views of children and young people
(904)
• Views of parents and professionals (121)
67
Key Needs Identified
• Unmet needs continue to feature which
do not fit in defined Specialist CAMHS
criteria e.g. challenging behaviour, self
harm as a coping mechanism
• 73% of a significant sample of young
people have body image concerns, this
increases to 90% of the sample of
CAMHS users. Eating disorders accounts
for a high number of CAMHS cases
• Behaviour Issues account for 52% of
paediatric referrals and a significant
number of CAMHS referrals. 38% are
inappropriate
• Anxiety and Depression is the number 1
reason for referral (and can lead to
eating issues or self harm as a coping
mechanism)
• We are a national outlier for self harm
and need to do work in this area. LSCBN
is monitoring. This does not include low
level self harm and the two dimensions
are frequently confused.
• There is a significant lack of knowledge
of services, what is available and how to
access.
• A number of initiatives and services are
without a central provision and are
impacting on emotional wellbeing
• The Common Assessment Framework
(CAF) has not been embedded across
the partnership for Mental Health
68
Review of Self Harm
(National Outlier)
• National rates of self-reported self-harm are 7% for 11-16 year olds but
several times higher in those with:
• emotional disorder (28%)
• conduct disorder (21%)
• ADHD (18%)
• 287 Children and Young People have presented at A&E for self harm.
Highest prevalence was 17-19, however the 11-16 year olds continue to rise
• Child and adolescent admissions for self harm per 100,000 (2010/11):
Northamptonshire 169.9 compared to England 124.8 (although we adhere
to the NICE guidelines)
• Applying national rates to Northamptonshire would mean that 3590 11-16
year olds would report self-harm. Our actual figure is lower, though in
secondary schools anecdotal evidence suggests the rates could be as many
as 50%
Review of Self Harm
(National Outlier)
200
180
160
140
120
Years 0-4
100
Years 5-11
Years 12-16
80
Years 17-18
60
40
20
0
All Inpatient Admissions in
2009-10
All Inpatient Admissions in
2010-11
All Inpatient Admissions in
2011-12
All Inpatient Admissions in
2012-13
Key Findings of the Review - Performance
Northamptonshire performs within the median average county regarding
performance despite a significant demand for service.
• Our waiting are average nationally: 95%
are seen within 14 weeks for Tier 3
CAMHS cases. This does not account for
the time between assessments and the
actual treatment interventions
• Our expenditure is slightly below the
national average for emotional wellbeing
and mental health services
• Max wait times UK are 40 weeks, best
waiting times 2 weeks – We can do better
• We have some of the lowest DNA figures
(national average is 21.24%) – our CAMHS
is c <12% (though closer to 20% in
counselling)
• Our referral rates are HIGH - 21 in 1000
prevalence for CAMHS referrals. National
average is 4.11 in 1000
Service Utilisation
Total annual
forecast
across the
Tiers: c£6.5m
Tier 4 In patient
ave. 50 CYP in the SETT pa
9 out of county
Tier 3 Specialist CAMHS
c£5m pa c2300 cases
ave. 300 refs per month
Waits are over 14 weeks for >5%
Tier 2 Targeted
c£669k pa (excluding £50k Bereavement Service). 85% of schools
engaged with TaMHS. Waiting list is 10 week average for counselling, 6
months VIG. 158 families had ADHD support. Est. 230 young people
access NHS funded counselling services each month
Tier 1 Universal
c£200k pa c171k CYP (24.8%) c108k in school
Sample of
prescribing
suggests <14%
of Tier 3 on MH
medication (exc.
ADHD meds)
Areas of Good Practice
• The Targeted Mental Health in Schools
(TaMHS) Programme has had a
significant reach in schools covering 85%
and is recognised as an area of best
practice in the September 2013 NICE
guidelines.
• Areas of speciality work that are
supporting vulnerable groups:
 Post sexual abuse therapy
 Victims of Interpersonal Violence
support through theraplay
 Designated Looked After Children
service
 Lesbian Gay Bisexual Transgender
Support work
 Designated Community Psychiatric
Nurses support youth justice
• We adhere closely to NICE guidelines
regarding crisis interventions and
omissions and operate an outreach
service to enable young people to stay in
the community
• The Talk Out Loud Anti Stigma project is
nominated for a CYP Now national award
• Hospital and Outreach education
provision has enabled children to step
down into mainstream education
settings in a managed way
• Voluntary agencies support a significant
number of young people and their
families within the community
…but we can do more!
775 Children, Young People and Adults told us:
• Young People believe they have a
positive future – though those that did
not know or did not agree was 30% (14%
national average)
• It is agreed children and young people
have more troubles than in the past
• Half of the people surveyed did not think • A significant majority believe there is a
there were positive family relationships
rise in mood swings and a lack of self
control
• 73-90% are worried about body image
• A significant majority believe low mood
and depression are common place
• A majority of respondents believe self
harm is increasingly used as a way to
cope with stress including an increase in
life threatening self harm
• There is work to do around supporting
young people to feel more comfortable
about issues to do with sexuality and
alcohol/substance misuse
• There is a perception that there is
inadequate support in the community
(except under 12s)
• Adults in particular are concerned about
not knowing where to go when they
have concerns
Other concerns were raised about bullying, not knowing how to handle stress and 66% of 10 year
olds questioned were not happy when away from their families.
What do you think contributes to having
emotional issues and concerns? Top 10
Difficulties at home, family stress , family relationships,
unstable families inc. divorce/seperation
Relationships with friends/peer pressure
Bullying/Rumours/Enemies
Schools/Teachers/Workload/Exams/Grades/Assessme
nts
Stress/Pressures (General)
Nothing/Don't know
body size/image/clothes/appearance/ self
perceptions/popularity
Influences of the
media/Celebrity/Society/Communities
Relationships/Partners
Insecure/Lack of confidence/Sensitive/Low self esteem
What do you think needs to be done to support young
people regarding these issues? Top 10
More people to speak to - counsellors etc/More supporting staff/community,
try to put someone in teens shoes to see what their going through so they
understand more (not patronising)
Improve Awareness of support, how to access it and what it can do (for children,
young people, schools and families)
Not sure/Don't know
More social clubs/Support groups or places where young peopl can be less
scared about talking about their problems
Make support more easily accessible/More places
More access to counselling and support services (can be teachers) and better
information in school
Educating of issues eg. In PSHE at school/More educational lessons about the
issues in school (awareness)/posters/leaflets/assemblies/Destigmatisation
programmes
People need to open up more e.g. to friends/family/teacher
More notice and support from teachers
More work on bullying in schools
Is there a need to build and teach resilience to manage stress and life events in groups
and through schools?
Who would you go to now if you were
concerned about any of these issues? Top 10
Family
School
Friend
No-one
Counselling /Advisor
Don’t know
Doctors
CAMHS
Find an alternative activity
Is there a need to help parents/carers to support their children with
advice?
Young People have told us they want….
• More people to talk to including
activities and groups (not just specialist
groups either)
• Access at home and school – on-line too
inc blogs. They want to know what is
available
• Shorter waiting times/greater
availability
• To be listened to, others want active
advice
• Staff who are:
 Less patronising
 Confidential & trustworthy
 Approachable/Understanding
• Something for people who may be worried
about talking to anybody
• People who understand the issues e.g. • To not be embarrassed or stigmatised
disability, autism, shared life experience
• They do not want to have to take 3-4 hours (due to buses etc.) for an appointment
especially if they do not want others to know they are seeking help.
Recommendation Areas For Improvements
• Reduce incidences in anxiety and depression
Improving Prevention
• Improving body self image
• Reducing self harm and suicidal ideation.
• Increase awareness of work around anti
stigmatisation, especially in primary years
• Strengthening parenting and carer support from
pre-birth to teen years (e.g. reduce
family/placement breakdown)
• Early years interventions are critical
Improving Early Intervention
• A whole system approach to supporting CYP with
traits of ASD/ADHD/Asperger's prior to diagnosis
and post diagnosis – not simply traditional
educational support, but also issues are dangerous
sexualised behaviour, hate crimes, YOS issues etc. A
new approach is recommended
Recommendation Areas For Improvements
• Young people have requested services nearer their
homes/schools as the buses can mean one
appointment can take 3 hours of their time.
Improving the Experience
• Communication has room for improvement with
families and agencies being updated on waiting
times, alternative interventions while awaiting an
assessment/service and when discharged/stepped
down.
• While the Crisis Team perform well with limited
resources, there are concerns from GPs and
Hospitals that there is not enough provision. 86% of
England have a 24/7 provision. This is an area to
explore further
• Develop new models for engaging and co
commissioning with schools
Improving Partnership
Working
• Work closer with GPs, Schools, Early Years settings,
Police, Community Groups, Faith Groups, Youth
Groups
Recommendation Areas For Improvements
• Support provision required for non traditional
CAMHS pathways
• Improve the impact of transitions
• There needs to be a managed approach to step up
and step down (inc. where appropriate bringing CYP
back into the county where placed outside)
Improving Processes
• Eased pathways with a greater awareness of issues,
services and access pathways across the tiers.
• Need to further reduce waiting lists and non
attendance at appointments
• Need to ensure there are no provision gaps during
the school holidays
• Waiting lists only tell a part of the story, there is a
need to review support in the time between waiting
and commencing interventions.
Recommendation Areas For Improvements
• The is a much greater need to reinvigorate the
multidisciplinary workforce development programme
Improving Workforce
Development
• Is there scope for an e training/accreditation that
staff need to do to be aware of how to access
appropriate services across the workforce. CAF
training and usage should include the emotional
wellbeing needs.
• Providers and contracts need to be financially
sustainable especially to be able to be able to support
individual budgets
Improving the Business
• There needs to be transparent and easy to access
data across children services.
• Better evidence the outcomes of programmes such as
TaMHS and understand demand/impact of alternative
creative/play therapies
Recommendation Areas For Improvements
• Challenging behaviour accounts for the largest
number of referrals to Paediatrics and the
largest number of inappropriate referrals
• Challenging behaviour does not always meet the
threshold for accessing Tier 3 CAMHS
Priority Number 1 –
Challenging Behaviour
• Challenging behaviour can take many forms from
self harm, aggression, sleeplessness, risk taking
behaviours, anti social behaviour and may lead
to poor outcomes such as school and social
exclusion.
• Support for children and young people
(including their parents, grandparents and
siblings) may take many forms, but can be
fragmented and difficult to access.
• Parenting support is required for all age groups
from pre-birth and especially in teenage years.
The effect of shifting the
mean of the mental health spectrum
From: Huppert Ch.12 in Huppert et al. (Eds) The Science of Well-being
Flourishing
Moderate
mental health
Number of symptoms or risk factors
Languishing
Mental
disorder
Our biggest challenge is to
ensure emotional wellbeing
mental health is everybody’s
business!
To get involved please email [email protected] or visit www.asknormen.co.uk
85
SEN, Disability, Complex and
Continuing Care
86
Speech and Language Therapy
• There is 1 provider of Countywide service – NHFT
• Ages 0-18 (Up to 19 in Special Schools)
• Caseload – 4,500 open (30% preschool - 70% school age)
• Referral Rate approx. 170 per month (55% Preschool and
45% school age)
• 40 cases per week
87
Speech and Language Therapy
Under 5’s Mainstream -Preschool/Primary (age 7 max)
• Approximately 80% of SLT preschool time is spent working
with this age group
• Referrals from Health Visitors e.g. picked up at 2.5 year
development check or parent direct referral
• Early assessment, intervention and advice for specific speech
and language delay
• Short term intervention - Discharged when child specific
speech and language outcome achieved
• Provided in children’s centres and clinic settings
88
Speech and Language Therapy
Under 5’s Complex -Pre school only
Approximately 20% of total preschool time spent on this group
of children
Recognised Long Term condition.
 sensory hearing loss
 mechanics of speech problems
 neurological/developmental delay
• Work with parents in Children’s Centres to facilitate child
reaching full potential. Not so much direct work with child
• Clinics and Parent workshops - More of a facilitation role
• Remain on caseload for much longer
89
Speech and Language Therapy
Older Child - Mainstream
• Clinics – Speech and Sound groups
• Provide staff training and programmes of delivery to meet
individual child targets
• Combination of school support with individual SALT sessions
Older Child- Complex/SEN
• Child with longer term complex needs – work within Special
School / DSP settings with school staff and families
• Facilitation role to support those working closely with child
• Develop training programmes for school and parents to follow
90
Speech and Language Service
• Management of acute/ and enduring dysphagia
 Specific early feeding problems
 Mechanical problems
• Specialist feeding clinic held at NGH – acute child
Videofluroscopies undertaken
• SLA in place to provide SALT into CDC assessments
• Complex child with dysphagia managed in Special Schools
• Advice for Augmented Alternative Communication (AAC)
91
Speech and Language Service
Key issues
• Different cohorts of children
• Pre school mainstream children take up the bulk SLT time
(80% of time)
• Challenge to manage parental and school, nursery and
children centres’ expectations of service
• Need to develop model of delivery to skill up school and early
years settings staff; and families to support child in all settings
with SALT needs
• Enabling a child to reach full potential – needs a whole
system approach
92
Occupational Therapy Service
•
•
•
•
•
There is 1 provider of Countywide service – NHFT
Ages 0-18 (up to 19 in special school)
They work in 2 teams - 1 North and 1 South
Caseload - 600 open
Referral rates approx. 50 per month
93
Occupational Therapy Service
Mainstream Child - specific physical disability
• 80% of caseload
Sensory difficulties including children with ASD
Fine motor difficulties
• Usually require short term interventions through
parent workshops and programmes in schools
• Weekly assessments of progress or just require one
off advice
94
Occupational Therapy Service
Complex Child
• 20% of caseload
Neuro development difficulties
Dyspraxic / coordination difficulties graded by
complexity
Assessments for specialist equipment provision in
schools and home
Post op cases to be seen in 48 hours of referral
80% of OT time is focused on this cohort
95
Occupational Therapy Service
Issues
• Teams work very separately
• South – operating from one base working in homes and clinics
• North –Treatment Centre. Records are merged with other
disciplines
• Dealing with a backlog on waiting list
• Referrals rates doubled in last 18 months
• There has been an increased need in school settings due to
variable practices in assessment and support provision
• NCC ASD Team capacity reduced in NCC – schools now refer
directly to Health for sensory support
• CDC in South – no OT involvement. Can lead to inappropriate
referral following CDC assessment
96
Physiotherapy South - NGH
There is a lack of detailed Caseload and Referral Data
Service provided in 3 settings
 Acute wards
 Special schools
 Community
Service provided for range of needs:




Complex Disability/ Cerebral Palsy
Developmental Delay
Neuro muscular conditions
Intensive post op recovery/ rehabilitation across OP clinics, home and
schools. ( Under 8’s only). Over 8’s managed through Adult Team
through OP Clinics
97
Physiotherapy Service - South
Acute Provision
The South Team provide a considerable amount of input onto
the Acute Wards
• Acute care of children with Long Term Conditions (LTC) with
respiratory illness such as chest infections
• Acutely ill children
• Physio also input into specialist clinics in hospital
• Funded 16 hours by Orthopaedic service for Extended Scope
Practitioner (ESP) support
98
Physiotherapy North - NHFT
• Caseload 500 open
• Referral rate 26 per month
• Service provided in 3 settings
 Community
 Special schools
 Acute (limited)
• Service provided for range of needs
 Low level neuromuscular delay – advice given
 More complex – Cerebral Palsy - large numbers with differing levels of
complexity which dictate physio input
 Developmental delay
 Post op cases referred from Tertiary and KGH. Expectation to respond
within 48 hours
 Cystic Fibrosis clinics – commissioned by KGH
99
Physiotherapy North - NHFT
Acute provision
• There appears to be a different approach to the NGH acute
provision
• Run joint clinics with Orthopaedic consultants
• Botox clinics
100
Physiotherapy North - NHFT
Issues
• Increasing volume of cases coming through
• Need to increase support into parental education to manage
the physio programmes designed for the child when at home
• Long Term Ventilated (LTV) cases – possible gap with
supporting this cohort
• Dyspraxia and coordination difficulties pathway inconsistent
south no provision – north needs refining
• Intense therapeutic support for Acquired Brain Injury (ABI)
children is a challenge to manage and respond to
101
Community Paediatrics
• 2 Providers NGH – South, NHFT - North
• Case load
 North - c1825, 60% behavioural 40% Complex disability
 South – Awaiting data
• Referral rates
 North – 117 per month
 South – Awaiting data
North – NHFT (based on Case Audit)
• Referrals mainly from GP’s, Health Visitors and Schools.
Majority of referrals from GP’s – approx. 1/3
• GP’s made the most inappropriate referrals - 38% and were
signposted elsewhere
102
Community Paediatrics
Reasons for referrals:
• Behavioural issues - (Highest rate of inappropriate referrals)
• Neuro Developmental delay/problems
• Complex Disability - SEN assessment
• LAC, Adoption & Safeguarding medicals
103
Issues
Community Paediatrics
• High % of inappropriate referrals for behavioural needs – especially from
GP’s – lack of alternative provision.
• Historical arrangement for 11 year olds and above with behavioural
problems referred straight to CAMHS for assessment.
• Potential lack of joined up approach between acute and community
paediatricians – Specialist/Tertiary
• Assessments for LAC children and adoption and fostering medicals can be
delayed due to lack of required paperwork/ information
• Lack of support in universal and targeted for undiagnosed child – Pre
school child with severe challenging behaviours
• Need for more robust data systems
• 2 different assessment models the under 5’s (CDC south , community
north) – there are merits and challenges of both
• Services delivered in special schools and localities (North/South
differences)
104
Community Children’s Nursing Service
South - NGH
 Long Term Conditions Team
 Specialist Nursing Team for specific diseases/conditions
 Continuing Care Team (spot purchased)
North - NHFT
 Generic Team/ Long term conditions
 Continuing Care Team (spot purchased)
 Admission Avoidance
 Respite Care Team
105
Community Nursing Service
Long Term Conditions: (Life limiting and/or life threatening)
• Cystic Fibrosis
 North 14
 South 35
• Oxygen dependent including neonates
 North 6
 South*
• Oncology
 North 7
 South c20
• Children requiring enteral feeding – complex disability
 North 24
 South 114
*Awaiting data
106
Community Nursing Service
Long Term Conditions: (Life limiting and/or life threatening)
• Long term ventilated children
 North 6
 South 0
This relates to treatment and support provision, not residency
• Cardiac conditions
 North 7
 South *
• Epilepsy
 North *
 South 300 known to specialist epilepsy nurse
• Rheumatoid Arthritis
 North 14
 South 17
*Awaiting data
107
Community Nursing Service
Long Term Conditions: (Life limiting and/or life threatening)
• Children and young people with palliative care needs
 North 8
 South 6
• End of life care
Over the last 8 years there has been an average of 7 childhood deaths per
year, ranging from 2 to 12 per year. There is an equal prevalence between
death due to cancer and death due to complex disability
 North average 4 per year
 South average 3 per year
*Awaiting data
108
Community Nursing Service
• Both services provide short term interventions in the
community for children discharged from hospital and
Continuing Care home care packages for our most
complex children
• Continuing Care home care support packages:
 North – 10
 South – 12
• Admission Avoidance Team North – CATCH
109
Community Nursing Service
• Case load
 North - c181 total
-
Admission Avoidance c53
Generic/LTC c124
Home Respite 4
 South – Awaiting Data
• Referral rates
 North – c75 per month of which
-
Admission Avoidance c58
Generic/LTC c16
Home Respite 1
 South – c8 per month short term interventions
110
Community Nursing Service
Issues
• In the North struggle with Adult services picking up cases
 Grey area with ages 16 - 18 accessing ward routinely
• General poor engagement with GP’s for children with long
term conditions
 Age 18 GP become Lead professional
• North - GP’s send acute cases straight to Paediatric
Assessment Unit (PAU)
• Children’s Community Nurses struggle to meet needs of
children on:
 Frequent Intravenous Antibiotics
111
Community Nursing Service
Issues
• Gap in North for Specialist Epilepsy Nurse
• Difficult to get appropriate multi-agency support in
community for families caring for babies with complex needs
who do not have continuing care needs
• It is a challenge for District Nurses to pick up young people
with LTC post 18
• Difficult to ensure we have a flexible and adequately trained
workforce who can meet the fluxuating needs of highly
complex children in the community
112
Acute Provision
• 2 Acute Hospitals in county: NGH/KGH
• Kettering General Hospital – Skylark ward
 28 Beds. 0-18 (or is it?)
-
2 HDU beds
8 beds – operational Mon – Fri (Surgical)
Adolescent Area
6 bedded PAU. 60% discharged home same day
Average length of stay 24 hours
113
Acute Provision
Northampton General Hospital: • Disney Ward
• Paddington Ward
• Gosset Ward
• Awaiting further data
Corby Paediatric Emergency Care Centre - 8 Paediatric Beds (day
cases 8am – 8pm)
All acute care paid by tariff
114
Acute Provision
Issues:
• Skilling up ward staff to meet needs of children with enduring
highly complex care needs
• Skilling up of staff working in the community
• Robust discharge planning for complex children- Lead
responsibility not clear- lack of Multi-disciplinary and Multiagency co-ordinated community support planning
• Surge of admissions when urgent care centres close at 8 pm
• Misuse of the ‘open access’ arrangements
• Continuing Care Teams unable to meet demand in a flexible
way with appropriately skilled staff
115
Questions?
116
Tea/Coffee
Return at 11.15
117
Table Top Task
• You are the experts with lived experience working
with children young people day in day out
• Each table has a task to carry out
• When completing the task please think about the
following……..
118
The key children, young people and family health
priorities for Northamptonshire
£
Improve
Health &
Wellbeing
Whole population &
vulnerable groups
Enhanced
Primary &
Community
services
Specialist
services complex needs &
support to primary
& community
services
£
119
Pre-birth - 5
6-11
12-18 (or 25)
And beyond
Joined up approach across the community to improve health & wellbeing
Build resilience from pre-birth to adulthood
Reduce risk of long term health, mental health issues and safeguarding
Improve prevention and early intervention across the workforce
Promote Personalisation and self management
Coordinated case management of “High Use” and Complex service users
Rehabilitation, recovery, and resilience is key
120
‘Step up’ and ‘step down’ model
4A Highly Specialist
Level 4
Specialist services
Level 3 Targeted intervention
Group and individual interventions delivered by
trained workers overseen by specialist services
Level 2 Early Help
Training and support within universal settings
Level 1 Universal
Awareness raising , skilling up universal providers, workforce development, information
and advice
GP’s ,children’s centres schools, youth and community services
121
Key Principles
• Children, young people and their families at the
centre of care planning
• Close to home/school/community
• Accessed at the right time
• Provided by the right people with the right skills
• Seamless access to services
122
Acute Hospital
CYP with
Complex
Mental
Health
Needs
Youth Offending
Placement
CYP Who Require an Emergency & Crisis
Response
CYP Who Become Acutely Ill
CYP with
Complex
Disability
SLD/PMD
/PD
Specialist
Residential
MH Inpatient
CYP with
Complex
Physical
Health
Needs/ LTC
Pre-Birth – 4 Assessment
CYP with
Complex &
Risky
Behaviour
Challenges
CYP with
ASD/
ADHD/
Aspergers
Looked
After
Children/
Adopted
CYP
who
Offend
5 – 18 (25 for LD) Assessment
Single Point of Access
Early Help and Targeted Interventions
Enhanced roles in community/group interventions/infrastructure development
Schools
NCC
YOS/
Universal Services Police
Early Help
Provision
Health Facilitator & Service Navigation
GPs
Early
Years
Design Features
• Who delivers
 Multi –disciplinary and multi agency? Core team- Wider team
• Whats delivered
 What service should be available?
• How is care co-ordinated?
• Where delivered?
 Provided locally? Countywide? Children's centres, schools, libraries, clinics, GP surgery,
hospital
• When delivered
 What hours?
• How accessed
 Single point of access? Use of CAF?
• Who accesses
 Age ranges 0-4,5-10,11-18 ,18-25 for LD?
• What needs catered for?
124
Design Features
• What level of care provided for?
 Level 1,2,3,4,4+
• How to transition
• What can be done to
 Enhance service delivery and support ‘within’ and ‘to’
children’s centres and schools, including special
• What infrastructure
 IT, Training, Buildings, rooms, equipment
• How to support vulnerable children/families
125
Next Steps & How To Get Involved
Richard Bailey, Deputy Head Joint Commissioning,
NHS Nene CCG and NHS Corby CCG
126
Next Steps
• Gather/Collate Outputs from Today
11th October
• Establish 3 Task & Finish Groups
11th October
• Explore, Discuss and Agree Models
22nd November
• Discussions with Key Groups
22nd November
– Including Shadow Board CYPPB
• Final Draft of Specification
29th November
• Stakeholder Workshop
3rd December
127
How To Get Involved
• Join the Task & Finish Groups
– Mental Health & Emotional Wellbeing;
David Loyd-Hearn
– SEN and Disability;
Sian Heale
– Complex and Acute Care;
Sian Heale
• Help Us Identify Key Groups
• Attend Stakeholder Workshop
120 Places Max
128
Q&A
Richard Bailey, Judith Cattermole, Sian Heale, David Loyd-Hearn,
Chris Horrocks
129
Closing Remarks
Dr Darin Seiger, GP Chair
NHS Nene CCG
130
Thank You for Coming
& For Your Input
131
Re-commissioning of Community
Health Services for Children and
Young People
Stakeholder Workshop