Early intervention in psychosis and transition team – Navigo – Winners #CYPMHAwards19

The Early Interventions in Psychosis and Transitions Service offers a service to young people who are at risk of developing psychosis and those who have developed a first episode of psychosis. We specialise in early detection and treatment of psychosis. We support from the age of 14 years old and help the young person transition from childhood to adulthood. We also provide a service to young people transitioning from CAMHS to Adult Services regardless of diagnosis or need. CAMHS services are provided by Lincolnshire Partnership Foundation NHS Trust and Adult mental health services are provided by NAViGO.

Webpage for service (if available): www.navigocare.co.uk



  • From start: No
  • During process: Yes
  • In evaluation: No


  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

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Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

The Early Interventions in Psychosis and Transitions Service offers a service to young people who are at risk of developing psychosis and those who have developed a first episode of psychosis. We specialise in early detection and treatment of psychosis. We support from the age of 14 years old and help the young person transition from childhood to adulthood. We also provide a service to young people transitioning from CAMHS to Adult Services regardless of diagnosis or need. CAMHS services are provided by Lincolnshire Partnership Foundation NHS Trust and Adult mental health services are provided by NAViGO. In order to provide a seamless transition between the two very different services the Early Intervention Team took on this role in order to bridge any practice gaps and ensure that this already difficult time for children and their families is made as easy as possible. The criteria for the two services are quite different and often the transitions importance has been overlooked. In order to bridge this service gap, the Early Intervention in Psychosis Team took this role as the sole Team in NAViGO to deal with under-18s it was the natural choice. The team have regular meetings with CAMHS in order to identify and prepare for transitioning the young person. Once identified and a referral from CAMHS is received the team then work jointly with CAMHS for 3-6 months until the child is 18; then the team work with the young person and their family independently until a service and care coordinator have been identified. Then joint working is done with the referred to service for an agreed period. At the very beginning of the service the young person and their family are engaged in care planning including discharge planning.

One of the main aims of the service is to facilitate exit strategies; the interventions provided by the team often facilitate the young person to make a recovery. In such cases the young person no longer needs to transition and they are discharge back to their GP, often into work or education programmes. This service has undertaken this role several years and whilst it has not been formally evaluated, investigation has yielded information from service users and families, who have given very positive feedback in various forms. Thank you cards, NAViGO Patient Related Experience Measures (PREMS) and verbal feedback have been wholly positive about the service that the team has offered transition clients. The Philosophy of the Early Intervention in psychosis is carried over to the Transition service it offers and so clinicians work with the young person and family inclusively. Using holistic Psychosocial Interventions to promote optimism, independence and recovery. The team role model for young people in order to forge therapeutic relationships and overcome any power imbalance within the relationship from professional to client. This yields excellent results often leading to the young person making a recovery and going back into education or even work. The transition is therefore only completed if needed following the interventions from the service.


What makes your service stand out from others? Please provide an example of this.

The team provide assertive and intensive recovery based approach to transitions, providing evidence based interventions to not only the young person, their family but also to the wider community. The team’s practitioners regularly give up their own time to promote community wellbeing, education and understanding, attending schools, a major part of this work is discuss the transition from Childhood to Adulthood as this can be a frightening time for young people when they are most vulnerable. They are part of project groups in schools such as NEXUS and Family SMILES (Simplifying Mental Illness and Life Enhancement Skills). A service that they offer out of their normal working hours as an unpaid service. The aims of attending schools are dispelling the myths and stigma associated with Mental Illness to promote better relations between the community members and also to promote positive mental health and mental health awareness.


How do you ensure an effective, safe, compassionate and sustainable workforce?

NAViGO policies and procedures are updated regularly and staff wellbeing is a high priority within NAViGO and within the Early Intervention in Psychosis and Transitions Service. Healthy and happy staff members are more effective, improving recruitment and retention and preventing burnout and compassion fatigue. Within the team there is an excellent skill mix, the team are friends and the team culture is one of openness, honesty, reflection and fun. A sense of humour is important and essential to survive in modern healthcare and the team’s culture reflects this. The team has a relaxed atmosphere which promotes honest feedback within group peer supervision, weekly MDT meetings and client formulation, often using morning and afternoon huddles to reflect on practice during that week/day. The team is led by a Band Seven nurse, providing clinical and managerial supervision to four Band Six Senior Care Coordinators, 2 of whom are Registered Mental Health Nurses, an Occupational Therapist and a Social Worker. A band three Support worker is supervised by the social worker within the team. A part time Administration Assistant is the glue that holds the service together. Psychiatric consultant support for the transitions service comes from the two transitioning services, CAMHS or the relevant adult service being referred to as appropriate. Staff members attend regular individual supervision where wellbeing, training and development as well as reflection on practice are encouraged.

Within this staff members have annual Performance and Development Reviews which focusses on their development over the coming year and also reviewing goal from the previous year to ensure that this is a fluid and evolving process. Staff attend regular mandatory training in key areas; we also source external training relevant to roles such as one of our nursing staff has been accepted onto the supplementary nurse prescribing course at the University of Hull. A staff Wellbeing Champion has been identified who attends regular Wellbeing meetings with senior management in attendance and staff wellbeing was recently added to the weekly MDT agenda. If staff members go off sick, sickness monitoring is used as a supportive tool to keep people in work, occupational health is utilised in this respect to enable solutions to allow people to return. Return to work interviews are then completed in a supportive and informal manner, if the cause is work related than solutions are found to ensure improvement. Because of the team culture and environment recruitment and retention in the team has been excellent with minimal staff turnover, this has helped keep consistent relationships for staff and service users alike. The aim of this is to ensure that the team has a warm, friendly, supportive and nurturing environment in which they can thrive both personally and professionally.


Who is in your team?

1.0 WTE Band Seven Clinical Team Manager (Registered Mental Health Nurse) 0.6 WTE Clinical Team Secretary 2.0 WTE Band Six Early Interventions Practitioner (Registered Mental Health Nurse) 1.0 WTE Band Six Early Interventions Practitioner (Social Worker) 1.0 WTE Band Six Early Interventions Practitioner (Occupational Therapist) 1.0 WTE Band Three Support Worker


How do you work with the wider system?

As stated above once a client is identified as needing a transition by CAMHS and referred to the service, joint working with CAMHS is undertaken for period of ideally six months. Once this period is over individual work is undertaken as needed, during this time assertive treatment is provided to facilitate exit strategies from secondary mental health services in order to promote recovery. The team then works closely with the young person and their family to identify aspirations, hopes and plans for the future. Once a plan has been decided upon, the team works closely with outside agencies as appropriate to facilitate the agreed plans and engage the young person with their new life. The outside agencies the team works with are: • Addaction (Addiction Services) • Housing Support Services • North East Lincolnshire Council • Shoreline (Housing) • NSPCC • YMCA (Homeless Support and Tenancy Support)) • YPSS (Connexions, Careers Service) • Open door (Counselling Service) • Centre4 (Community Hub) • Warehouse (Young People’s venue) • Youth Offending Service • Foresight (charity supporting sensory and learning difficulties) • Inspire 2 Independence Project (Employment and Education Programme). • Colleges • University • Job Centre • Employment Specialists • Aspire to Independence • Focus (Adult Social Services) • Young Carers Support Services • NEXUS (Youth Forum) Following interventions, if a transition to Secondary Mental Health Services is still required then the team has close working links with NAViGO internal services that the young may need. The team then work jointly for 3 months to complete the transition of care. The services commonly worked with include: • Adult Community Mental Health and Wellbeing Services • Eating Disorder Service • Accident and Emergency Liaison and Diversion Service • Crisis Team • Home Treatment Team • TUKES (Work Programme) The Young Person’s General Practitioner is also closely worked with as their physical health is also a priority for the team. The team complete a Wellbeing and Health (WHISe) and liaise with the GP to ensure that physical health and wellbeing is not overlooked.


Do you use co-production approaches?

The CPA process is used by the team to involve the service user and their family in the process of care. This helps to facilitate continuous feedback from the young person and their families, we use PREMS to identify the both good and bad service user experiences and seek constructive feedback. Patient Related Outcome Measures (PROMS) are used to identify effectiveness of the service; SWEMWEBS has been used for this service. As well as the above each practitioner seeks individual idiosyncratic verbal feedback from the young person and their family in order to facilitate their reflective learning. Early Interventions in Psychosis and Transition Service approach is heavily inclusive of families and behavioural Family interventions are used to facilitate change for the family. This process is also used to gain ideas for service development. Compliments and complaints are reviewed regularly as is DATIX Incident reporting is also used to identify issues. All of the above information is discussed as matters arise in Daily Huddles, the weekly Multi-Disciplinary Meeting and monthly team business meetings, this helps facilitate change processes as the whole team are involved with decision making based on the feedback from the service user and their family. The team work closely with in-house, engagement and project manager to ensure up to date knowledge of local public events and service user involvement. The way in which the service gains feedback from the transitions service users and involve them in service development is currently under review to improve the way in which we do this.


Do you share your work with others? If so, please tell us how.

The team meets regularly with CAMHS and Adult services for both individual cases but also to promote awareness of the impact this time can have on young people and their families and best practice in caring for transitioning young people. The team shares its good work with the wider community through engagement with the numerous voluntary schemes in the area and also by attending schools to talk to the children and teachers about mental health awareness and becoming adults. Early Interventions teams provide a service from the age of 14, therefore there is a wealth of knowledge and experience of working with young people making the transition from Childhood to Adulthood. As an Early intervention team we attend regular Early Interventions in Psychosis Network (EIPN) meetings, whilst the focus of these meetings is not Transitions it is a factor in the care and treatment of young people. Best practice is discussed and shared within this Forum, the team shares its knowledge and skills in all areas of its remit including transitions.


What outcome measures are collected, how do you use them and how do they demonstrate improvement?

The team uses the NAViGO experience questionnaire which is the local PREM used to collect Service user experience, this is then collated by the performance department and shared with the team via the electronic dashboard. The dashboard indicates performance levels in a number of areas PREMS and PROMS being one such area. This information is used to keep PREMS and PROMS in date and also the data collected from them is used to determine team strengths and areas for development in Team meetings. NAViGO has historically used SWEMWEBS as its main PROM, however the team is aiming to gain accreditation from the Royal College of Psychiatrists College Centre for Quality Improvement. In order to meet the Early Interventions in Psychosis Standards we are introducing two new Outcome measures recommended by the Royal College, these are Dialog, which is a life satisfaction measure and the Questionnaire on the Process of Recovery (QPR). The Dialog will help demonstrate any improvements or deterioration in life satisfaction which is an indicator of mood, activity and recovery. This will help identify areas within each service user’s life which may need intervention and also the effectiveness of the interventions provided by the team. The QPR is a recovery questionnaire that can highlight areas of importance to the service user, again identifying the area for intervention which demonstrates effectiveness of interventions used. Additionally other outcome measures will be used to highlight where interventions need to be focussed such as the Alcohol Use Disorders Identification Test (AUDIT) and the Drug and Substance Abuse Tool (DAST). These Outcome measures are also used as an engagement tool to promote a therapeutic relationship and build hope that people can recover from their mental health difficulty and live a normal life. These measures will be used with all service users including those looked after by the transition service to determine effectiveness and identify development needs for service and service user alike.


Has your service been evaluated (by peer or academic review)?

The service has been audited by the Care Quality Commission (CQC), NAViGO Community Services received an overall Good Award. The inspections did not highlight any area of concern within Early Interventions in Psychosis and Transitions Service. We are currently in the process of developing the service, working towards gaining accreditation from the Royal College of Psychiatrists, College Centre for Quality Improvement. Early Interventions standards include transitioning young people between children’s and adult services. Recent results gained from the CCQI highlighted our strengths in timely access, work and education support and Carers Education and Support. It also highlighted area for improvement such as CBTp and Family Interventions which currently have actions plans in development to correct these temporary deficits.


How will you ensure that your service continues to deliver good mental health care?

The team has an Operational Policy which is updated regularly; this describes the team purpose and philosophy as well as procedures and way of working. This ensures that things are done right and also will ensure continuity of service should there be a major change. The team has a service plan which is reviewed annually; this reviews last year’s goals and identifies the new year’s development goals for the team. We work alongside local commissioners and the NAViGO CIC Board in order to develop the service to meet the needs of the local populace. We have regular meetings with the senior management team to discuss performance, quality, staff wellbeing, infrastructure and estates, together with issues such as the NAViGO Work plan which reflects the Five Year Forward View. We are working closely with the senior management team and finance at the present time to secure funding for a CBT Therapist. We are also in negotiations for the Family Therapy Service to come under the team’s management structure to enable greater access and involvement. Early Intervention in psychosis philosophy is embodied with the team and within each staff member who aspire to give 100% to their service users, their commitment to maintain high standards of care is a privilege to witness.


What aspects of your service would you share with people who want to learn from you?

The team was set up with the Early Interventions in Psychosis philosophy of care to provide early identification and treatment, reducing the duration of untreated psychosis, promoting recovery. The team use assertive engagement techniques and psychosocial intervention with a normalising rationale to reduce stress, engage people and their families. We believe that people do not live in a bubble but in a perpetually changing social environment and so our treatment is focussed on helping the person navigate their way through their world to achieve their goals for life. This approach has been successful for this client group and is an approach that we use for all the young people we care for including those we help to transition from childhood to adulthood.


Additional Questions

The following questions are an opportunity for you to provide further details on how you implement positive practice in your service delivery and how you ensure your service is advancing access and equalities.  Answers to these questions will not influence how your PPiMH awards application is assessed, however any responses received may contribute to the potential inclusion of your service/team as a positive practice example within published guidance developed by NCCMH and NHS England.



How many people do you see?

The team has a caseload of 74 people and receives approximately 3-4 referrals a month, the service is time limited and has a maximum treatment period of 3 years. For transitions cases the treatment period is approximately 6-12 months dependent on need.


How do people access the service?

Referrals are taken from CAMHS, Access team, Crisis Team, Home Treatment Team, and also the Community teams; we also take referrals direct from GP and self-referrals. Specifically, for the transitions service we only take referrals from CAMHS. The team attends voluntary organisation groups, schools and other public events to maintain awareness of the service and promote the team, NAViGO and also reduce stigma. Assessment and treatment is done within 2 weeks of referral to meet CCQI Standards and CQUIN. And for those who may find access difficult we use assertive treatment techniques to engage people, assessment and treatment can be done in vivo to promote engagement. Referrals are taken via Letter, email, telephone or face to face. A discussion will take place with the referrer and then if accepted the referral lead person will contact the person to triage the referral, gain consent and then make an appointment for an assessment. This will then identify whether the criteria is met. If not then the person will be signposted on to another service or discharged. All referrals are discussed in daily meetings and weekly MDT’s. Specifically, for transitions service, regular meetings take place to discuss and identify possible transition cases and when identified it is then discussed in MDT and allocated to a worker, who will attend a meeting with the CAMHS worker, if after this discussion the young person is taken on by the team the transition process described above takes place.


How long do people wait to start receiving care?

All referral to the service are triaged, discussed and allocated within 14 days of referral, these access time standards set by CCQI and NHS England. Staff members will document care on the electronic system and log their contact, the waiting times are then collated by performance in order to meet the CQUIN. This information is then used in audits for NHS England and CCQI to monitor compliance with the EIPN standards for Early Interventions in Psychosis.


How do you ensure you provide timely access?

When a referral is received it is triaged on the same day by the days duty person, the referral is then discussed in the daily huddle and allocated to an Early Intervention Practitioner, from the Allocation rota. The practitioner then calls the person to make an appointment to see the person within 14 days of referral in order to meet the CCQI standards for Early Intervention in Psychosis.


What is your service doing to identify mental health inequalities that exist in your local area?

The team attend youth forums and also schools to talk to young people, families and teachers to promote mental health awareness, dispel myths about mental illness and reduce stigma. This is a service that the team’s practitioners offer out of their normal working hours as an unpaid service. This can also help families, young people and the service to identify when they or their loved ones may need a service that are otherwise slipping through the net.


What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

Access to treatment is often found to be more of a challenge in the more deprived areas of Grimsby. Numerous factors including lifestyle, education and culture affect this which is why the teams approach to care is so important to counter perceptions of services that people may have.


What is your service doing to address and advance equality?

Team philosophy is integral to promoting equality, the EIP ethos of inclusion and acceptance ensures fair and equal access to treatment. The team attend youth forums and also schools to talk to young people, families and teachers to promote mental health awareness, dispel myths about mental illness and reduce stigma. This is a service that the team’s practitioners offer out of their normal working hours as an unpaid service.


How do you identify the needs of a person using the service?

A full Care Programme Approach assessment is undertaken by the team, this includes Care planning, PREMS, PROMS and also specific assessments. Information is garnered from the young person, their family and carers as well as other professionals or services involved, previous notes if applicable and the person’s friend is appropriate. Screening tools used are: • CPA Assessment • Psychosis Checklist • CAARMS (Comprehensive Assessment of At Risk Mental States) • DICES (Risk assessment) • DIALOG • QPR • AUDIT • DAST • WHISe (Wellbeing Health improvement Service)(Physical health assessment)


How do you meet the needs of people using the service and how could you improve on this?

Early Interventions has a specific approach to care driven by an ethos of recovery and normalisation. The care we offer is determined by the pathway chosen. We provide care for At Risk Mental States (ARMS) and the First Episode of Psychosis (FEP) pathway. Both pathways are similar and provide evidence based interventions, compliant with NICE guidelines. Interventions offered are Cognitive Behavioural Therapy for Psychosis, Family Interventions, Employment and Education Support, Carer focussed education support, Medication, Physical health and Wellbeing advice and support as well as Psychosocial Interventions, social inclusion and community education schemes. Early Intervention approach to care has a huge evidence base and is recommended treatment modality by NHS England, CCQI and NICE. Working with commissioners, service users, their families and NAViGO senior management the team strives to improve all aspects of care it provides. The EIP approach supports transitions from childhood to adulthood within its philosophy; the transitions service incorporates this into transitioning young people to adult services. when transferring people to other services joint working is preferred for a period of time, the pace of which is dictated by the service user to ensure smooth transition to the accepting service.


What support do you offer families and carers? (where family/carers are not the service users)

All Families are offered a tailored Carer focussed education and support package, written and verbal information is given and discussed at length. Carers assessments are offered regularly and updated as needed and receive a support plan. Carers’ needs are also considered as part of CPA and Care planning for the service user. Family Interventions are a major part of treatment in Early Interventions; this is offered to every family that receives care from the team. The way in which this is delivered is currently under review, the Systemic Family Therapy Service is being brought under the management structure of EIP.


NCCMH mental health care pathways

Have you implemented any of the mental health care pathways developed by the NCCMH (on behalf of NHS England)?

Early Intervention in Psychosis Services


If you have implemented any of the above, what were the benefits and challenges?

The approach is youth friendly, promoting recovery, positivity and optimism; its benefits are in engaging people in early detection and treatment for psychosis. We are linked to services such as employment training and education in schools, colleges and universities there are tremendous benefits in these links.



Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England):

North East Lincolnshire Clinical Commissioning Group (NELCCG) and NHS England (Rharian Fields and Liaison & Diversion Teams)

Provided by (e.g. name of NHS trust) or your organisation: NAViGO Health and Social Care CIC.NAViGO is a not for profit social enterprise formed in 2011 under the Right to Request Agenda. The whole of mental health services in N E Lincolnshire transferred out of the NHS yet is still the preferred provider to the NHS delivering both statutory and a range of innovative additional services in N E Lincolnshire. Becoming a social enterprise has allowed the organisation the autonomy to develop innovative projects. Any surplus made by working smarter is re-invested to improve services for local people.


Population details

Brief description of population (e.g. urban, age, socioeconomic status):

North East Lincolnshire is a small unitary authority covering an area of 192km2 with a population of around 159,000. The majority of the resident population (around 94.2%) live in the urban towns of Grimsby and Cleethorpes with the remainder living in the smaller town of Immingham, or in surrounding rural villages. On the Northern border, the Humber estuary has been designated as a Site of Special Scientific Interest and to the south, the Lincolnshire Wolds are recognised as an Area of Outstanding Natural Beauty. Cleethorpes gained 4 national Seaside Awards in 2015. North East Lincolnshire has a distinctive economy, built on expertise in manufacturing, engineering, ports and logistics, and food processing. The local area has some significant advantages stemming from its location, labour force, and transport infrastructure that position it for growth in renewables, chemicals, advanced manufacturing and the food and drink sector. Taken together, Grimsby and Immingham constitute the UK’s largest port by tonnage shipped. Whilst the general direction of travel for the locality is around improving the environment and perception of the area, N E Lincolnshire does have pockets of high deprivation, ranking high on the IMDO (Index of Multiple Deprivation) which measures the following 7 deprivation indicators:- • Income • Barriers to housing and services • Employment • Living Environment • Health/Disability • Crime • Education/Training An example, East and West Marsh, two Wards within the North East Lincolnshire Council area, now rank in the top 1% deprived sub-areas nationally. As a result of the deprivation there are long standing health inequalities with those in the more deprived areas dying on average 8 – 10 years before those in the most affluent. According to the National Office of Statistics, around 18.46% of the population have some sort of emotional disorder. Other key points to note:- • The boundary of North East Lincolnshire is comprised of 106 Lower Super Output Areas (LSOAs); these LSOAs which contain a minimum population of 1,000 and a mean average of 1,500 are distributed amongst the fifteen electoral wards. • Overall, North East Lincolnshire is ranked as the 31st most deprived local authority in England, out of 326. (increased from 46th in the ID 2010.). • 32,567 residents, which is approximately 20% of the population are classed as income deprived with 25% of LSOAs being in the 10% most deprived for income nationally. • 15,140 residents are classed as employment deprived. • 20.1% of the working age (16 to 64) population of North East Lincolnshire have a known disability • 95.4% of the resident population of NEL are White British. • The January 2015 School Census shows 23,541 children on roll, 2981 ( 12.5%) of school pupils were identified as having Special education needs • Presently 28.5% (8,500) local children are thought to live below the poverty line

Size of population and localities covered:

Population c159,000 – NAViGO covers the area of N E Lincolnshire

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