Mental Health Services Follow-up

Mental Health Services Follow-up REGIONAL SUMMARY Performance Review Unit Department of Health, Social Services and Public Safety

CONTENTS page BACKGROUND... 3 STRATEGIC DIRECTION... 6 PROVISION OF SERVICES... 9 TARGETING... 16 SERVICE QUALITY... 20 CHILD AND ADOLESCENT MENTAL HEALTH SERVICES... 22 CONCLUSIONS... 29 WAY FORWARD... 31 APPENDICES... 32 1

BACKGROUND In 2002/2003 the Department of Health, Social Services and Public Safety commissioned a value for money follow-up review of Adult, Child and Adolescent Mental Health Services at the four HSS Boards and eleven Trusts. The original study was reported in 1998/1999. Detailed follow-up reports, together with action plans, have been agreed locally with Trusts. The objectives of the follow-up review were to: ascertain the progress made towards achieving the recommendations made in the original study; provide data to compare performance to the original study in the following areas: - service costs; - caseload review for community adult mental health services; - length of stay in adult psychiatric beds and re-admission rates; - caseload review for child and adolescent mental health services; and assess the extent of progress made by Trusts in specific areas highlighted in the DHSSPS Priorities for Action (PfA) 2002/2003 document. To enable benchmarking, data was collected for the 2001/2002 financial year from the Trusts involved in the review while audit tools were applied in 2002/2003. This Northern Ireland Regional Follow-up Summary sets out: the main findings on progress arising from the follow-up; progress made with emerging issues; and the key conclusions and way forward. Introduction Historically, children, adolescents and adults suffering from mental health problems were cared for in hospitals and special institutions, occupying longstay psychiatric beds. For several years, the focus has been on creating a wide range of mental health services in the community to care for individuals suffering from mental health problems. If the community-based services are adequate, flexible and sensitive to each individuals needs, the number of psychiatric beds can be reduced. 3

BACKGROUND 100% 90% Percentage 80% 70% 60% 50% 40% However, in planning the transition from hospital-based care to communitybased care it is important to ensure that a comprehensive range of communitybased services are developed, including early intervention and support to prevent crisis admissions and readmissions to hospital. Other Hospital Community 30% 20% 10% 0% Chart 1 shows the expenditure by Board area, in relation to the Mental Health Programme of Care. Overall in Northern Ireland, the proportion of expenditure on mental health services in hospital has remained at the 1999 level of 52%, A B demonstrating that there has not yet been a significant shift from hospitalbased to community-based mental health services. C D NI average 1999 NI average 2002 Board Chart 1: Mental health expenditure in Northern Ireland 100% 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% A B C D NI average 1999 NI average 2002 Board Other Community Hospital Source: Health Services Audit data compilation 2002/2003 There were, however, wide variations in the spending pattern amongst Board areas with spending on hospital services ranging between 45% and 60% in 2002. Trusts in Board B and Board C areas spent the lowest proportion on hospitalbased services, 45% and 46% respectively. Some of the initiatives taken by these Boards and their associated Trusts are set out below. 4

BACKGROUND Board B One ward was closed and long stay patients relocated to a new community based accommodation unit. Crisis beds and out-of-hours respite provision was created as an alternative to hospital admission. A unit has also been developed in association with two housing associations for users assessed as not necessarily requiring inpatient care. An out-of-hour deliberate self-harm service was established to which GPs can directly refer. A 24-hour helpline was set up. Community mental health teams (CMHTs) assess the appropriateness of hospital admission. The service operates between the hours of 9am and 5pm and an out-of-hours service is also available between the hours of 5pm and 1am. Board C A protocol for management of acute in-patient beds was agreed with Trusts and primary care professionals. Investment was made in out-of-hours emergency schemes including an out-of-hours community psychiatric nurse (CPN) service that operates every night until 1am. A supported housing scheme and a specialist unit was set up to provide medium to long term supported accommodation for a number of individuals, in addition to emergency/crisis management short term accommodation for a small number of users. 5

STRATEGIC DIRECTION This section of the report considers whether the strategic direction of the service is being planned effectively, giving consideration to: mental health policy; needs of the population; relationships with GPs and primary care; and involvement of stakeholders (users, carers and voluntary organisations). Mental health policy In the last few years, there has been significant development in mental health strategies in Northern Ireland, largely driven by the Department s Priorities for Action, which focus on: increasing the variety of specialist services for people with acute mental health needs thereby reducing the need for psychiatric beds; developing child and adolescent community mental health services (CAMHS) and increasing the number of regional adolescent beds; and undertaking a regional review of mental health legislation and policy. Specialist services and child/adolescent services are discussed later in this report. A regional review of mental health and learning disability was launched by the Department in 2003. Boards and Trusts are involved in the consultation process and it is anticipated that the review will take two years to complete. Three Boards have developed a mental health strategy and the fourth is in the process of developing a strategy. The Trusts are working with their relevant Boards in the development and implementation of the strategies in their area. There has also been consultation and co-operation between Boards at a regional level on a number of mental health issues, including: the provision of a Regional Medium Secure Unit; CAMH services and the increased provision of adolescent beds; and services for users with eating disorders or problems with drugs or alcohol. At a local level, Trusts have carried out a significant amount of work to secure the strategic direction of mental health services. For example, two Trusts have created a joint management structure over the provision of mental health services in their common area. This has allowed for greater communication between the two Trusts and ensures that a cohesive approach is taken in the provision of these services. 6

STRATEGIC DIRECTION Needs of the population In the four Boards, population needs are being considered with assessments carried out to inform service developments and influence strategic planning. One Trust has assessed the needs of the population in its area and has shared these results with the Board, and another Trust plans to address population needs when developing its strategy. These reviews are considered by the Boards to be integral to the implementation of their strategies and in the development of new services. Good Practice One Board has carried out a needs assessment review of its catchment population. The review is a distinct component in the strategy development process and the recommendations and results of this review will be incorporated into the Board-wide mental health strategy. Relationships with GPs and primary care The full implementation of Local Health & Social Care Groups (LHSCGs) should allow a wide range of stakeholders to be represented thereby increasing multidisciplinary involvement in strategic planning and commissioning. However, many Trusts and Boards are having difficulty in obtaining representation from various groups, in particular GPs. Prior to the establishment of LHSCGs, Trusts promoted links with primary care in various ways, such as alignment of GPs to CMHTs and by including GP representatives on planning teams and forums. 7

STRATEGIC DIRECTION Examples of initiatives taken by Trusts One Trust has carried out a significant amount of work to assess the relationship between primary and secondary services. A series of workshops were attended by the CMHTs, Trust Programme Manager for mental health, Board representatives, GPs, representatives from pharmacy and health promotion and a service user from the local area. To provide additional training to GPs and assist in appropriate referrals, the Trust has organised a number of seminars for GPs and developed a directory of Mental Health Services. At another Trust, primary care and mental health services are developing a care pathway for schizophrenia. Involvement of stakeholders The views of a wide range of stakeholders are being taken into consideration when planning mental health services at both Board and Trust level. Users, carers, GPs and voluntary organisations are involved in the strategic planning process through representation on strategic planning forums or through consultation processes during the development and implementation of strategies and services. Examples of stakeholder involvement A Consumers and Carers Panel contributed to a business case for the re-provision of mental health services at one Board. Another Board, in developing a mental health strategy, included stakeholders in a number of ways by: employing a user co-ordinator on the project team to facilitate, coordinate and bring forward the views of a wider range of stakeholders at all stages in the development of the strategy; creating a document considering the views of stakeholders for incorporation into the strategy; and setting up workshops involving users and carers to discuss preliminary draft findings. 8

PROVISION OF SERVICES The organisational structure of the service determines how effectively care is administered to the most severely mentally ill. New service developments, such as the creation of crisis services, which could be used as an alternative to an acute in-patient admission, are important elements in developing and providing mental health services. The provision of services is discussed under the following headings: hospital based services; community based services; assertive outreach services; crisis services; and Regional Medium Secure Unit. Hospital based services PfA 2002/2003 states that Boards and Trusts should work together to establish and maintain the appropriate level of acute psychiatric bed capacity. The 1999 review identified that adult psychiatric beds in Northern Ireland were characterised by high re-admission rates, short length of stays and high occupancy. These indicators are useful in determining how successful Trusts and Boards are in providing adequate community services to manage and support individuals with mental health problems. Chart 2 illustrates that the average level of re-admission in Northern Ireland, for the year ended 31 March 2002, was 36%. This indicates that more than one in three people were re-admitted within the one year period. 9

20% 10% 0% 11 6 4 PROVISION OF SERVICES 3 1 2 5 8 9 NI Average Chart 2: Acute Bed Re-admission Rate 1 80% 70% 60% Percentages 50% 40% 40 30% UQ 43% M 36% 35 20% LQ 20% 30 10% 25 0% 20 15 11 6 4 3 1 Trust 2 5 8 9 NI Average non Mean 10 5 0 Source: Health Services Audit data compilation 2002/2003 Chart 3 illustrates that the average length of stay in Northern Ireland was 23 days 2 (1) in 2002, 8 while 5 the 2 length (2) of 6 stay across 7 Trusts 9 ranged 1 from 4 14-34 11 days. 3 Chart 3: Average length of stay 40 35 Number of days 30 25 20 15 10 UQ 26 M 23 LQ 17 5 0 2 (1) 8 5 2 (2) 6 7 9 1 4 11 3 Trust Source: Health Services Audit data compilation 2002/2003 1. Trust 10 does not have any acute in-patient beds and hence, is excluded from charts 2, 3 and 4. In addition, Trust 7 could not provide information on re-admission rates for the financial year ended 31 March 2002 and is not included in Chart 2. 10

100% 80% 60% PROVISION OF SERVICES 40% 20% 0% The following chart illustrates the bed occupancy in 2002. It shows that the median occupancy rate in Northern Ireland is still high at 100%, with a range from 2 (1) 76% 9to 114%. 2 (2) 8 5 1 4 7 11 6 3 Chart 4: Bed occupancy 120% 100% UQ 106% M 100% LQ 89% 80% Percentages 60% 40% 20% 0% 2 (1) 9 2 (2) 8 5 1 4 7 11 6 3 Trust Source: Health Services Audit data compilation 2002/2003 Trusts are monitoring these indicators. However, a number of Trusts accept admissions from other Trusts and as such, management of the situation is in some cases outside their control. The example below indicates how Trusts are working together to manage acute admissions. Good Practice In order to reduce the high level of re-admissions and bed occupancy, one Board and its associated Trusts have an agreed protocol for the management of acute bed admissions. Community based services Community Mental Health Teams CMHTs provide most services for the mentally ill population in all Trust areas. These teams are multi-disciplinary and tend to include community psychiatric nurses (CPNs) and social workers. Other professions, such as occupational 11

PROVISION OF SERVICES therapy, psychology and psychiatry are also represented in the teams. However, the level of involvement varies between Trusts. Recruitment difficulties have been noted in some Trusts. In particular two Trusts have had difficulty in recruiting occupational therapists. The organisation of CMHTs has evolved in many Trusts since the original study was undertaken. Service managers assist in clarifying roles and responsibilities. In many Trusts team leader roles have been created and duties include monitoring caseloads, providing professional support and screening and directing referrals. Caseloads are routinely monitored in the majority of Trusts. Services A number of Trusts have introduced services aimed at supporting users in a community based setting and preventing admission to hospital: One Trust provides an out-of-hours respite provision service, week-end day care and evening groups. A domiciliary support team in one Trust provides practical services such as assistance with shopping or managing finances. A supported housing facility was recently developed by one Trust. The review of the caseloads of community based mental health professionals can determine how successfully the most severely mentally ill users are being targeted and treated. This is further discussed in the section on Targeting. Assertive outreach services In accordance with PfA 2002/2003 Boards and Trusts should develop assertive outreach services for people with severe mental health problems in the community in order to: reduce inappropriate hospital admissions; reduce the length of stay when hospitalisation is required; and increase the stability in the lives of these service users and their carers. Assertive outreach services support those people in the community who find it hard to use more traditional mental health services and can prevent admission to hospital. The services work more assertively than normal communitysupport services, meeting people in the familiarity of their own surroundings, at times that are convenient to the clients and investing a lot of time in building relationships with them. 12

PROVISION OF SERVICES This review of mental health services has illustrated that there has not yet been a significant shift from hospital-based to community-based services. Community-based services are not sufficiently developed to: prevent acute inpatient admissions in the first instance (median occupancy rate 100%); enable timely discharge from hospital (average length of stay high at 23 days); and prevent re-admission by supporting discharged users in the community (more than one third of people admitted were re-admitted within one year). In line with PfA recommendations, Boards and their associated Trusts are at various stages in developing assertive outreach services. The progress at Board level at the time of this audit is set out in the table below. Table 1: Progression with development of assertive outreach services Board Level of development A B C D The Board was driving the development of crisis intervention/home treatment teams at its Trusts as part of a phased approach in the establishment of assertive outreach services. A service review to be undertaken at one Trust was planning to address how assertive outreach services would be delivered. One Trust was seeking to facilitate such services through its CMHTs, with a view to further considering the area as part of a service review in 2004/2005. Two Trusts have full-time assertive outreach staff in post. One Trust was in the process of recruiting staff for their assertive outreach team. One Trust has had an assertive outreach and crisis response team operational from 1 April 2003. One Trust was in the process of recruiting staff for the assertive outreach service. 13

PROVISION OF SERVICES Crisis services Trusts have made progress in developing crisis services, as alternatives to hospital admissions. Examples of work undertaken by Trusts One Trust was preparing to open a thirteen bed intensive care home facility to support eleven individuals in medium to long-term accommodation and two individuals in emergency/crisis short-term accommodation. Additional capacity was factored into this project to allow emergency day care at weekends and public holidays for up to three people experiencing a mental health crisis. Another Trust has established six crisis beds at an existing facility to be used as an alternative to hospital admission. They are also in the process of developing an eight bed unit in conjunction with two housing associations and four of these beds will be available for acutely intoxicated users. This is an attempt to reduce the number of alcohol related acute admissions. Across Board areas there are a wide range of out-of-hours crisis services in place. These include: a deliberate self-harm service to which GPs can directly refer; the availability of 24 hour help lines; and the provision of an on-call facility to Accident & Emergency departments. Services have evolved and developed since the original study while new services have been created. 14

PROVISION OF SERVICES Example of Trust initiative One Trust carried out an audit of the time of admission to acute beds and found that 70% of admissions were in the evening or at weekends. They consequently introduced a gatekeeping system between 9am and 5pm whereby the CMHT receives GP referrals and the team member assesses whether a hospital admission is necessary. This scheme proved so successful that most admissions were then occurring outside of the hours when the service was operational. The Trust extended the hours of operation of this service and two members of the team are now on call between the hours of 5pm and 1am. They assess all referrals between these hours with the aim of preventing admissions wherever possible. Regional Medium Secure Unit The Department identified in its 2002/2003 PfA that Boards and Trusts should ensure that the development of the Regional Medium Secure Unit, including the workforce implications, is progressed in accordance with the project procurement plan. The Regional Medium Secure Unit is undergoing construction in line with the project procurement plan. The need to develop forensic mental health services parallel to completion of the Medium Secure Unit was identified as a need in the 2003/2004 PfA document, and this will be a future development of the mental health service. 15

TARGETING Community mental health services should be targeted towards those users with the most need. However, when considering this area of service provision it must also be considered that treating some people prior to severe mental illness becoming apparent may help to prevent more severe episodes. To ascertain how effectively services are targeted at users with varying levels of need, the following areas were considered: mental health professional caseloads; and initiatives to target the most severely ill. Mental health professional caseload review Percentage The caseloads for CPNs and social workers at community and combined acute 100% and community Trusts were reviewed and the results analysed. The Trusts used 90% a standard set of definitions to review the caseloads and these are detailed in 80% Appendix A. However, Trust 5 is excluded from the analysis as it has developed 70% its own protocol for categorising the severity of mental illness. 60% Caseloads for the remaining ten Trusts have been analysed under the following 50% headings: 40% 30% category of user; 20% 10% frequency of contact; and 0% length of contact with the service. 8 2 9 1 6 10 Category of user Trust Chart 5 illustrates by Trust the range of users on CPN and social worker caseloads 3 7 4 11NI average NI 2002 average 1999 None C2 C1 C B A Chart 5: Casemix in Trusts 100% 90% 80% Percentage 70% 60% 50% 40% C2 C1 B A 30% 20% 10% 0% 8 2 9 1 6 10 3 7 4 11 NI NI average average 2002 1999 Trust Source: Health Services Audit data compilation 2002/2003 16

TARGETING Overall the caseloads of mental health professionals have not changed significantly since 1999. Approximately 62% of the Northern Ireland caseload relates to the severely mentally ill, i.e. categories A and B, compared to 58% in 1999. However, this ranges widely between Trusts from 48% to 78%. On average, 10% of the caseload relates to category C2 users who have no 100% 90% 80% record of hospital admissions and no formal diagnoses for severe depression, anxiety or eating disorders. This represents a slight decrease since 1999 when it was 11%. Percentage 70% 60% 50% 40% Frequency of contact The frequency of contact of CPNs and social workers with users of the service was reviewed and the results illustrated in Chart 6. % <Once a month % Monthly % Fort-nightly % Weekly % >Once a week 30% 20% 10% 0% Category A and B users are in contact with CPNs most frequently, with 62% of category A and 46% of category B users being seen twice a month, or more frequently. By comparison, social workers are in contact most often with A and C1 category A users, B with 52% C1 and 48% C2 of the Arespective Busers being C1 seen atc2 least twice monthly. CPN social worker Chart 6: Frequency of contact 100% 90% 80% Percentage 70% 60% 50% 40% % <Once a month % Monthly % Fortnightly % Weekly % >Once a week 30% 20% 10% 0% A B C1 C2 A B C1 C2 CPN Social worker Source: Health Services Audit data compilation 2002/2003 17

100% TARGETING 90% 80% Percentage 70% 60% 50% 40% 30% 20% 10% 0% Length of contact with the service The length of contact of each category of user with CPNs and social workers was analysed and is illustrated in Chart 7. A and B category users have been with the service for the longest period of time. Over 70% of both A and B users have been in contact with the professionals of the service for at least one year. By comparison, 28% and 44% of the C2 users on the CPN and social worker caseloads respectively have been A B in contact with the service for this length of time. CPN C1 C2 A B C1 social worker C2 % >5 years % 1-5 years % 6-12 months % 3-6 months % 1-3 month % <1 month Chart 7: Length of contact with the service 100% 90% 80% Percentage 70% 60% 50% 40% 30% % >5 years % 1-5 years % 6-12 months % 3-6 months % 1-3 month % <1 month 20% 10% 0% A B C1 C2 A B C1 C2 CPN Social worker Source: Health Services Audit data compilation 2002/2003 In summary, the overall caseload review has shown that: there has been no significant change in the category of user being seen by the service; most users are in contact with the service at least monthly; and the most severely mentally ill have been in contact with the service for the longest time. Initiatives to target the most severely mentally ill Trusts have implemented schemes to relieve pressure on the CMHTs. These initiatives focus on creating new services for the severely mentally ill or creating alternative services for the less severely ill, so reducing the volume of less severely mentally ill referrals to CMHTs. 18

TARGETING Examples of work undertaken by Trusts One Trust has developed a Primary Care Counselling Service as an alternative for the less severely mentally ill C1 users. Two cognitive behavioural therapy (CBT) nurses are based in health centres and receive referrals directly from GPs. This has reduced the number of referrals to CMHTs. In another Trust area, those users referred to as less severely mentally ill are placed on a waiting list. A further Trust has piloted a referral system whereby GPs refer directly to a primary care facilitator who carries out an assessment of the patient. If deemed necessary by the facilitator, the patient is referred onto the CMHT. The waiting lists for the CMHTs have consequently reduced. At one Trust, a new, specialist mental health team consisting of two psychosocial nurses and two CBT nurses has been created to deal with severely mentally ill users and those with obsessive compulsive disorders (category A, B and C1). Work has been undertaken by one Trust to define mild and moderate mental illness and they are working on a 3 D (Disability, Duration and Discharge) definition of severely mentally ill. In addition, this Trust now has a protocol in place whereby CPNs only accept users who have a nursing requirement or where there is a clinical need. The range of services provided for the less severely mentally ill at another Trust include short-term intervention schemes, a befriending scheme and a community mental health support scheme. 19

SERVICE QUALITY Quality is an important aspect of service provision as many of the users will remain in contact with mental health services for most of their lives. However, the definition of quality is often set by the health professionals or commissioners and not by the users of the service. To assess how quality of mental health services is assured, the following areas have been considered: overall approach to quality; and communication with, and involvement, of users and carers. Overall approach to quality Three of the four Boards have ongoing quality programmes. The fourth Board is in the process of reviewing its approach to quality and clinical audit, as part of the development of a mental health strategy. Currently, this Board receives quarterly monitoring reports from its Trusts on pre-determined aspects of quality. Trusts have developed a number of methods of measuring and improving quality of services including quality strategies, an audit programme across programmes of care, quality action plans and quality forums. In addition, the approach to quality is an integral element of the clinical and social care governance agenda. A few Trusts have undertaken additional work in the area of quality. Examples are set out below. Good Practice One Trust was awarded the Health Quality Standard in 2001. In order to achieve this accreditation, the Trust: developed approximately 54 standards which cover all aspects of service within the Trust, including Mental Health; reviewed all policies and procedures in place at the Trust; and created formal structures to review the standards on an ongoing basis. A further two Trusts have been awarded Charter Marks in areas of mental health services, such as addiction services, occupational therapy and day services. 20

SERVICE QUALITY Communication with and involvement of users and carers The original review of mental health services in Northern Ireland recommended that users and carers should be involved in the planning and monitoring of services. The ways in which Trusts can increase the involvement of users and carers and improve communication with them include: developing user and carer empowerment strategies; consulting with users and carers in respect of service development by having representation on strategic planning forums, establishing user forums or meeting with users groups; and employing users or carers advocates for the mental health programme of care or Trust-wide, across all programmes of care. Some of the methods employed by Trusts to improve the information provided to users and carers include: carrying out surveys to gauge satisfaction with services and identify opportunities for improvement; developing, reviewing and updating leaflets; creating a directory of adult mental health services in the Trust area, including voluntary organisations; and a number of Trusts worked together to develop a Carer Educational Support Programme. Good Practice One Trust, in partnership with a voluntary organisation, has employed a users advocate for mental health services. A detailed service specification was produced and regular meetings are held between the Trust, the users advocate and the service manager of the voluntary organisation. In addition, the users advocate reports on issues, such as finance, incidents, accidents and complaints. One Trust commissioned a voluntary organisation to carry out a survey of users to determine the hours in which they require day service provision. It found that users generally do not need treatment outside of normal working hours but require the social aspect of support out-of-hours. The Trust is currently working with the organisation to progress recommendations arising from the survey. 21

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES One of the key messages emerging from the original review of mental health services in Northern Ireland was that Child and Adolescent Mental Health Services (CAMHS) were significantly underdeveloped. At that time, it was recommended that an investment programme was needed for the development of CAMHS. Progress and development of CAMHS has been reviewed by considering: regional developments; and the targeting and profiling of users. Regional developments The components of what is considered to be a comprehensive service is set out in a four-tiered model, the elements of which are detailed below. Tier 1 non-specialist services at primary care level. This would include services offered by GPs, health visitors, school nurses and social services. Tier 2 services provided by uni-professional groups relating to each other in a network, including clinical child psychologists, child psychiatrists, educational psychologists and community child psychiatric nurses. Tier 3 a specialist service for more severe, complex and persistent disorders. This is normally provided by a multi-disciplinary team or service including child and adolescent psychiatrists, social workers, clinical psychologists and community psychiatric nurses. Tier 4 tertiary level services such as day units, highly specialised outpatient teams and in-patient units for older children and adolescents who are severely mentally ill or at suicidal risk. These services are often provided at regional level and may include adolescent in-patient units, eating disorder units and specialist teams for neuro-psychiatric problems. There has been a significant amount of work carried out in the area of CAMH services. Each Board has performed a review of these services and the recommendations arising are currently being implemented through various working groups. 22

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES As an example, one Board established a group to undertake a strategic development review of CAMHS. As a component of this review a detailed needs assessment exercise was undertaken and the local services were evaluated against each tier of the four-tier model. A number of service gaps were identified at each level. A wide range of stakeholders were involved in this review including professional staff at the Trusts, service users and carers and statutory, voluntary and community organisations. In addition, users and carers are part of a reference group which has been established to oversee the implementation of the CAMH service. All four Boards have invested in CAMHS teams increasing the number of staff and in some cases, the professions and the range of skills. However, they have experienced some difficulty in recruiting CAMHS specialists. Within Board areas a range of service initiatives have been developed. These include: introducing therapeutic skills, such as family therapy; creating a service in respect of deliberate self-harm which GPs can refer directly to; developing a web-site which promotes and supports mental and social well-being for the under 18 age-group; and appointing counsellors as part of a Drugs and Alcohol strategy. Good Practice One Board has developed a suicide prevention strategy. Young people and educational providers were involved in this project and a CD-Rom developed for use in schools to promote an awareness of young people under pressure. In addition, workshops have been held and teacher resource packs have been developed. 23

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES Boards and Trusts have highlighted a number of service development needs, including: reducing waiting times for access to services; specialist and ongoing training for CAMHS specialists; investment in the voluntary sector; and specialist regional services for conditions such as Attention Deficit Hyperactivity Disorder (ADHD). The Boards should continue with their efforts to implement the four-tier model in order to establish a comprehensive range of CAMH services. The Department has prioritised the development of aspects of the CAMH services in line with the four-tier model. Since the 1999 review, it has commissioned a review of adolescent services and identified a need for 25 regional adolescent acute in-patient beds. A phased approach was planned. The first phase was to increase the adolescent psychiatric beds by ten by 30 June 2002. These additional beds are now provided by a Trust in Belfast. A four Board Consortium Group was established to monitor the service provided by this Trust and an agreement, similar to a service level agreement, is in place between the Group and the Trust. Each Board currently has access to a number of these beds. The second phased increase is planned and it is anticipated that the further beds will be provided in the west of the province. Further developments of tier 4 level services are required and the Boards have identified the need for certain services. One Board has identified four projects that it would like to implement. One of these is a Regional Social, Emotional and Psychological Unit. The unit would be used as a residential facility for children in the care system, aged 11-17, who are in crisis. It will provide them with intensive care and support for a specific period of time. Targeting and profile of users For the purpose of this review, a CAMHS caseload review was carried out at each community and combined Trust offering this service. The results were analysed by presenting condition, age profile, frequency of contact and length of contact. 24

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES Only seven of the eleven Trusts took part in this caseload review as some of these Trusts provide Board-wide CAMH services. Presenting conditions The range of presenting condition categories were reviewed and the results are shown in Table 2. There is wide variation in the occurrence of presenting conditions between Trusts. However, the most persistent mental health problems in children and adolescents appear to be behaviour and conduct, family relationships and emotional issues. These account for 62% of the total Northern Ireland caseload. Table 2: CAMHS Caseload presenting condition by Trust Source: Health Services Audit data compilation 2002/2003 1 2 3 4 6 8 9 Average % % % % % % % % Behaviour and conduct 49.8 14.2 41.4 51.1 23.1 22.2 21.3 31.9 Child sexual abuse 2.5 6.2 1.4 2.6 2.0 1.0 1.9 2.5 School problems 1.9 9.3 4.0 7.5 8.3 11.0 7.7 7.1 Eating disorders 3.1 4.9 3.3 2.1 2.7 3.0 1.3 2.9 Post Traumatic Stress Dis/Anxiety 6.2 4.7 4.9 3.2 3.5 6.8 10.0 5.6 Sex offending 0.0 0.0 0.0 0.1 0.2 0.3 0.0 0.1 Family relationship problems 6.2 20.3 8.4 12.9 13.3 16.9 21.1 14.2 Emotional difficulties 9.9 21.1 13.8 11.8 15.0 17.7 23.3 16.1 Mental health issues 14.8 13.4 8.7 2.8 21.2 4.8 3.1 9.8 Other 5.6 5.9 14.1 5.9 10.7 16.3 10.3 9.8 100% In determining whether Trusts had problems in transferring adolescents from the CAMH service to the Adult mental health services, the ages of the individuals on the caseloads were analysed. Approximately 76.5% of users in the CAMH services were between the ages of 9 and 17 years. The largest category of users was in the 15-17 year age group, accounting for 31.5% of the total caseload. A small percentage of users of the CAMH service were over 18 years of age (2.5%). 25

106% 106% 89% CHILD AND ADOLESCENT MENTAL HEALTH SERVICES Across all Trusts, waiting times for treatment for non-emergency referrals by CAMHS professionals are long, and range from 25 to 72 weeks. To determine why this is the case the frequency of contact by users with the CAMHS professionals and the length of time on the CAMHS caseload has been analysed. The average findings for the seven Trusts are illustrated in charts 8 and 9 below. Chart 8: Average frequency of contact with CAMH service More than once a week 2% Weekly 7% Less than once a month 37% Fortnightly 25% Monthly 29% Source: Health Services Audit data compilation 2002/2003 26

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES Chart 9: Average length of contact with the CAMH service > 5 years 8% < 1 month ago 4% 1-3 months 13% 1-5 years 43% 4-6 months 14% 6 months - 1 year 18% Source: Health Services Audit data compilation 2002/2003 On average, approximately 66% of users are seen by the service monthly or less than once a month. Only 9% were being seen at least weekly. In addition, 51% of the users have been on the service caseloads for a period of at least one year. In conclusion: waiting times are long; users, once on the caseload, are in contact with the service for a significant period of time; and approximately 34% of users are in contact with the service at least fortnightly. 27

CHILD AND ADOLESCENT MENTAL HEALTH SERVICES In this situation, it is apparent that initiatives are needed in order to reduce waiting lists while regular caseload review and monitoring is necessary to ensure efficient and effective management of waiting lists. An example of good practice in this area is explained below. Good Practice One Trust has developed a protocol with a voluntary mental health organisation to direct referrals in order to reduce waiting lists. More complex referrals come directly to the CAMHS team with less complex referrals being passed to the voluntary mental health organisation, ultimately allowing more patients to be seen. 28

CONCLUSIONS Strategic direction A regional review of mental health legislation and policy is underway. Boards and Trusts have made progress in the development of mental health strategies, and there has been increased involvement of stakeholders in strategic planning and service development. There has been regional consultation on mental health issues such as CAMH services, the Regional Medium Secure Unit, the provision of adolescent beds and the need for services for people with eating disorders or problems with drugs or alcohol. Provision of services In Northern Ireland, the overall proportion of expenditure on hospital based mental health services has not changed since 1999, remaining at 52%. This varies between Board area from 45% to 60%. Although it has not been quantified, indications are that the re-admission rate and length of stay at hospital has also increased since 1999. In terms of reducing the number of inpatient beds, community services have not significantly increased to prevent admission to hospital and support users upon discharge. Boards are developing assertive outreach services in their localities. However, the format of these services and the extent of development varies at Trust level. Progress has been made in developing community based and crisis services across Northern Ireland. The most severely mentally ill users are being targeted by CMHTs and other services are being developed to care for the less severely mentally ill. The Regional Medium Secure Unit is undergoing construction. A need for the development of forensic mental health services has been identified. Targeting There has not been a significant change in the caseloads of mental health professionals since 1999. The severely mentally ill users account for 62% (1999 58%) of the caseloads. These users have been with the service for the longest time. In addition, most users are in contact with the service at least monthly. 29

CONCLUSIONS Trusts have introduced a range of service initiatives in an attempt to control caseloads and target the most severely mentally ill. Service quality Boards and Trusts have introduced methods to measure and improve the quality of services. This is also being addressed through the clinical and social care governance agenda. Communication and the quality of information provided to users and carers has improved at most Trusts. Child and adolescent mental health services CAMHS have been developed in all Board areas, in addition to regional services such as the Adolescent In-Patient Unit. There are now 16 regional adolescent inpatient beds, with more planned. There is scope for improvement at each tier of the four-tier model and waiting times for the service need to be reduced. A small percentage (2.5%) of the users on the CAMHS caseload are older than 18 years old. At least 51% of users on the caseload have been with the service for one year and 9% are seen weekly, with 60% being seen monthly or less frequently. 30

WAY FORWARD Strategic direction Incorporate recommendations from the review of mental health and learning disability into existing strategic frameworks. Consult on mental health issues at a regional level, for example on components of an assertive outreach service, sharing good practice. Involve a wide range of stakeholders in strategic planning and service development. Provision of services Boards and Trusts need to focus on improving community-based services to reduce pressure on acute psychiatric in-patient beds. Develop assertive outreach services as an integral part of the existing mental health service. Develop forensic mental health services and work with voluntary sector to develop accessible regional eating disorder services. Targeting Undertake regular review and monitoring of CMHT professional caseloads to ensure appropriate targeting of users. Develop alternative services for less severely mentally ill users to relieve pressure on CMHTs. Quality Ensure quality of services through the clinical and social care governance agenda. Continue to improve communication and information provided to users and carers. Child and adolescent mental health services Further development of CAMHS in line with four-tier model, particularly services at multi-locality or regional level. Increase the number of adolescent in-patient beds and identify suitable premises. Boards and Trusts ensure appropriate mechanisms are in place for the transfer of users from CAMHS to the adult mental health service. Introduce measures and initiatives to reduce waiting times for CAMHS. 31

APPENDIX A Casemix category definitions A Psychotic diagnosis, organic illness or injury AND previous compulsory admissions OR aggregate one year stay in hospital in past five years OR three or more admissions in past five years B Psychotic diagnosis, organic illness or injury OR any previous admission in past five years C1 No record of hospital admission AND formal psychiatric diagnosis of: severe depression severe anxiety obsessive compulsive disorder phobic state anorexia bulimia C2 No record of hospital admissions AND none of the above psychiatric diagnoses 32

APPENDIX B Glossary of Terms ADHD: Attention deficit hyperactivity disorder CAMHS: Child and adolescent mental health services CBT: Cognitive behavioural therapist CMHT: Community mental health team CPN: Community psychiatric nurse DHSSPS: Department of Health, Social Services and Public Safety LHSCGs: Local health and social care groups OT: Occupational therapy PfA: Priorities for Action (DHSSPS) 2002/2003 and 2003/2004 33

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For further information please contact: Performance Review Unit Finance Directorate DHSSPS Castle Buildings Stormont Belfast BT4 3SQ Telephone: (028) 90520288