CAMHS - Report - 16 June 2014

CONTENTS

GLOSSARY OF TERMS ................................................................................................................................................. 5 CHAIRMAN'S FOREWORD .......................................................................................................................................... 6 PANEL MEMBERSHIP .................................................................................................................................................. 7 LEAD MEMBER OF THE REVIEW ............................................................................................................................................. 7

EXPERT ADVISOR ................................................................................................................................................................ 7 EXECUTIVE SUMMARY ............................................................................................................................................... 8 KEY FINDINGS ........................................................................................................................................................... 10 RECOMMENDATIONS ............................................................................................................................................... 13 PANEL RECOMMENDATIONS ............................................................................................................................................... 18

OVERARCHING RECOMMENDATIONS .................................................................................................................................... 19 ACTION PLAN ........................................................................................................................................................... 20

1. INTRODUCTION ............................................................................................................................................... 21

1. BACKGROUND ........................................................................................................................................................ 21
2. BACKGROUND FROM EXPERT ADVISOR ........................................................................................................................ 21
3. THE REVIEW........................................................................................................................................................... 22
4. WHAT IS CAMHS? ................................................................................................................................................. 23

2. THE 4 TIER SYSTEM.......................................................................................................................................... 23

1. CAMHS IN THE UK................................................................................................................................................. 25
2. COMPARISONS WITH OTHER JURISDICTIONS .................................................................................................................. 26
3. CAMHS IN GUERNSEY............................................................................................................................................. 26
4. CAMHS IN THE ISLE OF MAN.................................................................................................................................... 26

3. EXISTING CHILD AND ADOLESCENT MENTAL HEALTH SERVICES (CAMHS) ....................................................... 28

1. WHAT DOES JERSEY HAVE? ....................................................................................................................................... 28
2. CAMHS BEST PRACTICE .......................................................................................................................................... 30
3. HOW DOES JERSEY CAMHS COMPARE TO BEST PRACTICE? ............................................................................................. 31
4. WHERE ARE THE GAPS? ............................................................................................................................................ 31
5. WHAT IS MISSING? .................................................................................................................................................. 32

4. IMPROVEMENTS ............................................................................................................................................. 32

1. PREVIOUS RECOMMENDATIONS – WHAT HAS BEEN DONE ............................................................................................... 32
2. WHAT SHOULD CAMHS DELIVER ............................................................................................................................... 34

5 OTHER AGENCIES ............................................................................................................................................ 37

1. WHAT IS IN PLACE ................................................................................................................................................... 37
2. AUTISM JERSEY ....................................................................................................................................................... 37
3. THE YES PROJECT (JERSEY YOUTH SERVICE) ................................................................................................................. 37
4. MIND JERSEY ......................................................................................................................................................... 38
5. SUPPORT FOR PARENTS OF TROUBLED TEENS (SPOTT) .................................................................................................. 40

6. WAITING LISTS AND APPOINTMENTS .............................................................................................................. 40

6.1 CASELOAD ............................................................................................................................................................. 40

7. REFERRALS ...................................................................................................................................................... 42

7.1 RECENT INCREASE ................................................................................................................................................... 43

8. GOVERNANCE AND INFORMATION MANAGEMENT ........................................................................................ 44

9. FEEDBACK ....................................................................................................................................................... 45
10. HOLISTIC APPROACH TO CARING .................................................................................................................... 45

10.1 BLAMING PARENTS ............................................................................................................................................. 47

11. DIAGNOSIS AND TREATMENT ......................................................................................................................... 47

1. DIAGNOSIS OF AUTISM ........................................................................................................................................ 47
2. DIAGNOSIS OF OTHER CONDITIONS ........................................................................................................................ 49
3. TIMELY DIAGNOSIS ............................................................................................................................................. 50

12. EVIDENCE OF MENTAL HEALTH DISORDERS IN CHILDREN ............................................................................... 50

13. STIGMA OF MENTAL HEALTH .......................................................................................................................... 51
14. BUDGET .......................................................................................................................................................... 52
15. RESOURCES ..................................................................................................................................................... 53

15.1 STAFF .............................................................................................................................................................. 53

16. EMERGENCY ACCESS & INPATIENT PROVISION ............................................................................................... 53

17. PLACE OF SAFETY ............................................................................................................................................ 54

1. ROBIN WARD .................................................................................................................................................... 54
2. ROUGE BOUILLON POLICE STATION ....................................................................................................................... 55
3. APPROPRIATE ACCOMMODATION FOR THE FUTURE................................................................................................... 56
4. ORCHARD HOUSE ............................................................................................................................................... 56

18 THE EDUCATION SYSTEM ................................................................................................................................ 57

18.1 PRIMARY SCHOOLS ............................................................................................................................................. 59

19. MULTI AGENCY SAFEGUARDING HUB (MASH) ................................................................................................ 59

20. EARLY INTERVENTION ..................................................................................................................................... 60

20.1 EARLY INTERVENTION/ TIERS 1 AND 2 .................................................................................................................... 60

21. ETHNIC MINORITIES ........................................................................................................................................ 62

22. MEDICATION AND TREATMENT ...................................................................................................................... 62

22.1 THE TREATMENT OFFERED BY CAMHS .................................................................................................................. 62

23. FAMILY THERAPY ............................................................................................................................................ 63

24. ONGOING MONITORING ................................................................................................................................. 64
25. OUT OF HOURS SERVICES ................................................................................................................................ 64
26. CONFIDENTIALITY ........................................................................................................................................... 65

26.1 THE FRASER GUIDELINES...................................................................................................................................... 66

27. TRANSITION PERIOD ....................................................................................................................................... 67

28. MODELS RELEVANT TO CAMHS ....................................................................................................................... 68

28.1 CHOICE AND PARTNERSHIP APPROACH (CAPA) ....................................................................................................... 68

29. CAMHS OUTCOMES RESEARCH CONSORTIUM (CORC) .................................................................................... 69

30. CONCLUSION ................................................................................................................................................... 70

30.1 ADVISOR'S CONCLUSION ...................................................................................................................................... 70

BIBLIOGRAPHY AND EVIDENCE GATHERED .............................................................................................................. 71

BIBLIOGRAPHY ................................................................................................................................................................. 71 WEBSITES ....................................................................................................................................................................... 71 REVIEW HEARINGS ............................................................................................................................................................ 71 Public Hearings ....................................................................................................................................................... 71 Private Hearings...................................................................................................................................................... 72 WRITTEN SUBMISSIONS ..................................................................................................................................................... 72 APPENDIX 1: YOUNG MINDS REPORT – JERSEY CAMHS SERVICE REVIEW 2006 .......................................................................... 73 APPENDIX 2: CAMHS REPORT BY SPECIALIST ADVISOR ........................................................................................................... 73

ADVISOR REPORT ..................................................................................................................................................... 76

Glossary of Terms

• CAMHS – Child and Adolescent Mental Health Services
• CORC – CAMHS Outcomes Reach Consortium
• CAPA – Choice and Partnership Approach
• CYPF – Children, Young People and their Families
• NICE – National Institute for Health and Care Excellence
• NHS – National Health Service
• MASH – Multi Agency Safeguarding Hub
• YES – Youth Enquiry Service
• SPOTT – Support for Parents of Troubled Teens
• RCP – Royal College of Psychiatrists
• ADHD – Attention Deficit Hyperactivity Disorder
• TAASC – Team for Assessment of Autism and Social Communication
• ENCO – Educational Needs Co-Ordinator

CHAIRMAN'S FOREWORD

Mental health is not just the business of CAMHS, it is everybody's business.

"Every Child Matters" is a mantra that should be adopted by everyone. Children are our future and it is vital that we care for all their needs. This includes providing the necessary support to them to help them deal with the complexities of mental health. We must do more to ensure that our children are encouraged to speak openly about the difficulties they are facing. Greater emphasis needs to be placed on addressing the stigma attached to those people who suffer with mental health issues.

We must not lose sight of the fact that the whole family can be affected by a child's behavioural and mental health problems. We have a duty to help these families and to provide timely and appropriate support to assist them through these potentially difficult times.

Services need to be tailored to meet the need of the individuals in the same way as we provide for those suffering with physical conditions.

We are grateful to all those parents and others who took the time to share their views and experiences with us. This has helped us to appreciate the difficulties faced by individuals suffering with mental health issues and those closest to them.

It is the Panel's intention that this review will bring some positive improvement to the lives of those affected by mental health problems and their families.

We would like to acknowledge the contribution made by the professionals within the Health Department and other key stakeholders in assisting us with our review. We are also grateful for the  support  and  advice  given  by  our  advisor,  Francesca  Tummey,  who  has  helped  us  to understand  what  parents  and  children  should  expect  from  a  good  Comprehensive  CAMHS service.

Finally we would like to thank our Scrutiny Officer, Janice Hales for the considerable amount of work she has undertaken to help complete this report to whom we are extremely grateful.

It is our hope that the Minister will not only accept our recommendations but will fully commit to delivering the necessary improvements for a CAMHS service we can all be proud of.

Deputy Jackie Hilton

Vice-chairman of Health, Social Security and Housing Scrutiny Panel

Terms of Reference

Child and Adolescent Mental Health Services (CAMHS)

1. To assess the current assistance and available services for children, adolescents and their families to include:-

1. Comparison of existing available services to those in other jurisdictions
2. To determine if the existing available services are compliant with EU Regulations
3. To assess if the off island resources used by the Department meet the needs of the individual

2. To identify the role of service users and service providers and identify any matters that may need to be followed up and reviewed to include:-

1. The relationship with individuals and organisations whom CAMHS buys services from
2. The long term monitoring of individuals and organisations who provide this service

3. To examine existing resource and man power provisions
4. To examine the systemic planning and explore how the existing service matches the case load

PANEL MEMBERSHIP

The Health, Social Security and Housing Panel comprised the following Members:

Deputy Kristina Moore , Chairman

Deputy Jackie Hilton, Vice-Chairman

Deputy James Reed

Lead Member of the Review

This review was led by Deputy Jackie Hilton, the Vice-Chairman of the Panel due to Deputy Kristina Moore being on long term leave due to illness.

Expert Advisor

The Panel appointed the following expert advisor:

Francesca Tummey works as an advisor with Associate Development Solutions who offer bespoke and expert interventions for Child and Adolescent Mental Health Services (CAMHS). Previously she has worked as the West Midlands Regional Development Worker out of National CAMHS Support Service and was the national lead for CAMHS/ Early Intervention in Psychosis. She has much experience in running complex, transformational change programmes, as a clinical practitioner and operational lead for CAMHS and children's services. She has also been an expert advisor and performance reviewer for several CAMH services offering solutions and achievable action plans.

EXECUTIVE SUMMARY

In 2013, the Panel became aware of concerns from service users that not enough support was available to assist the Island's vulnerable young children and people with mental health issues. The reported increase of the effects of psychoactive substances (known as legal highs) on young people and the sudden deaths of two young males who were known to CAMHS brought these concerns to a much higher level and the Panel believed a thorough review of CAMHS was required.

Child and Adolescent Mental Health Services (CAMHS) is a name given to services provided for children and young people in the mental health arena with the National Service Framework in the UK setting the standard for CAMHS best practice. CAMHS should offer a multi-disciplinary service that is accessible, timely and integrated to offer effective assessment, treatment and support for children, young people and their families. There is no one size fits all CAMHS and it is therefore important that the service provided in Jersey meets the Islanders needs rather than mirror services in other jurisdictions. Although the National Service Framework has no jurisdiction in Jersey, the overall CAMHS service is likely to be influenced by it.

CAMHS do not have the necessary systems in place to record and collate data and as a consequence, caseloads are difficult to manage effectively. The Panel was informed the demand for the services of CAMHS is rising with a significant increase in referrals over the last 9 to 12 months. This increase was initially seen as a blip however, it has become clear that it is much more sustained with the waiting time for an appointment increasing from 6 weeks to 14 weeks in a year. The Panel was also informed that the number of open cases stood at 600 in February however this figure could not be relied upon as it had not been checked for some time. This information was updated to 732 in May raising concern with the Panel that due to the lack of monitoring, the actual number of open cases could not be verified.

An independent review was undertaken in 2006 by a UK charity called Young Minds regarding the CAMHS Service in Jersey resulting in a number of recommendations. The Panel was disappointed to learn that the majority of these recommendations had not been fully implemented and were in fact areas of concern some 8 years later. The absence of a registered family therapist for 18 months indicated that the importance of family therapy is being overlooked and parents reported an overall lack of holistic support stating their experience with CAMHS has left them feeling isolated and on a lonely journey. The Panel understood the general feeling from parents was a lack of confidence in the services provided by CAMHS which was unacceptable and an overview of services provided was urgently required.

The Panel identified that there was no designated place of safety to accommodate children and vulnerable young people in Jersey. Children and young people were being accommodated at the Paediatric Ward in the General Hospital and situations had occurred in the past where the police cells or interview rooms at Rouge Bouillon Police Station have been used. As a priority, the Panel feels that appropriate accommodation must be obtained to address this need as demand for mental health services for children and young people increase.

Accessing CAMHS is only possible through a referral from a professional and the CAMHS service operates on a 9-5 basis, Monday to Friday. Many parents expressed feeling desperate at weekends or evenings with nowhere to turn and were left with little choice but to call the States of Jersey Police or the Accident and Emergency Department. Agencies involved with CAMHS also voiced concern that they did not have an out of hours CAMHS specialist to contact instead having to rely on whoever was on duty at the General Hospital. The Panel do not understand how the complexities of mental health can be viewed as a 9-5 illness and would like to see a service provided that is appropriate for the needs of the Island and the individual.

The Panel believe the Department of Health and Social Services should actively engage with local organisations and key stakeholders who support parents and children with mental health issues. Inconsistencies between stakeholders seem widespread and there is a general misunderstanding of the services offered by CAMHS.

Although the Panel heard from parents who had received a positive service from CAMHS, the overwhelming majority reported the service received as negative. It is clear that improvements to the overall CAMHS service need to be made.

The Panel expect the Minister to deliver all of the recommendations contained within this report to make the CAMHS service in Jersey fit for purpose. The safeguarding of vulnerable children and young people must be a priority.

KEY FINDINGS

1. The majority of parents told the Panel their experience of the CAMHS service was one of little positivity with an overall lack of holistic support resulting in a feeling of isolation throughout the process (section 1.3)
2. Specialist CAMHS sits within the 4 tier system and it is important it is viewed as a specialist service within the overall Comprehensive CAMHS environment and its role is understood.
3. Jersey CAMHS comes under the Children's Service Directorate which incorporates all Children's Services (section 2.2)
4. The Panel believes 18 months without a registered family therapist is unacceptable and is very concerned the importance of family therapy is being overlooked (section 3.1)
5. The Specialist CAMHS team feel overwhelmed with the change in demand on service due to the increase on referral rates for urgent and emergency assessment of individuals. This increase in demand requires CAMHS to review the services provided (section 3.4)
6. The lack of a full range of care pathways needs to be addressed without delay. Intervention is not taking place as frequently as it should at tiers 1 and 2 resulting in cases being left unsupported (section 3.5)
7. The general lack of accurate information and statistics for month on month referrals makes it difficult to gain an understanding of the overall caseload or when a case should be closed (section 3.6)
8. The majority of the recommendations from the Young Minds Report in 2006 have not been fully implemented (section 4.1)
9. The official definition and description of CAHMS provided by the Health and Social Services Department should be the service parents and users expect to be available (section 4.2)
10. Parents found it frustrating that they could not access the excellent support service from Autism Jersey without a formal diagnosis and as a result, felt unsupported by the Department of Health and Social Services (section 5.2)
11. The Panel believe the approach of the YES Project achieves results and is meeting the needs of vulnerable children and young people who seek advice (section 5.4)
12. Mind Jersey offer support to adults with mental health issues and their families however, no similar service for families with children and young people is currently provided (section 5.5)
13. The Panel is aware of a number of local organisations who support parents and children with mental health issues. These groups must be included in any service development by the Department of Health and Social Services due to the fact they have first-hand experience of the difficulties faced by many families (section 5.5)
14. Due to the lack of necessary systems in place to collate data, CAMHS is unable to manage demand, capacity and its caseload effectively. In the absence of the relevant data and based on Royal College of Psychiatrists recommendations, the Panel's advisor believed CAMHS has capacity to manage the number of referrals being accepted and could manage its caseload and deal with the capacity to meet the increase in referrals with an improved framework of case management (section 6.1)

15. The Panel has concerns that following the initial referral to CAMHS the expectations of parents, children and young people could be raised even though there was no guarantee they would be seen and offered treatment (section 7)
16. Once a referral had been made by a Professional, CAMHS request further information from the patient and family resulting in the wait for routine appointments being lengthy with unnecessary delays. The waiting time for an appointment has more than doubled over a year from 6 weeks to 14 weeks (section 7)
17. Currently there is a lack of detailed information available on the number of admissions into the service of vulnerable children and young people who have self-harmed or suffering from other behavioral or mental health condition (section 7.1)
18. It is imperative that the service has a systemised approach to recording activity so that this can be closely monitored, ensuring quality standards do not slip (section 8.1)
19. Feedback on the effectiveness of treatment and outcomes are not currently available due to the infancy of the new system and insufficient data. The Panel is disappointed this practice was not implemented sooner (section 9)
20. Due to the general lack of holistic support received from CAMHS and other agencies, families are suffering. Siblings have been separated and have had to live outside the family home and instead of an overall family approach to caring, the focus tends to be on the individual rather than the family unit (section 10)
21. The Panel has serious concerns about the time taken to diagnose children who may be on the autistic spectrum, with the waiting list from referral to diagnosis of 9 months. The Panel believed the closure of the waiting list due to full capacity was unacceptable (section 11.1)
22. The Panel is extremely disappointed that mental illness is not held in the same regard as physical illness. Diagnosis of mental health still proves to be difficult and pathways are unclear. Without a diagnosis, support is not offered and the needs of undiagnosed children and vulnerable young people are not met (section 11.3)
23. Stigma is an important issue that must be addressed, otherwise children and young people are less likely to seek support for their mental health needs (section 13)
24. Although P.82/2012 is a 10 year plan, the specific area of children and young people's mental health does not seem to be a priority. As a result little will be done to address and bring to the fore increasing mental health issues in children and young people (section 13)
25. It is difficult to determine at present whether additional resource would find a solution to the existing problem of workload (section 15.1)
26. In the absence of alternative accommodation the paediatric ward within the general hospital is used to receive children and young people with a wide range of mental health problems (section 16)
27. Parents spoke positively about the work of the States of Jersey Police in helping parents to deal with potentially very difficult situations within the home environment, especially outside of normal working hours (section 17.2)
28. A subgroup has been formed to specifically look at accommodation for all individuals who have mental health problems and it was hoped the sub-group would report on their findings later in the year (section 17.3)  

29. There is no clear designated place of safety for young people in Jersey and little clarity around what a designated place of safety should be. Although Orchard House is an adult facility, it has been used in the past to house vulnerable youngsters under the age of 18 (section 17.4)
30. The Education Department has a major part to play within Comprehensive CAMHS and it is important the relationship between Education and Specialist CAMHS is strengthened (section 18)
31. Although the establishment of a multi-agency safeguarding hub was extremely positive, the length of time it has taken to establish was disappointing as it was a recommendation from the 2006 Young Minds Report (section 19)
32. The responsibility of early intervention does not just lie with Specialist CAMHS and all stakeholders need to understand their role (section 20.1)
33. There is a gap in provision for emerging mental health problems and the point at which Children and Young People attend at CAMHS with acute mental health problems. Early intervention and prevention are key to more positive outcomes for children, young people and families (section 20.1)
34. The Panel has concern that there could be vulnerable young people from ethnic minorities who are not able to gain immediate access to the service due to communication difficulties (section 21)
35. Once a child or young person is under the administration of CAMHS and receiving medication, only CAMHS professionals can prescribe that medication. Information received by the Panel from witnesses seemed to indicate that medication seemed to be the first choice of treatment (section 22.1)
36. Most parents did not believe their child was being re-assessed on a regular basis and as a consequence remained on the CAMHS register with no pathway or solid plans for future development (section 24)
37. All stakeholders raised concerns over the lack of an appropriate out of hour's service. As the Children's Service has overall responsibility of CAMHS and the treatment for mental health issues, the Panel was very disappointed that a suitable out of hour's service was not being provided (section 25)
38. Concern was raised that there was no clear guidance from CAMHS about what information could be shared with families resulting in parents feeling uninvolved in their child's care. The Panel has concerns that not enough attention is given to how the situation affects the family as a whole (section 26)
39. Currently the Island does not have a Mental Health Capacity Law to address matters of confidentiality for those suffering from a mental health condition (section 26.1)
40. In general, transitions between child and adult services could be better managed. Although the Panel recognises the need for continuity, there must be a more seamless practice in place to allow vulnerable young people to make the transition into adult mental health services (section 27)

RECOMMENDATIONS

Please note: The Panel worked closely with its advisor, Francesca Tummey, and has subscribed to each of her recommendations on CAMHS. The Panel believe these recommendations cover the key areas that need to be addressed within CAMHS and rather than duplicate these recommendations in its own report, the Panel has decided to limit recommendations in the body of the Panel report to those areas not covered by the advisor. As a consequence, the Report is not in the usual Scrutiny format where recommendations usually follow findings after a chapter.

The advisor's Report can be found appended to this report under Appendix 2 and a list of all the recommendations are copied below.

The Minister for Health and Social Services should ensure the following –

1. Specialist CAMHS – service provision

1. Articulating a vision CAMHS staff needs time to develop their vision and strategy going forward, this needs to reflect changing demand and changing workforce. The team would benefit from a facilitated team building day to develop and gain clarity on their vision (section 3.3).
2. Strategic planning to reflect current demands Increased demand requires a shift in provision by CAMHS. CAMHS needs to be sure of its role within children's services not just those provided by health and social care but with wider interdependent partners, for example acute care colleagues, education colleagues (section 6.1).
3. Development of protocols regarding working together across directorates The children's directorate includes social care and health. There is an advantage within the structure to develop clear pathways and joint working opportunities to address the needs of children, young people and their families who may need provision from both sets of services. This can be led by Senior Management who have oversight of several services which naturally work together (section 2).
4. Defining and developing care pathways The development of streamlined care pathways for eating disorders, neurodevelopmental disorders and transition to adult services would benefit the team, fellow professionals and those who use the service. There would also be the advantage of applying joint working opportunities to these pathways (section 3.4).
5. Develop CAMHS communication and marketing strategy

CAMHS has a website containing information about its provision, this should be regularly updated, ensuring that it is widely publicised. CAMHS management should link with the Directorate communications office to develop a marketing strategy and communication plan to ensure understanding of stakeholders and families around the CAMHS vision and offer. An emphasis should be placed on marketing Specialist CAMHS business so that stakeholders and families understand the service and don't develop expectations which cannot, and should not, be delivered by a specialist CAMH service (section 3.3).

6. Strengthen leadership for CAMHS, clarity about role and direction of travel for service CAMHS would benefit from a management team who are experienced in change management and strategic working to drive forward future plans for the service and embed within the children's directorate. There should be a developed philosophy of being outward facing to halt the perception that Jersey CAMHS is isolated and works in a silo as was often reported by witnesses. This needs to be modelled by management. CAMHS management should have sufficient knowledge and understanding with the authority to be able to support effective and efficient multi-agency delivery of CAMHS (section 3.5).
7. Professional mix The team need to ensure professional mix and provide a service which accounts for skills, competencies and capabilities of its team members.
8. Refresh supervision framework to ensure that any concerns about practice are addressed Ensure that a supervision framework is established which includes managerial supervision, caseload management and recognition of training needs. The framework needs to ensure that cases are being managed adequately and staff are receiving appropriate support and guidance. The team's case load is excessive which indicates lack of management of demand and capacity. Difficulties in recruitment to an island need to be observed. Ensuring skill mix management will support staff being developed to provide appropriate interventions which respond to needs of children accessing service (section 6.1).
9. Refresh Operational Policy for CAMHS to ensure its fit for purpose

With change in demand and provision, the operational strategy should reflect this.

2. Recommendations Governance and information management

1. Demand and capacity management model to be introduced The introduction of a capacity and flow model such as Choice and Partnership Approach (CAPA) will allow for a more systemised approach to managing demand and skill mix (CAPA is explained in more detail later in this report under the chapter "Models relevant to CAMHS"). The team will have to invest time in training for this and introducing this model as a systemised approach to manage demand. This approach was independently evaluated in 2009 and the benefits have been clearly recognised (section 28.1).
2. Training programme for workforce which is reflective of demand As recruitment of individuals with specialised skills is a challenge, the team will need to ensure that they have an up-to-date skills analysis to identify deficits and plan how to address these. CAPA can also assist with this (section 28.1).
3. Affiliation to a national body such as CAMHS Outcomes Research Consortium (CORC)  CORC provide a suite of measures and will assist with training and implementation The team can benchmark, receive training for staff and ensure that an outcomes approach is central to service provision (section 29).
4. Quality management and standard setting

Governance and accountability needs to be refreshed by the development of a quality framework which could include audit activity. Quality standards will need to be identified which fit to wider corporate objectives and NICE guidelines.

The introduction of a risk register will also be helpful for the team to ensure safe services. The team should keep a risk log which keeps a record of identified governance and quality risks, how they will be mitigated and when they need to be escalated. Quality frameworks can also include management of learning post incident or complaint as well as how the team benchmarks itself against the Directorate quality standards.

Establishing a clear relationship with the Safeguarding Board can be built into the framework, to strengthen accountability and the governance framework together with development of information sharing protocols which link together various services with defined working together agreements and pathways including a communications strategy (section 8).

5. Referral pathway Clarity around referral criteria is imperative to safe working practice. CAMHS should develop its inclusion and exclusion criteria based on the existence of definable mental disorders and impact of family and social functions. Process mapping the referral process to ensure efficiency and clarity and refreshing referral paperwork and consideration of making this accessible online (section 3.5).
6. Develop evidence about team's performance Collating data which reflects performance is imperative to understand activity versus demand and to influence any future investment. Senior Management may also like to consider putting in place some performance targets, for example an acceptable waiting time for first appointment and a reporting mechanism (section 3.6).
7. Ensure all staff understand and communicate the scope of confidentiality agreements with children, young people and their families Confidentiality agreements are in place in each child, young person and their families clinical file. Staff are au fait with Fraser guidelines (section 26.1).
8. Statutory versus private work All staff should be aware of conflict of interest around private practice and adhere to any guidelines from the Directorate around this. It was evident from information gleaned from witness interviews that at times this practice had become a point of confusion for service users.
9. Development of a detailed action plan

An action plan around future developments for CAMHS should be formulated and agreed and signed off by the Director of Children's Services. Regular reviews and reports of its progress need to be in place.

3. Recommendations – Early Intervention

1. Identify early intervention and early help for children, young people and their families

Map the resources across Jersey who contribute to children, young people and their families emotional health and wellbeing to understand the pathways and resources currently available (section 20.1).

2. Refresh the working arrangements between Education Psychology and Specialist CAMHS Explore the potential for teamwork around the child arrangements and the implementation of the common assessment framework, defining the role Specialist CAMHS would play into this. This would create great opportunities for joint working arrangements. There should be an emphasis on working across agency boundaries and within a variety of settings (section 18).
3. Supporting schools and primary care Explore the potential for providing specialist support to primary care and education through a consultation model. A referral screening approach could also be implemented situated in community settings. Training packages can be developed with Educational Psychologists for teaching staff in the recognition and management of mild mental health problems (section 18).
4. Ensuring accessibility and provision for individuals who have additional needs For example those with a physical or learning disability, new comers to Jersey and those from Black, Asian and Minority Ethnic backgrounds. Provision of information which promotes accessibility for all (section 21).
5. Development of self-harm and risk of suicide guidelines A multi-agency protocol should be implemented to assist those who work with, or support, children and young people in how to recognise risk of self-harm or suicidality and which outlines a subsequent course of action (section 19).
6. Development of a stepped care model

Develop a model in collaboration with afore mentioned colleagues which targets vulnerable CYPF and offers an early help early intervention approach with a clear pathway to more specialised need if deemed necessary (section 19).

4. Recommendations - Emergency access & inpatient provision

1. Communication and relationships The liaison role between the paediatric ward sister and CAMHS should continue. The protocol should be refreshed and re launched to ensure that all parties follow its guidelines. There should be a consistent response from the on-call provision which needs to be signed off and enforced by the Medical Director (section 17.1).
2. The consideration of a Registered Nurse for mental health to be employed to be ward based This role could oversee CAMHS patient risk management plans and provide consultation, supervision and training to ward staff (section 17.1).
3. The implementation of risk training for all staff

A risk training programme could be set up to engage staff from CAMHS and paediatrics, an example of this could be STORM which has different levels of training (section 17).

4. Development of a joint risk plan between paediatrics and CAMHS so that all the potential and actual risks are identified

This should be jointly agreed with supporting paperwork so plans can be written up and shared with professionals and families (section 17).

Panel Recommendations

1. The Panel believed a charity not unlike Young Minds would be beneficial to help the Island's vulnerable children and young people and communication should be entered into with other agencies to assess what could be made available (section 4.1).
2. The Health and Social Services Department should actively engage with those local organisations who support parents and children with mental health issues to improve outcomes. This should involve CAMHS attendance at monthly meetings with an agenda and action list. Full partnership with other agencies should also be encouraged together with more user engagement (section 5.5).
3. Support needs to be put in place for individuals who are undiagnosed but are presenting with problems (section 11.3).
4. More work around promoting positive mental health needs to be done. Early intervention is key and mental health service-users and professionals should come into both primary and secondary schools to help educate children. An on-going commitment to raising awareness should be implemented by the Department of Health and Social Services in particular with the Department of Education, Sport and Culture. Engagement with children and young people as ambassadors for mental health should be encouraged (section 13).
5. Children and Young People's mental health should be given priority within the next stage of the Health Transformation Programme 2016 – 2018, Caring for Each Other, Caring for Ourselves (section 14).
6. As the Department of Health and Social Services is undertaking its own review into mental health services, the Panel expect a designated place of safety will be a priority within that piece of work (section 17.3).
7. Discussion should be had with the Hospital Managing Director to utilise the private ward in the hospital as a short term measure to accommodate children and young people presenting with serious mental health issues. Discussion should also be had with CAMHS professionals to become involved in the feasibility studies for both the new hospital and the new police station to ensure adequate facilities are provided for the future (section 17.4).
8. Comprehensive family therapy programmes need to be implemented and available to parents and families led by a registered family therapist (section 23).
9. A CAMHS specialist should be accessible 24/7. A suitable out of hours rota and service plan should be implemented without delay to ensure the needs of children and vulnerable young people are met (section 25).
10. The changeover between children and young people to adult services needs to be reviewed to ensure a seamless transition. This should take account of individual's needs (Section 27)

Overarching Recommendations

In  addition to the above recommendations, the Panel has made a number of overarching recommendations which it believes will address the key areas of concern within CAMHS.

1. Adopt the action plan from the Panel's advisor and commit to delivering the proposed improvements within the allocated time.
2. Within the next 18 months, ensure that the recommendations contained within the Young Minds report from 2006 are fully implemented
3. Publish a 6 monthly report on progress of these implementations and present it to the States
4. Commit to the commissioning of a detailed independent review of the CAMHS service commencing January 2016 (which will allow time for the implementation of the above). This should consider all aspects of the CAMHS service and determine what progress has been made by the Department and other agencies in delivering the necessary service improvements as highlighted by the Panel's advisor and the Young Minds report.

Action Plan

1. Introduction

"Mental Health is not just the business of CAMHS, it is everybody's business"[1]

1. Background

There is no simple answer as to why some individuals become mentally unwell or develop mental illness, and others do not. Numerous factors can impact on an individual's mental health for example lifestyle factors, peer pressure, family structure.

In 2013, the Panel decided to undertake a review into mental health. The Panel had been aware that this was an area that had been neglected over the years. On closer inspection, it became apparent that in order to carry out an effective mental health review, the Panel would have to focus in one area. The Panel was conscious that the Department of Health and Social Services had agreed to undertake its own review into mental health with the attention being on the mental health service as a whole. With this in mind, the Panel became aware that concerns had been raised by service users and it seemed as if not enough was being done to assist the Island's vulnerable children and young people. This was brought to the Panel's attention through reports from parents of children who used CAMHS and the reported increase of the effects of new psychoactive substances (also referred to as legal highs) on young people. The sudden deaths of two young males in 2013 who were known to CAMHS also brought the concerns to a much higher level.

The Panel is expecting the Department of Health and Social Services to provide a much more detailed approach to reviewing mental health issues which had a small impact on the Panel's Terms of Reference. This required the Panel reluctantly to some degree, discount item 1c (to assess if the off island resource used by the Department meet the needs of the individual) from its report due to the fact this information would be provided by the Department of Health and Social Services in its overall review. This in turn allowed the Panel to focus purely on the Jersey CAMHS service.

In addition to its own findings, this report incorporates the key issues raised by the Panel's specialist advisor.

2. Background from Expert Advisor

This report has been undertaken to understand the function and purpose of specialist CAMHS in Jersey. The CAMHS Specialist Advisor has worked with the Health, Social Security and Housing Scrutiny Panel to compile a document which includes the advisors recommendations. The aim is to advise on improvements to services provided to children, young people and their families who need to access specialist CAMHS in Jersey.

Comprehensive CAMHS is a global term incorporating anyone who has a responsibility for the emotional health and wellbeing of children and young people; the ethos being that this is everyone's business. The Department of Health in the UK in its priorities and planning framework (2003 – 2006) reported an assumption that all CAMHS would provide a comprehensive service which included mental health promotion and early intervention by 2006. From this the National Service Framework for Children, Young People and Maternity Services (2004) set out standards for this delivery, stating that

"all children and young people, from birth to their eighteenth birthday, who have mental health problems and disorders have access to timely, integrated, high quality, multi- disciplinary mental health services to ensure effective assessment, treatment and support, for them and their families".

These standards continue to be upheld as good practice, setting out the premise for integrated pathways and collaborative working which cover the range of children's mental health problems. The National Service Framework expects that provision will be a multi- disciplinary CAMHS service that is accessible, timely, integrated and of high quality and that it offers effective assessment, treatment and support for children young people and their families. Comprehensive CAMHS organises itself across 4 tiers with the specialist element spanning tiers 2 and 3, as described by the NHS Health Advisory Services (1995). Typically tier 3 is multi-disciplinary in nature and Jersey CAMHS reflects this model offering a team which currently has 14.5 full time equivalent clinicians.

In 2006 Jersey CAMHS was reviewed by Young Minds who prescribed a set of recommendations which were bespoke to Jersey CAMHS. It is noted that some of these recommendations are still apparent today. Although the Department of Health and Social Service has devised an action plan around a series of the recommendations and implemented some of these, there is still scope to develop further in areas.[2]

3. The Review

On announcing the review, the Panel received in excess of 50 submissions from service users who were keen to share their experience of CAMHS in Jersey. The majority of these submissions raised serious concerns about the service received and the key themes indicated that improvements needed to be made. The Panel also spoke to, and received submissions from a number of CAMHS stakeholders and although it did not receive submissions from all of them, the Panel was satisfied with the cross section of stakeholders it did speak to and it was clear that there was a considerable degree of consistency in the messages given.

Some of the key issues from parent's who had children that used the services of CAMHS was one of little positivity, lack of holistic support and lack of clarity around their child's condition. Concerned parent's made the following statements:-

".nowhere to go, nowhere to turn, no help or support. I have been the mother, the family therapist, the support network trying to keep our family together."[3]

".how can a mother sum up the impact of trying to understand the complexities mental health? I would ask a question and felt I never got a clear answer to anything. There was nothing that gave me confidence."[4]

".We felt we had to agree because there was no-one else, we had nobody else to consult at that time. We should have been able to consult with some other doctor and the fact there were no registrars and no house officers, nobody else, and psychologists are not medical doctors and we were just left there. We did not know what questions to ask and had to agree with whatever was put in front of us."[5]

".they are not looking at the family in crisis. There is no holistic approach and there seems to be no plan."[6]

".much more needs to be done to bring all the services together to work with and alongside each other so children do not fall through the cracks."[7]

The Panel conducted several transcribed meetings with stakeholders and service users and were provided with operational detail regarding the delivery of CAMHS. This information was analysed to elicit themes and the advisor also spent two days in Jersey

facilitating informal meetings with professionals who influence the pathway for children, young people and their families through Jersey CAMHS.[8]

4. What is CAMHS?

The Definition of CAMHS

Child  and  Adolescent  Mental  Health  Services  (CAMHS)  is  a  name  given  to  services provided for children in the mental health arena. CAMHS is broken down into Specialist CAMHS and Comprehensive CAMHS and are often organised around a 4 tier system. Tier 3 services are referred to as Specialist CAMHS and the staff come from a range of professional backgrounds. The breakdown of the 4 Tier System is discussed in the next chapter.

2. THE 4 TIER SYSTEM 9

In the 1990s, a four-tiered model was used to describe the CAMHS system. Since then, this model has been used as a framework for commissioning and delivering services.

The following describes in more detail the services provided at each tier of the CAMHS operation.

Tier 1 – Child and adolescent mental health services at tier 1 are provided by practitioners working in universal services who are not mental health specialists. This includes:

• GPs
• health visitors
• school nurses
• teachers
• social workers, and
• youth justice workers and voluntary agencies

Tier 1 practitioners are able to offer general advice and treatment for less severe problems. They contribute towards mental health promotion, identify problems early in the child or young person's development and refer to more specialist services.

Tier 2 – Mental health practitioners at tier 2 level tend to be CAMHS specialists working in teams in community and primary care settings (although many will also work as part of tier 3 services). They can include, for example:

• mental health professionals employed to deliver primary mental health work
• psychologists and counsellors working in GP practices, paediatric clinics, schools and youth services.

Tier 2 practitioners offer consultation to families and other practitioners. They identify severe or complex needs requiring more specialist intervention, assessment (which may lead to treatment at a different tier), and training to practitioners at tier 1 level.

Tier  3 – Tier  3  services  are  usually  multidisciplniary  teams  or  services  working  in  a community mental health setting or a child and adolescent psychiatry outpatient service, providing  a  service  for  children  and  young  people  with  more  severe,  complex  and persistent disorders. Team members are likely to include:

• child and adolescent psychiatrists
• social workers
• clinical psychologists
• community psychiatric nurses
• child psychotherapists
• occupational therapists, and
• art, music and drama therapists

Tier  4  –  encompasses  essential  tertiary  level  services  such  as  intensive  community treatment services, day units and inpatient units. These are generally services for the small number of children and young people who are deemed to be at greatest risk (of rapidly declining mental health or serious self harm) and/or who require a period of intensive input for the purposes of assessment and/or treatment. Team members will come from the same professional groups as listed for tier 3. A consultant child and adolescent psychiatrist or clinical  psychologist  is  likely  to  have  the  clinical  responsibility  for  overseeing  the assessment, treatment and care for each tier 4 patient.

Comprehensive CAMHS

Comprehensive CAMHS is a global term incorporating anyone who has a responsibility for the emotional health and wellbeing of children and young people; the ethos being that this is everyone's business. The Panel found that during the course of its review, there were inconsistencies from the groups and agencies who had a responsibility to Comprehensive CAMHS and it seemed the overall CAMHS service was misunderstood. An example of this was found during the referral process where professionals made direct referrals to the CAMHS team at tiers 2 and 3 when in some instances the referrals could or should have been addressed at tier 1. The Panel found that not enough seemed to be happening at the lower  tiers  to  intervene  and  prevent  problems  from  developing  which  resulted  in  the majority of services going straight to tier 3. This is explored in more detail under the chapter Early Intervention.

The Panel questioned the Education Psychologist regarding the various tiers of services.

".Tier 2 services are where it is still quite targeted and preventative. CAMHS, like every other service, has a dilemma around early intervention in that every service would aspire to a more preventative tier 2 service, which is where you try and catch things before they escalate too high. But when you are a limited resource like CAMHS or any other service, the challenge is making sure that you do not spend all your time redirecting all your resources into top-end, complex, specialist statutory work because you are pulling the resources that you have, which are finite, away from where you really want them. So if you get  sucked  up  into  your  specialist  services  all  the  time,  you  cannot  do  the  tier  2 preventative work that you need to stop it getting there in the first place, and that is the challenge."[9]

Specialist CAMHS

Although Comprehensive CAMHS organises itself across all 4 tiers, Specialist CAMHS spans tiers 2 and 3. Typically tier 3 is multi-disciplinary in nature and Jersey CAMHS reflects this model offering a team which currently has 14.5 full time equivalent clinicians. It is important to understand where Specialist CAMHS sits within the 4 tier system however, it is also important that it is viewed as a specialist service within the overall Comprehensive CAMHS environment and its role is understood.

Tier 3 services provide care in the majority of cases requiring specialist input. The aim is to have a team led by a consultant psychiatrist, although other models exist and there is limited  evidence  of  what  system  works  best.  It  is  suggested  that  there  should  be  a consultant psychiatrist for a total population of 75,000, although in most of the UK this standard is not met.[10] Jersey currently has 2 psychiatrists for a population of 100,000.

Unlike the UK, Jersey CAMHS comes under the Children's Service Directorate which incorporates all of Children's Services. This puts Jersey CAMHS in a good position to work closely with other areas of the Children's Services.

1. CAMHS in the UK

CAMHS in the UK is generally provided by NHS services and commissioned through local agreements led by Clinical Commissioning Groups. These arrangements can differ in regions and localities, with commissioning bodies making decisions regarding the provision of services across the tiers, based on local needs assessments and standards as set out in the National Service Framework for Children Young People and Maternity Services (2004).

There is no one size fits all CAMHS service. The National Service Framework for Children expects that the CAMHS provision will be a multi-disciplinary service that is accessible, timely and integrated and offers effective assessment, treatment and support for children, young people and their families. It is therefore important that the service provided in Jersey meets the Islanders' needs rather than mirror services in other jurisdictions.

2. Comparisons with other jurisdictions

Although the principles of CAMHS are the same, the Panel has looked at other jurisdictions to determine how they compare to the existing service in Jersey.

3. CAMHS in Guernsey

In 2012, Guernsey published a research report called "Mental Health and Well Being in Guernsey and Alderney"[11] This report describes in detail the background to CAMHS in Guernsey, a brief description of which is below:-

The Child and Adolescent Mental Health Service in Guernsey was established in 1993 on the appointment of a Child & Adolescent Psychiatrist. Prior to this, children with mental health difficulties were seen either by an Adult Psychiatrist or a Psychiatrist with some child experience employed by the Education Department. Over the last 18 years, CAMHS has gradually employed more clinicians and now has a well-established multidisciplinary team. From this generic tier 3 team, sub-specialties have arisen; for example an ADHD clinic; a Community Clinic dealing with tier 2 difficulties and participation in the Autism Spectrum Disorder Assessment Team.

The CAMHS Outreach Team was set up in 2011 to provide intensive and rapid interventions for young people presenting with severe mental health difficulties, including eating disorders, with the specific aim of reducing the number of young people requiring off-island hospital care.

Unlike most UK services, CAMHS in Guernsey has no primary mental health workers working alongside primary care to offer early support. The development of such a service has recently been established for adult mental health as a strategic priority.

The summary of the strategic vision is:-

• promote good mental health and wellbeing;
• provide accessible and acceptable support for people as they live their lives and timely, respectful and effective intervention, in partnership, when needed, with an expectation of recovery and rehabilitation;
• recognise that a focus on prevention and early intervention is crucial in giving people the best chance to recover from an episode of mental illness; and
• improve outcomes and reduce the incidence of long term mental health problems

4. CAMHS in the Isle of Man

The CAMHS service in Isle of Man is based on the site of the general hospital and all building/utility costs are incorporated within the Department's Estates Services Directorate.

They offer talking therapies and medication and may offer help on an individual, family or group basis. They also provide advice, consultation and support to schools and other organisations that work with young people.

In the Isle of Man around 1 in 10 children and young people have problems with their mental health or emotional wellbeing at some stage. Mental health problems are more common than you might think - three children in every classroom have a mental health problem. This means that you are not alone, and many of these young people will have appointments with CAMHS too.

A brief indication of what is involved in the initial stages of attending CAMHS with various links offering more information and advice into mental health issues is detailed below and is based on what is offered in the Isle of Man. Although this information has been copied directly from the Isle of Man website under Health, the Panel feels it important to include what is offered in other Island jurisdictions to make comparisons.

What is an assessment?

An initial assessment is where you meet a professional from CAMHS and they will listen to you and ask you about your current difficulties. They will help you and your parents/carers think about the best way to help you with your difficulties

You may wish to bring someone with you e.g. family member, friend or someone they work with e.g. support worker, or the young person may feel they want to attend the appointment on their own. However, we do encourage additional support from an appropriate adult. In some cases, we may also invite the referrer or additional persons around the child or young person e.g. Support Worker, Teacher, Pupil Parent Advisor, that we feel would help contribute to the assessment.

After this meeting you may have;

• Further contact with CAMHS
• Advice without further contact with CAMHS
• Information about other services which may be more useful to you

If you do have further contact with CAMHS you will have more meetings with a worker from CAMHS and they will work with you and your family to help you address the difficulties you are experiencing.

What is confidentiality?

CAMHS is a confidential service which means not telling other people what you tell us unless you agree to us doing so because it would be helpful. However, the exception to this is if the CAMHS professional is concerned for you or others then they will have to share it to keep everybody safe.

What is consent?

This means agreeing to something that affects you. The person you see in CAMHS should check that you agree with the help they are suggesting and explain the possible choices if you do not agree. Informed Consent means that you fully understand what you are agreeing to.

What is a referral?

This is when an adult who knows you such as a doctor or teacher asks a CAMHS professional to make an appointment to see you so they are able to offer help and support to you.

What is..?

Here you will find information about mental health and mental health problems, how to cope with your feelings about it and where you can get more information and advice.

• Abuse
• Anger issues
• Anorexia nervosa
• Anxiety and phobias
• ADHD
• Autism & Asperger's
• Bipolar disorder
• Bulimia
• Bullying
• Depression
• Mental illness in family
• OCD
• Post-traumatic stress
• Schizophrenia
• Self-harm
• Young Minds -Self-harm[12]

3. EXISTING CHILD AND ADOLESCENT MENTAL HEALTH SERVICES (CAMHS)

1. What does Jersey have?

The Panel initially sought to understand what was offered by the CAMHS service on the Island by looking at information provided by the Department of Health and Social Services Mental Health support in Jersey for young people is from the age 2 – 18 with CAMHS supporting children from the ages of 5 through to 18. Information on the States of Jersey website states that a pre-school support service is in place for children aged 2-5 which offers support, help and advice to parents and carers in the development of their pre- school child who has special educational needs. It also offers advice to nursery provisions. Referrals to both are through a range of professionals which include GP's, health visitors, education psychologists, paediatricians, and so on. Once a child reaches 18, they go through  a  transition  period  before  accessing  support  from  the  Adult  Mental  Health Services. The transition process is discussed later in this report.

Who works in Specialist CAMHS in Jersey?

Many different types of professionals work together in CAMHS.

With CAMHS professionals, their aim is to:

• Assess what might be causing mental health difficulties
• Offer support, treatment and ideas about how to make things better.

Every CAMHS team will be slightly different, but usually consist of the following:-

Psychologists

Psychologists help families and children understand difficulties in their lives by exploring how they affect thinking, behaviour, emotions and physical health. Psychologists can also complete assessments which look at memory, concentration, attention and other thinking skills.

Psychotherapists

Psychotherapists work with individuals or families to talk through their difficulties and help them understand what might be causing them. With younger children this could involve play.

Family therapists

Family therapists assist family members to express and explore difficult thoughts safely, to understand each other's experiences and views, appreciate each other's needs, build on family strengths and make useful changes in their relationships and lives.

Child and adolescent psychiatrists

Psychiatrists are medically trained and as well as working with children and families to think about what might be causing difficulties, they can diagnose mental illness and prescribe medication.

Nurses  

Nurses working in CAMHS are trained to care for and support young people. They can prescribe medication.

Social workers

Social workers in CAMHS teams help support therapeutic work with families who are referred to the CAMHS team.

The current CAMHS team in Jersey comprises of

• 2 x Child and Adolescent Psychiatrists
• 5 x Psychologists
• 0.5 x Art Therapist
• 6 x Mental Health Nurses
• 1 x Social Worker
• 1 x Team Manager
• 2 x Secretaries/Receptionists

At the time of writing this report, an agency CAMHS nurse had been recruited for 6 months to help manage the current demand. A locum team manager had also been recruited for a period of 6 months. The Panel was also made aware that the family therapist had left the service in 2012 and an existing CAMHS psychologist was undertaking formal accredited training which will lead to registration as a family therapist. This was likely to happen in Autumn 2014.

The Panel was disappointed that there was currently no-one registered to offer family therapy and in addition, the position had been vacant for 18 months.

2. CAMHS Best Practice

CAMHS best practice is set out by the Children's National Service Framework.

The  National  Service  Framework  for  Children,  Young  People  and  Maternity  Services (Children's National Service Framework) is a 10 year programme intended to stimulate long-term and sustained improvement in children's health. It aims to ensure fair, high quality and integrated health and social care from pregnancy, right through to adulthood.

The Children's National Service Framework is aimed at everyone who comes into contact with, or delivers services too children and young people.

Although the Children's National Service Framework has no jurisdiction in Jersey, it is likely to be used as a reference point by the Department of Health and Social Services in Jersey as it represents a consensus of what good practice should be. It is also likely that professionals coming to Jersey and those being trained off Island will increasingly be influenced by the framework. The CAMHS standard includes a number of key principles:-

• Developmentally appropriate services - 0-18 with flexibility in the arrangements for 16-18 year olds
• Evidence-based practice
• Trained and competent workforce - including tier 1 practitioners
• Critical mass of staffing - offering the full range of treatment models and providing a timely service
• Accessibility – appropriate, as near to home as possible and in less stigmatising locations
• Users' views - both adult and child users to be consulted and involved in service development
• Development of care pathways for specific conditions
• Audit and outcomes – routine evaluation to inform service development[13]

At the heart of the Children's National Service Framework is a fundamental change in thinking about health and social care services. It is intended to lead to a cultural shift, resulting in services which are designed and delivered around the needs of children and families using those services, not around the needs of organisations.

The Department of Health and Social Services has also referred to the National Service Framework in its yearly business cases as "it helps establish clear national standards for services to improve quality and reduce unacceptable variations in standards of care and treatment".[14]

In 2006, the Department of Health and Social Services commissioned Young Minds to produce a Report relating to Jersey CAMHS. The Young Minds Report refers frequently to

the National Service Framework and agreed it should be an important reference point but that full compliance should not be expected.[15] (Presumably because it has no jurisdiction in Jersey  and  was  being  used  as  a  guideline).   The  Young  Minds  report  is  discussed throughout this report.

3. How does Jersey CAMHS compare to best practice?

Although the Panel's advisor informed it that Jersey Specialist CAMHS reflected the best practice  model,  she  also  commented  on  subjective  observations  from  CAMHS  team members who were feeling overwhelmed with the change in demand on service due to the increase on referral rates for urgent and emergency assessment of individuals. The advisor also made reference to the added expectation and pressure on the service due to the two youth suicides on the Island in 2013.  

The advisor also told the Panel this increase in demand requires a shift in provision by CAMHS. CAMHS needs to be sure of its role within Children's Services, not just those provided by health and social care but with wider interdependent partners for example acute care colleagues, education colleagues.

Health provision in Jersey is aimed at addressing the needs of an Island community and therefore it can be potentially difficult to benchmark against UK services. There are obvious differences between CAMHS in Jersey and CAMHS in the UK with Jersey having specific challenges to providing comprehensive CAMHS on an island.

It is important that the CAMHS service is promoted to show what is actually on offer. As previously mentioned in this report, the Panel noticed that the Comprehensive CAMHS team was unclear of what the Specialist CAMHS core business was and as a result, the Specialist CAMHS service was being overwhelmed. As referrals continue to rise, better understanding of Comprehensive CAMHS should be provided by CAMHS management working with the Department of Health and Social Services and other key stakeholders. A communication plan should be implemented to ensure families and key stakeholders are clear of the difference between Comprehensive and Specialist CAMHS and understand what to expect.

4. Where are the gaps?

There are a number of gaps between Jersey CAMHS and what is deemed to be best practice  with  the  main  area  around  the  development  of  appropriate  care  pathways. Throughout the review, it became clear there was a poor understanding of the difference between Specialist and Comprehensive CAMHS and poor communication between all Comprehensive  CAMHS  stakeholders.  However,  with  the  implementation  of  the  Multi Agency Safeguarding Hub (MASH) the Panel hoped the services would be more involved and a greater understanding of all services would develop. MASH is discussed in more detail later in this report. Presently there still seems to be a lack of clarity around what services should be covered by Comprehensive and Specialist CAMHS. Specialist CAMHS seem to be working outside of the remit of tiers 2 and 3 and as a result, have become stretched across all 4 tiers.

As discussed previously in this report and in more detail under Early Intervention, there appears to be a gap in services provided in the lower tiers where early intervention should take place and children and young people are being referred directly to specialist CAMHS at tier 3.

It is expected that CAMHS should offer a service to children from the ages of 5-18 however, the Panel received an unconfirmed report that this was not always the case and in some situations, young people remained with CAMHS until well after their 18th birthday. Although these cases were in isolation, this could impact on caseloads being managed effectively and cause an increase in waiting times with some children left without specialist support. When questioned around this area, the CAMHS staff explained that they felt responsible for these individuals and in some cases, did not believe they were ready for the transition to adult mental health services.

Referrals to Jersey CAMHS from a professional become the responsibility of CAMHS once they have been received by the CAMHS team. This is in contrast to CAMHS best practice where referrals are assessed by CAMHS before being taken on and "owned". CAMHS in Jersey have the responsibility immediately to a child that may not require specialist service which adds to the workload of the CAMHS team as each referral has to be assessed before being taken on or signposted to another area of Comprehensive CAMHS.

Another prominent gap between Jersey and CAMHS best practice was recruitment. With Jersey being unable to draw from a large specialist workforce, CAMHS found recruitment difficult which added to an already increasing workload.

5. What is missing?

Following receipt of written information from the Department of Health and Social Services, the  Panel  became  aware  the  CAMHS  team  lacked  the  systems  to  provide  accurate information and statistics for month on month referrals. Without the ability to monitor referrals on a monthly basis, the Panel has concern that the analysis of increase/decrease in activity would be impossible to manage resulting in a lack of understanding of the overall caseload, particularly when the Panel was told the number of open cases to CAMHS had increased from 600 in February 2014 to 732 in May 2014. The Panel also had concerns that there were no clear rules as to when a case was closed. There seemed to be a lack of overall clarity from the team regarding its core business resulting in a loss of focus on what Specialist CAMHS was. Greater emphasis needs to be placed on managing the change as necessary to drive forward the future plans and the monitoring of outcomes.

4. IMPROVEMENTS

1. Previous Recommendations – what has been done

Young Minds are a UK based charity which offers information and advice to children and young people regarding mental health issues. They also provide expert knowledge to professionals, parents and young people through their Parents' Helpline, online resources, training and development, outreach work and publications.

Young Minds is accessible through its website www.youngminds.org.uk and provide the following services:-

• Mental health information and advice
• telephone helpline
• live online chat
• email advice services for parents
• training for professionals (calendar available online)
• stories, links, news and blogs
• quarterly magazine

In 2006, the Department of Health and Social Services engaged the services of Young Minds to undertake an external service review into Jersey CAMHS in 2006.

This report suggested some 17 recommendations which were broken down into key areas:-

• High priority areas for development
• What could be done now with existing resources
• What could be done soon by shifting around existing resources
• What could be done with new monies

The Panel wrote to the Department of Health and Social Services to ask which of the 17 recommendations had been implemented and the status of those which had not and was extremely disappointed with the response. The majority of the recommendations had not been fully implemented and in fact, were still current issues some 8 years later. As a consequence, some of the recommendations made by Young Minds in 2006 have been duplicated within this report.

One of the main concerns highlighted by the Panel's advisor was the lack of available data and data collation. This was highlighted in 2006 by Young Minds and unfortunately is an area which still requires attention. CAMHS utilises the electronic data collection system FACE however, the Department confirmed this system was due to be updated to enable it to generate more sophisticated reports. The Panel found that basic information is not readily available with data being collated for operational needs and offered to strategic managers as and when required. The Panel's advisor explores this in more detail later in this report under Governance and Information Management and highlights the consequences of not having an up to date system in place.

Another area of recommendation within the Young Minds report was that family therapy should be developed with expertise amongst CAMHS staff to lead to a potential increase in capacity. Throughout the Panel's evidence gathering, a number of parents expressed the lack of family support and overall holistic care reporting extremely lengthy waiting lists – if therapy was in fact actually offered. One parent informed the Panel that they were told CAMHS was an assessment centre and a diagnostic centre who did not offer any other kind of support. Other parents who did receive family therapy reported a lack of understanding from the professional to the fact that the parent would have to offer support to the child throughout its life and seemed to concentrate on the here and now with no thought for the future.

Although a family therapist was appointed to CAMHS in 2010, the person in this post left the service in 2012 and was not replaced. This resulted in the service being halted. While family work is continuing within the team, formal practice is not being carried out by CAMHS due to the vacant post. CAMHS has informed the Panel that a psychologist has been  undertaking  appropriate  training  which  will  be  completed  by  September  2014 however, the Panel is unclear what, if anything, is being provided at the moment.

The Panel is disappointed that although family therapy was recorded as a recommendation in the Young Minds report in 2006 to be developed, it seems a low priority and as a result, families are suffering.

As Jersey is an Island with a relatively small population and a manageable number of children, it seems that it is well placed to develop the single children's information system that is one ambition of Every Child Matters on the mainland. [16]

Every Child Matters was implemented in the UK in 2003 following the death of a child. Its aims are to provide support to children up to the age of 19, regardless of background to:-

• Stay safe
• Be healthy
• Enjoy and achieve
• Economic wellbeing
• Positive contribution

The Panel believed a charity not unlike Young Minds would be beneficial to help the Island's vulnerable children and young people.

The Panel was also aware of an Education and Home Affairs Scrutiny Sub-Panel Student Suspension Review meeting held in 2009 which was attended by the Consultant Child and Adolescent Psychiatrist of CAMHS and the Directorate Manager of Mental Health Services where it was said

".within the Williamson implementation plan there is significant resources that will be flowing through for psychological and emotional wellbeing for children and young people or children and families within the Island, which will be very much ... the emphasis will be on C.A.M.H.S. They will not necessarily be within the Child and Adolescent Mental Health Services but, for example, psychology to support, looked after children, neuropsychology, family therapy, cognitive behaviour therapy, so there is a whole cluster of increase of psychological  and  emotional  therapy  that  we  can  start  rolling  out  because  of  the implementation ... the States approved a sort of implementation plan."[17]

2. What should CAMHS deliver Definition of CAMHS in Jersey

The local definition of the Child and Adolescent Mental Health Service in Jersey is clearly defined on their website – a summary of which is below.

CAMHS is a mental health assessment and therapeutic service for children and young people (up to the age of 18) and their families. The service is based at Royde House in St Helier. CAMHS offers assessment, diagnosis and treatment for children and young people suffering from:

• emotional difficulties
• behavioural difficulties
• relationship difficulties
• developmental difficulties
• other mental health disorders (eg psychosis, eating disorders)

CAMHS can help with a range of difficulties which impact on day-to-day activities. These can include:

• low mood or sad thoughts and feelings which do not go away. These can be caused by trauma (possibly following separation, loss or abuse) or severe depressive illness (which may involve thoughts of self-harm)
• worries and concerns for example anxiety disorder or obsessive compulsive disorder (rituals and repetitive thoughts that will not go away)
• brain development disorders for example attention deficit hyperactivity disorder, social and communication difficulties, and tic disorders
• other illnesses which are less common in young people eg anorexia nervosa, bulimia nervosa, bipolar disorder and psychosis

Accessing CAMHS

CAMHS can be accessed through referrals from one of the following professionals:

• general practitioners (GPs)
• consultant paediatricians / hospital doctors
• health visitors and school nurses
• school counsellors
• educational psychologists / education support team
• social workers
• youth action team / residential services
• Educational needs co-ordinator

Professionals write to CAMHS to give more information about the problems the patient is having and if required, CAMHS will normally write to the patient and family for further information. The referral is considered by the CAMHS team who will then offer an initial assessment, suggest a more appropriate service or provide the patient with written advice.

It should be noted that CAMHS are responsible for the patient from referral by the professional and not from CAMHS acceptance.

At the initial assessment, the patient is met with 1 or 2 of the CAMHS team members. The initial assessment allows CAMHS to gather more information and assess any concerns so that a plan of therapeutic intervention can be developed. This may take place with CAMHS or with other services.

The CAMHS team members include:

• child and adolescent psychiatrists
• specialist CAMHS nurses
• social workers
• clinical psychologists
• secretaries

What happens after the initial assessment?

After the initial assessment, CAMHS can offer a variety of treatments or refer to more appropriate agencies.

Treatment may include:

• individual therapy
• family therapy
• parent counselling
• group therapy (where children, young people or carers with similar difficulties are seen together in groups)

The person the patient meets will depend on their needs. CAMHS often work with schools, the Children's Service and other agencies that work with young people, to assist them to help you.

Where and when will the appointment be?

Appointments are generally at Royde House (this may take place with CAMHS or with other services), although home or school visits may be offered in certain circumstances.

CAMHS  is  open  between  9am  and  5pm,  Monday  to  Friday.  CAMHS  try  to  arrange appointments at convenient times, although most appointments take place during the normal working day. [18]

The official definition and description of CAHMS provided by the Department of Health and Social Services should be the service parents and service users should expect however, throughout the course of its review, the Panel heard from witnesses who did not believe this was being delivered to the level described. In particular, CAMHS appointment times need to be more flexible to accommodate working parent.

5  OTHER AGENCIES

1. What is in place

The Education system has a huge part to play in Comprehensive CAMHS and this is discussed in more detail later in this report. The Panel heard from a number of other agencies who offer services and support to children and vulnerable young people.

2. Autism Jersey

Autism Jersey was founded in 2005 by a group of parents, all of whom have children with autism. Autism Jersey is the largest organisation supporting people with autism in the Channel Islands. They provide support for families, individuals and carers, a Befriending scheme and training. They also have an adult social club which meets twice a week and a structured and supportive life and social skills programme. They run parent drop-ins, social events and fund raising events throughout the year and also provide short break services.

Autism  Jersey  champion  full  and  inclusive  lives  for  people  with  autism  and  pride themselves in being proactive in raising awareness about autism across the Island.

Autism Jersey is firmly established and is helping to make the needed changes to local education, social security, health care and law enforcement agencies and establishments in order to ease the difficulties faced by people with autism.

Services provided by Autism Jersey:-

• Training for families, friends, professionals and employers
• The Befriending Scheme
• Social Events for Children
• Youth Club opportunities through the Youth Inclusion Project
• Opportunities for parents to get together
• One stop shop for autism
• Lending library of autism related resources
• Holiday play scheme for children with autism
• Social opportunities with the Adult Social Club
• LINX project for siblings
• Life and Social Skills Training

Autism Jersey is run as a charity and as well as receiving a set amount of funding by the States, rely heavily on donations, sponsorship, grants and support. Although some parents had nothing but praise for the support that Autism Jersey provided to their child, others found it frustrating that they could not access this excellent support service without a formal diagnosis from the Team for Assessment of Autism and Social Communication (TAASC team). TAASC is discussed in more detail later in this Report.

3. The YES Project (Jersey Youth Service)

The Youth Enquiry Service (YES) first opened in 2008. As well as offering a drop-in service for young people they also provide one-to-one counselling as well as online advice on a broad range of issues. YES was developed by the Youth Service in partnership with the Jersey Youth Trust. It was created to support young people aged 14 - 25 with any issue that affects them. YES works with young people on any issue, for example, homelessness, benefits, advocacy work, crime, education, parenting, leaving care, drugs & alcohol, issues around  sexuality,  emotional  health,  relationships,  sexual  health  and  rights  & responsibilities.

Young people are central to the service of YES and have a right to quality information, advice and counselling services.[19]

The YES Project employs 6 counsellors who come in as and when required. Appointments with YES need to be pre-booked however, they do offer specific drop in times of Monday to Friday between 12 and 6 and Wednesday between 3pm and 6pm. During these times, a counsellor will be on duty to ensure any queries are addressed. YES also offers advice over the phone and over email.

In 2013, YES had 156 new clients and numbers have increased every year since its opening in 2008. Out of the 156 new clients, 125 have attended for counselling. Unlike CAMHS and other agencies, a diagnosis is not necessary and self-referral is possible to YES. Referrals can also be made by professionals. YES pride themselves on being able to offer what it is the young person needs and are flexible with appointments leaving it up to the young person to decide how often they want to access the service. Appointments are usually made with 10 – 14 days.

Senior Youth Worker – YES Project

 ".for me I think once a young person has made the decision to access us for that kind of support it is good to get them in as quickly as possible."[20]

The YES Project – Service Statistics 2008 – 2013[21]

4. Mind Jersey

Mind Jersey is an independent local charity that provides support to people living with mental illness. Their vision is of a society that promotes and protects good mental health for all, and that treats people with experience of mental illness fairly, positively and with respect.

Although  affiliated  with  Mind  in  the  UK,  Mind  Jersey  retains  its  independence,  both financially and operationally. All money raised by Mind Jersey stays in Jersey for the benefit of Island residents. Their affiliation ensures that they meet Mind's quality standards of governance and service delivery, follow best practice models of involving local people in their community – people who have had experience of mental illness – and provide good quality services.

Mind Jersey provides information, support and practical help to anyone with mental health problems. These are some of the ways that Mind can help:

Information: Mind can provide information on mental health conditions ranging from how to deal with stress to severe mental illnesses such as Schizophrenia.

Advocacy: Mind can help you voice your choices about treatment, understand your rights or reach out to sources of support with their advocacy services.

Carer and Family Support: Mind supports the families, carers and friends of those who are affected by mental health problems. Mind can help you understand your loved one's illness and how best to support them.

Residential Services: Mind can offer practical advice about day to day living with mental illness to anyone, and offer a residential service for eight people who have an enduring mental health illness. Mind also offer independent accommodation where they act as an "understanding" landlord.

Peer Support: Living with a mental illness can feel very isolating, the benefits of peer support are widely acknowledged in helping experience and recovery. Mind Jersey has launched a peer support service to help those in the Jersey community experiencing mental distress.

Awareness Raising: Mind believe mental health is everyone's business. Whether you are an individual wishing to increase your knowledge about mental health or an organisation looking for training for your staff, there will be a course for you.

Signposting: Mind can provide support and information for health professionals and the general public. They can partner with other organisations or we can help signpost you to a number of additional local and national support services.23

Throughout the course of its review, the Panel was aware of the lack of support being offered holistically to children and young people suffering with mental health problems and although Mind Jersey focus on providing support to adults with mental health issues and their families, no similar service for those under the age of 18 was in place that could offer support to families in need. Mind expressed interest in providing such a support service and although the Panel was aware of the charity Young Minds which provided support to vulnerable children and young people in the UK, there was currently no support service in Jersey.

Chief Executive – Mind Jersey

".We do not have the remit or the resources to service younger people at this stage, but it is something we would be very interested in considering."[22]

Mind explained that many of the people that seek support in the work that they do would undoubtedly have been served by CAMHS in the past and as they transfer into adulthood, some of them would come the way of Mind.

Carer Support Manager, Mind Jersey

".There are a few families who have come to us and said that when their loved one went through the C.A.M.H.S. experience that they felt, for them themselves, the family, the mum

and dad, that they could have done with some external support at that time, they felt it would have been helpful." [23]

5. Support for Parents of Troubled Teens (SPOTT)

SPOTT was set up in 2013 by 2 parents who were experiencing difficulties with teenagers as  a  support  group  for  parents  in  similar  situations.  SPOTT  exchange  ideas  and information, and help each other with practical solutions. What SPOTT hope to offer is a listening ear, knowledge that you are not alone, confidentiality, and the advice of other parents.[24]

SPOTT hold meetings on the last Wednesday of every month and the Panel attended a SPOTT meeting in February 2014 during the course of its review. The Panel hoped that this new group will be encouraged to share their experiences with the Health and Social Services Department as they have first-hand experience of the difficulties faced by many families with children facing mental health issues and are well placed to help identify necessary service improvements.

6.  WAITING LISTS AND APPOINTMENTS

6.1  Caseload

In February 2014, the Panel was informed that the CAMHS open caseload stood at 600 however, at the time of drafting this report, the Panel was told that CAMHS had 732 open cases. The Panel was alarmed at the difference and although time has not allowed for the Panel to understand why the number of cases has increased so dramatically, it is of the view that due to the lack of systems available to CAMHS to monitor its caseload, this information cannot be relied upon.

Of the parents the Panel spoke to, many thought the waiting list was too long with some waiting 5 – 6 weeks to see the CAMHS specialist after waiting 5 months for the referral. One parent had tried to send their child privately as there was such a long wait at CAMHS to get any support.

When questioned as to why the waiting times were so long, the Panel was informed that CAMHS  work  to  a  6  week  appointment  period  however,  with  the  recent  increase  in referrals, this had increased to an 11 week period. The Panel asked what was being done to address this issue.

Child Psychiatrist – CAMHS

".We are prioritising our caseload; we are also looking at getting some additional staffing in. Unfortunately finding specialist staff to come and support us has been very difficult so we have looked to bring in some specialist staff to help."[25]

The Panel received some information from the Department of Health and Social Services in May 2014 showing the average routine waiting times over the past 12 months. The Panel is alarmed that the waiting time has increased from 6 weeks to 14 weeks over the course of the year. A copy of this information is tabled below.[26]

Following its call for evidence, the Panel received a written submission from a medical practice raising concerns with how long it takes vulnerable patients to be seen stating "the timescale of children with potentially serious mental health issues to be seen can go into months which we find quite worrying"[27]

The Panel's expert advisor commented on the high number of caseloads that CAMHS had open to them:-

The current waiting time for an appointment is currently 14 weeks on average, which is double the time waited last year. It is reported that emergency or urgent cases are seen within 24 hours or 7 days respectively. The overall data should be explored to understand the significant increase over the past 12 months.

The team have a high number of cases open to them; 732 (May 2014). The number of referrals to CAMHS for the period between April 2013 – March 2014 was 495. Of these referrals 453 were accepted as requiring an assessment. During that period the highest number of referrals were received during July 2013 at 48 and the lowest in August 2013 at 24.

Using Royal College Psychiatrists (RCP) guidelines (2013) and assuming that 50% of a clinician's time is spent in administrative activity e.g meetings, paperwork etc and if each child and young person is seen for an average of 10 sessions, then a clinician could see an average of 39 new cases each year. Therefore if we assume that the referral period of 2013 – 2014 is an average year, than each clinician has had the capacity to see an average of 31 new cases per year. This is below Royal College Psychiatrist guidelines and suggests that currently Jersey CAMHS has enough capacity to manage the number of referrals being accepted. The focus would need to be on discharging and managing current case loads.

There was also a reported difficulty in transferring and letting go' of patients when they reach 18 due to a concern of where the individuals needs will be met in future. An unconfirmed report was that there were young people still being seen by CAMHS at age 21. However, it was reported that colleagues within adult mental health services were receiving training on how to address presentations which are common to CAMHS but may need further input in adulthood; e.g ADHD. For a service to run effectively demand and capacity must be managed, haphazard flow through the system prevents easy access to the service and subsequently a waiting list may develop. With the team reporting pressure from urgent appointments, managing the team's case load and throughput is imperative to meet demand and expectation and also support staff's capability. To assist with this, staff need  adequate  supervision  to  discuss  case  work,  case  management  and  other professional  issues.  Jersey  does  not  have  a  large  workforce  to  draw  from  around recruitment,  so  maintaining  a  clinician's  skills  and  ensuring  that  the  skills  match  the demand is imperative. The Royal College of Psychiatrists (2013) recommend maximising clinical  effectiveness  by  streamlining  processes  and  delivering  evidence  based interventions, especially during times of increased pressure on services.[28]

Based on these findings, the Panel believed CAMHS could manage their caseload and deal with the capacity to meet the increase in referrals with an improved framework of case management.

7. REFERRALS

It is not possible to self-refer to CAMHS. As previously mentioned in this report, referrals are made by a professional. Once the referral has been made, CAMHS request further information from the patient and family in the form of a questionnaire to assist in providing the appropriate staff to attend the young person on their initial assessment.

The Panel queried why, if a young person had already been seen by a professional, further assessments needed to be done by CAMHS via a questionnaire as surely this would hold up the process. The Panel was informed that the questionnaires were screened by the CAMHS referral team to ensure no risk had been missed that had not been identified by the professional.

The Panel received a written submission from a medical professional stating that "most organisations  are  happy  to  accept  a  referral  with  details  of  the  presenting  complaint included in the original letter but with CAMHS normally a form is sent later and in addition to being onerous, tends to slow the overall process of referral."[29]

The Panel was concerned that expectations could be raised by parents, children and young people when filling in the initial forms from CAMHS following referral as it was not an indication the child or young person would be offered therapy. One parent told the Panel that they had spent a long time filling in form after form, doing different profile tests only to be told "sorry, we cannot help you" with no explanation.

In addition to the 700+ open cases, CAMHS also offer consultations and supervision to staff  (planned  and  ad-hoc  as  needed)  so  will  often  be  offering  advice,  support  and signposting to a wide range of other staff who work with clients not necessarily known/open to CAMHS.[30]

It is not clear how this additional workload and signposting impacts on the Specialist CAMHS services.

There are three levels of referral which range from 1-3 with 1 being the highest. Referrals are usually received as written however, stage 1 emergencies can be referred over the telephone and a patient is usually seen within 24 hours.

The Panel asked for the timeframes and exactly what happens when a child is referred.

Child Psychiatrist – CAMHS

".we have written referrals. If it is an emergency, that is different and we take telephone referrals. We do have a system where anybody that is referred as an emergency will be seen within 24 hours. If it is an urgent referral, within the week and then we have our routine ones."

Deputy J.A. Hilton

".Who decides what is an emergency? Who makes the initial decision?...."

Child Psychiatrist – CAMHS

".Every day it comes through, we have a duty worker who will look at the referral. We then have one of the senior clinicians who is also available to discuss any ones that come through that are concerning. So it is made at that level. Referrals then go to a referral meeting. So once a week all referrals are looked at and, again, just looking at priorities and if there are risk factors there."[31]

7.1  Recent Increase

".Community studies vary a lot but I know for young people they talk at probably one in four will have self harmed at some point."[32]

At a Public Hearing with the Minister for Health and Social Services in February 2014, the Service Director of Children's Services told the Panel that there had been a significant increase in referrals to CAMHS during the last 9 to 12 months whilst stating that self-harm had increased across other jurisdictions in the western  world and interestingly, youth offending, had decreased. Initially, this peak in referrals was seen as a blip as peaks and troughs are not unusual on a small Island however, by the time the increases had carried through to the 6-9 month stage, it became clear that it was much more sustained.

In October 2013, UK statistics revealed an alarming rise in children who self-harm. These figures show that in the past year, NHS hospitals treated more than 18,000 girls and 4,600 boys between 10 and 19 after they had deliberately harmed themselves – a rise of 11 per cent. During the same period, cases involving children between 10 and 14 rose from 4,008 to 5,192 – a rise of 30 per cent.[33]

It has been reported by the head of ChildLine, that the increase in cases has been dramatic. In 2011/12, self-harm appeared for the first time in the top five main concerns for 14 year olds. This dropped further to 13 year olds in 2012/13, indicating that more young people are self-harming at a younger age. While some headlines have blamed a society increasingly obsessed with body image (which may help account for why girls are more prone to self-harming), the head of ChildLine believes a more serious problem is the 24/7 online culture. "In my day, if someone was bullied, they could find escape at home, but that isn't available now. Before you know it, something you said in confidence to one friend, or something unkind that someone else has said about you, is up there in neon lights for anyone to read for any amount of time."[34]

It should be noted that the Panel tried unsuccessfully to obtain local statistics from the Department of Health and Social Services which showed the number of admissions into the  service  of  vulnerable  children  and  young  people  that  have  self-harmed  or  been admitted for any other behavioral or mental health condition. In the absence of these statistics, the Panel has had to rely on UK figures to give examples.

8. GOVERNANCE AND INFORMATION MANAGEMENT

The Panel's advisor researched a great deal into how the CAMHS team monitored quality and performance.

Jersey CAMHS use an electronic recording system called FACE and some statistics are collated on a quarterly basis, although the services acknowledges that an undated version of this system is required to provide the team with much needed data. The team also described a difficulty with data collection due to not having sufficient administrative support. It is imperative that a service has a systemised approach to recording activity, so that this can be monitored, ensuring that quality standards do not slip. It would be helpful if the team were to develop a dashboard; this would be a summary of performance data e.g referrals, time  waited  from  referral  to  treatment  etc.  This  system  would  measure,  monitor  and manage information in order that the team becomes focussed on its activity to provide future strategy, goal setting, risk management and evidence to support any workforce increase. CAMHS can then transform from a reactive to a proactive service.

Referrals are accepted from any professional source and the Panel was informed that referrals are accepted as soon as they arrive at CAMHS. There is provision for a referrer to discuss a referral with a Duty Officer', referrals are triaged and if considered routine are put aside to be discussed in the weekly team meeting. This creates a potential delay in the process, in addition CAMHS should not own' referrals until they are clear that the problem can be treated by the service. Therefore the referrer should still be responsible for the referral until an agreement for assessment by CAMHS is given.

Consideration of the pressures unique to Jersey as an island should be actively addressed. There is not the scope of services in Jersey as there is on the mainland and as previously mentioned there are challenges around recruiting to an appropriately skilled workforce. However  there  are  also  distinct  advantages  to  smaller  services  by  creating flexibility, exploring opportunity for integrated pathways and encouraging a culture of inclusivity and transparency.  A  specialist  approach  to  managing  mental  health  problems  in  children, young people and their families should be provided through effective multi-agency working across  the  children's  directorate,  education  services  and  the  voluntary  sector.  This approach should be informed by arising and changing need in order to provide services that are accessible and delivered by an adequate and skilled workforce. In the Health and Social Services White Paper (2012) there is an expectation declared that services will wrap around each other to ensure a robust service to children, young people and their families.

Ensuring that the service is mindful of quality will support this approach. One of the Consultant Psychiatrists currently leads on audit and this activity is already in place within the team. How audit findings are disseminated and implemented are not so clear. Yet having this ethos of learning is a positive aspect. The team also use outcome measures, an example of which is strengths and difficulties questionnaire', this is good practice. Expanding  the  suite  of  outcome  measures  will  be  advantageous,  as  understanding children, young people and their families progress and experiences of services can be used to improve practice and the service.