Independent Oversight and Assurance Group on Tayside's Mental Health Services

Children and Young People's Services Work Plan

Recommendation 33

Focus on developing strategies for prevention, social support and early intervention for young people experiencing mental ill-health in the community, co-produced with third sector agencies.

Context of Oversight Group assessment: Are children and young people in the community getting the right support, in the right place, at the right time? Are more serious mental health problems in children and young people being prevented, through effective early intervention and prevention? This recommendation calls for children and young people to be able to receive good emotional and wellbeing support.

342. Connected Tayside: an emotional health and wellbeing strategy for children and young people (2020-2023) sets out how partners intend to deliver on that for Tayside's children. The strategy recognises that the needs of children and young people will "not be met solely by the skill and expertise which tests within clinical settings and consulting rooms" but will need all of the resources and supports which sit within communities to be activated and fully engaged. So, this recommendation goes beyond Child and Adolescent Mental Health Services: it requires the service to work alongside partners and listen to the voices of children and young people, so that they better understand their lives and the support they need.

343. We were impressed by the approach Tayside has taken to the planning of services for children and young people and that they had aligned this to the Tayside Regional Improvement Collaborative.

344. Between Connected Tayside and Living Life Well, a wide range of actions are proposed involving universal services, Child and Adolescent Mental Health Services, Neurodevelopment Needs Pathway, Psychological Therapies, and Transitions.

345. The pandemic has undoubtedly had an impact on the extent to which partners have been able to advance these plans. There is a need to 'take-stock' to establish the current position. It will also be important for partners to take the opportunity to review the effectiveness of current action plans in terms of delivering on their intended outcomes, taking account of rising demand for both universal and more specialist targeted mental health support.

346. We have also been impressed by what we have seen and heard about the work of Child and Adolescent Mental Health Services: some of it we believe to be of national significance. We say more about this in our assessment of responses to later recommendations.

347. However, we also think there is a need for Child and Adolescent Mental Health Services to reconnect and re-establish relationships with some third sector organisations and community partners, to ensure that opportunities for early intervention and local support for children and young people, are fully maximised.

348. In summary, Tayside has put in place what should be effective arrangements for the planning and the delivery for children and young people services. It is commendable that Connected Tayside was launched during the pandemic, and we recognise that this had a consequential impact on the progress Tayside has been able to make. We have not seen data to indicate that children and young people are getting the help when they need it or that more serious mental ill health conditions are being prevented. It will be important for Tayside to be able to evidence and report, and to take assurance that the actions they are taking, are delivering the outcomes they want to see.

349. While there is always more to do to ensure that children and young people get the support they need, when they need it, the Oversight Group has assessed this RAG status as Green.

Recommendation 34

Ensure that rejected referrals to Child and Adolescent Mental Health Services are communicated to the referrer with a clear indication as to why the referral has been rejected, and what options the referrer now has in supporting the patient.

Context of Oversight Group assessment: That children and young people get the support they need, when they need it, and that there is a reduction in the number of rejected referrals. As a consequence, the resources required for processing and audit should be reduced.

350. Tayside's Mental Health Strategy, Living Life Well, published in February 2021, reported that there had been a 22% increase in referrals to specialist services over the last 5 years, with an increase of 24% in the number of rejected referrals, during that same time.

351. The Independent Inquiry highlighted the problems caused by the number of rejected referrals and expressed concern over the resources that were being expended to manage and audit them, making the point that care needed to be taken to ensure that such resources could not be better used to assess a child instead.

352. The approach taken by Child and Adolescent Mental Health Services in response has been both thorough and proactive. This has included the development of new guidance for those referring to Child and Adolescent Mental Health Services and new communication processes for referrals that require redirection.

353. The development of the Young Person's Triage Service seeks to increase multi-disciplinary involvement around GP clusters at the point of assessment and prior to referral. The aim is to reduce the number of rejected referrals and maximise the opportunity for children and young people to be put in touch with the most suitable support, including third sector and community support. We are to understand that in circumstances where a referral is rejected, an individual letter is issued. It will be important for CAMHS to assure themselves that such communications are well received and understood and helping to ensure children and young people get the support they need.

354. A phased implementation plan for this new service is being taken forward. Recruitment is underway and once completed, the service will be operational in all GP clusters across Tayside.

355. These are early days, however, we are told results are encouraging with feedback from GPs indicating rejected referrals are less of an issue. We are to understand that CAMHS are gathering local data so that they are able to evidence children and young people are getting the right support at the right time. This is a significant development in terms of Child and Adolescent Mental Health Services but also services for children and young people, as set out within Connected Tayside. We consider Tayside Executive Partners, in terms of their wider collective leadership role, will wish to be assured that robust arrangements are in place for the collection and analysis of data and reporting of performance. We have RAG rated this recommendation as Green.

Recommendation 35

Ensure the creation of the Neurodevelopmental Hub includes a clear pathway for treatment with the co-working of staff from across the various disciplines not obfuscating the patient journey. The interdisciplinary nature of the Hub may give rise to confused reporting lines and line management structures/governance issues. A whole system approach must be clarified from the outset.

Context of Oversight Group assessment: We requested that Tayside Executive Partners' final submission provide a detailed timeline for completion of this pathway. Successful implementation of this service and pathway was expected by Tayside to see a reduction in the number of complaints received, pointing to robust arrangements in place for complaint handling and learning.

356. In June 2021, NHS Tayside Health Board were advised that 'neurodevelopment and mental health cross-over pathways have been implemented' and that this recommendation was RAG rated Green. This was subsequently downgraded by Tayside Executive Partners to Amber in November 2021, and they have reported to the Oversight Group in their final submission that the actions they have taken to date on this recommendation are not going to achieve the intended outcome.

357. It should be noted that in the Health Board's Covid Remobilisation Plan in September 2021 and in their second quarterly progress report to Scottish Government for their Annual Development Plan (as at September 2022), NHS Tayside RAG rate themselves as Red in relation to the development of a Neurodevelopmental Hub and/or pathway. Tayside Executive Partners have advised that there has been a different RAG rating system used in respect of Trust and Respect to that which they've used elsewhere. Regardless of the different RAG rating systems, the Oversight Group's view remains that plans require to be revisited and reset in a way that is open and transparent.

358. In the proposed further actions contained within their final submission, Tayside Executive Partners indicate that:

• A Neurodevelopmental Service Redesign and Waiting Time Management Improvement Initiative has been developed;
• Children and Adolescent Mental Health Services Workforce Plans are being developed to improve capacity and capability;
• Neurodevelopmental performance monitoring measures have been established
• A coordinator has been appointed to 'drive these improvements';
• Further discussions will take place regarding resourcing to fully implement the designed model.

359. We commend the Tayside Executive Partners for their candour in respect of their assessment. However, we find it difficult to understand what the 'urgent remedial action' is, that is being taken. From all that we have seen, we think there is a need to reset their forward plans and Tayside Executive Partners should assure themselves that this is progressed by the appropriate authority. We have RAG rated this recommendation Red.

Recommendation 36

Clarify clinical governance accountability for Child and Adolescent Mental Health Services.

Context of Oversight Group assessment: That arrangements are in place to provide clear and effective clinical governance for CAMHS.

360. Child and Adolescent Mental Health Services are positioned managerially within the Women, Children and Families Division of NHS Tayside. The Independent Inquiry in 2020 highlighted that Child and Adolescent Mental Health Services being located in another directorate from Mental Health had raised issues in the past, along with concerns over staff within the service not having access to the provision of professional support.

361. Tayside Executive Partners report on a wide range of actions taken to address matters. Staff now have access to professional support from Mental Health - for leadership supervision and there are established links though governance frameworks (dual reporting). New management structures support these professional connections, with new Nurse Lead and Senior Nurse roles, who have linkages with professional supervision from Mental Health as do medical and psychological staff.

362. Meetings take place in a monthly basis with meetings summaries being published within the Child and Adolescent Mental Health Services newsletter for staff.

363. The Oversight Group assess this recommendation as having been met and therefore rates it as Green.

Recommendation 38

Ensure statutory confidentiality protocols for children and young people are clearly communicated to all staff. The protocols should also be shared with patients and families at the outset of their treatment programme, so that parents and carers know what to expect during the course of their child's treatment.

Context of Oversight Group assessment: That clear protocols have been put in place for patient confidentiality and are shared with young people and their families and carers who in turn know what to expect during the course of their child's treatment.

364. The Independent Inquiry reported that patient confidentiality and a perceived unwillingness of staff to involve parents and carers in a patient's care planning, had been a significant concern to families and had repeatedly appeared in evidence submitted to the Inquiry.

365. Tayside Executive Partners in their final submission, recognise that Child and Adolescent Mental Health Services confidentiality protocols had been previously unclear and not always evident in staff practice, with patients and their families not always having clarity around expectations of confidentiality and information sharing.

366. A number of actions were taken by NHS Tayside, including a review of best practice, staff training and improvements to standard documentation. New confidentiality protocols have now been developed and are in use. Audit processes are in place to ensure compliance with results reported within established clinical governance arrangements.

367. However, it is less clear what the difference has been for parents and carers. The Independent Inquiry reported that parents and carers had not always found the way they were given feedback to be helpful and at times they felt they had no guidance on how they could best support their child at home. Child and Adolescent Mental Health Services have made positive changes in response to the Independent Inquiry in support of continuous improvement. They should now consider what arrangements they need to put in place for feedback and engagement with parents and carers.

368. Nonetheless, we are assured that Tayside Executive Partners have responded positively to this recommendation and therefore we rate it as Green.

Recommendation 39

Consider the formation of a service for young people aged 18 – 24, in recognition of the difficulties transitioning to adult services and also recognising the common mental health difficulties associated with life events experienced during this age range. This may reduce the necessity for these patients to be admitted to the adult in-patient services.

Context of Oversight Group assessment: That options for a transition service have been considered and a settled position reached in respect of how best to support young people at the point of transition between Child and Adolescent Mental Health Services and Adult Services.

369. The Independent Inquiry heard from parents and families who reported difficulties in their children's transition between services once they had reached the age of 16 and 18. These difficulties ranged from administrative errors in records, of not understanding how adult services operated, to feelings of isolation and fear within adult inpatient services.

370. It was considered that NHS Tayside's decision to change the age of transition to 18 would make a difference to the experiences of young people, some of whom were transferred at 16, if they had left school.

371. The Independent Inquiry heard from families who thought the creation of a new service for people between 18-24 would recognise the distinct needs of this group and the impact change can have on them, at this period in their lives. The scope of this recommendation was, therefore, to consider the merits of creating a transition service but in the event of the status quo remaining, Tayside clearly had to improve planning, communications and support for transitions.

372. Tayside Executive Partners have recognised the difficulties experienced by some young people and their families at the point of transition. Following the Independent Inquiry, a review was conducted to determine whether or not young people would be best served by the introduction of a new service or by strengthening existing services. Young people were consulted as part of this review. The review concluded that "inter-service collaboration to strengthen the existing transition process would better ensure good transitions".

373. We understand that new Child and Adolescent Mental Health Services standard operating procedures are in place to support transitions, in full compliance with current Scottish Government planning guidance on transitions.

374. A new Transitions Pathway sets out a process and the options for transition, including no transition. This can then be revisited until a decision is made, at which point the young person's core worker secures the involvement of other services who need to be involved in the process. There is engagement with Adult Mental Health Services and a Transition Care Plan is completed.

375. A Children and Young People Mental Health Transitions 18-24 Group has been established and they have identified Link Workers to support the process and also implemented the Child and Adolescent Mental Health Services standard operating procedure - this is now being trialled for the next 6 months across all localities. However, it is noted that Adult Services has yet to establish their standard operating procedure and that no date is given for its completion.

376. Plans have been made for audit and feedback, so that the experiences of young people who are supported through transition are understood and any required improvements are made. The date for this improvement outcome data has been pushed back to June 2023 to accommodate Adult Services put in place their Transition Links.

377. In terms of the scope of this recommendation, Tayside Executive Partners have considered options and decided to strengthen existing services rather than introduce a new service. The steps taken by Child and Adolescent Mental Health Services to enhance existing services are noteworthy. However, it is of concern that Adult Services has yet to produce a new standard operating procedure and there is no timescale for doing so. As a result, important evaluative work has been delayed. Accordingly, whilst the recommendation to consider service arrangements for transitions has been met, the concerns that gave rise to this may remain and inter-service collaboration as planned, has yet to be fully realised.

378. The Oversight Group has therefore assessed this recommendation as Amber.

Recommendation 41

Consider offering a robust supportive independent advocacy service for parents and carers of young people who are engaged with Child and Adolescent Mental Health Services. This may include carer support groups.

Context of Oversight Group assessment: How information on independent advocacy services is made available and the services accessed by young people who are engaged with Child and Adolescent Mental Health Services and what impact demand is having upon the service provided.

379. Advocacy offers young people and their families the support they need to; know their rights; represent themselves in meetings; work out what they want to say about the matters that affect them, and the decisions being taken about them.

380. The Independent Inquiry noted that an independent advocacy service for parents and carers of young people engaged with Child and Adolescent Mental Health Services may help to ensure that families do not feel isolated during the period of their child's treatment.

381. Tayside Executive Partners acknowledged that there was a need to provide information on the support that already exists through independent advocacy for young people and their parents and carers, and sought to put in place better signposting.

382. The action taken by Child and Adolescent Mental Health Services has included a review and redesign of their website with links to both local and national independent advocacy supports. Staff awareness of the importance of independent advocacy and the rights of the child is covered through mandatory training, with participation levels reported through established governance arrangements.

383. The Child and Adolescent Mental Health Services website is attractive and easy to navigate. The redesign was done with the involvement of children and their parents and carers and Allied Health Professionals. The website received positive comment from Dr Strang in his Progress Report July 2021, who noted that it had been very well received. Online information is supplemented by the Child and Adolescent Mental Health Services Information Brochure and other standard communications.

384. Child and Adolescent Mental Health Services point to their website as being the main platform for the community to access information on their services. In support of this, CAMHS need to develop their web reporting so that they better understand and are able to respond to user demand and experience. Colleagues will also need to be mindful that for many people in Tayside, digital access may not be a reality and it will be important, therefore, to ensure that other forms of communication are available and promoted.

385. We have valued the opportunity to meet with those organisations who provide independent advocacy to children and young people and their families. There are different arrangements in different places, based on different funding at different times. The scope for consolidating funding and better coordinating activity needs to be explored. Those we have met told us about the concerns they have over the demand for their services: demand they are struggling to meet. They also spoke about the potential they see for earlier intervention and greater joint working across organisational boundaries. We think discussion needs to take place with children and young people's independent advocacy providers to see how these issues can be addressed.

386. The Oversight Group has assessed this recommendation as Amber.