1. Mental Health Crisis Care for Children and Young People: Why is it different? What is the current experience? Dr Liz Fellow-Smith Crisis care lead C&A Faculty RCPsych

2. Aims Consider issues specific to CYP in crisis Summarise C&A Faculty (RCPsych) survey of members Outline Faculty health based place of safety position statement

3. Why is it different? Some challenges are different Some aspects are the same

4. Similarities Parity of access to appropriate 24 hour services Access to mental health advice \ single point of access Focus on resolving the reasons for crises Quality standards

5. Why is it different? Many crises are not mental health driven Prevalence of serious mental health disorder increases in mid-later adolescence Safeguarding and social care issues need to be considered Different legal frameworks PoS for assessment needed – different to a HBPoS

6. Why is it different? Pathways into and beyond crisis assessment are different Different model of MH care: no crisis teams, court diversion, liaison services, local beds, out-of-hours provision etc Demand is less – varies with age Stand alone or integrated services? Integrate with AMH or CSC?

7. Why is it different? Require developmentally appropriate assessments  environment – bespoke \ A&E \ AMH wards?  Staff with expertise in CYP  Age + developmental need – eg intellectual disability, autism

8. Crisis care concordat Crises in police cells CAMHs transformation plans ‘Future in Mind’ Psychiatric liaison Urgent emergency care Adult mental health Transition Social care Education Tier 4 review Paediatrics A&E Court diversion

9. Day time access to urgent care Out of Hours access to urgent care Access to crisis \ outreach services Assessment of S136 Faculty Survey: CAMHs Psychiatrists experience & current provision of crisis care March 2015

10. Responses = 202 No. analysed = 180

11. Areas covered by responses

12. 16-18 year olds Most have some provision in CAMHs\crisis services – interface with adult services important Some have no provision - relies on goodwill Many – default is A&E due to limited capacity <16 years Range... Duty clinician No provision – all to A&E Access dependent on capacity Access to urgent care: day time arrangements

13. Inconsistent access & crisis\outreach models CAMHs 24 hours5 areas CAMHS\AMH 24 hours4 areas CAMHs evenings8 areas CAMHs\AMH evenings2 areas CAMHs 9-5pm 1 area >16 only 3 areas No provision many Access to urgent care: access to crisis \ outreach teams

14. Arrangements within acute trusts vary ‘we have seven local acute hospitals in our Trust area all with different policies’ A&E emphasis on discharge not ‘safe pathway’ Access to medical and paeds beds varies MH liaison \crisis teams in some A&Es - adult or CAMHs Arrangements vary with time of day – often not 24 hour. Access to urgent care: A&E and self harm presentations

15. OoH CAMHs provision

16. CAMHs cover\advice for a wide area – not direct service: - 2 or 3 tiers of medical cover - MDT 1 st on-call (W Yorkshire) - Outreach RMN 1 st on-call - clinical manager & CAMHs cons (Swindon) CAMHs Consultant only: - face:face\tel only All specialty consultant on-call No cover Access to urgent care: OoH provision

17. S136 detained & assessed in -S136 suites on adult wards (majority) -A&E -Police cells -S136 suites adolescent unit Some areas no provision -No clarity – ad hoc – takes hours to sort Access to urgent care: S136 \ custody response

18. Increasing numbers presenting via S136 - why?? Delays - Fri–Mon no SW assessment - in PoS -Limited Tier 4 beds -no social placements available -S136 distant from home – impact on discharge possibilities Access to urgent care: S136 \ custody response

19. OUTCOME16-18 yrs11-15 yrs<11 yrs no significant MH disorder - discharged - requiring social care placement or urgent social care intervention 121 27%63 32.5%8 32% no significant MH disorder - admitted informally to a MH inpatient unit as no alternative placement 25 5.5%15 8%3 12% MH disorder - discharged for CAMHs followup 145 32.5%60 31%6 24% significant MH disorder - admitted informally to a MH inpatient unit 62 14%23 12%6 24% significant MH disorder - admitted under Mental Health Act to an inpatient unit 94 21%32 16.5%2 8% TOTAL ASSESSED44719325 Access to urgent care: S136 assessments undertaken past 2 years

20. HUGE VARIATION No uniform standards or commissioning for -<16s, 16-18 urgent care provision -Access to crisis care or outreach services -Day time urgent access -Out of hours urgent access -Self harm assessment service Evident problems along whole pathway Sig probs with social care access & placements Some well functioning \ developing models Access to urgent care: Conclusions

21. Defining a health based place of safety (S136) & crisis assessment sites: Faculty Position Statement Confusion ‘crisis’ = ‘mental health’ S136 = all crisis presentations Place of Safety = place for all assessments Crisis outreach teams exist

22. Thank you elizabeth.fellow-smith@wlmht.nhs.uk

23. 23 What is different about crisis care for children and young people that makes it more challenging to deliver? Claire Bethel -Deputy Director Children and Young People’s Mental Health and Wellbeing Team

24. 24 The vision for change The Government’s aspirations are that by 2020 we would want to see: Improved access for parents to evidence-based programmes of intervention and support Improved crisis care: right place, right time, close to home Professionals who work with children and young people trained in child development and mental health Timely access to clinically effective support A better offer for the most vulnerable children and young people A smooth and planned transition from children’s to adult mental health services More evidence- based, outcomes focused treatments More visible and accessible support Improved transparency and accountability across whole system Improved public awareness less fear, stigma and discrimination Information and self-help available via online tools and apps

25. 25 Future in mind Co-chaired by Department of Health and NHS England, working closely with Department of Education Formal consultation with 1600 young people and 770 health professionals Key themes : –Promoting resilience, prevention and early intervention –Improving access to effective support – a system without tiers –Care for the most vulnerable –Accountability and transparency –Developing the workforce £1.4 bn pledged over the next 5 years, including £150m for community services for eating disorders

26. 26 Delivering transformation: an integrated approach Emphasis on building resilience, promoting good mental health and wellbeing, prevention and early intervention. Cross-sector collaboration – NHS, public health, Local Authority, education, voluntary sector and youth justice. Improve transparency and accountability across the whole system – being clear about how resources are being used in each area and providing evidence to support collaborative decision making. A clear joined-up approach to support all, including the most vulnerable. Sustain a culture of continuous evidence-based service improvement delivered by a workforce with the right skills, competencies and experience. Leads to: a step change in how care is provided, moving away from services defined around systems to one defined around need.