Evaluation of referral trends for the LTHT Multi ... · The BPS argue that good psychological services can be beneficial at every stage of the physical health care pathway. Psychological

Evaluation of referral trends for the

LTHT Multi-Specialism Paediatric

Psychology Service

Catherine Wintermeyer

Commissioned by Dr Sara Matley and Dr Amy Naylor

Prepared on the Leeds D.Clin.Psy. Programme, 2019 2

1. Introduction ................................................................................................................... 3

1.1. Background ............................................................................................................ 3 1.2. CYP & Physical Health Problems ........................................................................ 3 1.3. Clinical Health Psychology & Paediatric Psychology Services.......................... 3

1.4. LTHT Paediatric Psychology Service .................................................................. 5 1.5. Leeds Multi-Specialism Paediatric Psychology Service ..................................... 5 1.6. Referrals to the LMPS ........................................................................................... 6 1.7. Rationale for Service Evaluation Project ............................................................ 7 1.8. Research Aims ........................................................................................................ 7

2. Method ........................................................................................................................... 8 2.1. Design ...................................................................................................................... 8 2.2. Data Cleaning ......................................................................................................... 8 2.3. Data Analysis .......................................................................................................... 9 2.4 Ethical Considerations ........................................................................................... 9

3. Results ............................................................................................................................ 9

3.1 Sample ...................................................................................................................... 9 3.2 Descriptive & frequency data .............................................................................. 10

3.2.1. Referral reason & whether this was accepted/rejected. ............................ 10 3.2.2. Referral department. .................................................................................... 12 3.2.3. Age of CYP referred. .................................................................................... 13

3.2.4. Reasons why referrals were rejected. .......................................................... 14 3.2.5. Time of year CYP referred. ......................................................................... 15

4. Discussion..................................................................................................................... 17 4.1 Key Findings .......................................................................................................... 17

4.1.1. Were there are any patterns in presenting concern in referral reasons? 17

4.1.2. Were there any patterns around referrals from different departments? 19 4.1.3. Were there any patterns in the ages of referrals? ...................................... 19

4.1.4. Were there any patterns in why referrals are rejected? ........................... 20 4.1.5. Time of year of referral. ............................................................................... 21

4.2. Key Recommendations ........................................................................................ 21 4.3. Strengths & Limitations ...................................................................................... 24

4.4 Conclusion ............................................................................................................. 25 4.5. Dissemination of results ....................................................................................... 25

References ........................................................................................................................ 26 Appendix .......................................................................................................................... 28


1. Introduction

1.1. Background

Leeds Teaching Hospital Trusts is one of the largest NHS Trusts in England, and

offers general and specialist hospital services (LTHT, 2019). Within LTHT, there is a

specialised Children’s Hospital. Leeds Children’s Hospital is one of the biggest UK’s

children’s hospitals providing support for a comprehensive range of specialist paediatric

services for children and young people (CYP) of Leeds and across the Yorkshire and

Humber region. The speciality departments include: ‘children's medicine and surgery,

gastroenterology, cystic fibrosis, respiratory medicine, hepatobiliary services, renal

medicine, neurosciences, paediatric critical care, neonatal services, oncology and

haematology, endocrinology, rheumatology, cardiac services, allergy, immunology and

infectious diseases and diabetes’ (LTHT, 2019).

1.2. CYP & Physical Health Problems

Between 10 and 30% of CYP are affected by acute or chronic physical illness or

physical health problems (BPS, 2019). Whilst many CYP and families cope well with

acute or chronic physical illness, for some CYP their health condition can affect their

emotional and social development and impact on their schooling and family life (BPS,

2019). CYP are more likely to successfully manage their health condition if their

healthcare addresses both their physical and psychological well-being (Jacobs, Titman, &

Edwards, 2012). CYP with physical health conditions are also more likely to experience

significant low mood, anxiety and psychological distress compared to their peers without

health conditions (BPS, 2019).

1.3. Clinical Health Psychology & Paediatric Psychology Services

There is an emerging evidence base for the clinical effectiveness of psychological

intervention in health care settings for a number of medical conditions and illnesses

(Jacobs et al., 2012). Government guidelines also recognise the importance of providing


psychological support for CYP with physical health problems (BPS, 2019). The BPS

argue that good psychological services can be beneficial at every stage of the physical

health care pathway. Psychological input can be helpful at the diagnosis stage to make

sense of the condition and planning of care and can also be helpful in making sense of,

coping with and adhering to treatment plans (BPS, 2019; NES, 2019). Psychological

support can also be helpful for CYP, families and staff during hospital stays as

understandably this can be a highly distressing and anxiety provoking time.

Paediatric Clinical Psychology is an ‘established but expanding’ area for CYP

with physical health needs (BPS, 2019). Psychology services are increasingly considered

to be an integral and routine part of CYP’s medical care, rather than just part of crisis

management (BPS, 2019). Research suggests that psychological support can have a direct

positive impact on health outcomes, improving use of health care as well as increasing

treatment adherence and reducing psychological distress (BPS, 2019; NES, 2019).

The most prevalent model of a Paediatric Psychology Service is that they are

located within a specialist Children’s Hospital, with psychology input being part of care

pathways for specific multi-disciplinary health speciality teams, with some services also

providing generic cover across paediatric specialities (Young et al., 2008). Within

specialist hospitals, there are often differences in service provision for different physical

health conditions (both medical and psychological provision), challenging nationwide

and local NHS aims to provide equitable services (BPS, 2019; LTHT, 2019). NHS

England has moved to a model of devolving budgets to local Trusts, who then make

decisions on local service priorities, meaning that psychological input can often be

vulnerable to priorities of current leadership teams and commissioning, funding and

service pressures (Young et al., 2008). Some areas have guidelines and specifications to

provide psychological input such as Paediatric Oncology (NICE, 2014), Diabetes (NHS

England, 2013) and Cystic Fibrosis (Cystic Fibrosis Trust, 2011) which has therefore

increased psychological provision in these areas (Young et al., 2019). However, there are

other physical health conditions which have very limited or no psychological provision.


1.4. LTHT Paediatric Psychology Service

Currently within LTHT, there are paediatric services that commission specific

psychology input for the following departments: Cardiology, Cleft Lip & Palate, Cystic

Fibrosis, Diabetes, Oncology, Neuropsychology, Pain, staff support for Neonates PICU,

Renal and Rheumatology departments. However, there are departments that do not

commission any psychological input into their teams.

The Leeds Paediatric Psychology Service provides for this commissioned

psychological input. The team is made up of Clinical Psychologists, Neuropsychologists,

Counsellors, and Assistant Psychologists. Trainee Clinical Psychologists from local

Doctorate of Clinical Psychology programmes and students on a placement year from the

University of Leeds also work with the team. The Leeds Paediatric Psychology service

provides support for CYP around their health condition, including managing diagnoses,

treatment and procedures and coping with their health condition (LTHT, 2019).

1.5. Leeds Multi-Specialism Paediatric Psychology Service

The Leeds Multi-Specialism Paediatric Psychology Service (LMPS) sits within

the wider Leeds Paediatric Psychology Service. The LMPS provides inpatient and

outpatient psychological input to any paediatric service within LTHT that does not have

commissioned input from a specific clinical psychologist. Therefore, referrals come from

consultants across different clinical areas which results in a large range of patients being

seen from across the Children’s Hospital.

The LMPS has been running in LTHT since 2003. The service was historically

structured so that once a referral had been received from a consultant, CYP were placed

on a waiting list and would be picked up for assessment and intervention by trainee

clinical psychologists on placement within the wider team and also newly qualified or

new members of staff also picking up a limited number of cases from the LMPS waiting

list. As the service was based on an unpredictable level of resource (depending on how

many, if any, trainees were on placement) the waiting times for CYP to be seen were

long, at one point waiting times were in excess of 12 months. A successful business case

https://www.leedsth.nhs.uk/a-z-of-services/paediatric-psychology/paediatric-neuropsychology/


to tackle these long waits was successful in creating a post for a designated Clinical

Psychologist for the LMPS and this role was taken up in December 2017 by a full time

Clinical Psychologist. Some CYP are still seen by a Trainee Clinical Psychologist.

1.6. Referrals to the LMPS

Referrals to the LMPS are accepted via letter or email from the referring

Paediatric Consultant and are discussed and allocated at a weekly referrals meeting.

Appropriate referrals are placed on the LMPS waiting list. If a referral does not meet

LMPS criteria or does not contain enough information in order to determine eligibility,

then the referral is rejected and sent back to the referrer. The aim is to offer patients first

appointments within 18 weeks of referral.

The ‘Inclusion criteria’ for the service details that the CYP must be:

under the age of 16 years old

receiving active treatment from a Paediatric Consultant at LTHT, for an acute or

chronic health condition

be presenting with emotional, well-being and adjustment difficulties around their

health condition or struggling to manage medical treatment effectively. (i.e.

emotional and behavioural problems not relating to a medical condition, and not

affecting treatment, should be referred by the medical team to locality services such

as CAMHS.)

The ‘Exclusion criteria’ for LMPS details that the referral will be rejected for the

CYP if they:

do not have a physical health condition. A clear medical diagnosis of difficulties is

required to access the psychology service.

are not under a LTHT consultant, or receiving active care from a LTHT consultant.


do not medically need to be under LTHT review (e.g. consultant is keeping them

open to purely access psychology service)

have psychological difficulties not relating to medical condition/ treatment (e.g.

family separation, custody disputes, bereavement work, sleep difficulties, tantrums)

have psychological difficulties in the context of significant sexual or physical abuse

have Medically Unexplained Symptoms (MSU) referrals where medical

investigations are on-going and physical causes have not been ruled out. A clear

medical diagnosis of difficulties is required to access the psychology service.

have Chronic Fatigue Syndrome. Regionally commissioned MDT support for CFT

is based at Sheffield Children’s hospital.

have mental health difficulties such as self-harm or suicidal thinking at a level

which needs to be managed by CAMHS with access to psychiatry

have a condition where specific services have been commissioned regionally and

therefore are centres of expertise held outside LTHT. (e.g. Obesity - Watch it

programme)

1.7. Rationale for Service Evaluation Project

This service evaluation project (SEP) has been commissioned by the LMPS. The

LMPS are interested in exploring some of the patterns of referral trends to the service in

order to tailor the interventions provided as demand for the service has been increasing.

Referral information for the last 20 months has been routinely gathered on an electronic

database. This SEP will examine this referral database.

1.8. Research Aims

Using this data, the SEP will aim to explore whether there are any patterns in referrals

including around exploring whether there are any:

patterns in presenting concern in referral reasons?

- e.g. could identifying any patterns provide a rationale for specific

interventions, e.g. a therapeutic group?

patterns around referrals from different departments?


- e.g. do certain departments refer more patients? Can this inform the support

we offer to particular departments?

patterns in the ages of referrals?

- e.g. are children of certain ages more frequently referred? Do these patterns

coincide with any transitional phases for young people i.e. school transitions?

patterns in why referrals are rejected?

2. Method

2.1. Design

Referral information for the past 20 months has been routinely inputted by the

LMPS team into a customised Microsoft Excel 2010 spreadsheet database. Referral

information that has been inputted by the team includes: date referral was received,

referral information (e.g. which consultant and department the referral was from and

reason for referral), name of CYP, NHS number and date of birth, outcome of referral

(accepted or rejected) and if rejected, the reason why the referral was rejected. It was

agreed that this time frame and the amount of data collected was suitable to gain an

understanding of referrals and patterns for this SEP. A quantitative methodology was

chosen to answer the research questions and aims because of the amount of data collected

and because the aims of the LMPS were to explore this data, it was felt descriptive and

frequency statistics would be helpful to satisfy these aims.

In order to examine the customised Microsoft Excel 2010 referrals database and

any potential patterns in referrals:

2.2. Data Cleaning

Firstly, the database was cleaned and data were coded for the analysis stage. The

age of participants at their referral date was calculated from their date of birth. Referral


dates were also coded by month of referral. The reasons for referral were condensed for

analysis as were departments referring and reasons for not being accepted. This

condensing down was done with the commissioners of the SEP. Referral and rejection

reasons were coded by an overarching area of referral or rejection reason and some

departments were condensed into similar areas of speciality. Please see Appendix 1 for

the original referral reasons, referring departments and rejection reasons before

condensing.

2.3. Data Analysis

The referrals database was then analysed using Pivot tables in Microsoft Excel

2010 to gain descriptive and frequency statistics.

2.4 Ethical Considerations

Ethical approval was sought for this SEP and granted from the University of

Leeds SEP Ethics Committee on the 22nd November 2018. See Appendix 2 for a copy of

this approval email. Identifying details such as name and NHS number were deleted from

a copy of the database made for this SEP analysis before the researcher accessed this

database.

3. Results

3.1 Sample

In total, there were 225 referrals made to the LMPS between the 1st April 2016

and the 14th November 2018. 136 of the referrals were accepted, 89 referrals were not

accepted – therefore, 39.6% of referrals were rejected.

Information about the referrals that had been inputted into the dataset was almost

fully complete – there were only seven referral reasons that were listed as ‘unknown’.


These referrals were still included and were coded as ‘no needs identified’ in the

condensed referral reasons.

3.2 Descriptive & frequency data

The following sections summarise the descriptive and frequency statistics from the

collected data:

3.2.1. Referral reason & whether this was accepted/rejected.

Figure 1. Overview of referral reasons and which reasons were accepted and rejected by

the LMPS.

Overall, the top five referral reasons were ‘impact of and/or coping with health

conditions’, ‘mental health’, ‘procedural distress’, ‘pain and headaches’ and ‘behavioural


difficulties’. See Figure 1 for an overview of referral reasons and why reasons were

accepted and rejected by the LMPS.

The referral reason of ‘impact of and/or coping with health condition’ was

referred 96 times, constituting 42.2% of the overall referral reasons. When broken down

into accepted and rejected referrals, of those referrals accepted, ‘impact of and/or coping

with health condition’ reasons made up 50% of referrals and made up 30.3% of those

referrals reasons that were rejected. After ‘impact of and/or coping with health

conditions’, ‘mental health’ and ‘procedural distress’ were referred 23 times each (10.2%

of overall referral reasons). ‘Mental health’ reasons made up 5.9% of accepted referrals

and 16.9% of rejected referrals. ‘Procedural distress’ reasons made up 14.7% of the

accepted referrals and 3.4% of rejected referrals. ‘Pain and headaches’ were referred 16

times (7.1% of referrals) and were accepted 6 times (4.4%) and rejected 10 times

(11.2%). ‘Behavioural difficulties’ were referred 13 times and were accepted 6 times

(4.4%) and rejected 7 times (7.9%).

See Table 1 for numbers of referral reasons, referral departments and age of CYP

broken down by overall referral number, those accepted and rejected and corresponding

percentages.


3.2.2. Referral department.

Figure 2. Overview of specialist paediatric departments referring to the LMPS.

The four highest referrers were neurology (53, 23.5% of referrals), dermatology

(33, 14.7% of referrals), endocrinology (25, 11.1% of referrals) and general paediatrics

(22, 9.8% of referrals). See Figure 2 for an overview of specialist paediatric departments

referring to the LMPS.



percentages.


3.2.3. Age of CYP referred.

Figure 3. Overview of ages of CYP referred to the LMPS .

For ages of CYP referred, 12 year olds were the most referred (28 times, 12.4%)

with 8, 11 and 15 year olds being referred 22 times each (9.8%). There were 11 people

that were referred that were over 16 (4.9%) and, therefore, unable to access the service.

Excluding the clients that were over 16 when they were referred, the range of ages was

from 0-15 and the mean age referred was 9 years old. See Figure 3 for an overview of

ages of CYP referred to the LMPS.



percentages.


3.2.4. Reasons why referrals were rejected.

Figure 4. Overview of why referrals were rejected by the LMPS.

Of the 89 rejected referrals, the top three reasons most reported for why referrals

were rejected were ‘difficulties not related to health condition’ 38 times (42.7% of

rejected rationales), CYP ‘over 16’ 12 times (13.5%) and ‘signpost to other LTHT

psychology speciality’ 11 times (12.4%). See Figure 4 for an overview of why referrals

were rejected by the LMPS.


3.2.5. Time of year CYP referred.

Figure 5. Overview of time of year CYP were referred.

The month that received the highest number of referrals was March 2018 with 23

of the overall referrals. The lowest number of referrals in one complete month of referrals

was 4 referrals in September 2017. The average number of referrals per month was 11.25.

See Figure 5 for an overview of time of year CYP were referred.

Table 1. Numbers of referral reasons, referral departments and age of CYP broken down

by overall referral number, those accepted and rejected and corresponding percentages.

Referral reasons (RR)

Number of

overall RR

% of

overall

RR

Number

of

accepted

RR

% of

accepted RR

Number

of

rejected

RR

% of

rejected

RR

Allergies & food aversion 4 1.8 2 1.5 2 2.2

Bed wetting/soiling 3 1.3 2 1.5 1 1.1

Behavioural difficulties 13 5.8 6 4.4 7 7.9


Bullying 6 2.7 4 2.9 2 2.2

Compliance 9 4.0 7 5.1 2 2.2

Concerns around

fabricated illness 1 0.4 - - 1 1.1

Impact of health condition

on mood & coping with

condition 95 42.2 68 50.0 27 30.3

Mental health 23 10.2 8 5.9 15 16.9

Neuro assessment 2 0.9 - - 2 2.2

No needs identified 10 4.4 1 0.7 9 10.1

Pain and headaches 16 7.1 6 4.4 10 11.2

Parental adjustment 8 3.6 7 5.1 1 1.1

Procedural distress 23 10.2 20 14.7 3 3.4

RTA 2 0.9 2 1.5 - -

Sleep 2 0.9 - - 2 2.2

Surgery build up 4 1.8 2 1.5 2 2.2

Tics and Tourette’s 4 1.8 1 0.7 3 3.4

Total 225 - 136 - 89 -

Referring departments

Number of

overall

referrals

% of

overall

referrals

Number

of

accepted

referrals

% of

accepted

referrals

Number

of

rejected

referrals

% of

rejected

referrals

A&E 3 1.3 - - 3 3.4

Allergies 16 7.1 12 8.8 4 4.5

Cardiology 2 0.9 - - 2 2.2

Community Paediatrics 2 0.9 - - 2 2.2

Dermatology 33 14.7 25 18.4 8 9.0

Endocrinology 25 11.1 15 11.0 10 11.2

ENT 2 0.9 - - 2 2.2

Gastroenterology 16 7.1 7 5.1 9 10.1

General Paediatrics 22 9.8 15 11.0 7 7.9

Gynaecology 1 0.4 1 0.7 - -

Liver 1 0.4 1 0.7 - -

Neurology 53 23.6 33 24.3 20 22.5

Neurophysiology 1 0.4 - - 1 1.1

None 1 0.4 - - 1 1.1

Ophthalmology 5 2.2 3 2.2 2 2.2

Oral Maxillofacial surgery 1 0.4 1 0.7 - -

Orthodontics 2 0.9 - - 2 2.2

Orthopaedics 1 0.4 - - 1 1.1

Paediatric Medicine 2 0.9 - - 2 2.2

Paediatric Surgery 12 5.3 8 5.9 4 4.5

Pain 3 1.3 2 1.5 1 1.1

Plastic Surgery 2 0.9 1 0.7 1 1.1

Radiology 1 0.4 - - 1 1.1

Renal 5 2.2 2 1.5 3 3.4

Respiratory 2 0.9 1 0.7 1 1.1

Rheumatology 3 1.3 1 0.7 2 2.2

Urology 8 3.6 8 5.9 - -

Total 225 - 136 - 89 -


Age of CYP referred

Number of

overall ages of

CYP referred

(ACR)

% of

overall

ACR

Number

of

accepted

ACR

% of

accepted

ACR

Number

of

rejected

ACR

% of

rejected

ACR

0Years Old 1 0.4 1 0.7 - -

1Years Old 3 1.3 2 1.5 1 1.1

2Years Old 8 3.6 5 3.7 3 3.4

3Years Old 6 2.7 3 2.2 3 3.4

4Years Old 5 2.2 2 1.5 3 3.4

5Years Old 8 3.6 5 3.7 3 3.4

6Years Old 8 3.6 6 4.4 2 2.2

7Years Old 17 7.6 11 8.1 6 6.7

8Years Old 22 9.8 15 11.0 7 7.9

9Years Old 11 4.9 8 5.9 3 3.4

10Years Old 14 6.2 7 5.1 7 7.9

11Years Old 22 9.8 11 8.1 11 12.4

12Years Old 28 12.4 20 14.7 8 9.0

13Years Old 18 8.0 12 8.8 6 6.7

14Years Old 21 9.3 16 11.8 5 5.6

15Years Old 22 9.8 12 8.8 10 11.2

16Years Old + 11 4.9 - - 11 12.4

Total 225 - 136 - 89 -

4. Discussion

4.1 Key Findings

This SEP was conducted to gain a greater understanding about the referrals to the

LMPS and to explore potential patterns in referrals. In total, there were 225 referrals

made to the LMPS over a 20 month period, between the 1st April 2016 and the 14th

November 2018. 136 of the referrals were accepted, 89 referrals were not accepted

meaning that a large proportion of referrals were rejected (39.6%). The highest referral

reason was for ‘impact of and/or coping with health condition’ and the ‘Neurology’

department referred the most CYP into the LMPS.

When considering the aims of this project (as specified in Section 2 of this

report), the following findings are of importance:

4.1.1. Were there are any patterns in presenting concern in referral reasons?

The results show that the top five referral reasons were ‘impact of and/or coping

with health conditions’, ‘mental health’, ‘procedural distress’, ‘pain and headaches’ and


‘behavioural difficulties’. It is promising that the top referral reason was ‘impact of

and/or coping with health conditions’ as this referral reason constitutes the majority of

the inclusion criteria for the LMPS.

It is interesting, however, that ‘mental health’ was the second highest referral

reason as ‘mental health difficulties’ not related to or not in the context of the physical

health condition is explicitly stated as an exclusion criterion. ‘Behavioural difficulties’

are also not something that LMPS accept referrals for if these are not related to the health

condition. This could warrant some future work with different clinical areas to think

about how general ‘mental health’ or ‘behavioural’ difficulties can be supported on wards

as the provision the CYP would be usually be referred to for support around these

difficulties is CAMHS, but CAMHS currently have very high referral thresholds (Young

Minds, 2018). Increased understanding of the role and remit of paediatric psychology

and how this differs from the support available in CAMHS would be useful. It could be

helpful to consider how to increase awareness in the referring departments of the referral

criteria and also other services that can support CYP to try and reduce the amount of

inappropriate referrals to the LMPS.

The results indicate that there are common issues for the CYP referred across

health specialities such as low self-esteem and anxiety in the context of the health

condition. This could mean that interventions across health specialities for these common

referred issues could be beneficial for CYP and these could be delivered through

therapeutic groups for CYP. Plante, Lobato and Engel (2001) argue that there are well-

established group interventions for a variety of paediatric populations but that more

research is needed to evaluate the efficacy of most group interventions for CYP with

physical health conditions.

Although the LMPS is experiencing an increased demand for their service, it

could be helpful to increase the profile of the LMPS within eligible departments so that

appropriate cases can be referred in for support. Teaching and training could also be

delivered to upskill ward staff and teams’ confidence in helping families manage these

difficulties as well as signpost to appropriate community services, such as ICAN nurses

and health visitors.


It is also interesting that the findings show that for the majority of the condensed

referral reasons, referrals were both accepted and rejected. It may be useful for the LMPS

to think about how they use their referral inclusion/exclusion criteria, and how they could

refine this referral criterion or develop ways that the criteria are used to ensure more

consistent use by the service.

4.1.2. Were there any patterns around referrals from different departments?

For departments that referred into the LMPS, the highest referrer was the

Neurology department, contributing almost a quarter of all referrals. As reported in the

results, of these referrals from Neurology 60% were accepted which constitutes a sizeable

amount of the LMPS caseload at 24.3%. Dermatology, Endocrinology and General

Paediatrics were the next largest referring departments to the LMPS. There were some

departments that referred into the LMPS that have their own commissioned psychological

support (Gastroenterology, Liver, Renal and Rheumatology). These referrals may have

come into the LMPS due to sickness or maternity leave of the named Clinical

Psychologist, however, it may also be that some Paediatric consultants were not aware of

the correct referral pathways for psychological support within their department. Again,

some of these inappropriate referrals were accepted and some were rejected. It would be

interesting to further investigate this qualitatively with LMPS staff as to why they did end

up accepting some of these referrals. As this would have to be done retrospectively, it

may be helpful to have a section on the database where any decisions that are made

despite the inclusion/exclusion criteria can be documented for future analysis.

4.1.3. Were there any patterns in the ages of referrals?

12 year olds were the biggest age group that were referred into the LMPS. After 12 year

olds, 8, 11 and 15 year olds were the next largest numbers to be referred. Aside from

managing their physical health condition, in thinking about the wider context that CYP

exist within, it was discussed with the commissioners that for 12 year olds this age is

when CYP generally have transitioned into secondary school. This may have contributed


to the referral and to CYP struggling to cope with their health condition for reasons

including the potential different expectations secondary schools have of CYP compared

to primary school, differences in the level of support available as well as other CYP being

more aware of differences as they move into larger year groups and peers they have not

grown up with. A report written for the Department of Health around school transitions

discussed how difficult school transitions can be for CYP and their parents/carers

detailing how they can negatively affect CYP’s emotional, social and academic outcomes

(Roberts, 2015). Roberts (2015) describes how CYP from disadvantaged backgrounds

such as those with special educational needs, looked after children or those with English

as an additional language are most at risk of experiencing poor school transitions,

however, CYP with physical health issues are not considered as a specific group in this

report. It would be useful to be able to explore further qualitatively with CYP, families

and medical staff as to whether periods of transition or other age/stage of life related

factors contributed to the CYP being referred for psychological support within LTHT.

There were 11 people that were referred that were over 16 and, therefore, unable

to access the service. Future work around increasing knowledge around referral criteria

could help to curtail these inappropriate referrals and ensure patients are referred to the

correct support in the first instance.

4.1.4. Were there any patterns in why referrals are rejected?

The top three reasons why referrals to the LMPS were rejected were that the

‘difficulty was not relating to health condition’, the CYP was ‘over 16’ and that there was

already a ‘commissioned psychological support for that department’. This also seems to

highlight again that the referral criteria do not always seem to be well understood (or held

in mind) by some paediatric consultants as these reasons are all explicitly listed exclusion

criteria.


4.1.5. Time of year of referral.

There was an average of 11.3 referrals per month, with the highest referrals in one

month being 23 and the lowest in a month being 4 referrals. As the database only spans

one and a half years, there was not enough data to see whether there were any patterns or

differences in the time of year that CYP were being referred. However, it was discussed

with commissioners that this would be interesting to consider in future analysis of the

LMPS database as the commissioners felt as if referrals did peak at certain times of the

year so this could help tailor future support, and times of year this support is offered.

4.2. Key Recommendations

After consideration of the results of this SEP, the following recommendations are

suggested:

1. Consider running groups for CYP across health conditions and departments

providing support for common issues such as low self-esteem, anxiety and low

mood connected to and/or coping with health conditions and dealing with

difference (i.e. how to answer difficult questions from people etc.).

- It may be interesting to further examine the age of CYP referred after more

data has been collected to see whether there are still any patterns for CYP

being referred in around times of transitions, for example, going to secondary

school. A qualitative SEP exploring this with CYP, families and staff could

help to examine this further.

2. Consider refining referral criteria and how this is used in referral meetings (as

currently some referral reasons are both accepted and rejected) to ensure

consistency in accepting and rejecting referrals.

- It would be helpful to develop and publish clearer guidelines around why

referrals are accepted or rejected (regardless of whether referral criteria are

refined).


- It would also be useful to also record on the database if there any times a

referral that does not fit the inclusion criteria is accepted and reasons for this.

- It could also be helpful for the LMPS to have a referral form with the referral

reason categories listed with a box to tick (instead of a free text box) to

remind referrers of the accepted referral reasons and help keep consistency in

the inputting of these referral reasons on the database.

3. Consider ways to increase knowledge in departments about the LMPS and the

referral criteria.

- Numerous reasons for rejected referrals were seemingly around departments

not knowing referral criteria (i.e. referring for issues not related to the health

problem and the CYP being too old for the service) so improving the

awareness of referral criteria for departments could help lower the number of

inappropriate referrals and improve the efficiency of referral pathways

(benefiting the CYP, the referring department and the LMPS).

- It might be helpful for the LMPS to spend some time with high referral

departments to gauge their understanding of the LMPS, referral criteria and

also the psychological support (including assessment and intervention) that

the LMPS can provide. This could be done, for example, through attending

some ward huddles and team meetings and providing advice on whether a

referral is appropriate, explaining the psychological theory and explanation

behind the acceptance/rejection or whether there is a different service better

placed to support the CYP and/or their family.

- This could include normalising distress within these health settings and

upskilling medical staff to feel more confident to manage, for example,

difficult situations with CYP on wards.

4. Consider developing and making available effective psychological resources (i.e.

psychoeducation leaflets and other resources) for both CYP and parents/family

members and departments around common issues CYP with a physical health


condition face, as well as some specific leaflets for common issues within a health

speciality.

- Consider what teaching and training could be delivered to staff and staff

teams, (i.e. psychoeducation around common issues families face and coping

strategies for these) to upskill ward staff and improve their knowledge and

confidence in supporting families.

- It would also be helpful to develop the Leeds Paediatric Psychology Service

section on the LTHT website as another resource for CYP, families and

professionals to use– which could also have downloadable copies of any

available leaflets etc.

- Leaflets/information about other services that are available to support CYP

and their families could also be included on here so that everybody has access

to this signposting information.

5. Consider whether there are any business cases for certain departments for funding

for commissioned psychological input. For example, there were many referrals

from the ‘Neurology’ speciality areas and a specific commissioned psychology

role for this department or others such as ‘Dermatology’ or ‘Endocrinology’ could

be useful for CYP, families and staff.

6. Ensure that all referrals continue to be recorded on the database. This is so that

referral data can continue to be analysed in future and if any changes are

implemented, that the utility of these changes can be examined.

- As discussed, there was not enough data to look at differences in times of year

that CYP are being referred but this could be something a future audit could

examine.

- It could also be important to think about what other information could be

recorded on the database (any information that might be useful to record that

is also easily acquired information for clinicians) such as gender and ethnicity

to gain this information to analyse. This could further help develop suitable

interventions for the service.


- Consider admin input into the department – support in maintaining the

database and communicating outcomes of referrals could be useful as

currently costly clinical time is being used to carry out these tasks.

4.3. Strengths & Limitations

A key strength of this SEP is that it is the first analysis of referrals and the referral

database for the LMPS. The results highlight some ways that the service and referral

criteria can be improved to help meet increasing demand. The referral database itself was

almost fully completed, with all of the necessary information recorded (expect for seven

unknown referrals reasons) which is a strength when undertaking analysis of the LMPS

database. Another strength of this SEP is in terms of the applications of this SEP. There

has been a 10 month closure of the LMPS due to the staff member leaving LTHT and

issues with recruiting to fill the vacancy. There are new Clinical Psychologists starting at

the LMPS as this SEP report has been finalised meaning that the results and

recommendations can be used to help further develop and shape the LMPS with these

new members of staff.

However, there are also limitations of this SEP. As the database has only been

kept electronically for 18 months, this meant that not enough data had been collected to

run any inferential statistics on whether there were any significant differences with

variables such as time of the year affecting referral rates. This was something that was

discussed at the conception of the planning of the project but was unable to be carried out

due to the limited time period that has been captured on the database.

A limitation of the data collected, which has already been discussed, is that there

was an inconsistency in the accepting and rejecting of similar referral reasons. This

highlights the need for refining the inclusion criteria and that the decision rationale is

recorded on the database for referrals that are accepted that do not meet inclusion criteria

so that the LMPS and referring departments can be very clear about referral criteria for

the LMPS.

Another limitation of this SEP was in the condensing of things such as the referral

reasons and referring departments. Although this decision was made so that an overview


and summary of information (such as similar referral reasons and departments in similar

areas referring in) could be made sense of and some conclusions around meaningful

patterns could be drawn, it also meant that some of the intricacies of the data such as

idiosyncratic referring reasons were lost. The condensing down of these lists was also

done by the researcher and commissioners (trainee/clinical psychologists) so there might

have been some bias in judging which referral reasons were similar or which departments

were similar that might have been condensed differently by medical professionals.

4.4 Conclusion

Overall, this SEP has provided a useful insight for the LMPS into their referral

database and some patterns within the referral data which should help to develop the

LMPS further. Recommendations have been suggested which the LMPS can consider

implementing to further develop the service to help make the LMPS more streamlined,

efficient and effective for CYP, their families and referring departments to ensure CYP

access the appropriate service to meet their needs and that they receive timely and

effective care.

4.5. Dissemination of results

This SEP was presented at a University of Leeds poster conference to the Leeds

Clinical Psychology Doctorate Course trainees, course team and some local clinical

psychologists who commissioned SEPs undertaken by the current cohort of trainees. The

commissioners and LMPS will receive a written copy of this report. The results of this

SEP will also be presented at the monthly LTHT Paediatric Psychology Team meeting in

due course.


References

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Retrieved from: https://www.bps.org.uk/member-microsites/dcp-faculty-children-

young-people-families

Cystic Fibrosis Trust (2011). Standards for the Clinical Care of Children and Adults with

Cystic Fibrosis in the UK. London: Cystic Fibrosis Trust.

Jacobs, K., Titman, P. & Edwards, M. (2012). Bridging Psychological and Physical

Health Care. The Psychologist, 25 (3), 190-193.

Leeds Teaching Hospitals Trust (2019). Retrieved from: https://www.leedsth.nhs.uk/a-z-

of-services/paediatric-psychology/

NHS Education for Scotland NES (2019). Paediatric Psychology - Psychosocial

Interventions. Retrieved from: https://www.nes.scot.nhs.uk/education-and-

training/by-discipline/psychology/multiprofessional-psychology/paediatric-

psychology-psychosocial-interventions.aspx

NHS England (2013). Best Practice for Commissioning Diabetes Services: An Integrated

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west-1.amazonaws.com/diabetes-storage/migration/pdf/best-practice-

commissioning-diabetes-services-integrated-care-framework-0313.pdf

National Institute for Health and Care Excellence (2014). Cancer Services for Children

and Young People. London: National Institute for Health and Care Excellence.

Plante, W. A., Lobato, D., & Engel, R. (2001). Review of group interventions for

pediatric chronic conditions. Journal of pediatric psychology, 26(7), 435-453.

Roberts, J. (2015). Improving school transitions for health equity. Report to the UK

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Young, J., O'Curry, S., Mastroyannopoulou, K., Deiros Collado, M., Gibbins, J., Donnan,

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https://www.bps.org.uk/member-microsites/dcp-faculty-children-young-people-families

https://www.bps.org.uk/member-microsites/dcp-faculty-children-young-people-families

https://www.leedsth.nhs.uk/a-z-of-services/paediatric-psychology/

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Psychology, 6(4), 331.

Young Minds (2018). #FightingFor Report. Retrieved from:

https://youngminds.org.uk/media/2258/youngminds-fightingfor-report.pdf


Appendix

Appendices 1

List of original and condensed referral reasons.

Referral Reasons Coded referral problem Superseding referral problem

"Emotional lability" following

symptoms of epilepsy.

Impact of health condition on

mood


mood & coping with condition

Adjusting to health condition-

turner syndrome.

Adjustment to condition/new

diagnosis



Adjustment to diagnosis

(epilepsy)/coping with diagnosis-

low mood.


diagnosis



Adjustment to diagnosis- anxiety. Adjustment to condition/new

diagnosis



Adjustment to diagnosis. Adjustment to condition/new

diagnosis



Adjustment to diagnosis. Adjustment to condition/new

diagnosis



Adjustment to diagnosis. Anxiety. Adjustment to condition/new

diagnosis



Adjustment to/coping with health

condition.


diagnosis



Allergies and food aversion Allergies & food aversion Allergies & food aversion

Anger due to health condition. Coping with condition Impact of health condition on


Anger related to health condition. Impact of health condition on

mood



Anxiety Mental health - anxiety Mental health

Anxiety about being different. Impact of health condition on

mood



Anxiety about home

circumstances.


mood



Anxiety after trauma Impact of health condition on

mood



Anxiety and IBS Impact of health condition on

mood



Anxiety and migraines Impact of health condition on

mood



Anxiety around health. Impact of health condition on

mood



Anxiety at school Mental health - anxiety Mental health

Anxiety due to accident Impact of health condition on

mood



Anxiety due to condition-

allergies.


mood



Anxiety due to eczema Impact of health condition on

mood



Anxiety due to epilepsy Impact of health condition on

mood



Anxiety due to health condition Impact of health condition on

mood



Anxiety due to health condition

(allergies).


mood




Anxiety due to health condition

(brain injury)


mood



Anxiety due to health condition-

alopecia


mood



Anxiety due to health condition. Impact of health condition on

mood



Anxiety following brain injury Impact of health condition on

mood



Anxiety related to symptoms of

illness


mood



Aversion to food Allergies & food aversion Allergies & food aversion

Bed wetting Bed wetting/soiling Bed wetting/soiling

Behaviour issues/parenting Behavioural difficulties &

parenting issues

Behavioural difficulties

Behaviour/parenting issues. Behavioural difficulties &

parenting issues


Behaviour/parenting. Behavioural difficulties &

parenting issues


Behavioural and social issues Behavioural difficulties Behavioural difficulties

Behavioural difficulties Behavioural difficulties Behavioural difficulties

Behavioural issues/parenting. Behavioural difficulties &

parenting issues


Behavioural problems Behavioural difficulties Behavioural difficulties

Behavioural regression after

meningitis

Behavioural difficulties Behavioural difficulties

Bullying at school Bullying Bullying

Chronic fatigue from Chron's Chronic fatigue Impact of health condition on


Chronic fatigue syndrome. Chronic fatigue Impact of health condition on


Coming to terms with diagnosis. Adjustment to condition/new

diagnosis



Concerns RE fabricated illness. Concerns around fabricated

illness

Concerns around fabricated

illness

Concerns RE long term impact of

health condition.

Coping with condition Impact of health condition on


Coping with condition- low

mood.



Coping with eczema Coping with condition Impact of health condition on


Coping with eczema- itching. Coping with condition Impact of health condition on


Coping with headaches Headaches Pain and headaches

Coping with health condition

(eczema)



Coping with health condition. Coping with condition Impact of health condition on


Coping with IBS IBS Impact of health condition on


Coping with illness Coping with condition Impact of health condition on


Death/health related anxiety Impact of health condition on

mood



Dermatitis artefacta (self-harm Mental health - self-harm Mental health


disguised as health condition).

Difficult to manage behaviour Behavioural difficulties Behavioural difficulties

Difficulties with sleep (not related

to health condition).

Sleep Sleep

Difficulty coping with eczema-

itching and sleep.



Difficulty eating Allergies & food aversion Allergies & food aversion

Distress over medical condition Coping with condition Impact of health condition on


Eating disorder Mental health Mental health

Eczema Coping with condition Impact of health condition on


Family adjusting to health

condition and treatment.

Parental adjustment Parental adjustment

Functional abdominal pain Functional pain/MUS Pain and headaches

Gender identity GID Surgery build up

General issues with mental health

(not health related).

Mental health Mental health

General issues with mental

health/self-harm (not health

related).

Mental health/self-harm Mental health

Headaches Headaches Pain and headaches

Headaches and vomiting Headaches Pain and headaches

Health problems Coping with condition Impact of health condition on


IBS IBS Impact of health condition on


IBS and anxiety Impact of health condition on

mood



Issues with eating Allergies & food aversion Allergies & food aversion

Lack of self-compliance Compliance Compliance

Low Mood Mental health - low mood Mental health

Low mood and anxiety due to

health condition


mood



Low mood due to brain injury Impact of health condition on

mood



Low mood due to epilepsy Impact of health condition on

mood



Low mood due to health

condition.


mood



Low mood- not related to health

condition

Mental health - low mood Mental health

Low mood. Mental health - low mood Mental health

Low mood/anxiety due to health

condition


mood



Low self-esteem Low self-esteem Impact of health condition on


Managing emotions Impact of health condition on

mood



Managing headaches Headaches Pain and headaches

Managing migraine Headaches Pain and headaches

Managing tics. Tics Tics and Tourette’s

Medically unexplained Functional pain/MUS Pain and headaches


symptoms- nausea.

Medically unexplained

symptoms- stammer.

Functional pain/MUS Pain and headaches

Medication compliance and low

mood.

Compliance & low mood Compliance

Medication compliance. Compliance Compliance

Needs motivation to use a

standing frame

Compliance Compliance

Negative self-image Low self-esteem Impact of health condition on


Neurological decline Neuro assessment Neuro assessment

No psychological needs identified

in referral.

No needs identified No needs identified

Non-compliance with treatment Compliance Compliance

Non epileptic seizures (MUS). Functional pain/MUS Pain and headaches

OCD Mental health/self-harm Mental health

Pain Pain Pain and headaches

Pain management. Pain Pain and headaches

Parasomnia Sleep Sleep

Parent struggling to adjust to

health condition.


Parental anxiety due to health

diagnosis (epilepsy)


Parents struggling to adjust to

DSD


Poor compliance with medication. Compliance Compliance

Procedural distress Procedural distress Procedural distress

Procedural distress and anxiety Procedural distress Procedural distress

Psoriasis triggered by stress Coping with condition Impact of health condition on


Psychological impact of health

condition



Psychological input before

surgery

Surgery build up Surgery build up

Query regarding gender identity. GID Surgery build up

Referral for routine input (not

clear in referral).

No needs identified No needs identified

Refusing medical intervention Compliance Compliance

Review of cognitive ability Neuro assessment Neuro assessment

Sadness due to health condition. Coping with condition Impact of health condition on


Self-esteem and confidence

linked to eczema

Low self-esteem Impact of health condition on


Self-esteem, body image and

responding to curiosity.

Low self-esteem Impact of health condition on


Self-harm Mental health - self-harm Mental health

Skin picking Mental health - self-harm Mental health

Social anxiety Mental health - anxiety Mental health

Social support for mum (not

related to health condition)

Parental needs not related to

health condition

No needs identified

Soiling Bed wetting/soiling Bed wetting/soiling

Stress Stress Impact of health condition on



Stress and hair loss Stress & hair loss Impact of health condition on


Struggling to accept condition. Adjustment to condition/new

diagnosis



Struggling with diagnosis Adjustment to condition/new

diagnosis



Struggling with medical

compliance


Support for parental anxiety due

to health condition


Support with weight management Weight Impact of health condition on


Tourette symptoms Tourette’s Tics and Tourette’s

Trauma following RTA RTA RTA

Trauma from accident RTA RTA

Treatment compliance (cream for

eczema)


Trichotillomania Mental health - self-harm Mental health

Turners Syndrome Adjustment to condition/new

diagnosis



Turners Syndrome Adjustment to condition/new

diagnosis



Unclear/letter sent in error. Unknown No needs identified

Unknown Unknown No needs identified

Weight management Weight Impact of health condition on


List of original and condensed referring department.

Original department Condensed list of departments

A&E A&E

Allergies Allergies

Brain Injury trust Neurology

Cardiology Cardiology

Community Paeds Community Paeds

Craniofacial Plastic Surgery

Dermatology Dermatology

Endocrinology Endocrinology

ENT ENT

Epilepsy Neurology

Gastro Gastroenterology

General medicine General Paeds

General or surgical? Paediatric Surgery

General Paeds General Paeds

General Paeds (epilepsy) General Paeds

General surgery Paediatric Surgery

Gynaecology Gynaecology

Hepatology Liver

ICAN nurses Community Paeds

Immunology Allergies


Immunology + Allergy Allergies

Immunology Allergies

Long term ventilation Respiratory

Nephrology Renal

Neurology Neurology

Neurophysiology Neurophysiology

Neurosurgery Neurology

None None

Ophthalmology Ophthalmology

Oral Maxillofacial surgery Oral Maxillofacial surgery

Orthodontics Orthodontics

Orthopaedics Orthodontics

Orthopaedics/pain Orthopaedics

Paediatric Medicine Paediatric Medicine

Paediatric Surgery Paediatric Surgery

Pain Pain

Pain Management Pain

Radiology Radiology

Renal Renal

Respiratory Respiratory

Rheumatology Rheumatology

Urology Urology

Vascular Surgery Paediatric Surgery

List of original and condensed rejected referral reasons.

Original rejection reason. Condensed referral reason.

16 years old. Over 16

16 years old. Forwarded to adults. Over 16

Accessing community support. Accessing support elsewhere

Adult- forwarded to Fielding House. Over 16

Adults. Over 16

Already seen by Amy, refer to CAHMS Signpost to CAMHS

Cardiology patient Signpost to other LTHT psychology speciality

CFS service signposting Signposted to community support

Dc from the hospital. Not under LTHT consultant

Difficulties not related to a health condition Difficulties not related to health condition

Discharged by medical team Not under LTHT consultant

DSD and no clear impact of condition on mood. No current needs identified/routine

DSD pathway. Accessing support elsewhere

Family want local help Family declined support

Forwarded to renal team. Signpost to other LTHT psychology speciality

Forwarded to trauma and orthopaedics. Signpost to other LTHT psychology speciality

GP referral, not under care of LTHT consultant. Not under LTHT consultant


Need to see renal team Signpost to other LTHT psychology speciality

Needs met by CAMHS Signpost to CAMHS

No current concerns, only anticipatory. No current needs identified/routine

No health condition (tics) Difficulties not related to health condition

No health condition (tummy pain) Difficulties not related to health condition

No medical condition identified Difficulties not related to health condition

No medical condition identified. Amy-

Forwarded to orthopaedics team/

Difficulties not related to health condition

No medical condition identified/ Amy-

Forwarded to gastro team.


No psychological difficulties that hinder

treatment


No psychological difficulties that hinder

treatment/problems not related to diagnosis


No referral information. Unknown

No underlying health condition. Difficulties not related to health condition

Not accepted Difficulties not related to health condition

Not due to health condition Difficulties not related to health condition

Not receiving active treatment, no clear needs

identified.

Not under LTHT consultant

Not related to health condition. Difficulties not related to health condition

Not related to health. Difficulties not related to health condition

Not seen due to history of non-engagement Not seen due to history of non-engagement

Not under active care of LTHT Not under LTHT consultant

Not under active care of LTHT consultant. Not under LTHT consultant

Other suitable services who could meet needs. Signposted to community support

Over 16 Over 16

Problems not related to diagnosis. Difficulties not related to health condition

Product of behavioural issues and mum not

accessed community support.


Sees Kate Hall. Over 16

Signpost to adult multispec. Signpost to other LTHT psychology speciality

Signpost to CAMHS. Signpost to CAMHS

Signpost to trauma/orthopaedics. Signpost to other LTHT psychology speciality

Signposted to watch it Signposted to community support

Signposted to watch it. Amy- Signposted to

community LD

Signposted to community support

Too old. Over 16

Under care of another psychology service Under care of another psychology service

Under care of another psychology service.

Amy- Forwarded to renal team.

Under care of another psychology service

Under care of another psychology service/Amy-

Forwarded to rheumatology team.

Under care of another psychology service

Under craniofacial/Maggie Bellew Signpost to other LTHT psychology speciality

Under gastro Signpost to other LTHT psychology speciality


Under Kate Hall Over 16

Under ortho team. Signpost to other LTHT psychology speciality

Weight management. Watch It recommended. Signposted to community support


No current needs identified/routine

Signpost to CAMHS

Appendices 2

Confirmation email for ethics.

Documents

Evaluation of referral trends for the LTHT Multi ... · The BPS argue that good psychological services can be beneficial at every stage of the physical health care pathway. Psychological