Croydon Child and Adolescent Mental Health Service Sue Goode Lead Clinician Croydon CAMHS
Overview Vision for CAMHS Impact of Mental health needs and implications for CAMHS Facts and Figures:-Child Mental Health Profile for Croydon Update on new initiatives in CAMHS Introduction of Choice and Partnership model Payment by Results
Impact of mental health problems No other health condition matches mental ill-health in the combined extent of prevalence, persistence and breadth of impact WHO (2008) figures for UK (total DALYs) Mental disorder 22.6% Cardiovascular disease 16.2% Cancer 15.9% Mental health problems occupy one third of a GP s time
Population levels of mental health disorders 17.6% of adult population have at least one common mental disorder (McManus et al, 2009 - APMS) Similar proportion experience sub-threshold symptoms Many of these adults had their first experience of a mental disorder during childhood. Half of all lifetime mental disorders start before the age of 14.
Vision for CAMHS Children, young people, and carers, have timely ease of access to effective services, in which they are fully involved, and that respond to the full range of mental health needs, are non-stigmatising, and relate to the diversity of Croydon s population. Effective mental health promotion and prevention will become widely owned goals - beyond those working in mental health services. No Worries CAMHS strategy 2005
Translation into something more concrete? Timely? Ease of Access? Where should children and young people be seen? Effective? Keeping children safe, reducing symptoms, increasing speed of recovery, reducing impact on family, identifying Child Protection concerns, preventing relapse, preventing them from getting worse? Patient Choice, patient information, shared knowledge, choice of location, choice of intervention? Responding to full range of mental health needs? Non stigmatising? Able to relate to Croydon s diverse population?
There is a Need for continued dialogue with partnership agencies about making this vision a reality
Facts and figures
% Sources of CAMHS Referrals Education Services 1% 1% 19% 4% General Medical Practitioner Other Clinical Speciality 1% 6% 32% School Social Services (non-slam) Self Other mental health trust A&E Department Other 22% 14%
Q&A 1. How many children aged 0-19 are there in Croydon Largest number of children of any of the London boroughs, with a population of approximately 88,496 under the age of 19. For comparison- Lambeth has approx 59,177, Southwark has 61,400 and Lewisham has 62,844 in this age range (2007 ONS surveys)
Q&A (cont) What percentage of these children will have a current mental health disorder percentage and what percentage will experience a mental health disorder at some time during Childhood 10% of children and young people have a clinically recognised mental disorder (Green et al, 2005) Over 8,800 Croydon children will meet ICD 10 or DSM IV criteria for a mental health disorder at any point in time with 40% meeting the criteria for a diagnosis of a mental health disorder at least one stage before they reach the age of 18
Q&A (cont) What percentage will experience some form of emotional or behavioural difficulty during Childhood Answer: most! Example:- DEPRESSED MOOD 35% DEPRESSED SYNDROME 5% CLINICAL DEPRESSION 3-4% Peterson et al. 1993
Q&A (cont) 6. What percentage of children with a mental health disorder are seen by someone with a professional background in mental health disorders? Only 20% of children with diagnosable mental health problems are seen by child and adolescent mental health specialist services, and a proportion do not receive professional help for these problems from anyone.
Q&A (cont) 75% of those with mild mental health problems do not access services. In an ideal world what should that percentage be?
Wide range of impacts of poor mental health Individuals, families and communities every family is affected Poor educational outcomes, school drop out Unemployment Anti-social behaviour, youth offending and crime Association with poor diet, less exercise, more smoking, drug and alcohol misuse Poor physical health Health inequality Suicide and self harm Stigma and discrimination Reduced life expectancy
Increased risk of poor adult outcomes Poor mental health in childhood and adolescence also leads to a broad range of poor adult health outcomes including higher rates of adult mental illness poor educational outcomes unemployment and low earnings teenage parenthood marital problems criminal activity (Richards and Abbott, 2009).
Health risk behaviours and Emotional and Conduct Disorder in Children and Young People (Green 2005) Risk Behaviour Emotional Conduct No Disorder Disorder Disorder Smoke Regularly (age 11-16) Drink at least twice a week (age 11-16) Ever Used Hard Drugs (age 11-16 Have ever self harmed (self report) 19% 30% 5% 5% 12% 3% 6% 12% 1% 21% 19% 4% Have no friends 6% 8% 1% Have ever been excluded from school 12% 34% 4%
Selected PCT expenditure across programmes as a percentage of total expenditure. Programme Budgeting Category Croydon PCT SHA Average 01 Infectious Diseases 2.28% 3.36% 02 Cancers and Tumours 6.57% 5.40% 03 Disorders of Blood 1.57% 1.63% 04 Endocrine, Nutritional and Metabolic 2.74% 2.66% 05 Mental Health Disorders 13.95% 15.66% 06 Problems of Learning Disability 4.35% 3.26% 07 Neurological 4.55% 3.71% 08 Problems of Vision 1.77% 1.79% 09 Problems of Hearing 0.34% 0.45% 10 Problems of Circulation 7.44% 7.17% 11 Problems of the Respiratory System 3.96% 4.31% 12 Dental Problems 4.74% 4.00% 13 Problems of Gastro Intestinal System 4.27% 4.52% 14 Problems of the Skin 2.60% 1.90% 15 Problems of Musculo Skeletal System 4.47% 4.05% 16 Problems due to Trauma and Injuries 3.35% 3.63% 17 Problems of Genito Urinary System 5.78% 4.98% 18 Maternity and Reproductive Health 4.56% 4.51% 19 Conditions of Neonates 1.98% 1.51% 20 Adverse effects and poisoning 1.12% 1.01% 21 Healthy Individuals 2.41% 2.50% 22 Social Care Needs 1.70% 2.01% 23 Other 13.51% 15.98%
Population Information about SLAM boroughs Borough Child Population % of children 0-15 living in Poverty Number of children 0-15 living in Poverty Southwark 61,400 33.9 20,815 Lambeth 59,177 43.2 25,564 Lewisham 62,844 37.3 23,440 Croydon 88,496 28.3 25,044
Characteristics in Croydon Diverse: 57% of school children are from black or minority ethnic groups 28% of children live in poverty. Highest numbers of looked after children in any borough- currently estimated at 1000, with 50% being unaccompanied minors. High numbers of children with developmental problems - ASD much higher than population statistics would indicate.
Information about SLAM Borough Population Budget Southwark 61,400 4,113 Lambeth 59,177 3,725 Lewisham 62,844 3,241 Croydon 88,496 2,822
Activity Data Service Area Item 2010/2011 Croydon Appointments offered 11,136 Appointments attended 8,374 Average Caseload 1,485 Lambeth Appointments offered 12,212 Appointments attended 7,957 Average Caseload 1,130 Lewisham Appointments offered 13,486 Appointments attended 9,563 Average Caseload 1,461 Southwark Appointments offered 13,331 Appointments attended 9,584 Average Caseload 1,537
High Demand- Limited Capacity
Service User Feedback (external audit) at 6 months Croydon Positive Feedback 29 (85%) Negative Feedback 5 (15%) Overall, the feedback given on the Service provided was highly positive, and the majority of the negative feedback was related to waiting times.
Potential problems with service user feedback Getting Feedback from Children requires a different approach Parents generally don t want to hear that there are family-related matters at the heart of their child s mental health problems, they will often be dissatisfied with the service they are offered (eg family therapy) as they believe the problem is with their child. Because of associated stigma, families do not always engage. One of the most important issues for service development is how to make services more responsive to the needs of these families but, until they engage, their views will not be captured in any service user / patient survey.
How are we addressing these criticisms?
New Initiative- Choice and Partnership Approach Clinical system based on offering users Choice and working in Partnership with them over jointly agreed goals. Based on NO waiting list Incorporates many ideas of demand and capacity management Includes the 10 high impact changes from the modernisation agency Aligns with the Choice agenda for mental health Promotes many of the Standards for Better Health Support the developing Out-patient CAMHS standards (QINMAC)
Framework Two initial appointment types CHOICE appointment and PARTNERSHIP appointment The initial Choice appointment is fully booked, 4-8 weeks after referral The Partnership appointment is fully booked from the Choice appointment and is the onset of treatment
Choice appointment choice as in booking choice of venue choice to engage or not in the service choice to change or not informed choice as to type of therapy choice of goals choice as to who in family comes choice of formulation e.g. to label / medicalise or not choice about subsequent appointments/booking
Current Waiting times Down to maximum of 12 weeks Looked after children can be seen within a week All children presenting at A&E following an incident of self harm are followed up within 7 days All children where risk is judged as high are seen within a week and where risks are very high- that or the next day
Challenges for us Need to ensure that we are sufficiently flexible to be able to manage children presenting with high levels of risk Approximately 60% of children referred under the age of 11 have a suspected developmental disorder. These children require more detailed assessment Where medication is indicated, children remain under CAMHS for review appointments and need to have an allocated care coordinator. Reduction in funding linked to CAMHS grant no longer being ring fenced Need to get the balance between demand and capacity. Demand currently exceeds capacity
Premises for CAPA Can Accept as many referrals per week as you have full time equivalent staff- so a team of 20 can accept 20 referrals per week. Prior to introducing CAPA we were accepting an average of 33 new referrals per week Applying referral criteria very strictly, now down to just over 20 per week.
Clinical Priorities- Those at high risk of harm to self or to others Those with Early onset psychosis Those with Eating Disorders Those at severe risk of family breakdown Those with Moderate to Severe mental health disorders which are causing significant impairment
Focus for Croydon Specialist CAMHS Croydon Specialist CAMHS accepts referral of children showing behavioural and biological symptoms which suggest that they may be suffering from a moderate to severe mental health disorder as defined by ICD-10 criteria.
Emotional Behavioural Psychosis Neurodevelopmental / Neuropsychiatric F30-39: Manic episode, Bipolar affective disorder, Depressive episode, Recurrent depressive disorder, Persistent mood [affective] disorders, Other mood disorders, Unspecified mood disorders (excluding those with psychotic symptoms) F40-48: Phobic anxiety disorders, Other anxiety disorders, Obsessivecompulsive disorder, Reaction to severe stress, and adjustment disorders, Dissociative [conversion] disorders, Somatoform disorders, Other neurotic disorders F93: Emotional disorders with onset specific to childhood (e.g. Separation Anxiety) F94: Disorders of social functioning with onset specific to childhood and adolescence (e.g. Attachment Disorder) F10-19: Mental and behaviour al disorders due to psychoact ive substance use F50-59: Behaviour al syndrome s associated with physiologi cal disturbanc es (e.g. Eating Disorders ) F60-69: Personalit y Disorder F90.1: Hyperkin etic conduct disorders F91: Conduct disorders F92: Mixed disorders of conduct and emotions F20-29: Schizophrenia, Schizotypal disorder, Persistent delusional disorders, Acute and transient psychotic disorders, induced delusional disorder, schizoaffective disorders F10-19: Mental and behavioural disorders due to psychoactive substance (.05) Psychotic disorder F30.2, F31.2, F31.5, F32.2, F33.3: Mood disorders with Psychotic symptoms F05, F06, F07, 09: Organic Mental disorders F84 Pervasive Developmental Disorders (ASD) F90: Hyperkinetic Disorders F95: Tic disorders
Clinical guidelines **Antenatal and postnatal mental health **Attention deficit hyperactivity disorder (ADHD) Anxiety **Bipolar disorder Dementia Depression **Depression in children and young people Drug misuse: opioid detoxification Drug misuse: psychosocial interventions **Eating disorders Medicines concordance **Nocturnal enuresis in children (bedwetting) **Obsessive-compulsive disorder Personality disorders - borderline **Post-traumatic stress disorder (PTSD) **Schizophrenia **Self-harm Violence
Relevant Completed Technology Appraisals Attention deficit hyperactivity disorder (ADHD) - methylphenidate, atomoxetine and dexamfetamine (review) Bipolar disorder - new drugs (replaced by CG38 Bipolar disorder) Conduct disorder in children - parent-training/education programmes Depression and anxiety - computerised cognitive behavioural therapy (CCBT) Drug misuse - methadone and buprenorphine Drug misuse - naltrexone Schizophrenia - atypical antipsychotics
Care Pathway ADHD Disorders Care Pathway Young people referred to CAMHS with concern relating to poor hyperactivity level, poor attention and impulsivity The Population Referrals from agreed local professionals Key Key decision making point Process/Task Assessment Intervention Aim/Objective Additional information ADHD Interventions Discharge from service Refer to other pathway Access available to multidisciplinary team including psychiatry and psychology No Comprehensive CAMHS Assessment including basic developmental assessment Yes Care Plan Implementation & Documentation of Interventions Educational advice, support and liaison Confirm and Cluster liaison AIM - to minimise impact of ADHD symptoms and treat co-morbid disorders with concomitant Outcome measures including CGAS, DDCGAS and others as appropriate Risk Assessment including Safeguarding is completed CGAS, SDQ & contact with schools, child health, Education, Psychology Complete Educational CAMHS PbR advice, support Parent group for ADHD (Child and Adolescent) Medication to include NICE Guidance and Technology Appraisals Connors if indicated. Consider DAWBA to screen for other emotional and behavioural problems Consider psycho social/environmental impediments. E.g. domestic violence, substance misuse, parental LD, Asylum issues Consider co morbidity: Depression, Behaviour Disorders, & other disorders ADHD Diagnostic assessment to include ADHD Specific: Developmental history, information re behaviour at school and at home to include observation/information across more than one setting. Full medical examination and investigation and cognitive assessment (developmental assessment alternative for <5 years). Consideration of co-morbid specific developmental disorders e.g. dyslexia Co-ordinated plan of intervention/care plan: written report discussed with parents and shared with GP, Child Health, Speech and Language Therapy, CAMHS. Optionally: Social Services, Education and voluntary sector. Medication based treatment Parent group for ADHD (Child and Adolescent) Reports including improvements at school Complex Diagnostic Assessment Specialist in-depth assessment parental interview suing ADHD specific diagnostic instrument e.g. PACSM, CAPPA to include observation/information across more than one setting Consider referral to medical genetics or other medical specialists Lead off to a separate and independent algorithm for the medication aspect Child or Young Persons Group Medication to include NICE Guidance and Technology Appraisals Medication based treatment Reports including improvements at school Child or Young Persons Group Patient requires an additional care pathway e.g. referral for assessment or treatment of Depression, Autistic Spectrum Disorder, ADHD, Behaviour Disorder or Depression Depression, Conduct disorder Review & Reassess including Risk Confirm Cluster Treat/refer as required by other pathway Outcome - Assessed by CGAS, SDQ plus other as required Exit Exit
Payment by Results A new funding system for care provided to NHS patients in England - Reforming NHS Financial Flows (Department of Health, 2002)
CAMHS Clusters PROPOSED BY WM A. DNA. UNABLE TO CODE CLUSTER 0 B. DNA AFTER TEL C. DNA AFTER MEETINGS DISCHARGE 1. LOW SEVERITY SOCIAL/FAMILY DYSFUNCTION LOW SEVERITY GREATER NEED 3. MODERATE 4. SEVERE CONSULTATION/ LIAISON EMOTIONAL 5. VERY SEVERE 6. OVERVALUED IDEAS CP REFERRAL Assessment NAT Needs Assessment Tool Completed BEHAVIORAL 7. ENDURING 8. CHAOTIC CHALLENGING 9 SUBSTANCE MISUSE 10. FIRST EPISODE 11. RECURRENT - LOW CP DISCHARGE PSYCHOSIS 12. RECURRENT - HIGH RECURRENT HIGH DISABILITY 14. CRISIS 15. PSYCHOTIC DEPRESSION 16. DUAL DIAGNOSIS CP 17. DIFFICULT TO ENGAGE ORGANIC- NEURODEV/ NEUROPSYCH 22. LOW NEED 23.. MODERATE 24. HIGH NEED - PSYCHOLOG 25. PHYSICAL & PSYCHOLOGICAL NEEDS
Emotional Behavioural Psychosis Neurodevelopmental / Neuropsychiatric F30-39: Manic episode, Bipolar affective disorder, Depressive episode, Recurrent depressive disorder, Persistent mood [affective] disorders, Other mood disorders, Unspecified mood disorders (excluding those with psychotic symptoms) F40-48: Phobic anxiety disorders, Other anxiety disorders, Obsessivecompulsive disorder, Reaction to severe stress, and adjustment disorders, Dissociative [conversion] disorders, Somatoform disorders, Other neurotic disorders F93: Emotional disorders with onset specific to childhood (e.g. Separation Anxiety) F94: Disorders of social functioning with onset specific to childhood and adolescence (e.g. Attachment Disorder) F10-19: Mental and behavioural disorders due to psychoactive substance use F50-59: Behavioural syndromes associated with physiological disturbances (e.g. Eating Disorders) F60-69: Personality Disorder F90.1: Hyperkinetic conduct disorders F91: Conduct disorders F92: Mixed disorders of conduct and emotions F20-29: Schizophrenia, Schizotypal disorder, Persistent delusional disorders, Acute and transient psychotic disorders, induced delusional disorder, schizoaffective disorders F10-19: Mental and behavioural disorders due to psychoactive substance (.05) Psychotic disorder F30.2, F31.2, F31.5, F32.2, F33.3: Mood disorders with Psychotic symptoms F05, F06, F07, 09: Organic Mental disorders F84 Pervasive Developmental Disorders (ASD) F90: Hyperkinetic Disorders F95: Tic disorders F Codes above refer to ICD-10 Psychiatric Diagnosis
Work in progress Needs Assessment tools have been piloted Work on Care Pathways Active
PHWP and mental health Poor mental health in childhood affects educational attainment, increases the likelihood of smoking, alcohol and drug use and has consequences for poorer physical health in later life. We also know that mental health and wellbeing are important factors for physical health. Focussing on mental health amongst young people is particularly important with half of all lifetime mental illness starting before age 14 Good wellbeing does not just mean the absence of mental illness it brings a wide range of benefits, including reduced health risk behaviour (such as smoking), reduced mortality, improved educational outcomes and increased productivity at work. Health is not just about the presence of disease or illness (be that physical or mental), but also about how well people are.
Better diagnosis and treatment, together with interventions across healthcare services and local government to improve population mental well-being, will help to improve the mental well-being of the local population and prevent mental ill-health particularly for higher risk groups such as families in lower socioeconomic groups, and families where there are dependent children.
A Cross-Government Mental Health Strategy Good mental health is essential for everyone How public service reforms will work for mental health Key messages for a cross government mental health strategy A twin-track approach will improve outcomes for people with mental ill-health and build resilience and well-being to prevent mental ill-health in the whole community A Call to Action with key stakeholders People with mental ill-health are likely to have better outcomes if they have real, well-informed choices over their care Improving public mental health and well-being, with prevention and early intervention, can cut the 105bn annual cost of mental ill health