Child and Adolescent Mental Health Services

22 September 2022

jerseyauditoffice.je  R.151/2022

Contents

Summary  3

Introduction  3

Key Findings  4

Conclusions  6 Objectives and scope of the review 7 Detailed findings  9

Design of CAMHS  9

Pattern of CAMHS delivery  17

Overall governance arrangements 21

Performance and risk management 32

How CAMHS performs  36

Referrals management 41 Appendix One – Audit Approach  49 Appendix Two – Summary of Recommendations 52

Summary

Introduction

1. Improving mental health and wellbeing is a major public health challenge. In part, this is because the underlying issues tend to be complex, and people's needs can be different. Evidence suggests that mental health problems in childhood and adolescence have a significant impact on physical health, education and on the ability to find and sustain employment.
2. The Government of Jersey has stated in the Government Plan 2022-2025 that the physical, emotional, and mental health of the Island's children and young people remain of the highest priority.'
3. Child and Adolescent Mental Health Services (CAMHS) comprises specialist mental health services for children and young people (up to the age of 18) and their families. CAMHS provides a range of services including assessment, diagnosis and treatment for children and young people experiencing:

• emotional difficulties

• behavioural difficulties

• relationship difficulties; and

• developmental difficulties.

4. CAMHS also provides specialist community-based services for those experiencing specific mental health issues such as psychosis and eating disorders. Services include individual therapy, family therapy, parent counselling and group therapy (where children, young people or carers with similar difficulties are seen together in groups).
5. The number of referrals to CAMHS has risen over recent years as shown in Exhibit 1. There continues to be a high level of demand for CAMHS.

Exhibit 1: Number of accepted CAMHS referrals

800 700 600 500 400 300

200 100 0

2017 2018 2019 2020 2021 Source: Government of Jersey

6. The Government Plan 2022-2025 includes planned investment of over £8 million for the implementation of a new model of care for children and young people's emotional wellbeing and mental health. As part of this new model of care, CAMHS is being redesigned.
7. My review has considered all aspects of CAMHS provision including services delivered by partners both on and off-Island. It has focussed on the responsibilities of the Children's Health and Wellbeing Service within the Integrated Services and Commissioning function of the Children, Young People, Education and Skills Department (CYPES). It has not considered the work of other CYPES functional areas such as children's social work or child and family support.

Key Findings

8. The key findings from my review are as follows:

• the Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025 (the Strategy) was launched in February 2022 by CYPES. The Strategy sets out a clear picture of what needs to be achieved and what good' looks like. It includes prioritised action and how improvements can be monitored and measured. The approach to developing the Strategy has been comprehensive, thorough and well governed

• there are early signs that new ways of managing referrals and the evolving service structure for CAMHS are having a positive impact on waiting times

• most community CAMHS is provided by the Government. Commissioning of community services from other on-Island providers is relatively under - developed but opportunities for partnership working are increasingly being identified

• for those small numbers of children and young people who require inpatient mental health care, Jersey does not have a dedicated facility. There are two developments intended to relieve this sub-optimal arrangement – Clinique Pinel and the Our Hospital Project. The timescales for these developments are not clear although I have been informed that the current forecast for the opening of Clinique Pinel is the end of 2022

• in circumstances where facilities on-Island are not adequate to meet the child or young person's need, services are commissioned from the UK. I identified some weaknesses with these commissioning arrangements

• governance arrangements for CAMHS have not been robust and have not operated effectively. Since June 2019, the Health and Community Services Department (HCS) and CYPES have had joint responsibility for delivering CAMHS. However there has not been a robust, agreed Memorandum of Understanding (MoU) in place to govern this relationship and to assure the safe and high-quality delivery of services. Whereas draft versions of the MoU have been considered and agreed in principle', there is no one version that all signatories to the MoU have approved. In addition, the Terms of Reference (ToRs) for the required Governance and Oversight Group have never been finalised and the Group has not fulfilled its overarching role of securing and assuring clinical and professional standards

• new governance arrangements are being established in 2022 - however the ToRs for key groups and boards within the new structure are yet to be finalised

• there has been no overarching and co-ordinated approach to consideration of CAMHS performance and risk data. There has been a disconnect in the management of clinical' (which is viewed as HCS's responsibility) and operational' (CYPES) performance and risk information. Alignment of data and information, to enable joint clinical and operational oversight of the quality of services, has been lacking

• for both CYPES and HCS, the range and quality of service data relating to CAMHS is recognised as in need of improvement. The data requirements of the Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025 are, I understand, now identified and being built into data sets for both CAMHS and for Public Health. The Children's Health and Wellbeing Operational Policy dated March 2022 sets out an aspirational

Minimum Data Set (MDS) for CAMHS. The MDS is dependent on systems changes currently being implemented

• compared to UK benchmarks, in 2019/20 the CAMHS caseload was twice as high as the UK average. The benchmark data indicated that Jersey CAMHS keeps children and young people on caseloads for longer than elsewhere. However, until recently, Jersey has included children and young people with Attention Deficit Hyperactivity Disorder (ADHD) in its CAMHS caseload information (unlike the UK). The most recent benchmarking data is not yet published but should be more comparable

• the Children's Health and Wellbeing Transformation Programme has assessed the staffing need for CAMHS. There is a current vacancy level of more than 21% of Full Time Equivalent (FTE) establishment staff against the planned establishment for CAMHS as set out in the Strategy

• the guidance on how to manage situations where children and young people did not attend' (DNA) their CAMHS appointment is not consistent with best practice and is not sufficient to ensure children and young people are safe and that they receive appropriate services and care; and

• performance data for the first quarter of 2022 shows the re-referral rate within CAMHS at 25%. At face value this means that a quarter of the children and young people who leave CAMHS were re-referred - however there are some known data quality issues with this reported rate. Data for June 2022 indicates a rate of 16%. The Children's Health and Wellbeing Service is more confident in the recent data, but the reasons underlying re-referrals are still being assessed.

Conclusions

9. The Government has committed to investment in the Children's Health and Wellbeing Transformation Programme, including CAMHS, through the Government Plan 2022-2025. This investment is supported by a robust Strategy launched in February 2022.
10. Governance, data collection, risk and performance management for CAMHS have been weak. For the Strategy to lead to a step change in service quality and range of provision it will need to be supported by stronger and more effective governance and other arrangements and more specific and detailed implementation plans.

Objectives and scope of the review

11. The review has evaluated:

• overall governance arrangements for CAMHS, including consideration of:

o how recommendations made in the C&AG Report Governance Arrangements for Health and Social Care – Follow up (2021) that are relevant to CAMHS are being monitored and implemented

o whether responsibilities and accountabilities are clearly set out and agreed, including in transition services between CAMHS and Adult Mental Health Services (AMHS)

o how the oversight of performance information drives improvement; and

o how performance improvement is being overseen

• service design including consideration of:

o the range of services offered

o how the range of services has been designed to meet known and anticipated need

o the design of transition services between CAMHS and AMHS

o how learning from previous reviews has helped to shape the range of services offered; and

o the engagement of multi-agency partners in the design of services

• referrals management including consideration of:

o who can make referrals

o how pathways from all referrers are set out and communicated; and

o how criteria for referral acceptance are agreed and implemented

• service delivery: how does the service as delivered:

o compare with the service as designed and with best practice; and

o maximise the use of available resources

• service resourcing: how do resourcing decisions:

• work across States of Jersey departments; and
• ensure a joined-up service for children, young people and their family and carers

• the effectiveness of commissioning and partnership arrangements, including consideration of:

o how decisions are made on which services to commission, which services are provided by Government and which services are provided in partnership with third sector organisations

o how the commissioning of services compares to best practice; and

o how partnership arrangements compare to best practice

• performance management and oversight, including consideration of:

o how the services are monitored and reported

o whether the targets and measures being monitored are designed to ensure better outcomes for children and young people

o the current and planned performance against key indicators

o how performance and targets compare with best practice

o how services are benchmarked; and

o how partnership performance indicators are measured, managed and monitored.

12. The review has considered all aspects of CAMHS provision including services delivered by partners both on and off-Island. It has focussed on the responsibilities of the Children's Health and Wellbeing Service within the Integrated Services and Commissioning function of CYPES. It has not considered the work of other CYPES functional areas such as children's social work or child and family support.

Detailed findings

Design of CAMHS

Drivers for change in CAMHS

13. The design and operation of CAMHS have been the focus of a number of reviews. The service recognises that there is significant public, media and political interest in Children and Young People's mental health issues and CAMHS provision. It acknowledges concerns regarding waiting times for treatment, use of agency staff, lack of consistency in support and service performance.
14. Exhibit 2 sets out key milestones for CAMHS including Scrutiny and other reviews. Exhibit 2: Key CAMHS milestones

Date  Event / milestone

Jan 2022  Service Manager Quality and Assurance appointed. Feb 2022  Service Manager Duty and Assessment appointed.

CAMHS Duty and Assessment moves into the Children and Families Hub.

Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022–2025 launched.

April 2022  Health and Social Security Scrutiny Panel issues follow-up report. Reports

some progress but more to be done.

Source: Jersey Audit Office analysis

Needs Assessment

15. In June 2021 a Joint Needs Assessment (JNA) was undertaken to assess the primary data available and set it out in a way that clearly demonstrated the needs associated with the emotional wellbeing and mental health of children and young people in Jersey'. This identified relevant data, including projected population, population by age band, ethnicity and language, living arrangements and schooling and pupil characteristics - for example those in receipt of the Jersey Premium and those with Special Educational Needs (SEN).

16. It also identified risk factors including:

• economic and socio-economic

• ethnicity and culture

• family status, tenure, income

• children in need of protection

• parental mental health or other long-term illness

• children with disabilities; and

• alcohol consumption and drug use.

17. While the identified risk factors would indicate a comprehensive approach to using available intelligence and risk assessment to predict need, there was little in the JNA to show that data specific to Jersey regarding these wider determinants of mental health were available or had been used to assess future demand for services.

18. Analysis of data on referrals to all mental health services in Jersey in the year to January 2021 demonstrates the increase in referrals to CAMHS compared with other services. In Exhibit 3 the horizontal axis is age of service user and brown line shows total referrals by age in the year to 31 January 2019, for comparison.

Exhibit 3: JNA analysis of total referrals to Jersey Mental Health services

140 120 100

80 60 Num4ber 0of cases

20 0

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97

ADS CAMHS

Community Adult MH Community Older Adult MH JTT Psychology

 JTT is Jersey Talking Therapies and ADS the Alcohol and Drugs Service Source: Jersey's Joint Needs Assessment issued June 2021

19. The JNA also analysed the characteristics of referrals to CAMHS. In the period 2017 to 2020 an increasing proportion of referrals was accepted onto caseloads and a higher percentage were marked as urgent or emergency' (see Exhibit 4).

Exhibit 4: Characteristics of referrals to CAMHS 2017 to 2020

800 100% 700 90%

71 80% 600 90

70% 612

500 155 149 571 60% 400 50%

300 386 430 40%

25% 30% 200

11% 14% 20% Referrals 1to CAM00HS 10%

0 0%

2017 2018 2019 2020 Referral accepted Referrals rejected Referrals marked as urgent / emergency

Source: Jersey's Joint Needs Assessment issued June 2021

Service development

20. In 2020, a business case submitted by CYPES seeking investment from the 2021 - 2024 Government Plan set out:

• an increase in waiting times

• an increase in complexity of referrals

• Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) referrals increasing

• a gap in support for neurodevelopmental disorders and disabilities, perinatal mental health and paediatric health psychology

• relatively high rates of alcohol-specific hospital admissions for under 18s

• the lack of early intervention services, intensive community support, home treatment and psychiatric liaison; and

• known issues in achieving an effective and efficient transition pathway from CAMHS to adult mental health or other services.

21. The Government accepted the need for investment in redesign and capacity but rejected the start date of 2021. There was though a commitment that Government Plan funding would be agreed for 2022-2025.
22. At the end of 2020, CAMHS submitted a business case for funding from the Government's Covid Wellbeing and Recovery Programme. In March 2021 the requested £995,000 was confirmed. This enabled some progress in key areas set out in the original 2020 business case.

23. The Government Plan 2022-2025 includes investment of £6 million over three years from 2022, with £2.25 million recurring from 2025 onwards. In addition, it includes investment in intensive support, out of hours and inpatient provision for CAMHS amounting to £13.4 million over four years 2022-2025.
24. The resulting Children's Health and Wellbeing Transformation Programme encompasses development and stratification of mental health services for children and young people. The intention is to provide a more comprehensive continuum of services.
25. The Programme also encompasses:

• development of neurodevelopmental and perinatal mental health services

• improved transition arrangements as children and young people move into adult mental health or other support services

• medical cover for governance and leadership; and

• improved quality and performance management.

Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025

26. In February 2022 the Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025 (the Strategy) was launched. The Strategy sets out a clear picture of what needs to be achieved and what good' looks like. It includes prioritised action and how improvements can be monitored and measured.
27. I have reviewed the Strategy against elements of good practice in strategy development (see Exhibit 5). The Strategy performs well in all areas.

Exhibit 5: Review of the Strategy against good practice

Critical reflection

• The Strategy starts with a look at gaps and weaknesses in current service provision. New structures and changes to the use of resources align with identified issues.

• Three surveys were used to gather views from children and young persons, from parents and carers and from professionals. More than 450 responses where received and feedback has clearly informed the proposed model of care. However, Jersey's Youth Parliament concluded that more could have been done to ensure all voices were heard.

Clear, balanced objectives

• The Strategy aligns with the Children and Young People's Plan 2019-2023 and its five guiding principles.

• It identifies four priorities and sets out what 'good' looks like.

• The level and use of stakeholder engagement supports a balanced approach based on need and impact.

Medium and longer term

• The Strategy includes fundamental redesign of service delivery with a view to solving immediate issues (in particular long waiting times).

• It also identifies changes to support medium and longer term improvements through, for example, increasing the delivery of services within multi-agency partnerships.

Focussed, actionable content

• The Strategy clearly targets key objectives and draws a coherent picture of what it seeks to achieve. It uses a model developed by the UK NHS's Child and Maternal Health Observatory to describe its approach.

• The Strategy defines specific service developments with overall ambition and specific actions against these. It is clear on how these form a continuum.

Owned

• The focus on wide stakeholder involvement in its development has resulted in broad ownership.

• The Strategy has a summary version which is more child / young person friendly, also provided in Portuguese, Polish and Romanian.

• Development of a Strategic Advisory Panel (SAP), including service users and community providers, to oversee implementation is important to maintaining ownership.

• The launch of the Strategy and of the SAP have been communicated and celebrated.

Deliverable

• The action plan sets out a clear pathway to delivering the objectives.

• A Programme Board is being established to manage progress. It is important that the approach has both strong governance and discipline but also built-in flexibility and opportunities for learning.

• How this aligns with responsibilities of the Governance and Oversight Group is however not clear.

Source: Jersey Audit Office evaluation against identified good practice

28. The approach to developing the Strategy has been comprehensive, thorough and well governed. A particular emphasis for the development has been a clear focus on engagement and co-production. The Youth Parliament was included in this engagement through a workshop and subsequent meeting.

Recommendation R1  Strengthen:

• the use of Jersey specific risk data and wider determinants of health in forecasting demand for children's mental health services (both capacity and services needed); and

• cross-departmental measures of the impact of interventions, including as part of the Jersey Performance Framework.

Pattern of CAMHS delivery

Community CAMHS

29. CYPES's specialist CAMHS provides targeted intervention through a range of evidenced based treatments, including but not limited to:

• brief solution focussed therapy

• Cognitive Behavioural Therapy (CBT)

• Cognitive Analytic Therapy (CAT)

• creative therapies, including art therapy

• Dialectical Behaviour Therapy (DBT)

• Eye Movement Desensitisation and Reprocessing (EMDR)

• evidence based group interventions including working with partner agencies

• Family Therapy

• Interpersonal Therapy (IPT)

• psychiatric intervention

• Psychodynamic psychotherapy

• medication provision and administration using shared care arrangements (where possible) with primary care GPs; and

• advice and skills programmes for parents/carers, schools and professionals.

30. Commissioning of community services from other on-Island providers is relatively under-developed in Jersey but opportunities, including for partnership working, are increasingly being identified and implemented. Currently, the services to support children and young people's mental health commissioned by Children's Health and Wellbeing are:

• Kooth - online counselling and emotional wellbeing support service for young people aged from 11 to 25. By February 2022, 975 young people had used the service and more than 90% would recommend it to a friend

• MIND Jersey - commissioned by CYPES to assess the needs of children and young people who have been referred to CAMHS but whose mental health needs are at a lower level. By October 2021 MIND Jersey had undertaken 17

assessments and of these, five no longer required CAMHS support. In December 2021 the contract with MIND Jersey was extended to the end of 2022. It was also broadened to include assessment of children and young people with ADHD; and

• two services providing assessment for Autism Spectrum Disorder (ASD):

• Island Autism; and
• Options Autism 8.

Inpatient CAMHS delivered by the Government of Jersey

31. For those children and young people who require inpatient mental health care, Jersey does not have a dedicated facility. Whilst the number of service users who require inpatient care is relatively low, it is recognised that current arrangements are not adequate. There are plans for improvements but the timeframe for all developments is not yet confirmed.
32. Those children and young people who have a medical emergency and need inpatient care are admitted to Robin Ward at the hospital. This is the children's ward, providing paediatric and nursing care but not specialist mental health services. There is a policy in draft, Clinical Management of Children and Young People with a Mental Health Disorder in an Acute Hospital setting.  
33. Currently, Orchard House – an Adult Mental Health facility – is the only other on - Island inpatient facility used by CAMHS. Risks for those under the age of 18 who use this facility are assessed on a case-by-case basis to determine the safeguarding and safety mitigations required.
34. There are two developments intended to relieve this sub-optimal arrangement:

• Clinique Pinel, which will be refurbished to replace Orchard House, will have a bed area and day space specifically for anyone under the age of 18 who needs hospital care; and

• the Our Hospital' project currently includes dedicated space for inpatient care for children and young people with mental ill-health.

Commissioned residential CAMHS – on Island placements

35. There are currently no on-Island residential, therapeutic facilities for children and young people with complex issues which include mental ill-health. CYPES has considered provision of a therapeutic children's home but has not yet concluded on the best way forward.

36. In 2021 an on-Island partner developed a specific residential service for children and young people. Hope House offered a 28-day residential treatment programme focussed on resilience and preventative wellbeing initiatives such as structure, exercise and coping skills'. However, Children's Health and Wellbeing has not been able to place any children or young people at Hope House: while it is registered as a children's home, it is not a therapeutic children's home, so does not have the approvals, facilities or staffing to meet the needs of children with the most complex needs.
37. This situation demonstrates the importance of a joined up, consultative and evidence-based approach to service development. New governance structures being established in 2022 are intended to better enable this (see Exhibit 8).

Commissioned inpatient and residential CAMHS – off-Island placements

38. In circumstances where facilities on-Island are not adequate to meet the child or young person's need, services are commissioned from the UK.
39. For all off-Island mental health placements, Independent Placement Panels (IPPs) consider submissions and make decisions. CAMHS off-Island requests are taken to the Children's IPP which sits as and when' a clinician identifies the need for services not available in Jersey.
40. The Procurement Strategy used in decision making for off-Island placements includes a due diligence' process, comprising a list of areas to be considered when choosing a service provider. Officers are aware that more could be done to ensure consistency in the way the listed items – for example the providers' Care Quality Commission (CQC) and Ofsted ratings and service user feedback – are used in decision making.
41. For children and young people, typically numbers identified as requiring off-Island care are low – at the time of my fieldwork for example there was only one placement in the UK. The Interim Director General for CYPES has asked for a review of criteria used by the IPP to ensure these align with best practice.
42. Having recognised the increase in incidence of eating disorders, the IPP is aware that there is low capacity within the UK to meet Jersey's need. The Interim Director General for CYPES has identified that a specific plan is required involving formal arrangement with a dedicated off Island provider. This is being taken forward currently.
43. In 2021 the newly appointed Head of Children's Health and Wellbeing undertook a visit to a young person receiving services off-Island. The outcome is set out in the case study at Exhibit 6.

Exhibit 6: Outcome of a visit to review a CAMHS off-Island placement

In 2021 the Head of Health and Wellbeing undertook a visit to a UK- provider of specialist residential CAMHS.  A core' package of care had been commissioned for this service user.

In discussion, the young person raised the issue that, while the facility offered an education service, the young person did not currently have access to that. There was an additional fee of £175 per day which had not been covered.

Funding was subsequently arranged, but this raises the following questions:

• why didn't the core' package commissioned from this provider include access to education, and why did no one notice this until it was raised by the young person? and

• would this have been spotted by the commissioner or raised by the provider if the visit had not happened?

What is clear is that mechanisms for ensuring high quality placements that meet the holistic needs of children and young people, have been lacking.

Recommendations

R2  Establish service needs and criteria for evaluating opportunities for services to be

commissioned for delivery in partnership with - or exclusively from - community providers.

R3  Ensure improvements to on-Island inpatient care for children and young people

are implemented, including by setting and monitoring Key Performance Indicators (KPIs) to demonstrate improved service user experience.

R4  Ensure that the IPP considers and commissions services to meet all needs of the

service user when deciding on a package of care.

R5  Ensure that the due diligence' items set out in the Procurement Strategy are

supported by high quality information and are used consistently when making decisions about off-Island placements.

Overall governance arrangements

44. Governance arrangements for CAMHS have not been robust and have not to date operated effectively.
45. Since June 2019, HCS and CYPES have had joint responsibility for delivering CAMHS. However there has not been a robust, agreed MoU in place to govern this relationship and to assure the safe and high-quality delivery of services. Whereas draft versions of the MoU have been considered and 'agreed in principle' at various departmental management groups, there is no one version that all signatories to the MoU have approved.

Departmental responsibilities for CAMHS

46. In 2015 my predecessor reported as part of her Review of Community and Social Services:

a lack of appropriate governance for managing business as usual' services. In Children's Services [which included CAMHS] there were no robust arrangements in place to identify and then address declining service standards.

47. Until 2019, both children's and adults' mental health services were managed as part of community-based health services by the Department for Health and Social Services (HSSD).
48. In 2019 the structure of Jersey Government departments changed in line with the OneGov Target Operating Model (TOM). Under the TOM, the management of CAMHS moved to the newly formed CYPES. The stated objectives for this move were:

• to achieve a fully integrated children's system with clear, effective pathways that work for children and their families, which is child focussed, delivered in the right way in the right place and at the right time

• to keep a strong focus on early intervention

• to remain multi-professional and multi-agency, requiring collaborative and partnership working; and

• for specialist clinical teams to work within a framework which includes clinical governance, legal frameworks and NICE (the UK's National Institute for Health and Care Excellence) guidelines.

49. At the time, it was agreed that:

• while CYPES became responsible for day-to-day management of CAMHS, HCS retained:

• general and clinical management of CAMHS doctors and medical staff, as part of its Women, Children and Families Care Group; and
• budget and a level of accountability for inpatient care both in Jersey and for off-Island placements; and

• in moving the service, opportunities would be taken to redesign pathways of care to more effectively meet the range of needs of children and young people being referred to CAMHS.

Governance and Oversight Group

50. In June 2019, a MoU between CYPES and HCS was drafted for the provision of CAMHS. The draft MoU established a joint Governance and Oversight Group to assure implementation of the MoU. Whilst the Governance and Oversight Group was established at this point, the MoU has been redrafted several times and there is no one version that all signatories to the MoU have approved.
51. The role, membership and functions of the Governance and Oversight Group have changed in the various iterations of the draft MoU. In the period to April 2022 there have been four redrafts. However, it is not clear that any version of the Terms of Reference (ToRs) has been signed off and adopted.
52. None of the draft versions of the ToRs for the Governance and Oversight Group specifically set out how the Group would ensure that the stated objectives of the move of CAMHS to CYPES would be met.
53. Reviewing the available Minutes and Agenda papers from the eight meetings of the Group between July 2019 and July 2022, it is evident that it has not fulfilled its overarching role of securing and assuring clinical and professional standards. This is not least because the Group has not met in line with the minimum requirements of the various draft MoUs and draft ToRs (see Exhibit 7).

Exhibit 7: Minimum schedule and actual meetings of the Governance and Oversight Group

Monthly  Intended  Actual  Quarterly  Intended  Actual schedule  meetings  meetings  schedule  meetings  meetings

July 2019 Aug 2019 Sept 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020

Q2 2020 Q3 2020 Q4 2020 Q1 2021 Q2 2021 Q3 2021 Q4 2021 Q1 2022 Q2 2022 Q3 2022

Source: Jersey Audit Office analysis

54. The meetings that have happened have the following characteristics:

• early lack of clarity on leadership. The Minutes of the first meeting of the Governance and Oversight Group show that it was agreed that the two Directors General would be co-Chairs, covering recurring six month periods. However, the Director General for CYPES was not at this meeting. In August 2019 it was agreed off-line' that the Directors General need not attend the Group meetings. As responsibilities and accountabilities had not changed, the basis for this decision is not clear. At the September 2019 meeting a key agenda item - to update on progress in integrating CAMHS into CYPES as part of the TOM - could not be covered as the Director General for CYPES was not present  

• early progress stalled. For example, an item raised at the first meeting – that there was a risk of fragmentation in clinical governance arrangements and that roles and responsibilities needed to be clarified – had an immediate response. A draft CAMHS Integrated Clinical and Professional Governance Framework was considered at the next meeting. However, this was never finalised – gaps in responsibilities set out in the document include staff training, quality improvement and the management and assurance of patient experience

• the meeting agendas were not well aligned to the Group's responsibilities. In January 2020, very significant items were managed under Any Other Business'. These included review and ratification of policies, service performance, CAMHS consultant workforce and leadership, service redesign, off-Island placement process and senior management cover arrangements

• few papers are taken to the Group meetings and updates have been chiefly verbal. For example, at the January 2020 meeting, the agenda items on workforce, KPIs, Health and Safety and Issues for escalation were all verbal; and

• notes of meetings were taken but due to the gap between meetings, it is not straightforward to track the delivery of agreed actions. Some actions were never delivered – key among these is that Directors General for HCS and CYPES (when no longer required to attend the Group) were to receive the meeting Minutes. There is nothing to show this was actioned.

55. In October 2021 the Governance and Oversight Group members attended an away day'. The outcome from the day was a set of joint principles:

• think Child and Family (not department and profession)

• no surprises

• share intelligence / insight

• maintain a joint policy, programme and project pipeline/plan

• presume to collaborate; and

• invest in the relationships (formally [structures] and informally).

56. The Governance and Oversight Group has met once since the away day', in early July 2022. At this meeting the Group concluded that the latest draft MoU and the Group's draft ToRs need further updating. It is not clear whether updates will explicitly take forward the joint principles.

Revisions to governance arrangements in 2022

57. In early 2022 a draft governance structure to support the Children's Health and Wellbeing Transformation Programme was proposed. The proposal as a whole makes clear that the Director General for CYPES and the Director General for HCS remain jointly responsible for the transformation of children, young people and family's community health services.
58. The structure as adopted is set out in Exhibit 8.

Exhibit 8: Governance structure including the Children's Health and Wellbeing Transformation Programme

Children's Strategic  Mental Health System  Health & Community

Partnership Board  Partnership Board  Board (Stakeholder Input) (Stakeholder Input)  (Stakeholder Input)

Corporate Departmental Risk Group

CYPES Senior  HCS Senior Leadership Leadership Team (SLT)  Team (SLT)

Health and Wellbeing

Delivery Forum (Delivery  CHWPB  GOG

of Strategy)

Programme  Operational Management  Steering Group Approach  meeting

Key:  Team delivering the project Oversight and accountability

Stakeholder input

CHWPB - Children's Health and Wellbeing Programme Board GOG - Governance and Oversight Group.

Source: Draft Children's Health and Wellbeing Transformation Programme Approach

59. In addition, a Strategic Advisory Panel (SAP) made up of young people, parents, carers and professionals was launched in May 2022. SAP will advise on the delivery of the Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025.
60. The Mental Health System Partnership Board is a new Board established in 2022 with the purpose of collectively developing an integrated mental health system for Jersey. The membership and Terms of Reference of the Board are yet to be finalised.
61. It is planned that the Board will:

• review progress against the existing Mental Health Improvement Plan; and

• oversee development of integrated mental health services, based on the priorities and objectives for the system partners collectively.

62. The Board will report to the HCS Board and the Public Health Programme Development Group. The draft ToR does not set out how the Board will ensure that the integrated mental health system is linked to the developments within the Jersey Care Model.
63. The CHWPB is a new body. It is planned that theCHWPB will oversee Children's Health and Wellbeing Transformation Programme developments.
64. In April 2022 the CHWPB had its first meeting. It was however poorly attended. Of the 18 people invited, five attended. There were ten apologies but no response from three Board members. A key member of the group – the Programme Manager – has yet to be appointed. A second meeting in June 2022 was better - attended and had a clear agenda.
65. The Terms of Reference for the CHWPB are still draft.

Arrangements for receiving and implementing C&AG recommendations

66. There is no effective process in place to identify and monitor progress against C&AG recommendations relevant to CAMHS.
67. The July 2019 MoU between HCS and CYPES set out that a key assurance focus was to monitor:

progress against C&AG and Scrutiny report recommendations relevant to children's mental health services and facilities.

68. The Governance and Oversight Group meeting in September 2020 included an action to pick up C&AG legacy' recommendations. Despite this, the Group has not considered C&AG or Scrutiny recommendations at any of its meetings.

69. My Report Governance Arrangements for Health and Social Care – Follow up (2021) includes recommendations pertinent to all health and social care services provided by or commissioned by the Government of Jersey. These recommendations have not been formally considered for any CYPES service.
70. An assessment of activities against key recommendations was prepared by officers from Children's Health and Wellbeing as part of this review. In Exhibit 9 I summarise and evaluate the response.

Exhibit 9: CAMHS actions against relevant recommendations from my report Governance Arrangements for Health and Social Care – Follow up (2021)

Recommendation Summary action / progress   Comment

R5 Publish an Annual Quality  CAMHS plan to publish a  Plans for a 2023 annual Account for all health and  Jersey annual report from  report to include quality social care services provided  2023.  indicators are reliant on the by Government  A CAMHS minimum data set  successful implementation

has been identified and  of the minimum data set. work is ongoing to

implement this.

R7 Ensure that robust  Care Partner (Community  How Routine Outcome arrangements are in place to  CAMHS data management  Measures data for CAMHS update the data supporting  system) is currently being  will be integrated into the the Jersey Performance  updated to allow improved  Jersey Performance Framework on a more  data collection.  Framework – so that activity regular basis  and quality information is

aligned and published in one place – is not yet clear.

R8 Document a long-term  The Children and Young  This is good progress. strategy for health and  People's Emotional

wellbeing to be delivered  Wellbeing and Mental

across Government, health  Health Strategy 2022–2025

and social care services and  was co-produced with key

key partners. Progress  stakeholders. It provides a

against the long-term  framework and action plan

strategy should be reported  to deliver the agreed vision

publicly  and outcomes.

Indicators are identified in the Strategy. An annual report is planned to be published in 2023.

Recommendation Summary action / progress   Comment

R18 Ensure that the quality  The MoU between the  The MoU has never been and safety programme to be  CYPES and HCS is intended  finalised.

implemented includes a  to ensure a clear

comprehensive strand of  Governance Framework is in  TMhoUe variohaveu ns dotrafbets ofen the

work aimed at developing  place.  successful in ensuring clear the capacity and capability

of all those involved in  gofor CveArnManHSce in arr panractge icmee . nts delivering governance

across health and social care The Governance Framework

is still draft.

Source: Jersey Audit Office analysis of Children's Health and Wellbeing Services' information return

71. The Government's centralised process which manages my recommendations, the C&AG Recommendation Tracker, requires a single lead to be nominated for each recommendation. It does though allow recommendations to be listed as relevant to more than one department. Currently all Governance Arrangements for Health and Social Care – Follow up recommendations are only listed as relevant to HCS.

Recommendations

R6  Agree, adopt and communicate a Memorandum of Understanding between

CYPES and HCS for the governance and operation of CAMHS.

R7  Agree, adopt and communicate a Terms of Reference for the joint Governance

and Oversight Group, ensuring that this documents:

• how all accountabilities are satisfied

• how the joint principles identified at the away day' will be carried forward; and

• how the stated objectives of the move of CAMHS to CYPES will be assured.

R8  Agree, adopt and communicate Terms of Reference for newly developed

governance groups including the Mental Health System Partnership Board and the Children's Health and Wellbeing Programme Board. Ensure that these Terms of Reference document the groups' relationships to:

• the Jersey Care Model; and

• the Our Hospital' project.

R9  Ensure arrangements are in place to monitor and manage compliance with all

governance processes.

R10 After a suitable period, evaluate how effectively all governance processes are

working in practice.

R11  Document and implement a comprehensive quality and safety programme across

CAMHS.

R12 Establish a process to ensure that all relevant departments, not just the lead

department, are aware of and properly engaged in implementing actions in response to accepted C&AG recommendations. Include this process in the Tracker Manual which covers roles, responsibilities, accountabilities and Tracker operation.

Performance and risk management

Responsibilities

72. There has been no overarching co-ordinated approach to consideration of CAMHS performance and risk data. To date, there has been a disconnect in the management of clinical' (which is viewed as HCS's responsibility) and operational' (CYPES) performance and risk information. Alignment of data and information to enable joint clinical and operational oversight of the quality of services, has been lacking. For example, there has not been a straightforward way to assess the impact on operations of changes in clinical practice.
73. Following implementation of the TOM in 2019, some key departmental systems and processes were not quickly joined up. In January 2020 it was agreed that Datix (HCS's risk management system) would be the single point of reference for CAMHS risks, to consolidate all CAMHS risk logs. The new CYPES risk manager, appointed in 2022, does not however have access to Datix. This increases the likelihood that risks will be missed.
74. Some elements of performance and risk are reported within departmental CYPES and HCS structures but:

• the existing departmental performance and risk assurance frameworks are not operating effectively for CAMHS, including because roles and responsibilities for CAMHS are not fully agreed and operational; and

• there is no overarching, co-ordinated cross-departmental approach.

75. The Governance and Oversight Group has not established systems or processes to enable it to provide any assurance on CAMHS performance, including management of risks. Instead, there has been:

• poor correlations of meeting agenda items to the responsibilities of the Group

• inadequate information either requested or considered

• no setting or review of standards or KPIs

• an inadequate process for developing and ratifying policies

• little consideration of risks; and

• no reporting or escalation from the Group.

76. Very little performance or risk information has been discussed at meetings to date.

77. Despite their accountabilities, there has been no effective mechanism in place to assure the Directors General for HCS and CYPES about the performance or quality of CAMHS. The current Interim Director General for CYPES has acknowledged that information about service quality is not driving improvements or continuous learning in the way it should.

Consideration of CAMHS performance and risk information

78. Within CYPES, the Directorate Leadership Team (DLT) meetings were replaced with weekly Senior Leadership Team (SLT) meetings in 2022. The SLT meetings incorporate, once in each month, a Performance Board and a Quality Assurance Board. I have not however been able to evaluate what or how CAMHS performance and risk information has been considered at either DLT or SLT meetings: for the period reviewed (2019-2021) DLT notes of meetings are partial, and SLT notes from January 2022 are currently only available as an automatic transcription from a recorded meeting. Decisions made and actions agreed have not been separately recorded.
79. CYPES risk meetings have comprised an overall discussion of risks in terms of numbers for each service area and consideration of trends. There are though no formal notes of discussions or decisions made at these meetings. Establishing a Performance Board and a Quality Assurance Board are important developments in managing CYPES' care-facing services, including CAMHS. However, there is more to do to ensure the performance and risk information considered is sufficiently granular to be meaningful and to indicate required actions.
80. The CYPES Informatics Team intends to develop a detailed set of dashboards to support CYPES' daily and weekly operational performance management. The timescale for this planned improvement is not however set out. There are clear opportunities to improve the level of detail in performance reporting – for example reporting against compliance with triage' waiting times as set out for urgent and routine referrals rather than just as an average.
81. HCS remains responsible for CAMHS clinical quality assurance. HCS's Women, Children and Families Care Group manages CAMHS doctors and medical staff. Clinical competence is overseen in the same way as for other consultants in HCS, including annual performance appraisal and job planning, revalidation for registration and routine supervision.
82. HCS's Mental Health Care Group holds the budget for off-Island inpatient services and HCS is represented at the Children's IPP where off-Island placements are discussed and agreed. However, until July 2022, HCS's Director for Mental Health and Adult Social Care was not part of any group which considered community - based CAMHS performance and risk information. He is now a member of the

Governance and Oversight Group and the new Mental Health System Partnership Board.

 Data Quality

83. For both CYPES and HCS, the range and quality of service data relating to CAMHS are recognised as in need of improvement. The data relating to CAMHS performance has, to date, been chiefly about waiting times and activity.
84. Jersey CAMHS has been a member of the NHS Benchmarking Network since 2015 but, unlike most other network members, has not been able to provide more qualitative data based on outcomes and service user experience.
85. In February 2020 an internal review of CAMHS data and systems identified a number of risks and issues. Key planned improvements are dependent on changes being made to data recorded on Care Partner (CAMHS host' information system). A pilot for these changes commenced in February 2022. I understand that new data forms and training to support their use are currently being rolled out.

Planned improvements in performance reporting

86. The Children's Health and Wellbeing Operational Policy dated March 2022 sets out an aspirational Minimum Data Set (MDS) for CAMHS. The plans to implement the MDS are however dependent on changes being implemented in Care Partner and successfully rolled out.
87. CYPES' Head of Informatics and the Children's Health and Wellbeing Quality and Assurance Managers are ambitious to improve performance dashboards. Ideas are being developed to incorporate new data such as pre- and post- intervention measures and particularly to enable closer monitoring of the impact and experience of new service models.
88. There is however no joined up and formalised plan, agreed across all those responsible and accountable for CAMHS. The data requirements of the Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025, including those that relate to risk factors, are, I understand, now identified and being built in to data development for both CAMHS and Public Health.
89. There is room for improvement in capturing and analysing data and information which will help identify potential inequalities in access to CAMHS. Currently, referral data includes the child or young person's age, school and General Practitioner. It also notes primary language and whether a translator is needed. This information is not analysed to spot patterns in referrals. There remains scope to gain significant intelligence by recording and analysing risk-based information about, for example:

• ethnic origin; and

• factors such as being a young carer or having a disability.

Recommendations

R13  Agree, map out and implement roles, responsibilities and arrangements for

CAMHS performance management across all areas of Government and all relevant structures, covering:

• setting standards

• identifying and capturing data for Key Performance Indicators

• establishing ambitious targets and benchmarking arrangements

• monitoring and overseeing performance against standards and targets

• reporting; and

• taking action to resolve identified weaknesses and implement improvements.

R14 Agree, map out and implement roles, responsibilities and arrangements for

CAMHS risk management across all areas of Government and all relevant structures. As part of this, review arrangements for ensuring all risks relevant to CAMHS are logged and can be appropriately cross-referenced in one document.

R15 Set standards for documenting the output and outcome of CYPES strategic and

key operational management meetings. As a minimum this should include attendance, items to be logged as risks, decisions made and actions agreed. Ensure these are appropriately accessible so that they can be meaningfully used by officers.

R16 In finalising a Minimum Data Set for CAMHS, make it sufficiently comprehensive to

encompass all data to be routinely collected, including as a priority data to identify potential inequalities in access to services.

R17 Formalise plans to improve the richness and quality of performance dashboards

within Children's Health and Wellbeing. Ensure the needs of all parts of the governance and advisory structure are considered, including the Annual Report planned for 2023.

How CAMHS performs

90. CAMHS data for the year to May 2022 is set out in Exhibit 10.

Exhibit 10: CAMHS data as reported to the CYPES Performance Board in June 2022 Measure  Jan-22  Feb-22  Mar-22  Apr-22  May-22

Monthly referrals to CAMHS  89  105  104  73  98

Average length of stay  3.4  2  0.8  -  2.7 CAMHS: Robin Ward (days)

Average waiting time for  4  3.8  4.5  3  3 CAMHS assessment (weeks)

Quarterly average waiting  -  -  25.3  -  - time assessment (neuro -

developmental) weeks

% re-referrals to CAMHS  25%  30%  13%  26%  24% (within 12 month of discharge)

Source: Informatics manager CYPES

91. There are early signs that new ways of managing referrals and the evolving service structure for CAMHS are having a positive impact on waiting times.
92. This data was presented live' to the CYPES Performance Board. There is no written narrative to accompany the data. I have not seen a note of risks identified, decisions made, or actions agreed following this data presentation.

Benchmarking performance

93. Jersey has been part of the NHS Benchmarking Network since 2015. Results for key CAMHS data for the period April 2019 to March 2020, compared with network averages, are set out in Exhibit 11.

Exhibit 11: Jersey CAMHS data for 2019/2020 compared with UK national mean values

Indicator and  Jersey  UK  Comment

performance  national

mean

Contacts per  59,601  24,124  The definition of contact' is loosely 100,000 population  drawn.

(0-18)  Frequent telephone and other forms Cost per contact £121  £276  of contact with specific groups of

Contacts per  service users can skew this indicator. clinician (FTE)  1,033  339

Community CAMHS  67  95  The CAMHS workforce in Jersey has workforce per  been decreasing.

100,000 population  The costing data might indicate a (0-18)  relatively rich skill-mix.

Cost per 100,000  £7.1  £6.1   Implementation of the new Strategy population   million  million  is changing the balance of the

workforce.

Source: NHS Benchmarking Network CAMHS data 2019/20

94. I have not seen any action plan linked to the 2019/20 NHS Benchmarking Network data.
95. Jersey has just submitted data for the 2021/22 NHS Benchmarking Network analysis and this is planned to be reported in October 2022.

Workforce planning

96. Delivering the new service models will require a significant increase in staffing. Analysis has shown that Jersey has fallen behind the typical rate of increase for CAMHS staffing levels:

• the UK NHS CAMHS workforce has doubled in size since 2012 (NHS Benchmarking June 2021). In 2019/21, the total CAMHS workforce per 100,000 population aged under 18 for Jersey was 67 compared to the UK national average of 95; and

• the Jersey CAMHS team in 2021 was small compared to other islands at 22.35 FTE. The Isle of Man, which is 25% smaller than Jersey has 23.5FTE. Guernsey (45% smaller) has 18 FTE.

97. The Children's Health and Wellbeing Transformation Programme has assessed staffing need, including how the roles for some existing staff would change.  An impact analysis was completed with some existing posts identified as needing consultation and discussion.

98. The final proposal is to increase CAMHS FTE from 28.58 to 64.58 (including the Head of Service).
99. The recruitment is phased to ensure it is within funding limits for 2022'. However, I have not seen a timetable for intended recruitment, or a summary document setting out which posts:

• remain vacant despite a recruitment campaign; and  

• have not yet been out for recruitment.

100.  A June 2022 staff diagram for Children's Health and Wellbeing shows vacant posts

by service area (see Exhibit 12).

Exhibit 12: Children's Health and Wellbeing: establishment and vacancies by service

Source: Jersey Audit Office analysis

101.  There have been examples of good practice in recruitment of CAMHS staff,

including early support in on-boarding' and in team building. One notable example is that the interview panel to recruit a nurse who specialises in Eating Disorders included a service user with lived experience of an eating disorder. Members of Youthful Minds, MIND Jersey's participation group, have regularly been part of recruitment panels.

102.  There is however recent learning to be taken from issues with retaining staff in

Jersey's Children's Social Care Services. Despite an apparently successful UK-wide

recruitment campaign in 2019, in November 2021 the Government had to launch a second campaign after more than half of the staff hired in 2019 resigned: of the 20 social work qualified posts filled in 2019, only nine remained. To fill the gap, £2 million had been spent on agency workers.

103.  It is not clear how learning from this experience has been documented,

communicated or changes actioned.

Recommendations

R18  When using online live' data at a meeting or group, ensure sufficient information is

recorded so that:

• risks identified, decisions made and actions agreed are clear; and

• the basis for those decisions and actions is evident – for example a screen shot of the relevant data.

R19  Ensure that learning from Jersey's participation in the NHS Benchmarking Network

for CAMHS is routinely captured as part of action plans to improve data quality and performance.

R20  Implement a process for regular CAMHS caseload review to ensure that caseloads

are managed consistently and in line with agreed criteria.

R21  Risk assess recruitment practices against relevant lessons from the issues

experienced in retaining social workers and take mitigating actions to reduce the risk to CAMHS recruitment and retention.

Referrals management

104.  Changes recently implemented are intended to improve the management of

referrals to CAMHS. Early indications are that these have been generally well received but that there are issues to resolve.

Process

105.  The majority of Children's Health and Wellbeing referrals are now processed

through the Children and Families Hub. This is an established facility which provides information, advice and support for families and young people. The aim of the Hub is to make sure that the right help is given at the right time.

106.  Since 21 February 2022 the Children and Families Hub has had a Mental Health

and Wellbeing practitioner on duty as part of the Hub team. This is intended to strengthen the holistic response to referrals.

107.  Exhibit 13 shows elements of the management of referrals as set out in the

Children's Health and Wellbeing Operational Policy and how these compare with good practice.

Exhibit 13: Children's Health and Wellbeing referral management compared to good practice

Area  Operational Policy Comparison and comment

Submitting  Referrals are made by  Using a straightforward and

referrals  completing an online  accessible form is good practice.

request for support' form  However, since its introduction in which asks:  February there have been teething

• What are you worried  problems with the level of information about?  provided.

• What is going well for  Also, the new form cannot be pre - the family and what  populated from the system used by resources / services are  GPs (EMIS) which has been a source already in place?  of frustration.

• What are the views of the  There have been examples of child(ren) and family?  duplicate referrals and currently

• What needs to change  systems are not effective in resolving such duplication.

and what support is

needed?  Potential for improvement:  

Consider:

• providing examples to help referrers phrase their concerns; and

• a post-implementation review. As part of this, analyse the use of urgent' by those making referrals and issues with duplicate referrals.

Who can make  Health Professionals  The list is comprehensive. It does not a referral  Educational Psychologists specifically include teachers but I

understand that teachers can directly School Counsellors  refer children and young people.

Educational Welfare Officers New referral processes mean that SENCos (Special Educational  children and families can self-refer to Needs Co-ordinators)  CAMHS. It is too soon to understand

the impact that this is having on Probation Officers  accessibility and service delivery.

Social Workers; and  Potential for improvement:

General Practitioners (GPs).  Establish criteria against which to

monitor the impact of self-referrals, including as part of understanding inequalities of access to CAMHS.

Involving the  If the referrer is not the  This is good practice. GP  family's GP, the GP is made

aware that a referral has

been made.

The GP will also be sent reports including the initial assessment, initial appointments, care plan, progress report and case closure report.

Logging data  As the Hub uses the Mosaic  There is a risk of error in the manual

system to store data, the  transfer of data between systems. Hub clinician will ask the  CYPES is aware of this risk but a Health and Wellbeing  solution is yet to be developed. administrator to open an

additional entry on  Potential for improvement: TrakCare and Care Partner. Explore options for automating the

process.

Criteria for  The Specialist Community  The newly designed continuum of acceptance into  CAMHS team works with  services within Children's Health and CAMHS  children and young people  Wellbeing means that those children

aged up to 18 who have  and young people who need moderate to severe  specialist CAMHS interventions are presentations (a list of  more easily identified.

potential disorders is

included).

Monitoring  All referrals are reviewed at  The regular review of referrals and

a weekly Children's Health  waiting lists represents good practice. and Wellbeing management  However, notes from the meetings do meeting to ensure oversight  not include decisions made and

by the multi-professional  action to be taken.

management team.  The Royal College of Psychiatrist's There is though limited  Quality Network for Community

detail on what information  CAMHS (2020) proposes that for non - will be proactively shared  urgent assessments, the team makes with the child or young  written communication in advance to person and their family,  young people that includes:

once a referral is accepted.  name and title of who they will see

• explanation of the assessment process

• information on who can accompany them; and

• how to make contact for any queries – for example access to an interpreter, changing an appointment.

The UK's Care Quality Commission includes in its assessment:

• Do [services] ensure that patients and families know that they can contact the service if the patient's condition deteriorates?

Potential for improvement:

• Keep a log of decisions made and action agreed at referral management meetings.

• Ensure that processes to keep in touch with those referred for assessment meet good practice.

Waiting times  If an urgent response is  These standards represent good

indicated due to significant  practice. They are though contained mental health risk (P1), a  in an internal document and are not Duty and Assessment  set out for the public.

Service practitioner will  The UK has mandated national

make contact and respond

to the referral the same day  stanpeopdle wards forith p wsyaitchinosg tis (imestwo w foer youeks) ng (within 9am-5pm hours).   and for those treated in the

If no immediate action is  community for an eating disorder indicated, then the referral is  (emergency: first contact within 24 triaged for assessment as  hours; urgent: one week; otherwise follows:  four weeks).

P2: Urgent - 48 hours  Potential for improvement:

P3: Soon - 10 days  Ensure referral triage target times P4: Routine - 36 days.  are widely understood.

• Although this is implicit in the triage process described, explicitly set standards for young people with psychosis and with eating disorders.

Discharge  Clinicians will produce a  Good practice would also include

closure summary report  explicit information on:

detailing presenting issues,  how to stay well

treatment summary and

outcome including pre- and  a summary of how the child or post- intervention measure  young person felt about being reports and feedback  discharged; and

conclusion.  whether they achieve the goals A copy of this will be sent to  they identified, or modified the

the GP, referrer, and child,  goals.

young person and / or  Potential for improvement: family.

Add these specific items to a discharge plan.

Source: Jersey Audit Office assessment of referral management as set out in Children's Health and Wellbeing Operational Policy (March 2022)

Disengagement from services

108.  I have found two descriptions of how situations where children and young people

who did not attend' (DNA) their appointment should be managed:

• the Children's Health and Wellbeing Operational Policy includes that:

the service will work proactively to offer appointments at times to suit and in environments that suit. Following three instances of DNAs a letter will be sent expressing concern and further efforts made to reflect on why and adapt approaches. Cases will only be closed if alongside several DNAs there is a lack of engagement, and no risk to closing the case; and

• the MIND Jersey contract states that:

cases will be closed when a young person or family repeatedly fails to attend or complete the intervention.

109.  I consider that, whatever the actual practice in these instances, the guidance as set

out is not sufficient to ensure children and young people are safe and that they receive appropriate services and care. Evidence from serious case reviews in the UK has demonstrated that missed healthcare appointments are an indicator of possible neglect and can be early indicators of wider safeguarding concerns.

110.  None of the Referral Management meetings I have reviewed has considered rates

of 'DNA' or the incidence of specific barriers to attendance. I set out in Exhibit 14 principles which I feel should drive policy for children and young people's services in this area.

Exhibit 14: Principles to guide policy for care services for children and young people

Children and (potentially) young people differ from adults in that they do not take responsibility for their own health needs. It is therefore important to consider children as was not brought' (WNB) as opposed to did not attend'.

Children and young people have a right to receive appropriate healthcare and it is the responsibility of parents / carers to access this on their behalf. The United Nations Convention on the Rights of the Child states that "Children have the right to good quality health care" (Article 24).

It is the responsibility of professionals to work effectively to engage with parents /carers / children and young people. Effective intervention is significantly influenced by the quality of engagement that the child / young person and their parents /carers have with the professional.

It is important for professionals to seek to understand why parents / carers do not bring their child for an appointment, in order to address any barriers that there may be to them attending.

Early intervention and prevention is the key to safeguarding children. Staff members need to be more curious about the reasons why a child is not being brought and to look for patterns of incidence. They should thoroughly explore potential options for support and have clear mechanisms for recording events in order to identify themes, patterns and trends.

Source: Jersey Audit Office Identified Good Practice

111.  Data from the NHS Benchmarking Network shows that Jersey's rate of DNA (using

the terminology as it is reported) was 9% for the period 2019/20. This is slightly

better than the NHS average rate of 10%. This data though is not helpful in understanding patterns and trends so that barriers and risks can be addressed.

Re-referrals

112.  Referrals to CAMHS are noted as re-referrals if they occur within 12 months of the

child or young person being discharged from the service. This is the case whether or not the reason for referral or the person making the referral is the same as before.

113.  NHS Benchmarking Network data shows that for the period 2019/20, Jersey's rate

of re-referrals was 11%, lower than the benchmarked average of 15%. However, performance data for the first quarter of 2022 shows the re-referral rate at 25%. This indicates that a quarter of the children and young people who leave Jersey's CAMHS (generic) services are re-referred. However there are some known data quality issues with this reported rate. The rate reported at June 2022 was 16%.

114.  This reasons underpinning the re-referral rate are still being assessed. Transition from CAMHS

115.  CAMHS criteria include that the service is for young people to their 18th birthday.

Feedback from one of the surveys undertaken in 2021 to support development of the Strategy included that young people felt that:

• they had not been sufficiently involved in decisions made about transitioning to adult services

• they did not feel ownership of their care plans; and

• they had not had adequate support during and after the transition process.

116.  The draft transition protocol provided to me as part of my review, which is

intended to support those young people who need to transfer to Adult Mental Health Services (AMHS) or other support services, is not yet complete or operational.

117.  It sets out that work will begin with young people aged 16 who have a high

likelihood of requiring services as an adult. The principles include that:

• referrals into AMHS occur no later than 17 years and 6 months, except where it is agreed that needs are best met within CAMHS

• at least one face to face meeting will be held for the young person with their CAMHS key worker and the key worker from the service to which they will move for further care

• for young people aged 17+ who are not likely to require a service from AMHS, a support plan will be developed

• a Lead Practitioner will work with young people to support them in their transition from CAMHS to AMHS; and

• a transition co-ordinator will hold cases across both services to ensure seamless transition.

118.  There are identified issues with fixing an age for transition – including the plans

that the young person has for higher education off-Island, which might be better supported by a later transition from CAMHS to UK or other local services.

119.  The Health and Social Security Scrutiny Panel review of Mental Health Services

reported in April 2022 that routine meetings are now in place between CAMHS and AMHS, but that there is as yet no agreed and finalised protocol.

120.  Development of a transition policy and protocol is included in the ToRs for the

Children's Health and Wellbeing Programme Board, through funding from the 2022-2025 Government Plan. I understand a new, more flexible, transition policy is in draft but is yet to be ratified.

Recommendations

R22  Undertake a post implementation review of the new process for receiving CAMHS

referrals to understand whether:

• including examples would help referrers phrase their concerns and improve information provision

• use of urgent' by those making referrals is in line with expectations; and

• there are issues caused by duplicate referrals.

R23  Establish criteria against which against to monitor the impact of self-referrals,

including as part of understanding inequalities of access to CAMHS and other Children's Health and Wellbeing services.

R24  Explore options for automating the process of logging referral information across

multiple systems (Mosaic, Care Partner and TrakCare), to reduce the risk of error. R25  Keep a log of decisions made and action agreed at the weekly Health and

Wellbeing Service Referral Management meetings, including any actions to

update the risk register.

R26  Ensure that arrangements to keep in touch with those referred and accepted for

assessment meet good practice.

R27  Ensure triage' target times are widely understood by, and performance is

reported to, referrers and the public.

R28  Although this is implicit in the triage process described, explicitly set and

communicate waiting times standards for assessment for young people with psychosis and with eating disorders.

R29  Set out clear discharge protocols to provide explicit and tailored information on:

• how to stay well

• a summary of how the child or young person felt about being discharged; and

• whether they achieved the goals they identified or modified the goals.

R30 Reconsider the approach to children and young people who were not brought' for

appointments, both for in house' and commissioned services. Ensure that the emphasis is on safety and the child's right of access to healthcare.

R31  Prioritise an understanding of the reasons for re-referrals to CAMHS and set out

any required actions in response.

R32  Finalise the protocol and arrangements for young people transitioning from

CAMHS to AMHS and other services, ensuring decisions on timing are criteria rather than age driven. Establish a process to oversee compliance which includes service user feedback.

Appendix One Audit Approach

The review included the following key elements:

• review of relevant documentation provided by the States of Jersey; and

• interviews with key officers within the Government of Jersey, the Office of the Children's Commissioner and MIND Jersey.

More than 150 documents were reviewed. Key documents included:

• Drafts of the Memorandum of Understanding between CYPES and HCS

• Drafts of the Terms of Reference for the Governance and Oversight Group

• Governance and Oversight Group meeting notes and agenda papers including draft Integrated Governance Frameworks

• Government Plans 2021-2024 and 2022-2025

• Procurement Strategy and notes from the Children's Individual Placement Panel

• CAMHS COVID Wellbeing and Recovery Programme management

• NHS Benchmarking Network report 2019/20

• Scrutiny Review of Mental Health service - report published in April 2022

• Children and Young People's Emotional Wellbeing and Mental Health Strategy 2022-2025

• Strategy development supporting documents:

o Business Cases for CAMHS additional funding 2020 and 2021

o Survey outcomes

o Needs Assessment

o Communications Plan; and

o Workshop attendees

• CAMHS Staff structure June 2022

• CAMHS / AMHS Transition Protocol (draft)

• Mental Health Strategy 2015-2020 and Mental Health Improvement Plan

• Draft ToRs for: Children's Health and Wellbeing Partnership Board; Strategic Advisory Panel; Mental Health System Partnership Board

• Children's Health and Wellbeing Operational Policy – March 2022

• CAMHS Inpatient Operational Procedure (draft)

• Agenda and other papers as available from:

• CYPES: Operational Risk Management meetings; Operational Steering Group meetings; the Quality Assurance Board; and the Performance Board
• HCS: Quality and Risk Assurance Committee October 2019 – May 2022; and Women, Children and Families Care Group Quarterly Reviews from July 2019
• Contracts management meetings with on-Island CAMHS partners; and
• CAMHS Referral Management meeting notes to end June 2022.

The following people and organisations contributed information through face to face meetings, by email, in conference calls and / or by phone:

• Business Manager, CYPES

• Consultant Psychiatrist, HCS

• Chief Nurse

• Chief Executive Officer, MIND Jersey

• Director General (Interim), CYPES

• Director for Public Health

• Executive Director of Mental Health and Adult Social Care, HCS

• Group Director for Integrated Services and Commissioning, CYPES

• Head of Commissioning, CYPES

• Head of Informatics, CYPES

• Office of the Commissioner for Children and Young People

• Risk Manager, CYPES

• Service Manager: Duty and Assessment, CYPES

• Service Manager: Family and Community, CYPES

• Service Manager: Specialist CAMHS, CYPES

• Service Managers: Quality and Assurance, CYPES

The fieldwork was carried out by an affiliate working for the Comptroller and Auditor General.

Appendix Two

Summary of Recommendations

R1  Strengthen:

• the use of Jersey specific risk data and wider determinants of health in forecasting demand for children's mental health services (both capacity and services needed); and

• cross-departmental measures of the impact of interventions, including as part of the Jersey Performance Framework.

R2  Establish service needs and criteria for evaluating opportunities for services to be

commissioned for delivery in partnership with - or exclusively from - community providers.

R3  Ensure improvements to on-Island inpatient care for children and young people

are implemented, including by setting and monitoring Key Performance Indicators (KPIs) to demonstrate improved service user experience.

R4  Ensure that the IPP considers and commissions services to meet all needs of the

service user when deciding on a package of care.

R5  Ensure that the due diligence' items set out in the Procurement Strategy are

supported by high quality information and are used consistently when making decisions about off-Island placements.

R6 Agree, adopt and communicate a Memorandum of Understanding between

CYPES and HCS for the governance and operation of CAMHS.

R7  Agree, adopt and communicate a Terms of Reference for the joint Governance

and Oversight Group, ensuring that this documents:

• how all accountabilities are satisfied

• how the joint principles identified at the away day' will be carried forward; and

• how the stated objectives of the move of CAMHS to CYPES will be assured.

R8  Agree, adopt and communicate Terms of Reference for newly developed

governance groups including the Mental Health System Partnership Board and the Children's Health and Wellbeing Programme Board. Ensure that these Terms of Reference document the groups' relationships to:

• the Jersey Care Model; and

• the Our Hospital' project.

R9  Ensure arrangements are in place to monitor and manage compliance with all

governance processes.

R10 After a suitable period, evaluate how effectively all governance processes are

working in practice.

R11  Document and implement a comprehensive quality and safety programme across

CAMHS.

R12 Establish a process to ensure that all relevant departments, not just the lead

department, are aware of and properly engaged in implementing actions in response to accepted C&AG recommendations. Include this process in the Tracker Manual which covers roles, responsibilities, accountabilities and Tracker operation.

R13  Agree, map out and implement roles, responsibilities and arrangements for

CAMHS performance management across all areas of Government and all relevant structures, covering:

• setting standards

• identifying and capturing data for Key Performance Indicators

• establishing ambitious targets and benchmarking arrangements

• monitoring and overseeing performance against standards and targets

• reporting; and

• taking action to resolve identified weaknesses and implement improvements.

R14 Agree, map out and implement roles, responsibilities and arrangements for

CAMHS risk management across all areas of Government and all relevant structures. As part of this, review arrangements for ensuring all risks relevant to CAMHS are logged and can be appropriately cross-referenced in one document.

R15 Set standards for documenting the output and outcome of CYPES strategic and

key operational management meetings. As a minimum this should include attendance, items to be logged as risks, decisions made and actions agreed. Ensure these are appropriately accessible so that they can be meaningfully used by officers.

R16 In finalising a Minimum Data Set for CAMHS, make it sufficiently comprehensive to

encompass all data to be routinely collected, including as a priority data to identify potential inequalities in access to services.

R17 Formalise plans to improve the richness and quality of performance dashboards

within Children's Health and Wellbeing. Ensure the needs of all parts of the governance and advisory structure are considered, including the Annual Report planned for 2023.

R18  When using online live' data at a meeting or group, ensure sufficient information is

recorded so that:

• risks identified, decisions made and actions agreed are clear; and

• the basis for those decisions and actions is evident – for example a screen shot of the relevant data.

R19  Ensure that learning from Jersey's participation in the NHS Benchmarking Network

for CAMHS is routinely captured as part of action plans to improve data quality and performance.

R20  Implement a process for regular CAMHS caseload review to ensure that caseloads

are managed consistently and in line with agreed criteria.

R21  Risk assess recruitment practices against relevant lessons from the issues

experienced in retaining social workers and take mitigating actions to reduce the risk to CAMHS recruitment and retention.

R22  Undertake a post implementation review of the new process for receiving CAMHS

referrals to understand whether:

• including examples would help referrers phrase their concerns and improve information provision

• use of urgent' by those making referrals is in line with expectations; and

• there are issues caused by duplicate referrals.

R23  Establish criteria against which against to monitor the impact of self-referrals,

including as part of understanding inequalities of access to CAMHS and other Children's Health and Wellbeing services.

R24  Explore options for automating the process of logging referral information across

multiple systems (Mosaic, Care Partner and TrakCare), to reduce the risk of error. R25  Keep a log of decisions made and action agreed at the weekly Health and

Wellbeing Service Referral Management meetings, including any actions to

update the risk register.

R26  Ensure that arrangements to keep in touch with those referred and accepted for

assessment meet good practice.

R27  Ensure triage' target times are widely understood by, and performance is

reported to, referrers and the public.

R28  Although this is implicit in the triage process described, explicitly set and

communicate waiting times standards for assessment for young people with psychosis and with eating disorders.

R29  Set out clear discharge protocols to provide explicit and tailored information on:

• how to stay well

• a summary of how the child or young person felt about being discharged; and

• whether they achieved the goals they identified or modified the goals.

R30 Reconsider the approach to children and young people who were not brought' for

appointments, both for in house' and commissioned services. Ensure that the emphasis is on safety and the child's right of access to healthcare.

R31  Prioritise an understanding of the reasons for re-referrals to CAMHS and set out

any required actions in response.

R32  Finalise the protocol and arrangements for young people transitioning from

CAMHS to AMHS and other services, ensuring decisions on timing are criteria rather than age driven. Establish a process to oversee compliance which includes service user feedback.

56 | Child and Adolescent Mental Health Services