1. High Intensity User Project
CDOP Conference – April 2019
Andy Fitton – Service Transformation &
Redesign Manager
Berkshire West CCG

2. High Intensity User Project
Audit
Profile
Factors
Insights
Live Cases
3 cases learning
What/ Why/ Who
Recommendations

3. High Intensity User Project
Age range is 15 plus
Mainly White British
Mainly Female
Disability a factor (above average) but no clear trend

4. High Intensity User Project
Significant number (87%) history with CSC
low conversion rate into S17 assessment and S47 investigations
Small number LAC and even smaller adopted.
Low conversion into CiN and even lower into Child Protection

5. High Intensity User Project
Missing
Going missing from home a significant factor
67%
Toxic Trio
But less of a factor for Domestic Abuse &
Substance misuse
? MH of adult
Sexual Abuse
1/3rd cases had sexual abuse as a factor

6. High Intensity User Project
Health
Significant number (73%) history with CAMHs
Significant number (80%) were admitted onto a ward.
Large number of CYP admission to a Tier 4 unit/ hospital
Significant number of A&E visits for 15 cases (113)

7. High Intensity User Project
Learning from our Audits
differing views between agencies about the level of risk often leads to increased escalating behaviour, repeat presentations at A&E and professional frustrations preventing decision making and actions.
When a CYP has a range of needs across domains, but has differing levels of risk and need attached to those domains that professionals use linear/ single agency thresholds for, it was seen that significant issues can be missed.
Multi-plier effect of differing risks and needs on each other is not evident and leads to missed identification of risks and opportunities to coordinate and intervene.
Managing and understanding Risk

8. High Intensity User Project
discharge planning (from RBFT or a tier 4 unit) is a significant opportunity to complete the necessary multi-agency risk assessment and planning.
There is a lack of clarity around protocol of who to include and invite and where the leadership of this process is, especially if this is an open case to CSC or should be open to CSC.
This results in an uncoordinated approach to a key transition and poor outcomes e.g. returning to A&E.
Discharge planning

9. High Intensity User Project
the ability for services (particular health) to increase the intensity of an offer when issues escalate. This does not mean an intensity of therapy but could result in an intensity of support in a therapeutic approach or relationship for the CYP/ Parent and Carer/ family unit.
opportunity for joint commissioning of bespoke services that are short term measures to prevent escalation into Tier 4/ becoming a child in care/ returning to A&E
joint risk assessment of whole CYP and family functioning at point of escalation of need at the hospital. The Rapid Response team providing the mental health formulation is helpful but there is the need to include a clear assessment of family and wider community functioning for the CYP that means discharge with confidence about risk is in place.
Gaps in offer

10. High Intensity User Project
noted concern that when a child is 17 year olds there is emerging evidence that agencies are often ‘hanging on’ for them to become an adult. This has resulted in poor decision making and a change in approach by professionals to the CYP case management and options of interventions.
the experience of the CYP when 16 plus in the RBFT is that they are treated as an adult. This affects the location of delivery (adult A&E/ adult ward stays) and therefore the exposure of this Young People other vulnerable adults.
Age of child

11. High Intensity User Project
Out of Area LAC - early notification and joint planning with placement (usually a care home) about meeting a CYP needs and response at A&E helps.
Early intervention and prevention is lacking in the majority of these cases (only evidence of 2 cases with this)
Response pattern to referrals is concerning with only 28% of CSC referral leading to a specific action.
Information sharing, as expected, when done well benefits the CYP but often is an issue (evidenced well in at least 2 of the cases audited)
MISC

12. High Intensity User Project
Live Case learning: 1
Importance of case management & system leadership skills to be able to bring practitioners together and create action plan - Speed is a success factor 2
The need for clear templates to create:
Multi-agency meeting discussions and notes
Identification of risk and putting a level of concern
Action planning
There are options e.g. CPA paperwork, but maybe need to put our own together. These need to be in an accessible place for people to be able to use, quickly and easily.

13. High Intensity User Project3
Discharge is not being caught early enough, and requires attention and management 4
There are often other processes going on for these children e.g. SEND, Social Care, that can cause confusion. Need a solution that can be rapid, and quick to the episode that can complement other maybe more ongoing processes 5
There is ongoing tension around the role and involvement of Children’s Services for these CYP. Issues of threshold and access to social work perspective on the ability of the family to cope/ manage the child’s need.

14. High Intensity User Project6
Information sharing continues to be vital – this is aided by participation and involvement in meetings, having secure ways of sharing information on line.
Could be aided by having digital solutions to communication made easier, access to Skype, face time or telephone/ conference call facilities 7
Organisation of communication, especially meetings is time-consuming and difficult. Need to find ways to create options and methods to administrate case management easier, including using digital solutions. 8
Importance of thinking about the parent/ carer dynamic and involving all parties (fathers) as well as extended family
Importance of considering the impact of the sisters/ brothers in the family.

15. High Intensity User Project
Recommendations
CCG with 3 Local Authority Children’s Services to jointly commission a Health/ Social Care/ Early Help rapid response service based at the hospital.
CCG with 3 Local Authorities to set up a joint commissioning process that enables the purchasing of short term bespoke services to prevent escalation into Tier 4/ becoming a child in care/ returning to A&E.
Health providers with support from partners to write a single discharge planning guidance and a standard operating procedure
BHFT to organise a regular review of all tier 4 patients with partners to ensure discharge planning is coordinated
Health and Local Authorities to co-author a shared risk assessment tool for CYP in crises that cover all domains of risk. 1 2 3 4 5

16. High Intensity User Project
Some Thank You’ s
Any Questions or comments