Mental Health Deep DiveInterim ICS Partnership Board

10 June 2021

Dr Dan Dalton, Chief Medical Officer, Norfolk and Suffolk Foundation Trust

Dr Ardyn Ross, Mental Health Clinical Lead NHS Norfolk and Waveney CCG

Introduction

• Mental Health is one of two main priorities for the Norfolk and Waveney system.

• This is a deep dive to better understand the main issues, not for assurance, but for shared understanding and solution seeking.

Increase in referral rates / demand for mental health

• There has been a year on year increase in referrals to mental health services, along with

accepted referrals.

• Further work is being done to fully understand the reasons for the high referrals and to identify

system gaps.

• Primary care has requested increased mental health support and is keen to work with the whole

system.

• We are planning for the impact of the transformation work which will better support patient

pathways and earlier access through community settings (as well as reduce impact on referrals).

• Joint working with primary care and NSFT on mental health practitioners in primary care has been

positive and improved relationships.

• Alliance approach to identifying support for children, young people and families at the earliest

point.

• The funds for the Mental Health Investment Standard (MHIS) for Norfolk in 2021-22 is an

additional 4.4%, which equates to £6.908m.

• We have additional funds from the Government Spending Review (national total £500m) – the

Norfolk and Waveney part is £5.025m to bring forward improvements as part of the COVID-19

response.

• Norfolk and Waveney also has Service Development Funds totalling £6.572m for mental health

initiatives.

• The whole health and social care system have been involved in a process to agree the investment

priorities which were approved by the CCG and the Mental Health Programme Board, and shared

widely with other leadership forums.

New funding overview

Adult Mental Health - System Transformation Priorities 2020/21

1. Enhanced support for Primary Care: PCN Mental Health Practitioners, Recovery workers and Link psychiatrists supporting GP Practices to guide patients to the right support and services, to commence April 2021.

2. Increased Access in Psychological Therapies (IAPT): Year on year additional capacity to improve access and support for all patients including those with long term conditions.

3. Enhanced support in the Community: Establishment of new Wellbeing/Crisis Hubs for early support and intervention in community settings, first Central Hub in Norwich to open June 2021, further four hubs in development.

4. Improve Community Services for SMI: Whole system health, social care, VCSE and adopting a neighbourhood approach to improve physical and mental health (focus on personality disorder, eating disorder and rehab) services for users with seriousmental health issues (SMI), working with Community MH and Primary Care teams, to commence April 2021.

5. Development of crisis support and alternatives: Building on all three acutes having MH liaison in place (nationally funded) the new service Community Support Teams (3 year Nationally Funded via Crisis Alternatives) will offer emotional support and service navigation 7 days per week, VCSE led service will focus building individual resilience to prevent the deterioration of mental health to the point of crisis, start April 2021. Hubs will provide alternative places of safety, de-escalation and recovery for those with acute mental distress.

6. Enhanced support for those who have experienced the psychological impact of COVID-19, including patients, carers, families and workforce.

7. First Point of Contact for Mental Health: Building on the new local Norfolk and Suffolk First Response Service (Telephone 0808 1963 494) for any mental health need, set up May 2020 (MHIS funded), next steps to link to 111 provider to offer joint physical and mental triage, access to Directory of Services for appropriate services and resilience from national provider.

New Community Mental Health Transformation

• NHSE bid approved for £13m investment over 3 years from 2021

• Focus on people with severe mental illness (SMI) with Eating Disorders,

Personality Disorder and requiring rehabilitation

• System-wide Partnership Programme chaired by Dr Dan Dalton & Dr

Ardyn Ross

• Re-engineer community teams, increase access and reduce waits

• Early support and easy access via place based care

• MH practitioners in all 17 PCNs by August 2021(14/26 in place)

• £18m investment in 181 new supported homes (NCC led) over 3 years

with accompanying Rehab model

Transformation Plans

N&W Community Mental Health Plan on a Page

New Crisis Support Transformation

Service developments offer alternatives to admission and support crisis:

• First Response Service (24/7 telephone access for all) set up May

2020 will transition to 111 integrated model by March 2022

• Holly Tree House, Crisis House (4 beds) opened February 2020 short

stay to reduce admission – two more to open 2021/22 in East & West

• Norwich Wellbeing Hub to open September 2021,two further hubs to

open Autumn 2021 in East and West (links with crisis teams)

• Crisis alternatives – NHSE approved investment over 3 years, focus

on reducing admission by expanding support and recovery capacity for

people in their own homes

Transformation plans

Eating Disorders Investment

• Invested in nationally supported early intervention model – additional staff in community eating disorder (ED) teams (6 new posts)

• Revised GP medical monitoring, training offered, physical support for patients

• New all-age carer support offer via Community ED teams (psycho-social) and CYP offer via BEAT

• Established weekly MDT meeting to plan and progress acute admissions

2021/22

• Investment £1,045,000

• New Team Intensive Community Outreach supporting alternatives to admission – 12 new posts, integrated with community ED teams

• Additional capacity into existing teams – 4.5 new posts

• New Provider Collaborative July 2021 – in-region provision

• New system all-age ED strategy refresh, clinically led

Transformation plans

Through Whole Health Economy Principles

• Work together as a system – learn lessons from the Pandemic

• Early access and support for wellbeing and inappropriate admission

• Easy access to services – community based

• Build on partnership working with VCSE (client knowledge and agile)

• Service user influence

• System pathways to focus on flow through system

• System leadership

Transforming the Mental Health System in N&W

Children and Young People Priorities – 2020/21

1. Meeting National Standard in line with the Five Year Forward View and the Long Term Plan – Minimum access of 35% increasing year on year and the Eating Disorder Access and Waiting Time Standard, 1 Week to Treatment for Urgent and 1 Week to Treatment for Routine

2. Multiple transformation programmes; including • Core CAMHS Commissioning

• Eating Disorders

• Crisis Presentations and Inpatient admissions

• Self Harm and Suicide Prevention,

• Improving Transitions (18-25 years)

• Children in Care

• Thriving and Universal (including the MH Offer to Schools)

• Digital e.g. digital solutions to case management and the online offer of support.

3. Ensuring Easy Access to CYPMHS and appropriate support regardless of presentation or severity of need (improving external referral forms, scoping an integrated front door, improving communications and access to advice and guidance, mobilising a shared case management system, and coproduced triage and assessment forms)

4. Reducing Waiting Times to access CYPMHS Therapeutic Team5. Improved Integration with wider statutory partners on ongoing transformation including Childrens Services (ECFS, Social Care, LAAC, Exploitation) and

Education6. Developing workforce skills7. Ensuring CYP and their families are involved in the ongoing development and improvement of CYPMHS 8. Addressing service gaps; Trauma (particularly linked to NDD agenda), Family Focussed Therapeutic Services, self harm/suicide prevention strategies

and pathways9. Programme of contract and performance management and short term projects e.g. improving discharge and reducing admissions, MHIS, Recruit to

Train Posts10. Managing the operational implications and complications of COVID19 and its wider impact on the Mental Health support available to CYP and families

One in six school-aged children has a

mental health problem.

This is an alarming rise from one in ten in

2004 and one in nine in 2017.

(NHS Digital, 2020)

Children and Young People’s Mental HealthThe Facts…

Children and young people’s mental health has never been so high on the public agenda. But it’s vital that we have the basic facts if

we are to see realised our vision of better mental health for all children, wherever they live, whatever their background or class.

At any one time, a child or young person may be anywhere on a spectrum between

being healthy and unwell. Many children move along the spectrum at different times.

75% of adults with a diagnosable mental

health problem experience the first

symptoms by the age of 24.

(Kessler et al., 2005; McGorry et al., 2007)

About one in twenty (4.6%) 5-19 year

olds has a behavioural disorder, with

rates higher in boys than girls.

(NHS Digital, 2018)

People who identify as

LGBT+ have higher rates

of common mental health

problems and lower

wellbeing than heterosexual

people, and the gap is

greater for older adults (over

55 years) and those under

35 than during middle age.

(Semlyen et al., 2016)

Common mental health issues,

such as depression and anxiety,

are increasing amongst 16-24

year olds, with 19% reporting to

have experienced them in 2014,

compared to 15% in 1993.

They are about three times

more common in young women

(26.0%) than men (9.1%)

(McManus et al., 2016)

70% of childrenwith autism have at least one mental health

condition.

(Simonoff et al., 2008)

There is an average 10-year delay between young people displaying first

symptoms and getting help.

First symptoms

Getting help10years

Only just over a quarter (27.9%) of children

and young people who experience both

a learning disability and a mental health

problem have had any contact with mental

health services.

(Emerson and Hatton, 2007 and

Toms et al., 2015)

Children from the poorest 20% of

households are four times as likely to have

serious mental health difficulties by the age

of 11 as those from the wealthiest 20%.

(Morrison Gutman et al., 2015)

34

of children in care

have a diagnosable

mental health

problem.

Refugees and asylum seekers are

more likely to experience poor mental

health (including depression, PTSD

and other anxiety disorders) than the

general population.

(Mental Health Foundation, 2016)

Children from racialised communities are

less likely than their white peers to access

traditional mental health services.

(Education Policy Institute, 2017)

However, they are twice as likely to access

mental health support via court orders (social

care or criminal justice related orders).

(Edbrooke-Childs and Patalay, 2019)

Research indicates

a high prevalence of

self-harm in young

South Asian women

aged 16-24 years.

(Lavis, 2014)

Two-thirds of children with a mental health problem

have had contact with professional services.

Over 40% of children in the youth

justice system in England and Wales

are from racialised backgrounds, and

more than one third have a diagnosed

mental health problem.

(Taylor, 2016)

Children and young people with

a learning disability are three

times more likely than average to

have a mental health problem.

(Lavis et al., 2019)Young people in the youth justice

system are 3 times more likely

than their peers to have mental

health problem.

(Mental Health Foundation, 2002).

Teachers were the most commonly cited source (48.5%),

followed by primary care professionals (33.4%), and

mental health specialists (25.2%).

(NHS Digital, 2018)

Pupils who have a mental health problem are

more likely to be excluded from school than

their peers.

In 2013/14, one in five students

with an identified social,

emotional and mental health

difficulty received at least one

fixed period exclusion.

(Department for Education, 2016)

Research suggests that school exclusions are

linked to long-term mental health problems.

(Ford et al., 2017).

Suicide is the largest cause of mortality for young

people under

35. Suicide rates have been increasing in recent

years.

(Office for National Statistics, 2020)

Self-harm is more common among young

people than other age groups. 25% of

women and 9.7% of men aged 16-24

report that they have self-harmed.

(McManus et al., 2016)

Key Challenges• Increased number of CYP presenting in mental health

crisis in A&E.

• Increased number of CYP being admitted to acute paediatric wards, especially eating disorders (ED), and staff do not have the appropriate specialist skills to manage the mental health need.

• Significant number of crisis presentations also have a neurodevelopmental disorder (NDD).

• Increased length of stay on acute paediatric wards, due to lack of mental health beds or alternatives to admission.

• Reduced in-reach from CYP Eating Disorder Team to support patient and clinical staff.

• Psychiatric Liaison not fully available across all acute trusts for CYP.

• Planned surgery programme about to restart, reducing capacity on acute wards.

Plan of Action• RUSH – Rapid Response Pathway for CYP who present in

A&E with self-harm. Funding approved to sustain and expand.

• Winter funding money used to pilot Intensive Support Team+ (IST+), in-reach to acutes. Funding approved to sustain and expand.

• IST+ will be an inclusive (multi-skilled) offer to support all CYP presenting in crisis irrespective of diagnosis (i.e. eating disorders and NDD) in the acute hospitals.

• Expansion of IST to become an inclusive offer to support all CYP at risk of a MH crisis, to de-escalate and provide additional support in the community.

• Development of an inclusive Home Treatment Team to provide alternative to admission.

• Expand capacity within Eating Disorder Community Teams to provide a liaison function with the acute settings.

• 3 band 4 assistant practitioners (within IST+) will provide additional capacity in each of the acute hospitals, with a particular focus on meal support.

• £500K 3 year recurrent funding + £200K for 2021/22 to increase capacity for ED and to develop alternatives to admission.

Children and young people – acute

Children and young people – community teams

Key Challenges

• Increased acuity and peaks in referrals

• Increase in suicide ideation and self-harm

• Significant increase in eating disorder referrals and acuity

including Avoidant Restrictive Food Intake Disorder

(ARFID) (Quadrupled),

• Historical long waits across early intervention and

specialist providers. Focus has necessarily been on

waiting lists and managing risk; capacity for treatment has

been challenging

• Patient flow – higher referrals into services compared to

discharge

• Lack of understanding and alignment of early intervention

and prevention provision across the system

• Workforce – national shortage of appropriate knowledge,

skills and experience; recruitment and retention

challenging

• Need for common digital infrastructure and processes

• Disjointed communication

Plan of Action• Increased capacity in core community teams,

through introducing new training roles and increasing

Mental Health Youth Workers

• Invested £700K to reduce historic waiting list;

working with NSFT, VCSE partners and remote

workers where suitable

• Waiting list triangulation across the system to identify

CYP at highest risk

• Extension and expansion of Kooth digital offer for all

CYP aged between 11 and 25 years

• Optimisation, demand and capacity modelling

• Co-produced leaflet to offer advice and guidance to

CYP who are waiting for appointments and to

support signposting and early intervention

• System working in Alliance, shared governance and

vision

• Mental Health Support Teams (MHSTs) – Whole

School Approach

• Skills mapping across the system to identify

available resource and enable planning to meet gaps

Voice of children, young people and families

Key Challenges

• Waits were too long

• Difficult to navigate the system for help

• CFYP want to be involved in development of services

• Bounced around the system, particularly those with complex presentations / NDD

• Telling their story multiple times

• No information whilst they were waiting

• Wanted support from wider system not just health

• Lack of parent / carer support

• Not understanding system investment

Plan of Action

• £700K Waiting List Initiative. Demands have increased but waits are reducing.

• Developing Single Point of Access for all emotional wellbeing and mental health support. Piloting improved electronic referral forms.

• Developing integrated working through Alliance and ensuring all services are inclusive, with age flexibility to meet the needs of the CYP.

• Developing plans to ensure all key providers are on the same Electronic Patient Record (EPR).

• Developed information leaflet for early support and self-help.

• £273K recurrent funding to deliver participation and social recovery model.

• Parent Carer support for CYP with eating disorders via BEAT.

• Developed stakeholder group to ensure that the wider workforce and CFYP are involved and informed of key changes.

Focusing on early help by:

• Enhancing our universal emotional resilience and wellbeing offer via “Just One Norfolk”

• Launched several media campaigns directly to reach out to children and Young People the campaign e.g. “#We’ve got this” - aims to promote

emotional wellbeing and resilience in children and young people (46k impressions)

• Provided webinars for parents on emotional resilience

• Increased support for the number of families choosing to electively home educate their children to assure ourselves in relation to safety, wellbeing

and ongoing access to appropriate learning

• Next phase of transformation focused on making step change in the early help system across education, social care and mental health

Providing greater support for children and young people in our specialist services:

• As part of the wider system community of practice, we have developed a significant clinical offer within Children’s Social Care, including a

clinical and therapeutic model within our Corporate Parenting Service and psychology and Speech and Language Therapy to work with young

people and their families as part of our New Roads Service.

• Within our Enhanced Fostering Service, clinical support is offered to the team around the child, particularly the foster carers

• Exploring joint workforce development between social care and MH practitioners to promote greater understanding, skill sharing and enable

more effective working

Children’s Services response –supporting families

Engaging proactively and early with children and young people by:

Using our wide range of young people’s participation groups to maintain contact with young people through virtual

meetings and activities, with some face to face ‘welfare walks’ with individuals when needed.

Undertaking regular online consultation sessions with young people on communication strategy and campaigns

Youth workers maintaining contact young people via telephone and social media platforms such as WhatsApp and text

messaging and email, engaged them in an anti-bullying conference and offered online Yoga and mindfulness sessions,

Commissioned services offering significant support for young carers offering mentoring, support activities for young

carers both 1:1 and groups, including virtual support via weekly Zoom sessions, one to one support via phone/video calls,

activity packs/wellbeing activities and activities on social media, as well as practical support.

Developing community and partner resources linking to with range of support i.e. wellbeing, financial assistance, COVID

advice, activity ideas etc.

Providing Family Learning Packs and 3000 Summer Fun activity packs for ages 6-11 which were developed and shared

with targeted schools/families.

Children’s Services response –supporting families

• As part of DfE wellbeing project offered a comprehensive package of support to ensure schools have all they need to

promote emotional health and wellbeing.

• Schools in Norfolk have been able to access live training events as well as a whole suite of support materials,

including toolkits, curriculum resources, audit tools and even ‘plug and play’ internal CPD sessions all authored for the project

to meet the needs of Norfolk schools.

• Significant response from Norfolk schools. So far, over 1,100 attendees have taken part in the project’s programme of

events, over 70 ‘toolkits’ have been downloaded and 140 schools registered interested in ongoing programmes of support.

The project is currently working with 61 primary, secondary, AP and special schools through two more intensive school support

programmes.

• Wellbeing webinars delivered to all schools with accompanying toolkits – these include a focus on the vulnerable groups

that are at additional risk.

• Promoting use of trusted emotional resilience and wellbeing apps.

• Key focus as part of school RHSE programme during summer term focused on wellbeing.

Children’s Services response –supporting schools

Children receiving in-patient care at tier 4

• Pilot project has been completed focused on two areas

• Improving joined up planning during hospitalisation in good time for discharge, and

• Improving work to avoid the need for admissions

• Close work between CCG and SCC to ensure active progress on the current group of children, strengthening the existing partnership

• Improving the understanding of health and social care’s respective responsibilities

• draft policy / protocol prepared and ready for authorisation.

Suffolk Model

What more should we see in Norfolk and Suffolk by 2024?

739 more women accessing community perinatal services

each year

• 2 new doctors,

• 6 psychologists,

• 3 nurses,

• 5 peer support workers

• Specialist maternity outreach clinics

1489 more children and 680 more young people receiving treatment in our NHS services

• 46 new nurses,

• 28 psychologists and therapists,

• 8 doctors,

• 6 social workers

• 28 new support workers

13,442 adults with SMI supported to access integrated

models of primary and community mental health care

• 56 new nurses,

• 29 psychologists and psychotherapists,

• 16 doctors,

• 101 peer support workers,

• 10 community pharmacists

New focus on some of the most disadvantaged people with SMI

• 13,000 people with SMI each year supported to have physical health checks in primary care

• 2000 people supported to access employment through IPS services

• Improved community support for adults with an eating disorder

• Specialist services for people with a diagnosis of ‘personality disorder’

• New services for specialist rehabilitation for people with SMI