The service model consists of CAMHS Crisis Nurses providing cover from 8:00 to 22:00, seven days a week with medical cover provided by existing CAMHS consultants. It differs from existing practice. NICE guidance currently recommends that all under 16s attending an A&E department following self-harming behaviour should be admitted to a paediatric ward overnight for psychiatric assessment the following day.
In April 2013 a bid was submitted to North Durham CCG, DDES CCG and Darlington CCG to seek funding to provide assessment, advice and treatment to under 18s in mental health crisis who require immediate input if they are at risk of harming themselves or others, including out of hours response.
Aims of service: To provide urgent mental health assessment and plan of care for children and young people including those with a learning disability, up until their 18th birthday who present with an acute mental health need; To develop a flexible and responsive service to meet the needs of young people experiencing a mental health crisis; To reduce waiting time for psychiatric assessment when young people are in crisis
Service description/model
The service model consists of CAMHS Crisis Nurses providing cover from 8:00 to 22:00, seven days a week with medical cover provided by existing CAMHS consultants. It differs from existing practice. NICE guidance currently recommends that all under 16s attending an A&E department following self-harming behaviour should be admitted to a paediatric ward overnight for psychiatric assessment the following day.
The new model of CAMHS Crisis Assessment & Treatment Team (C-CATT) was designed to incorporate principles of Crisis Care Concordat to offer mental health assessments within A&E departments and in other environments (e.g. home and police stations). The option to admit a young person to the paediatric ward for medical reasons and/or for a ‘cooling off period’ remains.
Service provides:
Comprehensive mental health and risk assessments; Time-limited intervention, tailored to meet individual needs; Intensive support within the home/appropriate setting, where appropriate, for up 72 hours post assessment or until risks are contained; Constructive advice-problem solving and solution-focused resolutions; Collaborative working with the young person, their family and/or carers and other relevant professionals and agencies to develop a crisis care plan; Liaison and consultation with other professionals and members of the children’s workforce; Telephone support for parents, carers, service users and other professionals, such as NHS 111, GPs, the police and social services; Training to other services and professionals (including GPs, Police; local authority care home staff, teachers), to help to identify children and young people with mental health needs earlier; Post suicide support including joint working with schools and police; supervision and support to professionals affected by suicide; Assertive engagement with young people and their families; A targeted approach, working with ‘hard to reach’ groups.
The service is responsive to needs of children and young people with mental health conditions, such as self-harm, suicidality, disturbed behaviour, depression or acute psychoses.
Acceptance criteria
Service available to any young person under 18 years. Presenting issue must be mental health crisis
Response times
Initial assessment appointment – service aspires to commence within 1 hour of referral being received; maximum wait of 4 hours within hours of operation. Young people presenting in mental health crisis outside of these hours continue to be admitted to paediatric wards overnight, with psychiatric assessment the following morning
Intervention
Once a young person with mental health needs is assessed, the team provides intensive support for up to 72 hours, or as required, either at home or an appropriate setting. Every service user gets a care plan so they know what action is being taken by all involved, including parents and carers.
Longer term ‘Crisis Recovery Plans’ are developed to support repeat service users, such as those with complex issues and more severe mental health conditions. Close working with adult services allows for joint assessments for those due to move from CAMHS, helping to prevent those in transition from falling into any gaps between services.
The service completed an initial evaluation which showed the following improvements for C&YP who present in access and the knock on effect on the wider health & social care economy.
45% of young people in crisis being assessment in the community; A&E attendance is reduced – 108 (25%) children and young people presenting with suicidal ideation, panic attacks or threats of self-harm in the community would normally have been referral to A&E; 24% reduction in paediatric admissions with admissions avoided; (15%) of referrals are admitted into an acute hospital bed – outside the CAMHS crisis and liaison service hours of operation; the evaluation highlighted that 27% of young people in crisis present between 10pm and 8am, highlighting the case for the service to be extended 24/7; Reduction in time waited for young people and families – from 26 hours pre-crisis service, to an average of 1hour 38 minutes.
Additional benefits:
Increase in multi-agency working around the identified risks and ensuring co-ordinated care for young people and their families; Police training – mental health awareness; All service, person centred care plans. Comprehensive care plans for all young people who move around specialist CAMHS services. These care plans are being developed in collaboration with the young people when they are not in crisis; Post suicide support interventions. The Crisis team has become an integral part of the community suicide response plan. Providing support where appropriate following a suicide of a young person. An example of this is CAMHS crisis staff attended vigils and community gatherings. Supporting school staff and police colleagues; Working alongside adult mental health colleagues to support transition from CAMHS to AMHS.
111 developments.
Working with commissioners to enhance the current 111 provision so callers concerned about the mental health of their child/young person can be transferred to speak to a CAMHS clinician for advice, rather than directed to A&E; Open support via telephone to the wider children’s workforce; An open, accessible, quick response to urgent mental health assessments; Support to parents and carers; Support and access to clinical advice for Durham Police force Support and access to clinical advice for Acute hospital staff.
Below is a summary of comments made by young people, parent & carer focus regarding the service:
Easy and quick access out of hours to CAMHS clinicians when needed; Telephone support; Support from staff within the home.
Feedback from parents, carers and young people “The service and staff were absolutely fantastic – the staff provided excellent support, understanding and advice at a really difficult time. Thank you so much. I don’t think I would of got through the weekend without them.”
“Personally I thought the care by the Crisis Team was helpful, they showed passion for your wellbeing as well as your views and feelings”
“I don’t think anything needs improving as they show care and seriousness about how to help young people”
“The service I received was the best I’ve had. Thank you.”
“They listened to me and what I had to say and what my family were saying, they were helpful.”
“Service was excellent. Speed and skill vital when my daughter is unwell (bipolar). Her Autism was taken into consideration.”
We continue to seek opportunities to review and improve the service, by working closely with our partners, ensuring there are clear pathways of care and a close interface with our main partners. This includes feedback from Professionals. There are clear qualitative as well as quantitative benefits from reducing the numbers of young people in crisis who are assessed in A&E or admitted to the paediatric ward. Having the CAMHS Crisis and assessment service available not only impacts favourably on A&E and Acute Trust pressures but enhances the resilience of the wider community, our main partners are: Local authority; Acute hospitals A&E and Paediatric wards; Looked after Children; Police, Education; Tier 3 CAMHS;Tier 4 CAMHS.
The service is also active in working closely with local commissioners around local transformation plans to continue to develop services for C&YP with emotional & mental health difficulties
The following feedback has been given by stakeholders:
“it’s crucial that the CAMHS crisis team remain in A&E as they are making a huge difference to patients and A&E staff”; “great support on the paediatric ward”; “parity of esteem”; “what a difference, for the good”; “the ongoing training that has been provided to Durham police force has hugely improved our officers knowledge of mental health and how to deal with young people presenting in mental health crisis more appropriately and avoid the use of the cells”; “Joint/shared decision making between acute staff and TEWV staff”.
Feedback from CQC inspection – highlighted under good practice within the report:
“The CAMHS teams in Durham and Darlington had recognised there was a gap in provision of crisis intervention for young people and children. In response, and using patients’ feedback to shape the service, the teams had developed a crisis service, open seven days a week 8 am to 10 pm, and piloted overnight. The service had good working relationships with the local police and had resulted in a reduction of admissions to hospital by over 50%”.
It is also imperative that the service maintains robust pathways for interface with community CAMHS (Tier 3) and inpatient units (Tier 4) e.g. person centred care plans incorporating all aspects of care across service.:- Joint home leave and discharge planning demonstrating ‘step-up/down’ approach depending on level of need; Continuation of established links with on-call and duty psychiatrists for times when urgent or ongoing medical input is required; Continuation of established links with Tier 3 for intensive psychological therapies or transfer of care for longer term therapeutic input where required; Continuation of established links with MDT when multi-disciplinary diagnostic processes and joint formulation is required; Continuation of established links with paediatric and A&E services to continue to develop pathways and joint working protocols e.g. frequent attenders, young people who have co-morbid medical and mental health needs, teaching and supervision; Signposting to appropriate services e.g. existing parenting programmes in Tier 3 & Tier 2, voluntary sector organisations and targeted services in the local area; Use of the Children’s Passport and joint crisis plans shared across the MDT
The service works closely with our service users and parents/carers. This includes:
Ongoing service user & carer feedback using friends and family test; Participation of young people, parents/ carers in service developments such as clinical pathways, information leaflets and recruitment of staff; We have established participation groups and work closely with investors in children, young people review our service and joint action plans are agreed to continue to improve services; We are working closely with the recovery college to develop the role of expert by experience and peer support; We have established parent groups and forums, where feedback is presented to our local Quality Asssurance Group; We have worked with young people and recently been accredited with young carers charter
As part of the initial bid we did not include a Team Manager, temporary funding was provided to include project management. However once the pilot was completed this resource was no longer available. Current line management responsibilities are absorbed within the service management structures, however going forward with the service being commissioned 24/7 this post is crucial to the team.
The team is very small (7.2 WTE nursing staff) we needed to ensure that we used resources well and were able to cover the large geographical area of County Durham & Darlington. The service introduced 12 hour shifts to enable us to maximise the resource allocated. However to ensure we are able to cover annual leave or sickness we have a small group of professionals from Tier 2/3 CAMHS who have completed an induction with the crisis team and are prepared to cover staff shortages as extra hours. This has enabled the crisis team to continue to deliver services despite the tight financial envelope.
We have worked with our local CCG to develop business plans and service specification to ensure the service receives recurrent funding and extended to 24/7. Evaluating the positive impacts that the service provides and sharing these both locally and nationally has supported this further investment
An initial evaluation was completed in May 2015. The evaluation highlighted both positive qualitative and quantitative results following the introduction of the team. The evaluation was completed internally and has been shared with local and national commissioners. It has been used nationally as part of crisis development, i.e. presented at Future in Mind, One year on conference and shared with the National Expert Reference Group. The service is currently completing a further evaluation.
Yes, the evaluation has been used nationally as part of crisis development, i.e. presented at Future in Mind, One year on conference and shared with the National Expert Reference Group. As a result the team has been visited by other Trusts to share good practice and support development.
As the team is small it is important to highlight that the team are extremely service user focused and flexible in their approach. The service continues to move forward and has applied for funding to the accelerated crisis vanguard money to introduce Intensive home Treatment. This team will be integrated with the current crisis service to again maximise efficiency and support an integrated model.
