Agenda item

CAMHS Referral Pathway Review - Witness Session 1


The Chairman welcomed those present to the meeting and noted that Members continued to speak to families involved with children and young people’s mental health services in the Borough.


Mr Alex Coman, the Council’s Director of Safeguarding, Partnerships and Quality Assurance, advised that the Council had a role in early intervention and prevention as well as statutory intervention and prevention.  Targeted adolescent services were available and included face-to-face sessions as well as online support.  Group therapy sessions were also provided through Hillingdon MIND.  It was noted that non-attendance at school impacted on a child’s wellbeing.


In 2022, the service had received 380 referrals which were triaged within seven days.  Of those, 350 were accepted and resulted in 1,500 counselling sessions with the children – around 100 children attended sessions each week.  Consideration was being given to the development of further services such as providing counselling in the child’s first language (this would be useful for asylum seeking children) and a yoga for wellness pilot. 


Of the 20,000 contacts made each year, about 30% had a statutory assessment, and mental health featured in the top three biggest issues arising.  During the year, many of these contacts would be signposted to mental health support.  Emotional wellbeing had been included in the Child Protection Plans and the Your Choice programme used Cognitive Behavioural Therapy (CBT) to engage with families. 


Members were advised that the School Inclusion Team had developed a guide for schools to help them to identify and deal with children with disruptive behaviour.  It was important that services worked with the whole family to avoid escalation. 


With regard to looked after children (LAC), Mr Coman advised that the Council acted as the corporate parent for around 350 children and young people.  Research had shown that LAC were more likely to suffer with mental ill health.  As such, assessments were undertaken annually with those aged over five and every six months for those under five years old.  A strengths and difficulties questionnaire was completed by children and young people to measure their wellbeing and gave them a score out of 40 (with a lower score being better).  In Hillingdon, LAC scored an average of 12.7 compared to a national score of 13.7.  If a LAC in the Borough scored 13+, action would be taken to investigate the matter further and referrals could be made to the psychology service. 


Members were advised that Give Space was a moving therapy that involved performing arts and had been piloted in Hillingdon with six young people.  Ask Jan was also available and provided individual sessions to around 60 young people in the Borough (the contract for this service would end this year with the possibility of an extension). 


When asked what success looked like, Mr Coman advised that all young people would have a plan in place based on their needs with targets, actions and outcomes identified.  Key performance indicators (KPIs) were in place for things like assessment timescales and were monitored during the routine reviews of the child’s plan.  Every child with a plan had a social worker assigned to them who would be able to help ensure that the plan was followed and achieved.  In addition, a strong accountability framework had been put in place where the Executive Leadership Group was ultimately responsible for safeguarding in the Borough. 


Mr Coman noted that officers worked in partnership with the families and children as well as with other agencies where relationship-based worked allowed each organisation to hold the others to account.  All agencies needed to talk to each other to ensure that they were putting the child at the centre of everything they did and to ensure that they were delivering on each child’s plan.  All professionals involved in a child’s plan were responsible for the delivery of that plan. 


The Children’s Safeguarding Partnership Board had been active in promoting engagement and partnership working.  Information sharing agreements had been put in place to ensure that information about a child was available at the point of need.  The Stronger Families Hub provided a single point of entry to the system (once the family had a social worker, they could agree to their information being shared). 


Although families could use the Council’s formal complaints system, they could also submit an informal complaint.  LAC had an independent service through which they could make a complaint but could also raise issues with the independent review officers who would make sure that what should be done, was being done.  Child Protection Plans were agreed at Child Protection Conferences and actions were put in place by independent people, having sought the child’s view. 


Members were advised that schools had a significant amount of contact with children and young people so were well placed to contribute to a child’s plan and form part of the way forward.  Social workers were in contact with schools, Child Protection Advisors had been placed in schools and safeguarding training was being provided for Governors. 


Members queried how accessible the non-statutory services were and how the success of the interventions could be measured.  Mr Coman advised that the Stronger Families Hub provided a single gateway into services and provided access to a lot of information about services that were available in the Borough.  Schools, GPs, primary care and community health services also played a big role in identifying issues as well as the family themselves (and extended family). 


Ms Jane Hainstock, Head of Joint Commissioning at North West London Integrated Care Board (NWL ICB), advised that a fairly long list of services were commissioned that straddled the old tiers and delivered universal and targeted services and services to young offenders.  Mental Health Support Teams had been set up in a number of schools in Hillingdon with direct access and it was anticipated that these would be rolled out to all schools in due course. 


ARRS (Additional Roles Reimbursement Scheme) provided funding for 26,000 additional roles to create bespoke multi-disciplinary teams in Primary Care Networks.  There were 12 new ARRS roles that could work across primary, secondary and community care, funded by the GP contract, which included: Clinical Pharmacist, Pharmacy Technician, Social Prescribing Link Worker and Health and Wellbeing Coach.


Ms Hainstock advised that specialist child and adolescent mental health beds were commissioned by NHS England. P3 was commissioned to provide emotional support workers to help older children with challenges in relation to things like money, work and relationships and to help younger children with things like bullying.  It was important that all parts of the system were working together to deliver successful outcomes for young people. 


KOOTH provided a digital offer to children and young people for online counselling and support and HACS (Hillingdon Autistic Care and Support) and the Centre for ADHD and Autism provided support for those with autism and ADHD as they were more likely to have mental health issues.  Work was also undertaken with the Youth Offending Service, particularly with young men that presented with speech and language difficulties. 


NWL ICB was able to respond to individual requests for support for issues such as Fragile X Syndrome and could also offer family support.  A two-year population health management pilot project was being undertaken to determine what support and interventions young people wanted and how the offer could be improved.  Benchmarking was also being undertaken in relation to individualised plans to see how the young person was feeling at the start of the plan and how they felt at the end. 


Members were advised that the Thrive methodology had been introduced to look at the needs based roots of children's mental health issues and to develop a systems approach to the support that was then provided.  A mapping exercise had been undertaken to identify all of the help that was currently available and this information had been sifted through to develop a shared understanding of where each service sat.  The micro, meso and macro levels had been worked through with partners to identify where improvements needed to be made. 


Concern was expressed that there were so many services offered to support children's mental health that it could make it difficult for parents and GPs to know where the child should go to get the best support for their situation.  It was suggested that, if there was some uncertainty about where the child should be referred, it was likely that the child would be referred to CAMHS by default, even if it wasn't the most appropriate place for them.  Ms Hainstock advised that the mapping exercise would continue with a view to eventually listing each of the services on the Internet with an explanation about the service that was provided and whether or not a referral was needed (and who could make the referral).  Consideration was also being given to establishing a Children's Mental Health Hub and the associated costs so that this could work together with the Stronger Families Hub. 


Although the outcomes were measured across all services commissioned in Hillingdon, Ms Hainstock advised that conversations were ongoing with CAMHS to develop measures that were meaningful and HACS had been commissioned to provide pre-diagnosis for autism.  Insofar as NWL commissioning was concerned, a series of programme boards had been set up to come together and make decisions and recommendations about service delivery (one of which was in relation to children and young people's mental health).  It was at that level that influence needed to be exerted to ensure that Hillingdon maintained a voice.  This structure also provided the opportunity to develop pilot projects. 


Ms Tina Swain, Services Director for CAMHS and Eating Disorders – Goodall Division at Centre and North West London NHS Foundation Trust (CNWL) advised that CAMHS provided 24 hour advice and support and provided an opportunity to signpost to other services.  Information was shared with GPs when required. 


Members were advised that primary care made more referrals to CAMHS than any other sources such as urgent care, education, social services or paediatrics.  It was anticipated that the Thrive model would provide a needs-led service to get children help at the earliest opportunity.  For those children under five years old, parent training and targeted support were provided. 


After a young person had been referred to CAMHS, they could be accepted or declined.  Currently, around 1,500 young people made up the Hillingdon caseload with 50 more referrals made each week.  Ms Swain advised that a lot of work had been undertaken to manage waiting times but it was unclear whether the time to second treatment was going up or down so she would look into this and forward the information on to Members.  Initiatives included alternative therapies for children coming into the service.


In order to ensure that the patient voice was heard, participation groups had been set up (Children and Young People Shadow Board and Parent Shadow Board) and a dedicated feedback week had been set up to provide an informal feedback opportunity.  Routine site visits were undertaken and the Friends and Family test continued to be undertaken.  The Urgent Care Team was also available to provide intensive community support to children, young people and their families to help them to maintain school attendance. 


After a referral had been made to CAMHS (which could be made by the parent through CAMHS' Single Point of Access (SPA)), it could take a long time before the assessment was undertaken and, if accepted, for subsequent interventions to be put in place.  It was queried whether there was adequate knowledge in place about alternative non-statutory services that the parents and children could be advised of during the intervening period.  Ms Swain advised that CAMHS might suggest services provided by another organisation in the interim when waiting for an assessment and might signpost to services such as KOOTH whilst awaiting core CAMHS services.  The Waiting Well initiative had also been put in place to provide CAMHS and the parents with regular touch points. 


Members noted that 636 referrals had been declined between 1 April 2022 and 31 January 2023.  Ms Swain would undertake a deep dive to ascertain why these referrals had not been accepted and bring this information back to the Committee at its meeting on 15 June 2023.  Members suggested that the 5 Urgent referrals to CAMHS during this same period seemed quite low.


In terms of timescales, Members expressed concern that a six week wait for an appointment seemed like a very long time.  Ms Hainstock advised that there were key performance indicators in place and that CAMHS had recently been meeting all of its targets.  Dr Paul Hopper, Divisional Medical Director at CNWL, advised that the national CAMHS target from referral to treatment was 18 weeks and that, locally, CAMHS had been achieving 100% within 18 weeks from referral to first and second contact.  P3 (which provided wellbeing support and drop-in advice foryoung people aged 13-25) could also hold a case whist the young person waited for CAMHS.  However, sometimes families did not want anything other than CAMHS. 


Ms Swain advised that provision had been made for a mental health specialist in some schools (children and young people’s wellbeing practitioners (CWP)) and that other services could be put in place to support young people. 


Concern was expressed that parents were not routinely advised of other services that were available to support their children and that timescales for contact were not always provided.  It also seemed that the various agencies involved in supporting children and their families were not always communicating effectively.  Members asked whether parents were advised at the outset of their initial contact with CAMHS about the procedure for making a complaint if the process was not working effectively.  Ms Swain advised that this information was available online and on social media but that testing would be needed to establish if it was as accessible as it should be. 


It was recognised that there would be times when inappropriate referrals were made to CAMHS but Members queried how these cases were dealt with and whether staff were provided with training on dealing with the difficult task of rejecting a referral.  Ms Swain advised that a vision and purpose had been set for the team which supported the need for their communication to be honest and transparent and to provide clear reasons for why the child had not met the threshold.  It would be important to receive feedback when this was not the experience of parents so that action could be taken to rectify the situation for those parents as well as others. 



1.    Ms Swain establish the waiting times to second treatment and forward the information on to Members;

2.    Ms Swain establish why 636 referrals had been declined between 1 April 2022 and 31 January 2023 and bring this information back to the Committee at its meeting on 15 June 2023;

3.    Ms Swain investigate whether or not information in relation to making a complaint was as accessible as it should be; and 

4.    the discussion be noted. 

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