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Young Minds Report into CAMHS Jersey - CAMHS - Research - June 2006

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Jersey CAMHS: Service Review

Dr Jennie Crickmay, Dinah Morley

& Peter Smith

June 2006

CONTENTS

Acknowledgements  5

  1. ExecutiveSummary 5
  2. Introduction 9
  3. PolicyFrameworksonthe Island and Mainland 11
  4. EvidenceofNeed 16
  5. TheJerseyContextwithOutlineofServices 18
  6. UserPerspectives 21
  7. Findings 23

AppendiX A: Model of Tiers  37 AppendiX B: Matrix of People Seen  38 Appendix C: Comprehensive CAMHS  39 Appendix D: Contributors  42 Appendix E: References and Sources   45

ACKNOWLEDGEMENTS

YoungMinds wishes to thank all those who contributed to this report their experience and opinions, information and documents, advice, time, administration and refreshments. We take responsibility for the final report and any shortcomings. We very much hope it will contribute to the development of CAMHS services in Jersey.

  1. EXECUTIVE SUMMARY
  1. InJanuary2006theMentalHealthDirectorateoftheStatesofJerseyDepartmentofHealthandSocialServicescommissionedYoungMinds to undertake a review ofSpecialistChildandAdolescentMentalHealthServices(CAMHS) in Jersey. Thereviewis to include:

• The range and quality of service provision.

• Remit and referral criteria

• Effectiveness of cross-agency working arrangements

• The arrangements for children with learning disabilities and mental health problems

• Current arrangements for intensive work, inpatient and residential care and on-call services.

  1. Overallwe found a picturesimilartomanyareasintheUnitedKingdom, a CAMHSteamwith a number of highlyprofessionalanddedicatedstaffprovidinghelpfulservices to childrenwho gain access to the service. Thespeedandflexibilityofresponse to highprioritycaseswouldbetheenvy of a numberofservicesonthemainland. Thehighqualityaccommodationprovidesan excellent environment to enhancethesensitiveanddifficultwork of the staff. ThesefeaturesofCAMHSinJerseyareon a levelwiththebest on themainland.Wehaveidentified a number of changesnecessarytoputspecialistCAMHSon a strongerfootinginJerseyandwhichwouldmakeprogresstowardstheachievementoftheCAMHSstandard in theChildren'sNationalServiceFramework(NSF)inEngland.
  2. Wehavepitchedourrecommendationsinthecurrentcontextofchildren'sservicesinJersey.WhileourremithasbeentoreviewspecialistCAMHS,prioritiesforspecialistCAMHScannotbe set in isolation from related services forchildrenandyoungpeoplewhicharetheresponsibility of childhealth,socialservicesforchildrenandspecialneeds,adultmentalhealth,andeducation. ToquotetheNSF:The lack of provision in one service may impact on the ability of other services to be effective. Partnership working is an essential requirement of high quality service provision'(DepartmentofHealth,2004,page 7).
  3. Weseethree key risks totheeffectivedeliveryofCAMHS in Jersey:

• The isolation of specialist CAMHS from the wider world of children's services

• The isolation of a single consultant child psychiatrist whose clinical and managerial burdens are not sustainable over the longer period

• The lack of rigour in current supervision and governance arrangements.

  1. ProfessionalsinJersey in generalhavemoreautonomyandarelessaccountable.Theyhavemorepower to respondflexibly to needsastheirprofessionaljudgementdirects. OurimpressionisthatthereforeservicesinJerseyaremorevariable,sometimesbetterandsometimesnot.Thereisanabsenceofsystems to identifyandlever up lowstandards. Governancearrangementscaused us someconcern in a servicemore than usuallyfacedwith risks associatedwithisolation.
  1. TheChildren'sExecutivehasbeen set up to reducefragmentationofservicesandtherefore, with theMentalHealthDirectorate,shouldplay a leadingrole in ensuringrecommendations arising fromthisreportareimplemented. This would be a broadening of theremitoftheChildren'sExecutiveandadditionalmembership would berequired,particularlyfrom child health, to carrythroughtheCAMHSagenda.
  2. In commonwithotherreviewersofchildren'sservices on the island, wehave identified fragmentationas a keyissue to tackle.Thereis a substantialoverlapbetweenthechildren described as having severeemotionalandbehaviouraldisordersandthosewhorequire child andadolescentmentalhealthservices. It wouldnotmakesensetoconstructnewcoordinatingmechanisms to drivethroughourrecommendationsinsuch a closelyrelatedservicearea. It would bemoreeffectiveand efficient inour view to considersomeadditionsorreformofthewaythecurrentChildren'sExecutiveworks.
  3. WethinkthatCAMHS could bestrengthened in a numberofways.

This section gives broad outline of high priority areas for development.

  1. Inter-agency

• Clarification of the remit of specialist CAMHS within the broader range of children's services in the four-tier model

• Attention to the gaps in service below the specialist team, perhaps through the development of Primary Mental Health Workers

• Strengthening links to other children's services through joint appointments following the model of the Youth Action Team (YAT), for example looked after children

• Consultation with partner agencies about the balance of specialist CAMHS staff time dedicated to direct clinical work and to advice/training/liaison which will enhance the CAMHS expertise of tier 1

• Development of care pathways for specific conditions with relevant stakeholders including families

• Development of information sharing protocols with partner agencies about individual families

• Co-ordination and strengthening of fragmented services for learning disabled children with mental health problems.

  1. SpecialistTeam

• Development of activity data to inform management and stakeholders

• Additional training, support and supervision for the specialist team to offset the inherent risks of professional isolation,

• Development of a systematic approach to supervision, case and clinical audit, and external review to ensure that current resources are deployed to best effect.

• Developing systematic processes to ensure the views of service users influence service delivery

• Increasing the capacity and expertise of the specialist CAMHS team by recruiting a second consultant psychiatrist to focus on the 16 and 17 year olds, the secure unit and intensive packages of care.

• Ensuring that future recruitment to the team moves Jersey towards providing a comprehensive service by covering all treatment modalities.

• Recognition of the role of the voluntary sector and strengthening its contribution to the four-tier model.

This section makes some proposals about the sequencing of our recommendations.

  1. Whatcouldbedonenowwithincurrentresources

• Review Did Not Attends (DNAs)

• Locate family therapy in Royde House

• Clarify referral criteria and remit through Children's Executive which will identify gaps between services, and place CAMHS within children's services system on the island

• Develop a shared plan for dealing with/managing any gaps identified

• Develop care pathways for specific conditions

• Develop and implement a management information system that allows for efficient oversight of caseloads and the aggregation of data to be disseminated to partner agencies.

• Look for opportunities to include voluntary sector, for example, designing user feedback

• Develop information sharing protocols with partner agencies about individual families

• Ensure robust audit and supervision arrangements are in place across specialist CAMHS and including the schools counsellors

• Clarify school counsellors' role and management arrangements, considering overlap with any future Primary Mental Health Worker role.

  1. Whatcould be donesoon by shiftingaroundexistingresources

• Introduce system of user feedback in consultation with Jersey Focus, voluntary sector groups, and Youth Forum once it is active, analytical work to be done centrally

• Provide more training at Tier 1, for example self-harm which is a concern to children's services, schools, residential workers and Brook counsellors.

• Allocate the additional resource following the Social, Emotional and Behavioural Difficulties (SEBD) review to a post for looked after children

• The staff training policy should be updated with a transparent and dedicated budget.

• Set up a virtual team for learning disabled children with child health, special needs and special education to map areas of expertise and develop a plan to address gaps in expertise and service on a multi-agency basis.

  1. Whatcould be donewithnewmonies

• Employ a second consultant psychiatrist

• Employ Primary Mental Health Workers, with a focus on minority communities, and partly located in different venues, for example large GP surgeries and the voluntary sector

• Implement plans for a more coherent service for learning disabled children

• Develop the full range of available therapeutic models and professional backgrounds

• Look to different models of joint appointments to reduce the fragmentation of services faced by families.

  1. Thesearenotdistinctphasesasneedsassessmentandgapanalysiswillbenecessarypreparatoryworkbeforeallocation of anynewmonies.
  1. INTRODUCTION The Commission
  1. InJanuary2006theMentalHealthDirectorateoftheStatesofJerseyDepartmentofHealthandSocialServicescommissionedYoungMindstoundertake a reviewofSpecialistChildandAdolescentMentalHealthServices in Jersey. Thereviewis to include:

• The range and quality of service provision.

• Remit and referral criteria

• Effectiveness of cross-agency working arrangements

• The arrangements for children with learning disabilities and mental health problems

• Current arrangements for intensive work, inpatient and residential care

• On-call services.

The YoungMinds Approach

  1. YoungMinds has undertaken many similar reviews and bases its work on a number of principles:

• Child and Adolescent Mental Health Services (CAMHS) are multi-agency and multi- professional. The specialist CAMHS team, often referred to as tier 3, is at the core of local CAMHS but is part of a broader system of children's services that make direct impacts on children's mental health. These community-based services for children are described as tiers one and two of a CAMH service. (See Appendix A for a diagram of the four-tier comprehensive CAMHS model). Our commission in Jersey has a specific focus on specialist CAMHS but the extent to which specialist CAMHS can work effectively is strongly influenced by the effectiveness of all four CAMHS tiers on the island.

• CAMHS is everybody's business. This has become something of a mantra but the phrase contains an important truth. All professionals working with children have a role to play in the promotion of a child's mental health; their interaction with the child can strengthen the child's resilience or increase the child's susceptibility to mental health problems. In addition many professionals working with children have a role to play in helping the child address problems of day-to-day living and referring to more specialist levels of help should problems become more serious. Mental health problems in children are too common for there to be a realistic expectation that referral to a specialist team should always be the automatic or first choice for professionals faced with a child with mental health problems.

• A child- and family-centred view. YoungMinds advocates the importance of the participation of children, young people and their families in the planning, monitoring and delivery of services. This is integral to the Children's NSF, which states that: The views of service users are systematically sought and incorporated into reviews of service provision.' Access for all to CAMHS is a fundamental principle and underpins the CAMHS standard in the Children's NSF in England. There is often not a close association between level of mental health need and access to mental health services. Some groups of children who are particularly susceptible to mental health problems tend to

have lower levels of access, for example learning disabled children, children from hard- to-reach and disaffected social groups and ethnic minority families.

Fieldwork

  1. Fieldworktookplace in March2006.Ourapproachis to gainperspectivesfromdifferentgroups of stakeholders in health, education, socialservicesanduserandcommunitygroups,inorder to gain a sharp focus on localissues. Weinterviewedpeoplefromdifferentlevels in organisationssectorfromfrontline to chiefexecutive.Weinterviewed 65 peopleabout a quarterofwhomwereserviceusers.PleaseseeAppendix Bfor a tableofgroups of peoplewhocontributed to ourfieldwork.
  2. Inadditionwesentquestionnaires to GPsandheadteachers to ensurethattheirviewsinfluencedthefindings of thereview.We received responses from seven GPsbutmanyresponsesrepresentedtheviews of theGPpracticeratherthan just theindividual.
  3. On 3 Marchtherewas a midwayreviewoftheproject,whichprovidedtheopportunityforfeedback of ourinitialimpressionsand to ensurethattheconsultancywasontrack.
  4. On 29Marchtherewas a veryusefulstakeholdereventwhichhad two primarypurposes,first to provide a realitycheck on theemergingfindingsfromourfieldworkand second toagreesomeprioritiesforthefuturedevelopmentofCAMHS in Jersey.
  5. WhilewehavenotbeenabletointervieweveryonewithaninterestinCAMHS in Jerseyweare satisfied thatwehavespoken to a goodcrosssectionofstakeholdersandtherehasbeen a considerabledegreeofconsistency in themessagesgiventous. However it wasmostunfortunatethatthereviewtookplaceat a timewhentheteammanager,obviously a central figure, was on compassionate leave.

The Children's National Service Framework in England

  1. YoungMindsandthecommissionersofthisreviewdiscussedtherelevanceoftheChildren's NSF andagreed that it shouldbeanimportantreferencepointbutthatfullcompliance should not beexpected. Inlegaltermsthe NSF has no locusinJersey,butwerefer to it frequently because:

• It represents a professional consensus of what good practice should be

• Professionals coming to the island and those being trained off island will increasingly be influenced by the NSF

• The health and social services business plan 2005 refers to the standards in the NSFs, specifically the (adult) mental health NSF (Department of Health, 1999) and it would not seem reasonable to give different emphasis to the NSFs for adults and children.

The report

  1. ThisreportprovidesthepolicyframeworkforEnglandandJersey,summarisestheevidenceabouttheprevalenceofmentalhealthproblems, refers tosomefactorsspecific to JerseyandoutlinesCAMHS on the island, refers touserperspectivesonthe island aswellasthemainlandbeforedescribingourfindings in each of theareasdetailedinourcommission. Wehave attempted tokeepthisreportreasonablybriefasrequested.
  1. POLICY FRAMEWORKS ON THE ISLAND AND MAINLAND
  1. Jersey Strategic Plan
  1. JerseyStatesStrategicPlan2005–2010, agreed inJune2004,setsoutnine key strategicaimswithunderpinningcommitments(StatesofJersey2005a). ThisdocumentprovidestheframeworkforourunderstandingofthepolicydirectionforJersey. Ourrecommendationsaddresstheaimsandcommitments in thePlanandinparticularwill support theaimtoinvest in Jersey'syouth(pages25-26)bycontributing to thereduction of healthproblemsassociated with youngpeoplethroughearlieridentificationandinterventionaswellasaccess to a full rangeoftreatmentmodalities.
  2. Of particularrelevance to ourreportarethefollowingstatements in theStrategicPlan:

• To improve access to services and co-ordination with greater equity, greater integration of health and social care (op cit page 16)

• To provide levels of care which compare favourably with accepted professional standards (op cit page 18)

• To encourage the integration of services for more effective delivery

• To develop a performance management culture with one success indicator being a more customer focused workforce (op cit page 36)

• To value the voluntary sector (and cut duplication).

  1. Theover-ridingpolicyimperative in thefiscallyprudentStatesofJerseyis to balanceincomeandspending.Thisrequiresclosescrutinyofpublicexpenditure.
  1. Health andSocial Services Business Plan 2005 and the Kathie Bull report
  1. TheHealthandSocialServicesBusinessPlan(StatesofJersey,2005b)isthemeansforthisdepartment to deliveritscontribution to theStrategicPlan. Themainfocusforthedevelopmentofchildren'sserviceshasbeenthereportbyKathie Bull, Review of Principles, Practices and Provision for Children and Young People with Emotional and Behavioural Difficulties and Disorders in the Island of Jersey,often referred toastheSEBDreport (Bull, 2002).
  2. ThesummaryofrecommendationsarisingfromthisandsubsequentreportsbyKathieBulllists a number of actions to provide a widerrange of effectiveinterventionsforchildrenwithsevereemotionalandbehaviouraldifficultiesand to improvetheco-ordinationoftheseinterventions.KathieBull'sremitwas to review existing practicesandprovisionforchildren with emotionalandbehaviouraldifficulties(EBD)andourremit is toreviewspecialistCAMHSbutwe should notforgetweareaddressingtheneeds of verylargelyoverlappingpopulations. This fact should notbeobscuredbyourdifferentfocusanduseoflanguage. FromJanuary2003,KathyBull'sremitwasextended to includetheservices EBD childrenreceivefrom each agency, including CAMHS. This appears to recognisethepotentiallykey role CAMHS can play in deliveringthebestpossiblementalhealthinterventions to reducethe

risk of emotional and behavioural problems in children becoming chronic and persistent in adulthood.

  1. Relevant recommendations from the SEBD report

• Set up Children's Executive with responsibility for and oversight of all matters relating to children in need

• Develop a strategic plan

• Establish statistical database

• Establish new secure facility

• "The Child and Family Service (CFS) be re-designated as a child, adolescent and family mental health service with roles and responsibilities clearly delineated within the four-tiered model and transparent to all would be and actual clients. Any remit for this service in managing referrals from other agencies, at  present Children's  Services, Education and Home Affairs regarding under-18s who offend or challenge the system be diverted to a specialist psychiatric service to be based in the new facility. The current work of CFS nurse therapists to be reviewed. This to ensure that one year from January 2003 tier 1 work which  should  fall to maintained  secondary  schools  is  transferred to  the new  in-school services to be developed within the same time scale".

• All secondary schools should have their own specialist support service.

• Additional CAMHS input to the multi-agency campus to include an additional child and adolescent psychiatrist and two nurses focusing on children and young people with conduct disorder, unsupportive family backgrounds, a tendency to misuse drugs and exhibiting offending behaviours. Initially a two-bedded facility on campus was proposed. The aims were to reduce the likelihood of being treated off island, to reduce pressure on children's and adult inpatient beds and to provide capacity to help on an outpatient basis to other young people in residential care.

  1. TheSEBDreviewhastriggeredanambitiousandradicalchangeprogrammeinchildren'sservices to tacklesomelong-standingproblems,forexamplethefragmentationofservicesandtheoveruse of residentialhomes.ApartfromoneadditionalpostcomingonstreamthisyeartheCAMHSrecommendationsintheSEBDreporthave not beenresourced. However,theinvestment in KathieBull'sworkwassubstantialand a changeprogramme is underway. Wehaveshapedourrecommendations to beconsistentwiththecurrentdirectionofchangeandhavealsowe identified manysimilarproblemstoaddress.
  2. The2005BusinessPlanstatesunder a heading of Target/ What will success look like?, servicesforchildrenwithemotionalandbehaviouraldifficultiesarebettercoordinated,and that resourcesaretargetedtowardseffectivelyandefficiently meeting theneeds of children with SEBD. Weagreethesearedesirabletargets.
  3. Therearealsoplansunderway in thementalhealthdirectoratewhicharerelevant to thedeliveryofimprovedCAMHSforexamplethecommitments in theBusinessPlan:

• To develop clinical psychology with more cognitive behavioural therapy (States of Jersey 2005b, page 13)

• To review and expand psychiatric liaison service (op cit page 14)

• To aim for DNA rate for all clinics to be less than 5% (op cit page 15).

• To develop working relations with service users, with the success measure proposed of involvement of users in service development (op cit page 27).

  1. In policyandpracticedevelopmentCAMHShasto keep one eye onthementalhealthagenda,primarilydrivenbyadults,andtheothereye on thebroaderchildren'sagendawhichtendsnot to thinkmentalhealthunlessprompted to do so.
  2. Anotherimportantconcurrentdevelopmentistakingplaceincommunity child healthservices. TheexternalreviewcommissionedfromtheRoyalCollegeofPaediatricsandChild Health found that children'sservicesinJerseyarefragmentedwithmultipleandincompatibleinformationsystemsandweaknesses in clinical audit (issuesalsoidentified in this report). OurreviewofspecialistCAMHShasaninterface with twoimportantareaswiththechildren's health review,servicesforlearningdisabledchildrenandtheidentificationandtreatment of ADHD.TheRoyalCollege review wasfoundedontheprinciples of theChildren'sNSFandthereareunsurprisinglythemessharedbythechildren'shealthandthechildren'smental health reviews.
  1. Policy in England

Every Child Matters

  1. TheDepartmentforEducationandSkillswebsitetells us:

"Every Child Matters: Change for Children is a new approach to the well-being of children and young people from birth to age 19. The Government's aim is for every child, whatever their background or their circumstances, to have the support they need to:

• Be healthy

• Stay safe

• Enjoy and achieve

• Make a positive contribution

• Achieve economic well-being.

This means that the organisations involved with providing services to children - from hospitals and schools, to police and voluntary groups - will be teaming up in new ways, sharing information and working together, to protect children and young people from harm and help them achieve what they want in life. Children and young people will have far more say about issues that affect them as individuals and collectively."

  1. TheEveryChildMattersprogrammeaims to ensurethatservicesareorganisedaroundtheneeds of childrenandfamiliesandnotaroundtheconvenienceandtraditionsofserviceproviders.Throughcommonassessment,sharedinformationsystemsandintegratedorganisationalstructuresEveryChildMattersaimstoreversethefragmentationofserviceswhichconfusesfamilies,wasteslimitedpublicresourcesandisatroot of most of therecentfailuresinsafeguardingchildren. Instead the vision of services is child centred,withthevoice of theusercentraltoindividualinterventionsandservicedesign,andtheeffectiveand efficient deploymentofpublicresourcesdedicated to improvingactualoutcomesforchildrenand families.
  2. Two importantnewpostshavebeenmade to championchildren'sissuesinGovernmentandthecountry,theChildren'sMinister first appointed in 2002andtheChildren'sCommissioner first appointed in 2005. Theintention is that thesehighlevelappointmentswillprovidesustainedsupportforchildren in needandbepowerfuladvocatesinsideandoutsideGovernmenttoensurethattherecent flood ofpolicypronouncementslead to perceptibleimprovementstochildren'slives.

National Service Framework (NSF) for Children, Young People and Maternity Services  

  1. TheChildren'sNationalServiceFrameworkisthemeansbywhichtheEveryChildMattersprogrammewillbeachieved in health. The NSF waspublished in September2004andincludesthestandardsagainstwhichchildren'sserviceswillbeinspected. Itcontainsfivecore standards, promoting health and well-being, supporting parenting, user centred services, growing into adulthood (transition) and safeguarding. In addition there are six standardsaddressingchildren in hospital,illchildren,disabledchildren,mentalhealthandpsychologicalwell-being,medicinesandmaternity.
  2. Standard 9 coversthementalhealthandpsychologicalwellbeing of childrenandyoung people. It states:

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, multidisciplinary mental health services to ensure effective assessment, treatment and support, for them and their families'.

  1. Thestandardoutlinesthe following visionforthefuture:

• An improvement in the mental health of all children and young people

• That multi-agency services, working in partnership, promote the mental health of all children and young people, provide early intervention and also meet the needs of children and young people with established or complex problems

• That all children, young people and their families have access to mental health care based upon the best available evidence and provided by staff with an appropriate range of skills and competencies.

  1. It isimportant to remembertheNSF is a framework,it is not a blueprint. It allowsforandencouragesflexibility:differentareaswillachievethestandards in differentways. HowevertheCAMHSstandardincludes a numberof 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 modalities 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.

  1. Since1998theGovernment in Englandhasallocatedadditional funding to CAMHS in recognition of theshortfallofservices in relationtodemand. TheTreasurystrongly supported theallocationofthis funding becauseuntreatedmentaldisorder in childhoodoftenleads to persistentmentaldisorder in adulthood, a lifetime of socialexclusionandfailuretoachieveeconomicself-sufficiency. Inthethreefinancialyears from 2003/04 to 2005/06theGovernmentallocatedanadditional£300 million to CAMHS.
  1. TheNSF is plannedas a ten-yearprogrammeofchangeand so servicesarenot expected toachieveallstandardsimmediately. Howevertheadditionalfundinghasbeenallocated to CAMHS in orderthatcomprehensiveservicesareavailablein each area.(SeeAppendix Cfordescription of comprehensiveCAMHS). A performancemanagementsystemhasbeenintroduced to monitorprogress. To simplifytheadministrativeburdenthat such monitoringentailsthreeproxieshavebeenusedfor a comprehensiveCAMHS,servicesfor 16 and17yearolds,emergencyout-of-hourscoverandservicesfor learning disabledchildren.
  2. InWalesandScotlandtherehasalsobeensubstantialattention to CAMHSwiththepublicationofthe NSF inWales in 2005largelyreflectingtheEnglishmodel. In Scotlandthe Framework for Children and Young People's Mental Health (2004)outlines a goodenoughCAMHSanddevelops a shared vision andsharedownershipofCAMHS linking withthe Scott ishreportHealthforAllChildren – particularlyaroundprimarypreventionandearlyintervention.
  3. Onthemainlandthere is recognitionthatthesubstantialandsustainedinvestmentinCAMHS is leading to measurableimprovementsalthoughmuchprogressremains to bemadebefore a comprehensiveCAMHSisavailableinallareas(DepartmentofHealth,2006). In England a substantialand costly apparatusofsupporthasbeenestablished to promoteandmonitorprogresstowardstheestablishmentof a comprehensiveCAMHS.ForexampletheNationalCAMHSSupportServicehasundertaken a widerangeofinitiatives to improveservices,butthishas cost wellover£1mperannum. 
  4. Thesedevelopments on themainlandmaywellhaveimplicationsforJersey in termsofpublicandprofessionalexpectations. Theinjection of resourcesaswellasthemainlandfocus on CAMHSpolicyandperformancemanagement could leadtoJerseylaggingbehindwithpossibleadverseeffects on Jerseypresenting a competitivecareeroptionforprofessionals in demand.
  1. EVIDENCE OF NEED
  1. Reliableinformationabouttheprevalence of mentalhealthdisordersinchildrenhasrecentlybecomeavailable.ThereportbyMeltzeretalfortheOfficeofNationalStatistics(ONS, 2004) showsthat9.6% of childrenandyoungpeopleintheUKbetweentheages of 5 and 16 havementaldisorders. Boysaremorelikely to have a mentaldisorder than girlswith10%boysand5%girlshaving a mentaldisorder aged between5–10 years. Theproportionschangeto13%boysand10%girlsaged11-16years.
  2. Thenumberofyoungpeopleinlone-parentfamilieshavedoubletherate of disordercompared with two-parentfamilies, in reconstituted familiesrateswere24%comparedwith9%infamilieswith no step children,17% of children with a parentwith no educationalqualificationscomparedwith4%ofthosewithparentwith a degree-levelqualificationand20%against 8% whereparentswere not in full-timepaidemployment.
  3. Economicdisadvantage,disabilitybenefit receipt, routineoccupationalgroups, living in socialhousinganddeprivedareasallcontributed to higherratesofmentalhealthproblemswithyoungpeople.

 Table 1: Prevalence of mental disorders in 5-16 yr olds by age and sex 2004 (ONS 2004)

 

Age

5–10

11-16

All children

 

Boys

Girls

All

Boys

Girls

All

Boys

Girls

All

Type of disorder

 

 

 

 

 

 

 

 

 

Emotional

2.2

2.5

2.4

4.0

6.1

5.0

3.1

4.3

3.7

Conduct

6.9

2.8

4.9

8.1

5.1

6.6

7.5

3.9

5.8

Hyperkinetic

2.7

0.4

1.6

2.4

0.4

1.4

2.6

0.4

1.5

Less common disorders

2.2

0.4

1.3

1.6

1.1

1.4

1.9

0.8

1.3

Any disorder

10.2

5.1

7.7

12.6

10.3

11.5

11.4

7.8

9.6

  1. Thesampling on whichthisresearchisbasedcoveredtheUnitedKingdombutnotJersey. Fromwhatweknowaboutfactorsassociatedwithhigher risks ofmentalhealthdisorder,it could bearguedthatratesofmentalhealthdisorders in Jerseywillbelower:

• Lower indices of social deprivation

• Less exposure to some drugs.

  1. It could equally be argued thatrates could behigher:

• Alcohol use

• Parental absence because of high work commitments

• Lack of support for some families whose extended family is in the UK or European mainland.

  1. Our view isthattheUKresearchisverylikely to providegoodestimateofprevalenceand should be used forserviceplanning in Jersey. ApplyingtheONSprevalence rates to Jerseygivesthe following estimates of mentalhealthdisordersfor 5 to 16 yearolds.

Table 2: Estimated level of mental health disorders in Jersey

 

 

5-10 (all)

11-16(all)

All

Emotional

144

300

444

Conduct

294

396

690

Hyperkinetic

96

84

180

Less common

78

84

162

Any disorder

612

844

1476

 

  1. Planningservicesalso requires aninterest in timetrends in childandadolescentmentalhealthproblems.Arehigherpercentages of childrenandadolescentssufferingfrommentalhealthproblemsandthereforelikely to needservices? Thisappears to bethecase from researchreported to theNuffieldFoundation in 2001.Examiningdatacollectedoncohorts of 15 and16yearoldsoverthelastthreedecadestheresearchersconcludedthe results clearly showed that the mental health of adolescent in the UK declined overall across this period'. Thistrendspecificallyrefers to disordersofconduct,anxietyanddepression.
  2. Itis not onlyevidence of needthatislikelytodeterminedemand on services. In commonwithmanyotherareas of health care identification of certainconditionsand of childrenatriskis improving andknowledgeofeffectiveinterventionsisdevelopingwhichfuelpublicandprofessionalexpectations of what a CAMHSserviceshouldprovide.
  1. THE JERSEY CONTEXT WITH OUTLINE OF SERVICES
  1. Jersey is anislandcommunityonehour'sflyingtime from themainlandoftheUK. Itspopulationattheend of 2004was87,700with15,664agedunder16atthecensusinMarch 2001. Thereis on average just underonethousandchildren in each yeargroup.
  2. Wewerestruckbytheapparentparadoxof high publicexpectations of serviceandhighexpectations of a continuinglow tax base,despitesomeinescapablyhighercostsassociated with provision in anislandcommunity.Outofareaplacementsofallkindsareparticularly costly, forhealth,notonlythe cost ofthehospitaladmissionitselfbuttheassociatedcostsof visiting thepatientandthetravelnecessary to makeplansfor a return home.
  3. Thereis a furtherparadox in that a number of intervieweescommentedthatthey found Jersey a highlyintrusivesocietyintofamilylifewhileatthesametimepromotingthevaluesof self- sufficiency. Weweretoldthat40%of island youth wasprocessedthroughtheparishhallsystem.
  4. ProfessionalsintheUKandelsewherehave tended tobecomemorespecialised,inpart to keepabreast of increasingknowledge,butthisoptionis not available in a smallcommunitywherethepopulationbaseisinsufficient to supportallspecialisms.Jerseyrelies on theflexibilityandcreativityof it staff to provideservices.
  5. Thereisanevidenthighriskofprofessional isolation onJersey. Singlespecialistsarecommon.Recruitmentappearsincreasinglydifficultandsome staff inchildren'sservicesareappointed to postsforwhichtheywouldprobablynotbecompetitive on themainland.Forboth of thesereasons training andprofessionalsupervisionaredoublyimportantbutthecostsofprovidingthesearehigher.
  6. Theburdenofinspectionandperformancemanagementismuchlighter in Jerseywithmuch

being left to the individual practitioner. While this has the advantage of enabling front line professionals to get on with the jobs for which they trained it has the potential disadvantage of allowing poor practice to persist for too long without challenge. The creativity and occasional irritation of constructive challenge is not built into practice in Jersey as systematically as on

the mainland.  Health and Social Services have invited the Health Care Commission to monitor services in Jersey and there is now a timetable agreed.

  1. Therearecurrentsofchange in Jersey,primarily resulting from theSEBDreportbutCAMHS also hastotakeaccount of policyandpracticechangesinmentalhealthandchildhealth. Thecommitmentoftheresource of staff timewillbeessentialatdifferentlevelsofCAMHS to generatemomentumforchangeandensureCAMHSisconsideredinconcurrentchangeprogrammes.

Outline of services

  1. Wehavenotintended to undertake a definitivedescriptionofallservicesthat touch onchildren'smentalhealthandwhatfollowsis a verybriefoutlineoftheservices that wehave identified asthemaincontributors.
  2. The island is served byonespecialistCAMHteam,which is centrallybased in St.Helier. Theteamis led bythesoleconsultant child psychiatristandtheseniorCAMHSnurse,whoreports to themodernmatron. Therestoftheteamconsistsofoneclinical child psychologist(not in post atthetimeofthis report), fiveWTEnurses,one social worker,onefull-timeseniorsecretary/administratorandoneclericalassistant. DataprovidedfortheSEBDreport showed that referralsincreasedfrom240 a year in 1995 to 423 in 2001. RoydeHousedatashows in 2002, 2003and2004therewere408,363,and 538 referralsrespectively. In 2005therewere 317 referrals,whichdoesnotincludeemergencies, eating disorder,complexneedsteam or ADHD referrals. Differentcomponentsofthehealth service, primarilyGPs,providednearlytwo-thirdsofthereferrals,educationreferred22%,socialservices10%,with youth justice,self-referralandothersaccountingfortheremaining4%.
  1. At thetimeofthereviewtherewerefourschoolcounsellors in thenon-feepaying/non- selectivestatessecondaries,formallysupervisedbytheconsultant child psychiatrist. Two ofthesecounsellorswerepart of MASTs;theplanisfortheother two schoolstodevelopMASTs in September2006. This summerterm2006 a schoolcounsellorhasbeenappointed to workbetweentwo of thefee-payingschoolsandtheselectivestateschool. Linkswiththefeederprimarieswere not veryevident. 
  2. Educationalservices,whichsupportchildrenwithlearningandbehaviouraldifficulties,runalongsidetheschoolsandnurseries,identifyingchildrenwithproblemsat a youngageand putting supports in placeforthem,includingensuringtheyareplacedatschoolswhichare resourced todealwiththeirdifficulties.
  3. In 2005SocialServiceslookedafterabout 120 children on averageatanyonetimewithabout40 living in children'shomes.Theaveragenumberofchildrenonthechildprotectionregister in the first halfof2005was25,and in 2004therewerebetween 450 and500activecases in children'sservicesatanyonetime.
  4. In addition to thesechildren'sservices,disabledchildrenare served bySpecialNeeds services that provide respite, servicesforchildrenandyoungpeoplewithautisticspectrumdisorders,andanintensivebehaviouralsupportservice.
  5. TheBridgeis a newventurewhichprovides a multi-agencycentretosupportvulnerable families, mainly from theimmediatelocalitybutotherfamiliesdohaveaccess. TheBridgebringstogetherbothstatutoryandvoluntarysectorservicesandisthebaseforJerseyChildCare Trust.
  6. ParentingSupport,whichreachesoutintothecommunitythroughearlyyearsfacilitiesandschools, is basedatTheBridgeandtheprogrammemanageroffers a servicetoallcomersaswellas a Webster-Strattonbasedservice to targetedgroups.
  7. Importantadditionalservicesareofferedbythevoluntarysector,includingtheMindenPlacecounsellingandyouth service, AutismJersey,theBrookCounsellingservice,the ADHD parents group andtheNSPCC'sPathwaysproject. ThePathwaysprojectisnotbasedcentrallyand serves a needyhousingestatepopulation east of St. Helier. TheBrookhad8000contactswithchildrenandyoungpeoplelastyearandisverywellknownindeedto them as a source of help andadvice.
  8. Schoolsalsoprovidemuchthat is supportiveofchildren'smentalhealth,forexample A Quiet Place, CircleTimeandbreakfastclubs.

CAMHS in Guernsey and Isle of Man

  1. Guernseywith a population of justunder60,000has a CAMHserviceconsisting of 2.5psychiatrists,three clinical andoneeducationalpsychologist,and1.5nurses. One of thepsychiatristshas a specificremitforlookedafterchildren,andone of thepsychologistshas a specific remitforlearningdisabledchildren. Despitethislarger resource, GuernseydoesnotprovideintensivepackagesofcarelikeJerseyandtendstomakemoreuse of inpatientadmissions.
  1. TheIsleofManhas 8 clinicians,5.6fulltimeequivalents, 1 full timeconsultantpsychiatrist, 1 full timeclinicalpsychologist, 1 psycho-dramaspecialist, 1 fulltimepsychotherapistforlookedafterchildren, 2 nursespecialists(both0.8), a clinicalassistantto help with ADHD clinic, anoccupationaltherapist(0.8)and a servicemanager(0.6). The child populationoftheIsleofMan is about17,000.

Table 3: Clinical Staffing levels Jersey and comparators

 

 

Jersey

Guernsey

Isle of Man

Royal College et al

Population

87,000

60,000

75,000

100,000

Psychiatrists

1.0

2.5

1.0

2.5 (Royal College of Psychiatry)

Psychologists

1.0

4.0

1.0

5.3 (British Psychological Association)

Psychotherapists

-

-

2.0

1.25 (York, 2005)

Nurses

6.0

1.5

1.6

 2 per consultant (York, 2005)

Social workers

1.0

-

-

-

Others

-

-

0.2 (clinical assistant)

-

Total Full Time Equivalents (FTEs)

9

8

5.8

 

  1. USER PERSPECTIVES The National Picture  
  1. Thepotentialbenefitsofappropriatelyandgenuinelyconsultingwithserviceusersandcarers on servicedesignandplanningincludebettertargeting of resources,betteruptakeofservices,andgreatersuccess in reachinghardtoengagegroups.Thereisalsosomeevidencethatparticipationimprovesclinicaloutcomes (CAMHSInnovationProjects in Street, 2005)
  2. Participationcanrange from full child initiatedshareddecisionswithadultsthroughthelessparticipatoryconsultationandinformingofyoungpeople.TheParticipationLadder(SherryArmsteininStreet 2005) is a usefultool in understandingwhatlevelofinvolvementmightbepossibleandappropriateinanygivensituation. Theinvolvementofchildrenandyoungpeople in thedevelopmentof a comprehensiveCAMHserviceisresource-consumingandneedsproperplanningandfacilitation. UKGovernmentpolicy now requiresthatuserviewsaresoughtand acted uponacross all serviceareas(Children's NSF 2004andEveryChildMatters2004). This can be a tokenexerciseunlesssustainabilityisbuilt in andresourcesallocatedaccordingly.
  3. Research on childrenandyoungpeople'sviews of servicestypicallyfindsadversecomment on theformalityof clinic services,beingpatronised, not listened to, beingdischargedfor non- attendanceandresentingwhatseemslikeintrusivenessofquestionsinanintake/assessmentinterview(StreetandHerts2005, S. Laws1999InvolvingChildrenandYoungPeopleinthe Monitoring andEvaluationofMentalHealthServices,HealthyMinds 6). Most,but not all,young people tend to prefer addressing their mental health problems with people in thecommunitywhomthey know andtrust,olderadolescentsbeingthehardestgrouptoengageeffectivelywith a traditionalCAMH service.

The Local Picture

Young people and families using the specialist CAMH team

  1. Wemetwith15serviceuserswhoinevitablyhad a rangeofexperiencesandviews.Allhad received a responsewithin a reasonabletimescale,even if it did notseemso to them,and appeared tofeelthatthey could re-connectwiththeteam in futureifnecessary.
  2. Someuserswerefullofpraisefortheservicethattheyhad received in crises; others felt that they hadwaited too longforaninitialassessmentanddiagnosis. Itwasclear that familieshadmadestrongrelationshipswithparticulartherapistsandthatveryflexibleresponseshadbeen possible.
  3. A commonthemewas just how importantCAMHSwere to thefamiliesinvolved. Forfamilieswhoengagedquicklyandwhobenefitedsubstantiallyphrases such a life-savers'wereused.Forfamilieswheretheoutcomeshadnot been sopositivefeelings ran quitehigh,againbecausethepossibility of effectivetreatmentfor a child indistressis so incrediblyimportant.
  4. Familiesgreatlyappreciatedthe efforts ofCAMHS staff to carefortheirchildren on theisland. In generalthey found thestaffandenvironmentatRoydeHousewelcoming,but a bit scaryfor one ortwochildren.
  5. FamiliesthoughtliaisonbetweenthespecialistCAMHSteamandtheschool could beimproved, both in theassessmentandthefollow-up.Betteruse could bemadeatassessment of

information already held about their children within the school, and educational psychologists could play a valuable role in drawing the specialist treatment and child's school life together. Families did not feel that there was much of a sense of teamwork between therapists and school.

  1. Wewerenotable to meetwithfamilieswhohadnotattendedorwhohadbeenunable to accessCAMHSeffectivelyfor a range of reasons. A DNAauditwouldbenecessary to provideinsightintotheirviews.
  2. In 2002therewas a surveyofclientsatisfactionwith39responses. Therewereverypositiveratingsofhowfamiliesweretreatedby clinic staff andthemajority of familiesfeltbetterable to managetheirproblems.However a quarter of theyoungpeople did notfeelcomfortableattendingtheserviceand a third of families did not feeltheyhad a betterunderstandingoftheproblemsaftertheirattendance.Therehas not been a furthersurveyofuserviews.
  1. FINDINGS
  1. Overallwe found a picture,similartomany areas intheUnitedKingdom,of a CAMHSteam with a numberofhighlyprofessionalanddedicated staff providinghelpfulservices to childrenwhogainaccess.Thespeedandflexibilityofresponse to highprioritycaseswouldbetheenvy of a numberofservices on themainland. WethoughtthatthehighqualityaccommodationatRoydeHouseprovidesan excellent environment to enhancethesensitiveanddifficultwork of the staff.
  2. The range and quality of service provision
  1. As inmostotherplaces in theBritishIsles,JerseyCAMHSisnotable to meetthemental health needs of childrenandyoungpeopleidentifiedbyschools,GPs,healthvisitors,socialservices,andvoluntarysectoragencies. Thereis a mismatchbetweenwhat specialist CAMHS is able to doandtheexpectations of referring agencies.Thisbecomes a sourceof tension thatisplayedout,probablyrepeatedly, in relation to individualcases,asthereis no formalmeetingwheredifferencesofexpectations can beaddressed.
  2. Serviceusers, in commonwithpatientsacrossalldisciplinesandlocalities, find thatgenerallytheyhave to waitlongerthantheywantandexpectforappointmentsandtreatment. Jerseydoeswellenoughandverywell in someaspectsbycomparisonwithEngland.The2004CAMHSmappingexerciseshowedthat51%ofpatients waited less than fourweeks,31%lessthanthreemonths,11%lessthan six monthsand7%over six monthsforaninitialappointment(http://www.camhsmapping.org.uk/2004). Thedataarenot specific aboutwaitsfortreatmentbutindicatethat39%waitedover six months.  
  3. Agenciesareunsure how to copewithvulnerablefamiliesandchildrenwhomtheyfeltneeded a specialistCAMHSinterventionbutwhofallbelowtheaccessthreshold. Much is facilitated on a personalbasis,betweenpeoplewhoknow each otherwellandcan lift thephoneanddiscuss a casepriortoreferral. Whenthishappensreferralsaremoreappropriateandtend to beacceptedbytheteam. Howeversomeprofessionals,forexampleGPs,reportedthatthey found it impossibletomake a successfulreferral to CAMHSofcasestheydeemedappropriate.
  4. Therewasalsoconcernabouttheeffectivenessofthe services currentlyoffered in reachingsomevulnerable families.  Weweremadeawareofinstanceswherefamilieshadnotattendedtheirappointment,oftenfor a variety of practicalreasons - thedifficultyforsomepeopleof getting into St. Helier, taking timeoffworkandeven in reading theappointmentletters. WeareconcernedthatthesefamiliesareregisteredasDNAanddonotreceivetheservicethey need. This is notsolelytheresponsibilityofspecialistCAMHSwhodogobacktothereferrer in such cases, butas a wholethesystemseems to beunresponsive to children in thesecircumstances.

We recommend a review of DNAs with an exploration of the reasons and consideration of options for improvements.

  1. Referrals and Case Loads
  1. Thespecialistteamhas raised thresholdstocopewithdemandastheyareunable to meetmanyoftheneedspresented to them. Thishasbeenparticularlytrueoverthelastyearwhentheyhavebeencarryinglong-termvacanciesof key personnel. Referralspeakedat 538 in 2004and raising thethresholdlastyearcontributed to thereduction of referrals in 2005 to 317excludingthecategories listed in para5.9above.(Thedatabasegivesanoverallfigureof380buttherearedoubtsaboutthereliabilityofthis figure). A keyaspectof meeting demand from newreferralsisefficientmanagement of throughputofcases.Wehave not seenevidence of this. Theinformationprovidedaboutthenursesdoesnotgive a full picture oftheirwork. At best it showsthatthenurseshadtenappointmentsperweek. Subsequentinformation from a reviewofnurses'diariesfromJanuary to March2006shows that theyaveraged 12 appointmentsperweekwithtwoDNAs. It originallyappeared to us from thedata that oncereferralshavebeenacceptedbyCAMHStheyareheldtherefor a long time. 124newcasesappearedtogenerate3170follow-ups - that is, 25 attendances on averagefor each child. However, on furtherdiscussionwelearnedthatcases closed overthelastthreemonthswereroughlyequal to casesopened,whichsuggestsanappropriatethrough-putandthat, on average,caseswereseenaboutfourtimes.Therehavebeendifficulties in adaptingtheHealthand Social ServicesdatacollectionsystemtoprovidemorecomprehensivedataforCAMHS. 
  2. Activitydatabystaffdonotappear to beroutinelyavailableor used as a managementtool in ensuringefficientuseofresources.
  3. TheRoyalCollege of Psychiatrists'consultationpaper(2005)suggeststhatCAMHScapacitycalculationsshouldbebased on 40 newreferralsperWTEperannum. This shouldallowservices to respondquickly,offer flexibility inservicedeliveryandprovideevidencebasedtreatmentsfor long enoughforthebenefits to beapparent. TheJerseyCAMHteamexperienced a slightlyhighernumber than thisin2005 – approximately 47 newreferralsper WTE, assumingthat all postswere filled, whichwasnotthecase. In addition to managingthishighernumbertheJerseyteamhas to putsignificantresourcesintohigh-level support ofverychallengingpatients, a particular need andpriorityforanislandcommunity,whichhas to befactoredin to calculatingreasonablecaseloads in Jersey.  

We recommend that activity data are routinely collected, are available to the staff group and reported to management quarterly, providing the basis for an annual report for stakeholders.

  1. Whilewehaveanimpressionof a serviceunderpressureandunabletomeetdemands,currentdatadoes not providestrongevidencethat existing resourcesarebeingusedmosteffectively.
  1. Looked After Children andother children in need
  1. In commonwithmost services inEngland,thereareparticulargroupsofchildrenwithhighlevels of needwhorequirespecialattention. Lookedafterchildrenareanimportantexample.ThereareexamplesintheUKofCAMHScreatingdedicatedpoststoworkcloselywithsocialservices to supportthesevulnerableyoungpeople(LearningfromtheCAMHSInnovationProjects2003).The Isle ofMan established a small,dedicatedservice in 2004. Theproposals in the2005SocialServicesBusinessPlan to developfosteringandreducethereliance on residential care aremorelikely to besuccessful given sufficient CAMHScapacity to supportthefosterchildrenandtheircarersinthecommunity. Thissubstantialinvestment in a fundamentalchange in policyforlookedafterchildrenrequiresjointinvestment to ensurethe level ofCAMH support whichiskey to theTreatmentFosterCaremodelbeingpiloted in England.

We recommend that there should be a joint appointment between children's

services and CAMHS to work directly with looked after children and to develop the mental health understanding and competence of their carers.

  1. This wouldbe a similararrangement to the joint appointmentwithYATwhichworkswell.We support theplansforfurtherinvestmentinthis work. Theearlierinterventionsthatthesearrangementsallowhavethepotential to reducetheloadattheheavier end oftheservice.
  2. Thechallengeofmeetingthementalhealthneedsofabusedandneglectedchildrenrequires a jointapproach from CAMHSandchildren'sservices. With a socialworker now in postthere is greatercapacity to addresssome of theseneeds,notleastbydevelopinganunderstanding of theremit of each agencyforthementalhealthofabusedchildren.
  1. Range of treatment modalities
  1. WeareconcernedthattheCAMHSteam is unable to offerthefullrangeoftreatmentmodalitiessuchas child psychotherapyandcreativetherapies,aswellas a sufficient cognitivebehaviouraltherapyandfamilytherapy.
  2. TheSEBDreportalsomentionedthe key role whichcanbeplayedbyfamilytherapyandthe limited provisionontheisland. Thesmallfamilytherapy clinic has a considerablewaiting list anduncertaintiesaboutaccommodation.
  3. Greaterintegration of thefamilytherapyservice could achieve a numberofbenefits;service users wouldhavereadyaccess in verysuitableaccommodation,andmore joint workandcasediscussion could lead to theenhancement of familytherapyskillsamongtheCAMHSteam. There could alsobebenefitsforimproveddatacollectionandadministrativesupport.Theextentofintegrationwouldbesubject to negotiationdepending on existing contractsandoptimumsupervisionarrangements.

We recommend that the family therapy clinic is based in Royde House which should help develop family therapy expertise amongst the staff and lead to a potential increase in capacity.

  1. Themakeup of thecurrentteamisunusualwith a greaterpreponderanceofnurses than would be expected in a similar-sizedteamonthemainland. This ispartlyforhistoricalreasonsasthisestablishmentisbased on thetimewhentherewereinpatientbedsbut no community service. Becauseoftheimportance of treatingquiteseriouslevels of mentalillness on the island, ifat all possible a strongcohort of nursesorotherswithcompetenceatworkingresidentiallyremainsnecessary.Infuturerecruitmentwerecommend that thepersonspecificationemphasises skills, forexamplecognitive-behaviouraltherapy(CBT),familytherapyorpsychotherapy,aswellashavinganappropriateprofessionalbackground. To achieve flexibility in having theskillbase to offer a full range of treatmentmodalities to families in Jersey, it is importantthattheCAMHSbudget is pooledunderoneheading except forspecifiedsharedposts. Suchanintegration of thebudgetwould help recruitmenttoanyfuturePrimaryMentalHealthWorkerpoststhat could attractnurses,socialworkers,orothermentalhealthprofessionals.
  1. School counsellors andPrimary Mental Health Workers
  1. The five schoolcounsellors aremaking a much-neededcontribution to CAMHS, filling – to some extent – thefeltgapbetweenschoolsandthespecialistteamandreferring on whennecessary. Thecounsellorsarevariouslyqualifiedandsomeareable to undertakesignificant pieces ofworkwithmentallydisorderedyoungpeoplewithsomesupervision from the child psychiatristandelsewhere,extendingthereach of CAMHSeffectively. Theyalsooffer support to theschool staff, workwithparentsasnecessaryand run groups. Integral to theirworkisliaisonwithotheragencies,mainlythroughtheMulti-AgencySupportTeams(MASTs),whichstrugglewithsocialworkrepresentation.Itisimportant that theMASTSarefullystaffed, including fillingthesocialworkposts,astheyprovide a safetynetandearlyidentificationfunctionfortroubledchildren.
  2. Wedetectedinsufficientsupervisory support forthecounsellorswhorequireopportunitiesforregulargroupandindividualsupervision. An earlyopportunity should besoughttoclarifytherespectivemanagementandsupervisoryrolesandresponsibilities of theagenciesinvolvedwith them.
  3. In viewofthispatternofdevelopment,thecounsellorshavebecomemorelikePrimaryMentalHealthWorkers. Whilstthepractitionersthemselvesare enjoying thisvariety,it is reducing theamountofcounsellingtimeavailable to pupils.Wesuggest,therefore,that two PrimaryMentalHealthWorkerpostsbecreatedasanintegralpartofthespecialistCAMHservice - linking withtheMASTsandthecounsellors,andabletoworkattheinterfacebetweenCAMHSandotherreferringagenciestomeettheunmetdemand. TheChildren's NSF andassociatedpolicysets a requirementforonesuchteamineverylocality(Children's NSF 2004andImprovement, Expansion and Reform 2002). ThesePrimaryMentalHealthWorkers,whomwerecommend should begeographicallybased,willlinkwiththeprimaryschoolsandnurseriesandofferadditionalsupporttoschools,groups,voluntaryandstatutoryagencies. Someschools like Mont à L'Abbéwithhighlevelsof need areoutsidethecurrentremitoftheschoolcounselling service. (Forfurtherinformationaboutthe role oftheChildPrimaryMentalHealthWorker see Gale et al,2004).

We recommend giving consideration to setting up bases out of St Helier such as with pathways and in outlying GP surgeries. The creation of primary mental health worker posts would provide a bridge between services at tiers 1 and 2/3.

  1. Minority Communities

7.7.1 The potentially different needs of the newer Jersey communities, most notably Portuguese and Polish residents, many of whom are unqualified in housing terms, should be considered. It would appear that these families are disproportionately disadvantaged and the children have a higher risk of mental disorder. Ethnicity data are not collected, and so we do not know how well founded is the concern expressed to YoungMinds that minority communities may not be finding it easy to access CAMHS.

If Primary Mental Health Worker posts are developed we recommend this as an opportunity, skills permitting, to recruit from a minority community.

  1. Tier 1 Needs
  1. Thereis a generalneedforgreatermentalhealthawarenessattier 1, amongstforexample youth workers,teachersandvoluntarysector staff. On thewholeschoolswereinvesting in thementalhealth/emotionalwell-beingoftheirpupilswithsomeprimaryschoolswanting to establishnurtureclasses to offersomesanctuary to troubledchildren. Fundswerenotavailableforthisdevelopmenthoweverandthereistheriskthatclassesmaybeestablishedwhicharenotable to followrigorouslytherecognisednurturepattern. WesuggestthattheStatesfunds a pilotnurtureclass,whichismonitoredby a multi-agency steering group including CAMHS,inorder to understandfullythenurture role andresourcerequirements(Boxall2003).

Infants

  1. Therearecurrently no plans to developaninfantmentalhealthservicewhichtend to bequiterareacrosstheUKbuthavesignificantbenefitsforfamilies,youngpeopleandcommunitiesat large. A virtual'teamisrequiredacrossprimarycareandCAMHSforinfants(YoungMinds2004,http://www.youngminds.org.uk/policy/documents.php). Thisisanarea that theStatesHealthandSocialServicesDirectoratemaywant to consider in future,especially in view oftheemergingevidencethatthe crucial developments taking place in the infant brain set a patternforfuturebehaviour(Balbernie2001).

Parenting

  1. TheparentingservicebasedatTheBridgedoes sterling workandis referred toby a rangeofotheragenciesaswellasofferingdirectaccesstoparents. We think itwouldbeveryhelpful to prioritiseparentingclassesforgroupsorfamilieswhosechildrenareatgreaterriskofdevelopingmentalhealthproblems,forexampleparents of learningdisabledchildrenandparentswithmentalhealthproblems.  
  2. TheBridgeitself is a significantprojectwithcapacity,providingresourcesforserviceco- ordinationaremaintained, to drawdisparateagenciestogethertoprovide a trulyseamlessserviceforthecommunity. ItisessentialthatCAMHSremainsinvolvedwiththisdevelopment,which could become a prototypeforsimilarventuresacrossthe island.

Young adults

  1. Currently16and 17 yearoldsareacceptedbyadultmentalhealthiftheyareout of educationandbyCAMHS if theyare in education.There is some flexibility, forexamplewithCAMHSmorelikely to workwithyoungpeoplewithdevelopmentaldisordersandadultmental health morelikely to seeyoungpeoplewithmajorpsychiatricdisorder. Whiletheeducationcriterionmayappear to provide a clear-cutdistinction, it iswidelyseenasconfusingbecausetheeducationalstatusofyoungpeopleisoftenunclearwhentheirlivesarein such turmoilas to require a referral to CAMHS.Werecommend that allyoungpeople up to their18thbirthdayarereferred to CAMHSwithinvolvement from adultmentalhealthasrequestedbyCAMHS. This is consistentwiththepolicyframeworks in England,ScotlandandWales. Theimplementation of thisrecommendationwillhaveresourceimplications,asCAMHSwillbeprimarilyresponsibleforanagegroupwherethereisincreasingprevalenceofseriousmental health disorders.
  1. Remit and Referral Criteria
  1. Oneofthestrongestmessagesfromourfieldworkwas that otherchildren'sservicesdonothave a clearidea of theremitofspecialistCAMHS,normuchbeyondanecdotalinformation of whattheydo.
  2. Thedecision in April2005tochangereferral criteria causedsomedisquietamongst fellow children'sservices. Thelettersannouncingthisdecisionwerebased on theunderstandable need to restrict demandtomorenearlymatchcurrentresourcelevels. The fall-out from theselettershashighlightedtheimportanceofconsultation on rolesandprioritieswithallstakeholders. Wehaveseen a CAMHSSpecificationsdocument,whichis a helpfulbeginning,but it appears to be a draftandwedonotknowwhether it has been subjecttoconsultation, approved anddisseminated.
  3. CAMHSaresubject to multipledemands,mostly in relation to seeingchildrenindividually or with theirfamilies. Referralscomefrommanydifferentsourceswithindifferent sectors. Only theCAMHserviceitselfhasanoverview of demand. Therearealsomultipledemands ranging fromrequestsfortraining on aspectsofchildren'smentalhealth(which is muchappreciatedbystakeholders), to membership of a projectgroup to ongoingconsultationandadvice on groups of childrenwithpotentialvery high levels of disturbance.Jugglingthesedemands can beachievedmoreeffectively if theremitforCAMHSisnegotiated,transparentandthereisfeedback on activity to referring agencies.

We recommend that the CAMH service consults on the draft specifications document and that it negotiates with its partners about reasonable expectations of feedback, both on an individual case basis with client consent, and about overall activity levels.

  1. It isnotonlyamongstpartneragenciesthatthereislittleawareness of whatCAMHSactually does.

We recommend that reporting mechanisms be established up to the Executive Board and three ministers. This should include activity information and an annual presentation to develop better understanding of CAMHS at the chief executive and ministerial level.

  1. ThereportbyDr.Geller(2006),writingonbehalfofTheCommunityChildren'sServices Steering Group, set outtheintentionforallchildren'sservices to bepathway-based',meaning that thefamily'sjourneyissupportedas they experience services through the provision of high quality care, delivered by teams which link together seamlessly to assure the best outcome for families using the services'.

We recommend that CAMHS be pro-active in the development of care pathways for specific conditions agreed with relevant stakeholders including families.

  1. DrLenton'sreport(2005) echoed theSEBDreport'sconcernsaboutmultipleandfragmentedinformationsystems. DrGellerstresses that information systems will be vital in delivering coordinated pathways of care'. As Jerseyhas such clearboundariesand a manageablenumber of children,itseemsthat it iswellplaced to developthesinglechildren'sinformationsystemthat is oneambition of EveryChildMattersonthemainland. (Forfurtherinformation,pleasesee http://www.camhs.org.uk/default.aspx?q=doas&c=2orhttp://www.everychildmatters.gov.uk/resources-and-practice/search/EP00037/). It is

beyond the brief of the YoungMinds team to comment on IT issues, but we would suggest that an island-wide system be established on the principle that the child and family are at the centre and design follows their needs, rather than design following organisation imperatives.

We recommend that this work be undertaken within the remit of the Children's Executive to ensure that it links closely to other work to implement the SEBD review. It is essential that the implementation of recommendations arising from this review takes place in tandem with the child health review.

  1. Effectiveness of cross-agency working arrangements
  1. Weheardofmanyexamples of goodjointworking on individualcasesatthefrontline. Staff frompartneragencies found co-working on casesparticularly effective, providingfamilieswith a multi-agencyco-ordinated service, aswellasstaffdevelopingCAMHSexpertiseandknowledgeof how partnerorganisationsoperate. Staff from otherservicesforchildrenappreciatedtrainingtheyhad received fromspecialistCAMHS.
  2. However on thewholewe found specialistCAMHS a ratherisolated service, with few formallinks to other services andwithtoolittleinformationdisseminatedaboutthework it does.Stakeholdersoftenmentionedtheimportance of CAMHSandcommentedpositively on particularclinicians,buttherewas no senseofCAMHSasanessentialcomponentof a system of children'sservices.We found anover-reliance on personalrelationshipsand a reluctance to formaliseinter-agencyworkingarrangements. It wouldnotbe cost effectivefor a jurisdictionlikeJersey to allocatesubstantialresources to thedevelopmentofprotocolsandinter-agencyagreementsbut,aswerecommend in paragraphs 7.1 and 7.2, there should be:

• Agreement about basic activity information necessary to inform stakeholders

• A negotiated agreement about the remit of CAMHS

• Care pathways for specific conditions agreed with relevant stakeholders including families.

  1. ThespecialistCAMHservicehasbecomeratherisolatedwithinsufficientunderstandingandappreciationofitsroleamongstotherchildren'sservices.HoweverthereareserviceswherelinkswithCAMHSaregood,andwherethere is a developedunderstandingofthecontributionCAMHS can makealongsideotherchildren's services. Thenursetherapist role intheYATis a goodexample. Wethinkthedefault'positionforanynewappointment is thatisshouldbe a sharedappointmentwithanotherchildren's service. This could rangefrom a jointlyfunded post withlocation spilt betweenRoydeHouseandanothercentreaccessedbythepublicforchildren'sservices,forexample a specialschool, to anentirelyhealthfundedpostwith a dedicatedoutreachcomponent. High prioritiesforsuchsharedappointmentswouldbe a mentalhealthspecialistforlookedafterchildren,PrimaryMentalHealthWorkersand a specialist in LearningDisabilitypart-locatedatMont à L'Abbé.
  1. Wedonot think theisolationfromchildren'sservicesis a functionofbeingmanagedwithinthementalhealthdirectorate as, untilrecently,CAMHSwaspart of children'sservices. WhereverCAMHSisplacedorganisationally,ithas to looktoadultmentalhealthandchildren'sservicesandlinkshave to bebuiltacrossorganisationaldivides. Wethinkthere is little merit in relocatingCAMHS in children'sservices.Timedevoted to majororganisationalupheavaltakestimeawayfromnegotiatingthetype of agreementsmentioned in 7.3.2above.
  2. FamiliesinparticularcommentedthatCAMHShadnotmade full use of informationabouttheirchildrenalreadyavailableatschool. It seemed thateducationpsychology in particular could bemoreclosely linked toCAMHSassessmentsandtreatment so thatthe child experiences a moreholistictreatmentpattern in schoolandathome.
  3. Therewassomefrustration in partneragenciesthattheydonotknowwhatishappening following a referraltoCAMHSandthat if theywerebetterinformedthey could bedoingmore to support a child'streatment.Therewasrecognitionabouttheimportanceofconfidentiality,butsometimesparentswere said towantmore joint workingandhad not beenaskedforpermission to shareinformation.

We recommend that an information-sharing protocol be developed between specialist CAMHS and their partners.

  1. ADHD Clinic

7.11.1 The ADHD clinic is currently run by CAMHS with careful assessment by the specialist nurse and consultant psychiatrist. This condition has such a major impact on a child's functioning in school we would see it as a golden opportunity for joint education/CAMHS activity, with education support workers and educational psychologists contributing to both the assessment and advice to teachers on management of these children. Such joint work could also have the benefit of improved consistency in managing the child's behaviour in school and at home. We also suggest that the prescription of medication be passed to GPs so that it is integrated with other aspects of health care, leaving the CAMHS team to focus on specialist techniques such as parent training courses.

  1. The arrangements for children with learning disabilities and mental health problems
  1. InJerseythereare a numberofservices that might help withthementalhealthproblemsof learning disabledchildren,forexampletheintensivesupport service, a hospitalpaediatrician,educationalpsychologyor specialist CAMHS.Weweretoldthat,althoughspecialistCAMHSdoes not officiallyseechildrenwithlearningdisabilities,individualcliniciansdoprovidetreatment. It wasbroadlyagreedthatchildren with learningdisabilities including autisticspectrumdisordersarelesswellserved.Servicesare in organisationalsilosanddo not wraparoundthechild. Thesmallnumberofspecialistswouldprovide a morefamily-friendlyserviceiftherewereclearpathwaysfor specific conditionsshowingthecontributiondifferentprofessionalsmake to the care ofchildren.
  2. Thesepathwaysshouldclearly show thepublic in Jersey how to access a service. Such a pathwaywillbebased on theprincipleoftheequal right of a disabled child to treatmentandsupersedethepresentinformalarrangementswherebysomechildrenappear to getinas a resultofspecialpleading.Thereappears to be a surprisinglevel of fragmentation,bearingin mind thatthe key playersknow each other. Amongsttheprofessionalsweinterviewedtherewasnot a shared view ofwhatwasanappropriatereferralforwhichservice. This mustmakeunderstandingthesystemverydifficultfor families.
  3. Thereis no sharedregisterofdisabledchildren,nor a sharedinformationsystem.Thenumbersofdisabledchildrenarequitesmallandmanyareknown to a smallnetwork of professionalsfrombirth,butthoseworkingwitholderchildrencommented that childrenwithSpecialEducationalNeeds (SEN) anddisabilitiescanfallthroughthenet.
  4. Thereis a limited communitypaediatricservicewithhealth visitors, partoftheFamilyNursingandHomeCare service, but no communitypaediatricians. Thismeansthatworkoftenundertakenbypaediatric services intheUKfalls to CAMHS.TheimplementationoftheYoungMinds review andtheoutcomesoftheconcurrent review ofpaediatric services should bedealtwithtogether.Thereis a shortfall in meeting thementalhealthneeds of disabledchildren. Addressingtheseneedshastobenegotiatedattheinterfaceof child health,specialeducationandCAMHS. Althoughourfocusis on childrenwith learning disabilitiesweheardconcernsaboutarrangementsforchildrenwithphysicalimpairmentswhoareathigherriskofdevelopingmentalhealthproblems.InJerseythereappearstobe a shortfallofclinicalpsychologyprovision that generallyhasspecificexpertiseindevelopmentaldelay.
  5. Thereissomeunmetneedforshort-termbreaksandafter-schoolprovisionforfamilies with disabled children. This isanissuebeyondthepreciseremit of ourproject,butis a likelysource of increasedpressure on families, depletingtheirownresilienceandincreasingthe likelihood thattheywillseekothersources of support.
  6. ThespecialistCAMHSteam is notcloselyinvolvedwithMont à L'Abbéschoolwithitspopulationofover90disabledchildren,many of whomhavehighlevels of emotionalandbehaviouraldisorders. A visitingconsultant clinical psychologistfromMadrid,DrPilarMartin,provideshighly valued expert advice in devisingandmonitoringbehaviourplansforchildrenwho on themainlandwouldoftenbein 39- or52-weekresidentialprovision.DrMartinwasintroduced to theschoolvia a parentsomeyearsagoandcomestoJerseyfourtimes a year,spendingaboutthreedays in theschool. Hercontractwitheducation is reportedlyratherfragileandliaisonwithherisratherhamperedbyherdomicile in Madrid.While it is a goodexampleofJersey'screative flexibility inresponse to particularneedatthespecialneedsschool, it doesnotpromote a holisticandco-ordinatedresponse to Jerseychildren.

We recommend a 'virtual team' model drawing on interested and appropriately skilled members of the specialist CAMHS, paediatricians, special needs service with close links to SEN, with consultation arrangements in due course on the mainland.

  1. This virtualteam should mapitsareasofexpertise,whichareconsiderable,developing a shortandlonger-termtraininganddevelopment plan toaddressidentifiedgaps. Thecomplexneedsteamis a commendableflexiblemulti-agencyresponse,butisfocused on complexneedsand so willnotincludemostlearningdisabledchildren.
  2. Whileweareclearthatservicesforchildrenwithlearningdisabilitiesarenotadequate,the detail ofplansforservicedevelopmentmusttakeaccountofthechildhealthreviewandbenegotiatedwith a numberofkeystakeholders,includingsocialservicesspecialneeds, clinical psychology,JerseyAutism,Mencapandspecialeducation, including theheadteacher of Mont à L'Abbé1.
  1. Current arrangements for intensive work, inpatient and residential care andon-callservices.
  1. Childrenandyoungpeoplewithmoreseriousmentalhealthproblems,forexample attempted suicide, received promptandresponsivesupportfromspecialistCAMHSwhen they werereferredbyaccidentandemergencyor a hospitalward. 
  2. HistoricallytherewasaninpatientunitonJersey,andwhenthis closed, childrenwho required admissionformentalhealthproblemswent to themainland. At onetimetherewerearrangementsforthem to beadmitted to anadolescentunitatSouthampton. Latertherewas a furtherarrangementwiththeMaudsleyHospital,SouthLondon. Neitherofthese proved satisfactory,becauseofeitherthedifficulties in obtaining a promptresponseto a requestforadmissionorthe clinical outcome,andthechildrenandtheirfamilies found thelengthyseparationdifficultandcounterproductive.
  3. MorerecentlytheCAMHSteam,with support from theMentalHealthDirectorate,hasdeveloped a moreinnovativeanduser-friendlyapproach.At a timewhentheintensityandrangeof a child'sdifficultieswouldseem to warrantadmission, a personalisedpackageof care isdevisedthatcanbedeliveredatanappropriate location: thefamilyhome,children's ward or a slightly separatearea of theadult mental healthadmissionward.Thesearrangementsare rated a successbytheprofessionalsandbyfamilies,andadmissions to themainlandhavedecreaseddramatically,excepton rare occasionswhen a highlyspecialisedassessmentisrequired.
  4. This workdoeshave a significantimpact on theroutineCAMHSworkload,astheconsultantandnursingteamneed to puttimeasidefromregularcommitments to providetheintensivepackage.Thesuccessofthesepackagesisdependent on flexibleandspeedychangesinworkingpracticewithadditionalnurseinputfromadultmentalhealth. So far, they havebeen required aboutthreeorfourtimes a year; it isdifficult to see howtheservicewouldcope if morethanone child atanyonetimeneededsuch a package.It is notclearhowthisworkis reflected inactivitydata;itseems to besubsumedunderroutineclinicattendances if it appearsatall.Sincethesepackagesareresource-hungryandrepresent a substantial financial saving, wewouldsuggestthattheyareloggedmoreclearly.Theyare a significant

1 Jersey is not alone in providing insufficient mental health services for families with learning disabled children. In England, the Department of Health is monitoring progress towards the Public Service Agreement for access to

comprehensive CAMHS by the end of 2006. Three proxy indicators have been selected as being representative of progress towards a comprehensive CAMHS as defined in the Children's National Service Framework. The percentage of Primary Care Trusts that were commissioning these services for autumn 2005 was: 24/7 emergency service - 81.2%, CAMHS for those with a Learning Disability - 49.8% and service for 16/17 year olds - 71.9%.

extra duty for the consultant who is already over-performing in terms of routine outpatient attendances and we consider that they add to the case for a second consultant; it would be impossible to deliver an intensive package if the consultant were on leave.

We recommend that a second consultant be appointed to focus on intensive services.

  1. Theon-callserviceisanessentialelement of anintensivepackage;howeverwearenot convinced thatit is well used ornecessaryon a routinebasis.Other island communitiesthatwehaveheardaboutdo not offeron-callbyCAMHSandwewouldquestionwhetherthisis a gooduseof limited resources. Werecognisethathavinganout-of-hoursservice is anessentialcomponentofthecomprehensiveserviceenvisagedbytheChildren's NSF onthemainland,butwearemindful of the need toconsidertheapplicabilityoftheNSF in relation to demandsarisingfrom a communitythesizeofJersey.
  2. A secureresidentialresourceiscurrentlybeingdevelopedbySocialServices to provideeightbedsforchildrenwhowillpresumablyhavechallengingbehaviourandarelikely to have a numberofco-morbidmentalhealthproblems.Psychiatricnurseinputisenvisagedforthis unit. It is not clear how itwillimpactontheuseofintensivepackages of mentalhealthcareandthe need forconsultantpsychiatristinput,butthelattermaywellincrease. Neverthelesssomeadmissionsoff-islandmaysometimesbenecessary.
  3. Theestablishmentofaneatingdisorderteamonthe island hashad a significantimpactonthe need forhospitaladmissionforbothadultsandchildren,with a markedreduction on thepaediatricward.
  1. Involvement of service users
  1. Againincommonwithmanymainlandservices,inJerseythereis no systemforgatheringuserfeedbackabouttheirexperience,noranyuserinvolvement in planningservicedevelopment. The client satisfactionquestionnaire in 2002was a goodbut isolated exercise. In EnglandtheHealthCareCommission is expecting to see evidence of userfeedback in allitsserviceimprovement reviews. TheNSF(DepartmentofHealth,2004)descriptionof a comprehensiveservicestates that delivery of services should be informed by a multi- agency assessment of need which incorporates (among other things) the views of all stakeholder including those of children, young people and their families'.

We recommend that feedback forms be routinely issued and followed up, collated and including in audit and any service review.  They should be analysed away from Royde House if at all possible.

We recommend the forms be developed in association with users and with the voluntary sector.

  1. Werecommendthatat each stageofservicedevelopmentthequestionof how best to elicitserviceuserviews is considered.Thereis a numberofwaysofdoing this, from exit questionnaires to fullysupporteduserplanninggroupsthatare a sustainablepartoftheannualplanninground.
  1. Governance
  1. ProfessionalsinJersey in generalhavemoreautonomyandarelessaccountable.Theyhavemorepower to respondflexibly to needsastheirprofessionaljudgementdirects. OurimpressionisthatthereforeservicesinJerseyaremorevariable,sometimesbetterandsometimesnot.Thereisanabsenceofsystems to identifyandlever up lowstandards. Governancearrangementscaused us someconcern in a servicemore than usuallyfacedwith risks associatedwithisolation.
  2. DrGeller'sreport on child healthmakesreference to governanceandthe need forrobustclinicalandmanagerialarrangements. Sheidentifies a needforcontinuousimprovementingovernancewhich,drawing on SimonLenton'swork(2005),isdescribedasdoingthe right things, intherightway,tothe right people,atthe right time,withanoptimaloutcome.  
  1. Supervision

7.16.1 Supervision arrangements appear informal and occasional, rather than systematic and rigorous. It seems that some cases drift without clear plans for their conclusion or review. This is probably masking a poor use of resources and is potentially dangerous.

  1. Audit
  1. Perhapsbecause of theabsenceofkeystaffoverthelastyearthefocusonauditappears to haveslippedback. Wehave read theSuicidePreventionandCarePathwayAudit(2004),whichwas a thoroughexaminationofpractice including localanalysis,nationalinformationandserviceuserviews.Wehavealso read the following audits:schoolcounselling(2004), feeding clinicaudit(2004)andcaseauditevaluation2002(?).
  2. Thelackofrigorousclinicalauditallowsdifferentapproaches to beusedbydifferentpractitionersforthesamedisorders. Wethink a programmeofbothcaseandclinicalaudit should beestablished covering theworkofallmembers of theteam so that reviewing practicebecomesroutine.
  3. TheHealth of theNationOutcomeScaleforChildrenandAdolescents(HoNOSCA)wasintroducedfrom 1 March 2003, but it hasnotbeenpossible to presentanyoutcomeHoNOSCAdataforthisreview. Theprocessesofinternalauditandexternalaccountability would begreatlyassistedbytheuse of HoNOSCAdata.
  1. External reviews

7.18.1 External reviews do not happen regularly and cannot be a comprehensive means of ensuring effectiveness of service, especially when the review is relatively brief and the reviewers have little data to rely on, for example samples of user views, copies of recent audits, management information data, HoNOSCA scores. Unlike the Isle of Man, Jersey has been fortunate not to have experienced a tragic case leading to a high-level review that would delve in detail into services caring for children. The lack of robust governance arrangements would leave Jersey vulnerable to criticism should such a situation arise.

We recommend a systematic approach to supervision, case and clinical audit, and external review.

  1. Staffing and Training
  1. Activitydatadoes not appear to be routinely availableforthespecialistteamanddoesnotappear to give a fullpicture of theworkofthespecialistteam.
  2. Somethoughtneeds to begiven to theoptimumbalancebetweenclinical,managerialandadministrativetime in thespecialistteam.Aswehave said above,ourreviewhasunfortunatelytakenplaceat a timewhentheteammanagerwhohasbeenoncompassionateleave so theseissues could notbediscussed. Wearemakingrecommendationsabout improved managementinformation,audit,andinter-agencyworkingbutitis not clear to us given thestaffworkingatthetime of ourreviewwhowouldhavethecapacityandauthority to driveforwardthenecessarywork. In theIsleofMantheCAMHSmanagerpostprovidescapacity to undertakemanagerialtaskswithout taking away from clinical time.
  1. Role of consultant psychiatrist

7.20.1 There is a danger of the consultant child psychiatrist being over-stretched. She is required to represent the service, to provide advice and consultation, sit on working parties and act in a management role as well as see children referred as soon as possible. Dr Coverley does undertake some continuing professional development and has met the requirements of the Royal College of Psychiatrists in this respect. Some peer supervision is provided by meeting with colleagues in Guernsey on a roughly quarterly basis. We would like to see enhanced opportunities for peer supervision and consultation. There do not appear to be opportunities for teaching or research. We would advise senior management within the Directorate to review the consultant job plan as a matter of urgency.  

  1. Training
  1. Itseems to usself-evidentthatanisolatedservice should investmorethanmost in traininganddevelopmentof staff. Jerseydoesnothaveanabundanceofavailable staff to fill posts in children's services andanadditionalcommitment to training isnecessaryifhighpublicexpectationsare to be met. Bearing inmindthesefactorsparticulartoJersey,weweredisappointedattheapparentlackofpriorityfor training andknowledge of theavailablebudget. Theadditionalcompetenceandconfidencewhichwould follow fromfurtherpost- qualification training wouldallow a moreequitabledivisionofresponsibilitieswithinthespecialistteam.
  2. The Training Policy(dated 20 June2002)andtheannual training plan' should beupdatedassoonaspossibleandbethebasisfor a realistictrainingbid in nextyear'sbudget.Thepossibilitiesforre-allocatingmoneythisyearintothe training budgetshouldbeinvestigated.Wewouldsuggestthatthepolicyisrevised to give fuller recognition to theimportanceof training foran island community. The sort ofchangewesuggestisneededisillustrated in the following revisionofparagraph 1 (suggestednewtext in bold type):

In order to provide a high quality efficient service, team members would be expected are required to continue with their professional development, and will be expected be involved in training and attend conferences to enhance the service. Training is an essential activity to offset the dangers of isolation inherent in working in an island community'.

  1. Role of voluntary sector

7.22.1 Autism Jersey is good example of the voluntary sector developing services to promote children's mental health. Voluntary organisations can attract resources, both human and financial, which are not available to statutory services. This might offer a more rapid route for developing the range of services available to children than a total reliance on States funding. The importance of the sector in advocating on behalf of children should be recognised, given the lack of a children's commissioner, a post that we do not think could be justified in a community the size of Jersey.

We recommend that CAMHS recognises the role and strengthens the contribution of the voluntary sector by:

• Supporting existing voluntary organisations (the ADHD group is a good example) and recognising the contribution made by the Brook counselling service, Minden Base and the NSPCC Pathways project.

• Considering which other voluntary bodies could be encouraged to make a positive contribution to the mental health of the children of Jersey, for example school- based programmes like Pyramid and Place to Be, and organisations which offer cognitive-behavioural therapy.

• Appreciating and strengthening where possible the sector's advocacy role.

APPENDIX A: MODEL OF TIERS

Taken from Department of Health (2004) National Service Framework for Children, Young People and Maternity Services, the Mental Health and Psychological Well-being of Children and Young People, pgs 46-47.

The Four Tier Strategic Framework

 

Tier

Professionals Providing the Service Include

Function/Service

Tier 1

A primary level of care

GPs

Health visitors

School nurses

Social workers Teachers

Juvenile justice workers Voluntary agencies Social Services

CAMHS at this level are provided by professionals working in universal services who are in a position to:

Identify mental health problems early in their development

Offer general advice

Pursue opportunities for mental health promotion and prevention

Tier 2

A level of service provided by uni- professional groups which relate to each other through a network rather than a team

Clinical child psychologists Paediatricians (especially community)

Educational psychologists

Child & adolescent psychiatrists

Community nurses/nurse specialists

CAMHS professionals should be able to offer:

Training and consultation to other professionals (who might be within Tier 1)

Consultation to professionals and families

Outreach

Assessment

Tier 3

A specialised service for more severe, complex or persistent disorders

Child & adolescent psychiatrists Clinical child psychologists Nurses (community or inpatient) Child psychotherapists Occupational therapists

Speech and language therapists Art, music and drama therapists

Services offer:

Assessment and treatment Assessment for referrals to Tier 4 Contributions to the services, consultation and training at Tiers

1 and 2.

Tier 4

Essential tiertiary level services such as day units, highly specialised outpatient teams and inpatient units

Child and adolescent inpatient units

Secure forensic units Eating disorders units

Specialist teams (e.g. for sexual abuse)

Specialist teams for neuro- psychiatric problems

APPENDIX B: MATRIX OF PEOPLE SEEN

 

Sector

Frontline

Managers/ Directors/ Heads

Health

13

5

Education

4

15

Social Services

2

7

Users, Carers, Voluntary

15 +2

 

Others

1

1

Total number of people seen = 65.

APPENDIX C: COMPREHENSIVE CAMHS

Taken from Department of Health (2004) National Service Framework for Children, Young People and Maternity Services, the Mental Health and Psychological Well-being of Children and Young People, pgs 48-52.

Appendix 2: A Comprehensive CAMHS

Improvement, Expansion and Reform has set the expectation that a comprehensive child and adolescent mental health service (CAMHS) will be available in all areas by 2006. This means that in any locality, there is clarity about how the full range of users' needs are to be met, whether it be the provision of advice for minor problems or the arrangements for admitting to hospital a young person with serious mental illness. This is reiterated in National Standards, Local Action, which sets out the priorities for 2005/06-2007/08 for the NHS, and emphasises the need to maintain the levels of service achieved through the 2003-06 planning round.

Clear pathways should be set out to show how the range of mental health needs of children and young people will be met, whether from within services whose prime purpose is to deliver mental health care or from other services with a different primary function. This will not necessarily mean that all services will be in their final configuration or available in every locality by 2006. Where local provision is not appropriate or possible, commissioners will need to set out the collaborative arrangements that will ensure that there is an agreed care pathway to meet the specific needs from an alternative service. Further improvements and developments will be required throughout the lifetime of the National Service Framework implementation to extend the range of services provided and ensure the highest standards of care. The aspiration should be to continually improve and develop the services in the context of multi-agency partnerships across the spectrum of need, and informed by the best available evidence.

A comprehensive service in practice

Commissioners will require a clear definition and description of a comprehensive CAMHS. This can be set out under a number of separate headings:

Underpinning Principles:

>Access to CAMHS should be available to all children and young people regardless of their age, gender, race, religion, ability, class, culture, ethnicity or sexuality.

>Effective CAMHS commissioning is a multi-agency activity and requires that the commissioners have the requisite skills, knowledge, time and executive authority to undertake the task.

>Both the commissioning and delivery of services should be informed by a multi- agency assessment of need that is updated regularly. This needs to incorporate:

- Locally adjusted epidemiological information on the prevalence of children's mental health problems to reflect the diversity of the population and other local demographic circumstances.

- An assessment of the needs of particular groups of children and young people in the locality who are vulnerable or at risk

- An audit of services currently provided by all agencies that address both directly and indirectly the mental health needs of children and young people.

- An analysis of current service usage.

- The views of all stakeholders including those of the children, young people and families.

- The available evidence of the efficacy and effectiveness of interventions and service models.

- Current national and local policy priorities.

>Services should be commissioned to ensure that the workforce is of sufficient critical mass to have the capability to meet the range of defined needs safely, effectively and efficiently.

Range of Services:

>The range of services and their settings should reflect the specific needs:

- Related to the age of children and young people using the service

- Related to the circumstances of the child, particularly if they may affect access to services

- Associated with the presence of a learning disability.

>Arrangements should be in place to ensure that 24 hour cover is provided to meet urgent needs and a specialist mental health assessment should be undertaken within 24 hours or during the next working day.

>There needs to be a balance of service provision in order that all levels of need can be met as required:

- Within primary level services (Tier 1), those in contact with children need to be able to have sufficient knowledge of children's mental health to be able to: identify those who need help; offer advice and support to those with mild or minor problems; and have sufficient knowledge of specialist services to be able to refer on appropriately when necessary.

- Child mental health workers (Tier 2) need to be available to support, train, liaise with, consult to and provide direct work with other agencies providing services for children.

- Specialist multidisciplinary teams in all localities should be able to provide:

• Specialist assessment and treatment services

• Services for the full range of mental disorders in conjunction with other agencies as appropriate.

• A mix of short term and long term interventions and care according to levels of complexity, co-morbidity and chronicity.

• A full range of evidence-based treatments;

• Specialist services that are commissioned on a regional or multi-district basis, including in-patient care.

Workforce and Skills:

>The professional mix within specialist services and teams should be balanced to ensure the availability of an appropriate representation of skills, in particular, professional and team isolation should be avoided in all services.

>Staff have the skills, competencies and capabilities that are necessary. All services should ensure they can:

- Work across agency boundaries and within a variety of settings;

- Engage children, young people and their families who have difficulty accessing services.

- Deliver interventions based on the best available evidence.

>Services require management expertise with sufficient knowledge, understanding and executive authority to be able to support the effective and efficient multi- agency delivery of CAMHS.

>The administrative workforce should be sufficient to ensure that all necessary administrative functions, including data collection, can be fulfilled.

>Commissioners in conjunction with specialist providers should support the development of CAMH expertise within all children's agencies.

Training and development:

>Clear supervisory arrangements and structures should be in place to ensure accountable and safe service delivery.

>Multi-professional training and consultative work, undertaken both within and across agencies, is essential.

>The necessary resources to support the training and development requirements of the CAMHS workforce should be available.

Organisational arrangements:

>Agreed protocols should be in place to manage waiting lists and times according to need. >Services should be accommodated in buildings fit for supporting all the expected functions.

>Where services are located in non-CAMHS dedicated community settings (e.g. schools), arrangements should be made to provide suitable accommodation for supporting service delivery.

>The equipment and accommodation used for direct work with children should ensure that children's safety is of paramount concern.

>IT resources and equipment to support high quality care and the monitoring and evaluation of services should be available in all appropriate settings.

>Where interfaces exist between services, as between adult and children's mental health services, arrangements should be negotiated to ensure clarity and effectiveness of separate and joint service responsibilities and smooth transitions of care.

>Where service delivery demands effective partnerships between agencies (e.g. children and young people with complex, persistent and severe behavioural disorders) joint protocols should be agreed at senior officer level between the NHS, social services and education.

>Clinical governance arrangements should ensure that all staff are trained, supported and able to deliver sound, ethical and safe services.

APPENDIX D: CONTRIBUTORS  

 

First Name

Surname

Area/Title

Philip

Anderson

Deputy Head, Hautlieu School

Marnie

Baudains

Directorate Manager: Social Services

Barbara

Bell

Clinical Governance & Performance Manager

John

Birtwhistle

Prinicpal Educational Psychologist (retired)

Grant

Blackwell

Manager, Youth Action Team

Dr Gil

Blackwood

Consultant Psychiatrist

Richard

Boak

Speech & Language Therapist

Darren

Bowring

Coordinator: Intensive Support

Sarah

Briggs

Rouge Bouillon Primary School

Margaret

Brown

Educational Psychologist

Ann

Campion

CAMHS Nurse

Janet

Clark

CAMHS Nurse

Brenda

Cochrane

Senior Educational Welfare Office

Shirley

Costigan

Youth Service

Janet

Coutts

CAMHS Nurse

Dr Carolyn

Coverley

Consultant Child & Adolescent Psychiatrist

Ann

Curzons

Head Teacher, D'Auvergne School

Hazel

Delucci

Health Visitor

Phil

Dennett

Service Coordinator, Children's Executive

Laura

Dicker

NSPCC

Shirley

Dimaro

Senior School Nurse: FNHC

Linda

Dodds

Manager: Assessment & Child Protection Team

Chris

Dunne

Manager: H&SS, Special Needs Service

Ian

Dyer

Directorate Manager, Mental Health

Sharon

Eddie

Head Teacher, Mont à L'Abbé School

Jill

Fa

Dietician, H&SS

Cheryl

Findlay

CAMHS Nurse

Jane

Finlay

Clinical Manager, Alcohol & Drug Service

Jo

Forrest

Principal Educational Psychologist

Vicki

Frederick

Attendance Officer, Haute Vallée School

Michael

Gafoor

Alcohol & Drug Service

Steve

Guy-Gibbens

Prison Governor

Dr Dale

Harris on

Consultant Psychiatrist

Andrew

Heaven

Senior Health Promotion Officer

Rosemary

Hill

Beaulieu Convent

Di

Hooper

Head Teacher, St Martins Primary School

Nola

Hopkins

Manager, Pathways, NSPCC

Wendy

Hurford

Coordinator, The Bridge

Andrew

Kawalek

Educational Psychologist

Nikki

Kelly

School Counsellor, Haute Vallée School

Ann

Kelly

Modern Matron Paediatrics

Joe

Kennedy

Manager: Residential Units, Children's Executive

Martin

Knight

Health Promotion Officer: Sexual Health

Phil

le Claire

Autism Jersey

Carole

Le Cocq

Deputy Head, Haute Vallée School

Nicky

Le Conte

CAMHS Nurse

Karen

Le Mouton

Head of Statementing & Pupil Support

Tony

Le Sueur

Service Manager, Children's Services

Marie

Leeming

Modern Matron, Mental Health

Bronia

Lever

Jersey Brook

Tina

Levesley

School Counsellor: Les Quennevais School

Mario

Lundy

Assistant Director: Schools & Colleges

Tim

Malpas

Consultant Paediatrician

Kevin

Mansell

Head Teacher for Alternative Provision, Greenfields

Charlotte

Martin

Head Teacher, Jersey College for Girls

Rob

Matthews

D'Huatree House School

Sharon

McClelland

School Nurse, Mont à L'Abbé School

Katherine

McGovern

CAMHS Social Worker

Heather

McLelland

Autism Jersey

Jeannie

Moiani

Director: Student Support, Grainville School

Michael

Moretta

De la Salle College

Miriam

Morrison

Student Support, Victoria College

Gill

Marsden

Deputy Head, D'Auvergne School

Lisa

Perkins

Speech & Language Therapist

Mike

Pollard

Chief Executive

Pauline

Rapson

Health Visitor

Sarah

Reeves

Clinical Psychologist

Chris

Rogers

Head Teacher, St James School

Karen

Rooney

School Counsellor: Le Rocquier

Dr John

Sharkey

Consultant Psychiatrist

Anton

Skinner

Director, Focus on Mental Health

James

Speight

Head Teacher, Rouge Bouillon Primary School

Mike

Swain

CAMHS Nurse

Annette

Temperton

SEBD/ENCO, Haute Vallée School

Patricia

Tumelty

Parenting Support, ESC

Annette

Urry

Occupational Therapy

Dr Tracy

Wade

Consultant Clinical Psychologist

Jim

Ward

Community & Day Services Manager

Mark

Warr en

Forensic & Challenging Behaviour Team

Lorraine

Wells

Eating Disorders Team

Danny

Wherry

Manager: Placement & Support

NB We have not named the 15 service users who contributed to the review.

APPENDIX E: REFERENCES AND SOURCES

Balbernie, R (2001) Circuits and Circumstances: the neurobiological consequences of early relationship experiences and how they shape later behaviour. Journal of Child Psychotherapy. New York: NY Basic Books

Boxall M. (2003) Nurture Groups in School: principles and practice, London. Paul Chapman Publishing

Bull K, (2002) Review of Principles, Practices and Provision for Children and Young People with Emotional and Behavioural Difficulties and Disorders in the Island of Jersey

Collishaw S, Maughan B, Goodman R, Pickles A, (2004) Time trends in adolescent mental health, Journal of Child Psychology and Psychiatry, 45 (8), pp. 1350-1362.

Department for Education and Skills (2003), Every Child Matters. London, The Stationery Office.

Department of Health (2004) National Service Framework for Children, Young People and Maternity Services, the Mental Health and Psychological Well-being of Children and Young People.

Department of Health (1999) The National Service Framework for Mental Health: modern standards and service models. London: Department of Health.

Department of Health (2006) Child Health and Maternity E-Bulletin, February 2006.

Gale F, Dover S, Edwards J, Anne Flemming A. (2004) On behalf of the national (UK) committee for primary mental health workers in CAMHS and National CAMHS Support Service. The role of the child primary mental health worker. London. Department of Health

Green, H., Aine, M., Meltzer, H. et al. (2005). Mental health of children and young people in Great Britain 2004. London: Palgrave.

Kennedy P. (July 2003) Views of future for adult mental health services in Jersey

Kurtz, Z. and James, C. (2002) What's New: Learning from the CAMHS Innovation Projects (report to Department of Health).

Lamb, C. Building and Sustaining Specialist CAMHS, Consultation Paper on Workforce, Edited by Anne York, Child and Adolescence Faculty, Royal College of Psychiatrists. Unpublished paper, 2005.

Lenton S. (October 2005), Imagining the Future: Improving health services for children and families in Jersey, a discussion paper.

Meltzer, H., Gatward, R., Goodman, R., et al. (2000). The Mental health of children and adolescents in Great Britain. London: Stationery Office.

Meltzer H, Gatward R, Corbin T, Goodman, R, and Ford T, (2003), Persistence, onset, risk factors and outcomes of childhood mental disorders, The Stationery Office.

Meltzer et al (2004) Mental Health of Children and Young People in Great Britain. London: The Stationery Office

Phillips, S. (2004) Suicide prevention and Care Pathway Audit. States of Jersey (2005a), Strategic Plan.

States of Jersey (2005b), Heath and Social Services, Business Plan.

States of Jersey (May 2005), Substance misuse treatment pathways, service specification. Street C, Herts B; (2005); Putting Participation into practice. London: YoungMinds.

Tough, S (1998), Common assessment and the lead professional. Telford & Wrekin Borough Council. See http://www.everychildmatters.gov.uk/resources-and-practice/search/EP00037/

Wolpert, M. (2005), Do Once and Share CAMHS Initiatives, See National CAMHS Support Service web site - http://www.camhs.org.uk/default.aspx?q=doas&c=2

YoungMinds (2004) Mental Health in Infancy. London: YoungMinds

YoungMinds (2003) Mental Health Services for Adolescents and Young Adults. London: YoungMinds

Other documents from Jersey CAMHS:

ADHD report, undated

CAMHS A&E Audit 2001–2003

Case audit evaluation, 2002(?) Client satisfaction 2002

Feeding clinic audit, 2004

School counselling audit, 2004 2001–05 demand, proposal for ISTT.

Recent News

New report raises concerns over lack of Government strategy for declining use of cash in Jersey 4 February 2025
States Meeting summary: 4-5 February 4 February 2025
Public Accounts Committee hears evidence from business leaders on Government procurement 31 January 2025

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