Mental health: PfG delivery plan

Reforming Children and Young People's Mental Health Services

Action
Children and young people will have a much wider range of help available to them.

A decisive change is needed in the way that children and young people are supported. The recent Audit Scotland report on children and young people's mental health^[1] highlighted that there is often too great a focus on crisis and specialist services at the expense of early intervention and prevention.

The report concluded that in order to achieve the aims of the Mental Health Strategy, the Scottish Government and the Convention of Scottish Local Authorities (COSLA) needed to work together with delivery partners to shift spending from acute to preventative services. At the same time, the Scottish Government commissioned an audit on rejected referrals to CAMHS, and accepted the recommendations in full when the report was published in June.^[2]

In response, also in June, the Cabinet Secretary for Health and Sport announced a Taskforce on Children and Young People's Mental Health, which would report jointly to Ministers and COSLA. Under the Chair of Dr Dame Denise Coia, the Taskforce will make recommendations for improvements in the provision of children and young people's mental health in Scotland.

The Taskforce will, in partnership, develop a programme of sustainable reform of services. That work will fully complement the delivery of the Programme for Government commitments discussed here, and is set out in the Taskforce's workplan, also published on 19 December.

The Taskforce plan sets out a work programme, with the following set of workstreams.

Generic children and young people's mental health services

This workstream will focus on how Scotland's mental health framework needs to operate effectively to deliver prevention and early intervention mental health services for young people experiencing emotional distress and related conditions. It will focus on how additional mental health services can be developed and delivered across the country to provide a wide range of support for less acute mental health issues.

The workstream also will interact with the specialist and neurodevelopmental workstreams to ensure those with clinical mental health conditions and neurodevelopmental conditions are supported to access the appropriate services as easily as possible.

Specialist children and young people's mental health services

In order to reduce waiting times and avoid referrals to specialist services being rejected, radical development in children and young people's mental health services is required (including specialist clinical services). It is also vital that specialist services are closely linked to wider children's services to facilitate a seamless link from the perspective of children and young people and their families.

Neurodevelopmental services

We will take forward a specific workstream covering neurodevelopmental services. Young people with neurodevelopmental conditions (such as autism and ADHD) may require specific support with a neurodevelopmental focus, and may also benefit from specialist clinical CAMHS.

Additional services for children and young people at risk

Some children and young people who are at heightened risk of poor mental health, have not been able to access mental health services. These include: younger children; care-experienced children and young people; black and ethnic minority youth; refugee families; those who, for various reasons, do not have a settled home setting (for example, children in temporary accommodation or who move home regularly); young people in transition to adult services; and other marginalised groups. This group will take a focused approach to how the mental health needs of these children and young people can be met, both within existing and enhanced services, in line with the Getting it Right for Every Child (GIRFEC) approach.

In taking forward the four key strands we will consider at all stages how they interact to support seamless, effective and efficient care and treatment for children and young people and for their families.

There are also three cross-cutting Taskforce workstreams which underpin this activity on workforce, information and knowledge, and finance.

To complement this work of the Taskforce, we will take forward action through the Programme for Government in three broad areas:

• improving support during pregnancy and after birth;
• providing a wider range of help for children and young people; and
• improving specialist children and young people's services.

Improving support during pregnancy and after birth

Action
We will provide three tiers of support across Scotland, in line with the needs of individuals.

At the earliest stage, we must ensure that parents are well equipped to support their children. We will substantially expand the range of perinatal support available to women. Almost 20% of all women will experience mental ill health during their pregnancy or first postnatal year: that is a huge concern for them, but can also have far-reaching impact on their children and families. We want to transform the services that they receive by providing more counselling support for less acute issues and better specialist support for more severe problems.

We will ensure there is sufficient investment in service provision for equitable access to perinatal counselling services, perinatal and infant mental health promotion, and preparation for parenthood for those who need it, including in the third sector. All mental health staff should have the knowledge and skills necessary to promote good maternal and infant mental health, and recognise and manage, to their level of competency, mental distress and disorder.

To do this, by March 2020, we will:

• publish a refreshed Perinatal Mental Health Curricular Framework;
• develop a suite of educational tools to meet workforce needs across all tiers of service provision; and
• develop high quality digital resources for both workers (such as e-learning) and women and families (such as information about perinatal mental health).

For those women who need more specialist help

We will ensure rapid access to psychological assessment and psychological treatment (PT). There should be sufficient primary care PT services across Scotland so that all women experiencing mild-to-moderate mental health problems in the perinatal period can be assessed and treated in a timely way, in line with maternal and infant mental health needs. Peer support – through group or individual help, and through digital, online or tele-health resources – should be available to all women with mild-to-moderate mental distress or issues.

From the start of 2019 onwards, we will:

• recruit and train primary care psychological therapists; and
• invest in community capacity-building, where individuals who have experienced perinatal mental health problems have an opportunity to support others with similar needs and concerns.

For those women with the most severe illness

We will develop specialist services and consider whether there is a need for a small number of additional inpatient beds or enhanced community provision. All women with, or at risk of, moderate-to-severe perinatal mental difficulties, and their families, will have access to specialist mental health community services wherever they live in Scotland. There will be sufficient inpatient mother and baby unit beds in Scotland to ensure that women are admitted with their infants, in accordance with the Mental Health (Care and Treatment) (Scotland) Act 2003.

To achieve this, from the start of next year and over the next five years, we will:

• publish the Perinatal Mental Health National Scottish Service Standards and Recommendations Report;
• recruit Specialist Perinatal Mental Health teams in high birth number areas as well as low/dispersed birth number areas and island Boards;
• develop and implement a model of maternity and neonatology psychological services provision;
• develop a national induction programme for new workers in specialist services;
• review inpatient bed provision; and
• recruit multi-disciplinary staff to provide additional inpatient care or intensive home treatment to serve remote and rural areas.

Infant mental health

Action
We will improve the training and awareness of people working with vulnerable families and deliver improved infant mental health support for those families that need them.

All infants, and their parents, who have significant disruption of the parent-infant relationship or impaired infant development, should have access to specialist infant mental health services, wherever they live in Scotland. From the start of next year onwards, the Children and Young People's Mental Health Taskforce's specialist and at risk workstreams will work closely with the Government, Local Authorities and other partners on the implementation of this commitment.

Providing a wider range of help for children and young people

Action
We will develop services for community mental wellbeing for 5-24 year olds and their parents to provide direct and immediate access to counselling sessions, self-care advice, family support, peer-to-peer support and group work with links to other care settings.

Early intervention to support children and young people needs to be more broadly based than specialist services. That means not only providing better resources for children and young people, as well as parents, carers and families, but ensuring that schools, higher and further education, and community health services have the right support, and the skilled workforce to provide that support.

There are already outstanding examples of this type of support available in different parts of the country. The 'Generic' workstream of the Children and Young People's Mental Health Taskforce will focus on learning about and sharing good practice, and exploring how this can be built upon, replicated and delivered in other parts of Scotland where appropriate.

Case study
Feels FM is an innovative, co-designed approach to involving and supporting young people with their own mental health and wellbeing. Funded by the Scottish Government and launched as part of the Year of Young People, the project created the world's first emoji-based jukebox for mental health. 'Feels FM' is an online platform to help young people express their feelings, using music as a positive coping strategy to find new ways to talk about mental health stigma and discrimination.

Support for children and young people

Action
We will expand the Distress Brief Intervention (DBI) programme pilots during 2019 to include people under 18.

The Scottish Government's DBI programme is a form of 'listening with empathy and practical problem solving'. It is currently being tested in Aberdeen, Inverness, Lanarkshire and Scottish Borders, and offers up to 14 days of support to people presenting in distress to frontline services. Over 1,200 frontline staff have been trained, with over 1,600 people being referred to and benefiting. The Programme has provided a model for local collaboration, and satisfaction levels are high with positive measured reductions in distress.

The DBI Extension Programme has three complementary parts.

• Part 1: extending the DBI programme initially to those aged 16 and 17. The first stage of extension would include those aged 16 and over and in doing so, increase understanding of how DBI impacts on young people, families and local service provision.
• Part 2: undertaking a scoping exercise to review the potential applicability of DBI for those aged 15 and younger and considering the recommendations for further extension.
• Part 3: establishing a DBI associate programme for other regions wanting to implement within existing programmes.

We will roll out the extension in several phases:

• developing the programme extension and commence controlled delivery and testing for 16 & 17 year olds (by May 2019);
• Incremental upscaling for 16 & 17 year olds at four sites (by March 2020);
• scoping of DBI applicability for those aged 15 and under (by April 2020);
• controlled testing of DBI applicability for those aged 15 and under (from Oct 2020); and
• report on DBI for under 18s and on the evaluation of DBI for adults will be available from March 2021.

Support for parents, families and carers

Actions
Parents will have a much clearer understanding of the kind of help that is available, and where and how to access it.

We will launch a new website containing trusted help and information for young people and their families.

We will build on information resources by linking together existing help more effectively, and creating new, targeted resources.

• During 2019, we will launch a new website containing trusted help and information for young people and their families.
• We will develop services for community mental wellbeing for 5-24 year olds and their parents and carers to provide direct and immediate access to counselling sessions, self-care advice, family support, peer-to-peer support and group work with links to other care settings.

Case study
The Junction is a relationship-based health and wellbeing service for young people aged from 12 to 21 in Edinburgh. It offers holistic one-to-one and peer support, counselling, information and education, parental substance use support, sexual health and complementary therapy provision. It remains open in the early evening for individuals to come in on their own or with friends. Its drop-in provision is a good example of how community services can provide meaningful support for young people without waiting lists and tailored to what young people say is important to them. (More information can be found at www.scphrp.ac.uk/the_junction_2018/.)

Support for schools

Actions
Schools will be better supported to deal with wellbeing concerns, and will be able to direct children to counselling services.

We will invest over £60 million to create around 350 counsellors in school education across Scotland and ensure that every secondary school has counselling services.

As part of our work to enhance services to prevent and deliver early intervention for children and young people's mental health and wellbeing, we will work with partners to deliver access to counselling through schools across Scotland. Our aim is to ensure that school counselling is delivered locally, is aligned to local services, provides counselling services throughout the year, and allows services to be available to those who need support beyond school time. These services will link with wider services: in communities; for children and their families; and to other health services, such as school nursing and CAMHS.

We will also support school staff's understanding of mental health and wellbeing through training and resources, to ensure appropriate identification of needs and engagement with other services.

This approach will build further capacity beyond CAMHS and bridge a range of services to support children and families, ensuring that children and young people receive faster, more effective support to meet their needs. This commitment will be delivered in two phases, with counselling available in schools across Scotland in place by September 2020.

Action
We will enhance support and professional learning materials for teachers on good mental health.

By the end of the 2019/20 academic year, every Local Authority will be offered training for teachers in mental health first aid, using a 'train the trainer' model for dissemination to all schools.

The training helps to remove stigma and fear and give confidence in approaching a young person in distress. Local Authorities who access the training are asked to identify members of the school community – including pupils where appropriate – who are best placed to identify that a pupil might be struggling with a mental health issue.

Action
We will have an additional 250 school nurses in place by 2022.

School capacity to help children and young people will be strengthened by a stronger school nursing role. Planning is underway to implement a national learning and development plan for school nurses, which outlines how Integration Authorities support staff to access not only the new postgraduate programme, but also Continuing Professional Development (CPD) for those wanting to undertake the programme but who are not yet ready to do so.

We are also planning for school nurses to assess and deliver mental health services and interventions at tiers 1 and 2, thereby providing earlier access to upstream support. This should also contribute to reducing inappropriate CAMHS referrals, where earlier assessment can lead to referral to the range of alternative resources available.

By March 2019, we will:

• establish accurate workforce statistics (in posts/vacancies);
• undertake a further school-nursing scoping exercise with NHS Boards and get an accurate baseline of numbers and those who hold the qualification;
• establish workforce plans with NHS Boards to achieve a minimum of 50 per year (for years 1, 2 and 3) and 100 (by year 4); and
• commission NHS Education in Scotland to engage higher education institutions to scale up school-nursing education programmes in conjunction with NHS Board workforce plans, and develop appropriate CPD programmes.

By September 2019, we will have the first funded cohort in training.

Support for further and higher education

Action
We will provide 80-90 additional counsellors in further and higher education over the next four years.

We will provide the additional counsellors in further and higher education over the next four years through an investment of around £20 million. We have also committed to wrap-around support for students from the first day of their studies through to qualification and graduation, focusing on support for their wider wellbeing.

We will work closely with the sectors. The Scottish Funding Council (SFC) and Scottish Government are already considering a financial allocation to both sectors as part of the 2019/20 academic year funding allocations. This will ensure that the first tranche of counsellors is in place by September 2019.

A survey to capture baseline information on how many student counsellors are currently employed in both sectors, and the scale of unmet demand, is being prepared by the SFC (in consultation with the Scottish Government and stakeholders). The survey will be issued to all colleges and universities, and will provide a Scotland-wide baseline to inform implementation. To complement the SFC counselling baseline survey, NUS Scotland, as part of its 'Think Positive' work, will commission Scotland-specific research on student mental health and provision of support across further and higher education sectors.

A new Student Mental Health and Wellbeing Working Group, based on the successful Equally Safe in Colleges and Universities model, will shape implementation. The group will work closely with the Children and Young People's Mental Health Taskforce.

Inpatient CAMHS

We will continue to improve the inpatient psychiatric experience for children and young people who need it. Reconsideration of admission criteria and processes will ensure that specialist beds are available when they are needed, reducing non-specialist bed use unless it is in the better interests of a patient and their family. In addition, the provision of intensive and secure psychiatric beds for young people will be considered, with a new national secure CAMHS inpatient facility opening in NHS Ayrshire and Arran in 2020. We have also committed to a learning disability CAMHS inpatient unit in Scotland and will work to put this in place at the earliest opportunity.

Through 2019, Healthcare Improvement Scotland (HIS) will roll out its inpatient psychiatric safety principles to child and adolescent inpatient units. It will also deliver a programme of work to understand how early intervention in psychosis is currently provided in NHS Boards, and will compare this to best practice national clinical guidelines. HIS will work on improving data collection in relation to early intervention in psychosis and disseminating best practice.