Agenda item

CAMHS Referral Pathway Review - Third Witness Session


The Chairman welcomed those present to the meeting.  He noted that the Committee had started this review about six months ago and, during its investigations, had found the subject to be both interesting and intimidating.  As well as including the positive feedback that Members had received in its final review report, the Committee would also be looking to make a number of recommendations which would cover a number of themes, including the following three areas of improvement:

·         Signposting – there seemed to be a huge range of services available, but signposting to them did not seem to be as effective as it needed to be;

·         Reducing the waiting time – there appeared to be a lot of waiting, during which time the young person's mental health could be deteriorating; and

·         Communications – some of the communications from service providers seemed overly clinical which could come across as insensitive to some children and young people and their families.


Ms Lisa Taylor, Managing Director of Healthwatch Hillingdon advised that the three themes were largely in line with the feedback that Healthwatch had received from families.  She was aware that work had been undertaken by partners and that a concerted effort had been made to improve access to the front door.  Ms Taylor had circulated an updated version of the Thrive service map to Members.  It seemed that there was a lot of support available for children and young people's mental health but that they were finding it difficult to know how to access these services and which ones would be most appropriate to meet their needs. 


Although Ms Taylor advised that Healthwatch Hillingdon was receiving fewer reports of issues in relation to access to mental health services for children and young people, this did not necessarily mean that the issues had reduced.  The feedback from one parent had identified that if had been difficult to understand the referral pathway and that there had been a long wait to be seen.


Dr Ritu Prasad, Co-Chair of the Hillingdon GP Confederation, advised that GPs concurred that there appeared to be a lot of services but that they were difficult to find out about and access and that there didn't seem to be a way to escalate.  Whilst the service signposting was important, there also needed to be improvements in the inter-referral pathways.  Interventions such as art therapy and early support services were available but young people sometimes needed more and might need to be escalated to the Child and Adolescent Mental Health Service (CAMHS). 


Members queried whether there were issues of GPs not being aware of the most appropriate place to refer a young person with mental health issues or whether it was that there was not enough capacity in the services that were available.  Dr Prasad advised that it was a little of both: demand for services had increased but there was also a lack of awareness of what was available and what would be the most appropriate course of action.  She noted that not all GPs would be aware of the range of services that had been identified during the Thrive mapping process and a single point of access for these would be useful. 


Concern was expressed that this lack of awareness sometimes resulted in young people being passed from one service to another.  Dr Prasad advised that this could be alleviated by improving communications between the different service providers.  Each organisation should be responsible to making sure that a child was passed to the most appropriate service that would ensure that their needs were being addressed and not add to their issues. 


Given the variable levels of knowledge amongst GPs about the interventions that were available to support children and young people with mental health issues, it was queried whether the default action was to make a CAMHS referral.  With regards to GP referrals to CAMHS, Dr Prasad advised that every GP would be aware of what needed to be included on the referral form.  However, sometimes the information provided by the child's school might not be sufficient and the parent would need to liaise with the school to obtain the information required.  This could cause delays. 


Ms Tina Swain, Service Director for CAMHS and Eating Disorders – Goodall Division at Central and North West London NHS Foundation Trust (CNWL), advised that the experience of children and young people post-Covid had been different.  A single point of access for assessment (SPA service) had been set up by CNWL that young people could contact themselves for advice on where to go but this needed to be more widely publicised.  A range of modes of communication were available for this publicity including newsletters, apps and posters. 


Dr Azer Mohammed, Clinical Director for CAMHS at CNWL, stated that Hillingdon CAMHS received around 150 new referrals each month (this had doubled on the previous year) and that the team comprised 12 members of staff.  Most young people were seen within 6-7 weeks (many were seen within 5 weeks), which was well below the national standard of 18 weeks.  When they were seen, they were assessed and a care plan was put in place if the referral was accepted.  Dr Mohammed advised that he would be very disappointed if clinicians had rejected a referral and not provided signposting to alternative sources of support. 


Ms Swain assured Members that very few of the young people that were referred to the CAMHS service were rejected based on a paper exercise.  Most attended an assessment where they were triaged and either signposted on to alternative more appropriate services or provided with a treatment plan.  Ms Swain would provide the Democratic, Civic and Ceremonial Manager with information on the number that were rejected, signposted and accepted for treatment so that this could be circulated to Members of the Committee. 


Any waits experienced were usually in relation to specialist assessments or treatment.  Hillingdon had been using goal-based interventions whereby the young person and their family set goals to be achieved over a 6-7 week period.  This work had resulted in a reduction in the need for specialist treatment. 


Members were pleased to hear that young people were being seen within 6-7 weeks but queried what support was available to them in the interim as 6-7 weeks could still feel like a very long time.  Ms Swain advised that children and young people were able to contact CAMHS at any point to see if additional layers of support could be provided, and this was encouraged if their mental health had been deteriorating. 


A range of outcome measures had been put in place to determine the effectiveness of any interventions undertaken.  The baseline was completed at the start and then assessed at regular intervals and then again at discharge.  Although during the previous month there had been a 100% completion rate on these measurements, there was currently no requirement to report on them (this requirement would be introduced in the near future).  Approximately 60% had shown mild to modest improvements. 


Dr Mohammed recognised that publicity of the services needed to be improved to advertise the services but also to manage expectations.  Work had been undertaken with the North West London Integrated Care Board (NWL ICB) to develop clinical decision trees that would provide the options that were available for a range of conditions and highlight where an individual could be referred to.  These clinical decision trees were available to GPs on the ICB website.  It was suggested that this information should also be available to schools and CAMHS staff for those young people that did not meet the threshold for CAMHS services.  Ms Swain advised that, if partners were truly Thrive informed, there would be no wrong front door. 


Members had heard about how a negative experience of CAMHS could become fraught and confrontational quite quickly and asked about the availability of a parent support group.  Was there somewhere for parents to provide feedback in a less confrontational way?  Dr Mohammed advised that a Parents' Support Group was run by a family therapist and that clinicians attended meetings to present on specific topics and receive feedback.  There were also strong participation groups for children and young people and an ethos of co-production with them and their families. 


Service users needed to be involved in any new service developments.  A recent quality improvement project about discharge had spoken to parents who had talked about their anxiety around their child being discharged.


Ms Swain advised that work was being undertaken to understand the capacity needs in outer London as part of the wider system.  This would look at demand on services.  Action needed to be taken to reduce the need for children and young people to use specialist CAMHS services rather than just looking at increasing capacity in CAMHS. 


Dr Mohammed advised that schools referred the second largest number of children and young people to CAMHS (GPs referred the largest number).  The NHS long term plan talked about mental health provision in schools and each already had an identified mental health lead (usually a teacher).  Mental Health schools teams were also available to 15 schools in Hillingdon and were required to see young people within four weeks (generally for low level mood and anxiety issues).  Clear packages of care were provided to prevent further referral.  Some schools chose to provide additional support to their young people. 


The population in Hillingdon was very diverse and it was recognised that there were communities for which mental health issues was a taboo subject.  In addition, it was noted that an increasing number of women were being diagnosed with autism and eating disorders.  Ms Jane Hainstock, Head of Joint Commissioning at NWL ICB, advised that the local voluntary sector had identified individuals that they were concerned about and had spoked to clinicians about them.  This communication needed to be built on.  NWL ICB had obtained funding to support diverse communities and had been working with Healthwatch Hillingdon to target these hard-to-reach groups. 


Ms Hainstock noted a number of actions that needed to be taken forward which included: how best to publicise the Thrive map; and how best to publicise the clinical decision trees.  Work needed to continue to ensure that the Thrive methodology was supported.  Mr Richard Ellis, Joint Borough Lead Director for NWL ICB, suggested that the Thrive map be presented in a simpler format, perhaps like a tube map that showed how each service interacted with others. 


The Chairman noted that, once some recommendations had been drafted, partners would be contacted for their thoughts. 



1.    Ms Swain provide the Democratic, Civic and Ceremonial Manager with information on the number of CAMHS referrals that had been rejected, signposted or accepted for treatment so that this could be circulated to Members of the Committee; and

2.    the discussion be noted. 

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