Guidance for commissioners of mental health services for young people in transition

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This guide describes good quality mental health transitions services for young people making the transition from child and adolescent to adult services.

It also describes the benefits of transitions services and explains why a transitions service is important for the commissioners of specialist mental health services.

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Guidance for commissioners of mental health services for young people in transition

  1. 1. Guidance for commissioners of transitions services 1VolumeTwo:Practicalmental healthcommissioningGuidance for commissioners ofmental health services foryoung people making thetransition from child andadolescent to adult servicesJoint Commissioning Panelfor Mental Healthwww.jcpmh.info
  2. 2. Joint Commissioning Panelfor Mental HealthCo-chaired by:Membership:www.jcpmh.info
  3. 3. 2 Practical Mental Health CommissioningContentsExecutivesummaryIntroduction04What aretransitionsservices?Why are transitionsservices importantto commissioners?05 06What do weknow aboutcurrent transitionsservices?07What would agood transitionsservice look like?08Supporting thedelivery of themental healthstrategy13Resourcesand references14
  4. 4. Guidance for commissioners of transitions services 3Executive summary• Mental illness frequently starts inchildhood and the teenage years.1Theages 16–18 are a particularly vulnerabletime when the young person is bothmore susceptible to mental illness, isgoing through a period of physiologicalchange, and is making importanttransitions in their education.• It is also the age at which the youngperson already in contact with mentalhealth services will move from childand adolescent services (CAMHS) toadult services (AMHS).• The way mental health services arecurrently structured creates gapsthrough which young people mayfall as they undergo the transitionfrom CAMHS to AMHS.• Young people with mental healthproblems whose needs have beenmet primarily by paediatric services,education or social care may find thatthere is no equivalent service for adults.• Models of stand-alone and integratedtransitions services have addressed theissue and should be commissioned inconsultation with transitions forums.• These should not be limited to strictage boundaries but should operatein response to need and to providecontinuity.• Formal joint working arrangementsshould be put in place to addressstructural and procedural difficultiesarising from the interface of CAMHS andAMHS and the differences in approacharising from cultural differences betweenthe two services.• Commissioning effective transitionsservices should lead to reduced numbersof young people lost to services at thiscritical time and reduced periods ofuntreated illness and poor outcomes.• This should, in turn, lead to reducedmorbidity, thus reducing downstreamdemand on generic services.• Commissioners must work with publichealth colleagues to ensure that theneeds of young people with mentalhealth problems, including those youngpeople whose needs are primarily metwithin education, social care and non-statutory agencies and young people incontact with the criminal justice system,are identified in the Joint Strategic NeedsAssessment (JSNA).• Commissioners should ensure that thequality and productivity of services foryoung people at the point of transitionare improved in line with best practice– including services for young people inout-of-area placements.
  5. 5. The Joint Commissioning Panelfor Mental Health (JCP-MH)(www.jcpmh.info) is a newcollaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists,which brings together otherorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• Service users and carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• Afiya Trust• British Psychological Society• Representatives of the EnglishStrategic Health Authorities• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.The JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health.1IntroductionThe JCP-MH has two primary aims:• to bring together service users, carers,clinicians, commissioners, managers andothers to work towards values-basedcommissioning• to integrate scientific evidence, patientand carer experience and viewpoints andinnovative service evaluations in orderto produce the best possible advice oncommissioning the design and deliveryof high quality mental health, learningdisabilities and public mental health andwellbeing services.The JCP-MH:• has published Practical Mental HealthCommissioning,2a briefing on the keyvalues and principles for effective mentalhealth commissioning• provides practical guidance and adeveloping framework for mental healthcommissioning• will support commissioners of publicmental health to deliver the bestpossible outcomes for communityhealth and wellbeing• has published a series of short guidesdescribing ‘what good looks like’ invarious mental health service settings.Who is this guide for?This guide describes what ‘good’ lookslike for a modern transitions service fromchild and adolescent mental health services(CAMHS) to adult mental health services(AMHS), and should be of value to ClinicalCommissioning Groups (as they will becommissioning secondary services)and the NHS Board, as some patientsin CAMHS Tier 4 will be affected.How will this guide help you?This guide has been writtenby a group of CAMHS/transitions experts.The content is primarily evidence-based butideas deemed to be best practice by expertconsensus have also been included. By theend of this guide, readers should be morefamiliar with the needs of young peoplewith mental health problems in transitionfrom CAMHS to AMHS and other servicesand be better equipped to:• understand what a good quality,modern transitions service looks like• understand why a good transitionsservice delivers the mental healthstrategy and the Quality, Innovation,Productivity and Prevention challenge– not only of itself but also by enablingchanges in other parts of the system.This guide also addresses issues relatingto commissioning transitions services.It describes:• the benefits of transitions services• why a transitions service is importantfor the commissioners of specialistmental health services.4 Practical Mental Health Commissioning
  6. 6. Guidance for commissioners of transitions services 5What are transitions services?This document is based onthe guidance Planning MentalHealth Services for YoungAdults – Improving Transition:a Resource for Health andSocial Care Commissioners,3published by the former NationalMental Health DevelopmentUnit (NMHDU), the NationalCAMHS Support Service (NCSS)and the Social Care Institutefor Excellence (SCIE).Current commissioning models oftenplace CAMHS and AMHS within differentframeworks, structures and organisations.CAMHS are generally planned andcommissioned as part of children’s services,which brings the benefits of closer linksbetween physical and mental healthservices and between CAMHS and otheruniversal and targeted services for childrenand young people. However, it also meansthat AMHS and CAMHS commissioningstrategies and care pathways may developseparately, which becomes particularlyproblematic for young people withmental health problems as they moveon from CAMHS and other servicesfor young people. CAMHS and AMHScommissioning therefore needs to bemore integrated.Transitions services are designed tomeet the needs of young adults (usuallyin the age range 16–18) who are:• moving from CAMHS to AMHSand who remain with AMHS• moving to AMHS but whosubsequently drop out of services• referred to AMHS but are notaccepted for a service• not referred to AMHS as they arebelieved to be ineligible for a service• not required to move to adult servicesif CAMHS can work with themfor longer• not in need of a move to adult services• are supported in generic primary orsecondary services (including specialeducation, social care and paediatricservices) where the workers may besupported through CAMHS consultation• are supported by voluntary sectoragencies and/or are not engaging withstatutory mental health services• are perceived as too difficult for CAMHSto work with (these might include youngpeople in contact with the criminaljustice system).Transitions services should supporta further cohort of young peoplewho experience transition but may notbe in receipt of a service from CAMHS.They include:• young people with risk factors formultiple poor outcomes (includingmental illness) as adults• young people whose symptoms areinsufficient to meet diagnostic criteriafor mental disorder (ie. sub-threshold)but have a considerable impact ontheir lives and who are at risk ofdeveloping mental disorder that meetsdiagnostic thresholds• young people who have previouslyundiagnosed and unmet needs,particularly those whose needs becomemore acute as adolescence progressesand family/educational/ other supportsdiminish. These needs may include:– emerging personality disorder– early stage psychosis– attention deficit hyperactivity disorder– high functioning autism spectrumdisorder– eating disorders, which occur mostoften in females aged 15–19 years.
  7. 7. 6 Practical Mental Health CommissioningWhy are transitions services important to commissioners?There are particular groupsof teenagers and young adultswho are at much higher riskof developing mental disorder(and who are therefore alsoat higher risk of transitionproblems). They include:• looked after children, who are atfive-fold increased risk of any childhoodmental disorder4and four- to five-foldincreased risk of suicide attempt asan adult5• children with learning disability, whohave a 6.5-fold increased risk of mentalhealth problems6• children with special educationalneeds, who have an increased risk ofconduct disorder7• children with physical illness, whohave an increased risk of emotionaland conduct disorder7• homeless young people, who are atan eight-fold increased risk of mentalhealth problems if living in hostels andbed and breakfast accommodation8• young offenders – young men incustody age 15–17 are at 18-foldincreased risk of suicide;9women incustody age under 25 are at 40-foldincreased risk of suicide;10both sexesare at four-fold increased risk of anxiety/depression11and three-fold increasedrisk of mental disorders11• young people who self-harm• young people with teenage onsetdepression, who are regarded asexperiencing normal adolescent turmoil• teenage parents.Most mental illnesses have their origins inthe teenage years. The years 16–18 are aparticularly critical period of vulnerabilityto mental illness, as well as a period ofmajor physiological, emotional and socialchange in the young person’s life. It isparticularly important that care remainsconsistent and uninterrupted throughoutthis time of heightened vulnerability. Yetthis is also the period when the youngperson is expected to move from CAMHS,where they may have established strongand positive relationships, to AMHS, whichoften have very different systems andstructures and work to a different ethos.The quality andproductivity challengeThe Quality, Innovation,Productivity and Prevention(QIPP) programme presentsan opportunity to improvethe quality of transitions andoutcomes for young people andtheir families, as well as achievecost savings. Department ofHealth guidance12and healtheconomics research13pointto the economic savings thatcan follow effective interventionin the early years.It is widely recognised that interveningearly at the onset of mental illnessimproves prognosis, reduces futuredemand on mental health services andleads to better outcomes for patients andtheir families.14Early intervention thusimproves quality by preventing lifelongmental illness and increases productivityby reducing demand on inpatient bedsand other costly support and welfareservices, both of which should enablecommissioners to achieve QIPP savings.13
  8. 8. What do we know about current transitions services?The reasons for the well-recogniseddiscontinuities between child and adultmental health services (and it should benoted that many young people find thereis no appropriate service to move to, sodo not experience a transition in anymeaningful sense) are numerous.The TRACK study15of young people’stransitions from CAMHS to AMHS hasfound that up to a third of teenagers arelost from care during transition and afurther third experience an interruptionin their care.Generally, CAMHS are designed tomeet the needs of children and youngpeople with a wide range of disordersand problems such as attention deficithyperactivity disorder (ADHD) or autisticspectrum disorder (ASD), whereas AMHStend to focus on services for people withsevere and enduring illnesses such aspsychosis or severe depression.Many young people with ongoing mentalhealth needs can find that AMHS do notprovide the same level of specialist care,and therefore fall into a gap betweenCAMHS and adult care. Those thatdo make a transition across can stillexperience poorer quality of care.In practical terms, a numbers of factorshave been identified that present barriersto young people’s transitions from CAMHSto AMHS.16They include:• training of professionals involved• financial factors, including difficultyaccessing resources• differing expectations of mental healthservices poor inter-agency co-ordination• lack of planning• lack of adult mental health professionalswith skills to work with young people.In addition, there is still considerablevariation across the country in the cut-offpoint between CAMHS and AMHS. Insome places CAMHS continues up to 18years of age; in others it ends at age 16;in yet others it is 16 if the young person isno longer attending school, and 18 if theyare still in education.Continuity of care between child and adultservices is not helped by the differencesbetween the care planning systems usedin CAMHS and AMHS, (for example,CAMHS uses the Common AssessmentFramework; AMHS uses the CareProgramme Approach ), the structuresand types of care teams and fundingarrangements.A great deal of research has beenconducted to find out what youngpeople and young adults want fromservices and what makes a goodtransition. Essentially, young peoplesay that they want:• to be listened to and understood• to be taken seriously• to experience well planned,smooth transitions• to receive flexible services• to have information and choice• to have continuity of care.17Guidance for commissioners of transitions services 7
  9. 9. 8 Practical Mental Health CommissioningWhat would a good transitions service look like?Model of service deliveryThere is no prescribed ‘bestpractice’ model to meet theneeds of young people intransition. Many differentmodels can be found across thecountry. Services need to relateto local need and circumstances.In some areas, AMHS andCAMHS are bridged bytransition workers; other areashave not formalised this role.The good practice guidance, Workingat the CAMHS/Adult Interface, describesa range of models which have beendeveloped to support young people andyoung adults as they seek to move fromchild to adult services.18It recommendsany of the following service models,delivered singly or in combination:• a designated stand-alone transitionservice.Example: The Wirral 16-19 TransitionServiceThere are five key stages to thetransition process in the 16-19 service:1 The young person is placed in the16-19 service2 The young person’s key worker/caseco-ordinator liaises with the AdultService Team Leader to co-ordinatetransition. This may involve a periodof joint working up to the point oftransition3 A written referral is made to theAdult Team and care co-ordinationdocumentation is completed – thiswill include a history of professionalinvolvement with the young person andthe relevant family history4 The Adult Service confirms acceptanceof the referral in writing, copied to therelevant professionals, the young personand their carers5 Clinical responsibility remains with the16-19 service until formal discharge andacceptance by the Adult Service. Thecase file follows the young person and issigned to verify receipt.• a designated transitions team withinan existing AMHS or CAMHS service.Example: NorthamptonshireDedicated Transitions Service teamIn Northamptonshire the Transitionand Liaison Team (TLT) has beendeveloped to support young adults withdevelopmental conditions during theirtransition from children’s services toadult services including AMHs. It coversan age range of 15-18.The TLT offers highly specialiseddiagnostic assessments and interventionsfor clients with Aspergers syndrome,ADHD and Tourette’s syndrome. TheTLT supports young people with thesedevelopmental conditions who aredue to leave school and transfer intoadult services.This model enables expertise regardingneurodevelopmental difficulties tobe shared across CAMHs and AMHsto inform decisions regarding futuresupport or treatment needs.8 Practical Mental Health CommissioningThe Common Assessment Framework is a shared assessment and planningframework for use across all children’s services and all local authoritiesin England. It aims to help the early identification of children’s additionalneeds and promote co-ordinated service provision to meet them.http://www.cwdcouncil.org.uk/cafThe Care Programme Approach is used by mental health services, incollaboration with social services departments, to put in place specifiedarrangements for the care and treatment of mentally ill people in thecommunity. http://cpaa.co.uk/thecareprogrammeapproachThe Care Programme Approach can be used across both child and adultsettings, and can also be linked to the Common Assessment Framework.For example, one area includes in its CPA assessment the simple question‘Has a CAF been undertaken?’, which prompts practitioners drawing up theCPA to contact the CAF lead professional.
  10. 10. Guidance for commissioners of transitions services 9• designated staff trained in workingwith young people seconded toAMHS teams.19Example: Leeds CAMHS serviceLeeds CAMHS, including inpatient andcommunity CAMHS, extended the ageof service users to their 18th birthdayfrom their 17th birthday as from April1st 2010 (inpatient), and October 1st2010, in the rest of CAMHS. This hasled to a renewed focus on transitionprocesses. AMHS and CAMHS seniormanagers and clinicians meet every sixweeks to review the transition protocoland to revise their practice continuallyin response to the views of service usersand staff.Two dedicated transition worker postshave been employed to work withyoung service users from the age of16 and their families where the youngpeople could benefit from mental healthsupport beyond 18 years of age.Leeds is also developing a multi-agencytransition strategy with CAMHS inputoutlining the principles of best practicefor all agencies in Leeds who areworking with young people movingbetween children’s and adults’ services.Some organisations have developedmultidisciplinary teams to bridge andwork with CAMHS and AMHS to meetthe generic mental health needs of olderadolescents. There are many examples ofthese teams linking with or being part ofEarly Intervention Service for Psychosisteams. Many have developed strongpartnerships with AMHS Home Treatmentand Crisis Resolution Teams and otherservices and agencies in the public andvoluntary sectors.18Some areas have established a localTransitions Forum to improve liaison andco-working between all the relevantagencies. These forums bring togetherrepresentatives from CAMHS, AMHS,the voluntary sector and young people’sgroups, who meet regularly to agree,review and monitor transition protocols(see below), and provide an arena fordiscussion, consultation and servicedevelopment.Many areas have taken part in a transitionsupport programme under the umbrellaof the joint, three-year Department forEducation/Department of Health AimingHigh for Disabled Children programme,and have appointed transitions co-ordinators. Transitions co-ordinators reviewprogress to improve transitions locally,identify where the gaps are and advisehow joint working could fill these gaps.Bringing CAMHS and AMHSrepresentatives together with youngpeople and parents to consider whatactually happens to young peopleduring transitions will highlight gaps andobstacles. It is essential that CAMHS andAMHS practitioners have the opportunityto map and review how the system isworking and that young people and theirfamilies (those who have been receivingservices and those who have not) areable to contribute their expertise andexperience to improving and developinglocal services.Key components of adesignated transition serviceA designated transition service is the termused to describe a multidisciplinary teamthat has been set up specifically to bridgethe gap between and work jointly withCAMHS and AMHS to meet the genericmental health needs of older adolescents.As reported above, there are manyexamples of these teams linking with arange of specialist early intervention andcommunity mental health services in boththe public and voluntary sectors.Good practice examplesCity and Hackney extended CAMHSEast London Foundation NHS Trust hasextended the City and Hackney CAMHSto continue Tier 3 service provision toyoung people aged 18–25 years. Theaim of the extended service is to createadditional capacity to continue to supportthese young people through the periodof transition.The extended service works primarily withyoung people who do not currently meetthe threshold for AMHS in Hackney butwho are thought to need support froma mental health service. The extendedservice also targets young people whoneed a period of preparation before theyare ready to make the transition to adultservices, because of their developmentalneeds. It also provides additional supportthrough the transition process to youngpeople who need it. The service willmaintain contact until the young personis fully engaged with AMHS, rather thanclosing the case at the point of referral.The service is part of the wider City andHackney CAMHS service and works inpartnership with primary and social care,youth services, adult services, third sectororganisations and local education colleges.
  11. 11. 10 Practical Mental Health CommissioningWhat would a good transitions service look like? (continued)Some young people receiving CAMHS caredo not meet the criteria for AMHS whenthey reach age 18, and in some cases maylose other statutory support. The extendedCAMHS service is preventative, as itenables young people to remain in touchwith services. This increases their chancesof completing treatment and avoidsunnecessary transitions at a point whenthey might otherwise drop out of contact.Typically the extended service managesa moderate level of risk, in line with therest of the generic CAMHS, and providescare to young people with the followingconditions (often in combination):• emotional and psychological problemsin the family and social environment• neuro-developmental disorders suchas Aspergers syndrome and ADHD• mild learning disabilities• depression• anxiety disorders, including generalanxiety, obsessive compulsive disorder,social anxiety and health anxiety• self-harm and emotion regulationdifficulties• eating disorders and bodydysmorphic disorder• conduct disorder.If a young person has active psychosisthey are referred to the Early Interventionin Psychosis team (EIP). Those aged18+ who need a Care ProgrammeApproach (CPA) or are actively suicidalare referred to AMHS. CAMHS staff inthe generic team also continue to workwith young people after they turn 18,where clinically appropriate. The workis primarily outreach, so the dedicatedextended service posts are managedby the multidisciplinary Youth SupportMental Health Team, a specialist teamwithin CAMHS that uses an assertiveengagement model.Central Norfolk early interventionyouth teamThe Central Norfolk Early Intervention inPsychosis service (CNEIT) has establisheda specialist youth team to work specificallywith 14–18 year olds referred to its EarlyIntervention in Psychosis (EIP) service.These young people are at the lower agerange of those using the EIP service.Young people in this age group cancontinue to receive the EIP service for upto five years, rather than the usual threeyears, in order to reduce the need forunnecessary transitions between servicesand to improve the transition to AMHS orback into primary care.Typically the youth team will workwith the individual, their families andthe support system around them (eg.school or college). Interventions includea combination of cognitive behaviouraltherapy (CBT), assertive case management,support work and family work. The teamfocuses on promoting social activity andengagement with existing educational andvocational services, and peer and familysupport. The aim is to discharge the youngperson to primary care. For those whoneed ongoing support after age 18, theteam works with adult services to ensurea smooth transition with ongoing supportand access to care and treatment.Sheffield ADHD transitions clinicThe Sheffield ADHD transitions clinic isfor young people with an establisheddiagnosis of ADHD, who are thought toneed continuing management of ADHDsymptoms following transition to AMHS.The clinic was set up to address the fearsand anxieties that young people may haveabout AMHS and to reduce the frequencyof unattended appointments by youngpeople with ADHD once they have movedto adult services. Patients can only receiveprescribed medication from their GP if theyare reviewed by AMHS every six months,in line with the Shared Care Agreementwith the PCT.The clinic provides an opportunity forthe young people to meet with AMHSstaff and learn a little about ADHDin adults and how adult services areorganised in Sheffield. Each young personattends a single clinic meeting, whichcan involve a number of staff, includingCAMHS consultants, nurses, therapistsand AMHS psychiatrists. Parents/carersalso usually attend.The meeting is used to:• review the patient’s needs, medication,and plan transition• introduce patients and carers tomembers of adult services• provide information (including a leaflet)about adult ADHD services• invite young people to join the Livingwith ADHD transition group.
  12. 12. The Living with ADHD group is forclients from the transition clinic and otheryoung patients with ADHD receivingadult services who might benefit frompsychosocial groupwork. These aremainly young people with ADHD on thecaseloads of AMHS clinicians. All are aged16–25 years of age. The sessions providethe young people with an opportunity toask questions, develop useful strategies tocope with ADHD and learn more abouttheir condition and treatment.Key components of placingdesignated transitions staffin AMHS teamsEvaluations of this model suggestsome elements are consistently effective.They include:• access to a multidisciplinary teamwith expertise from both CAMHSand AMHS providing individual andfamily psychosocial and psychologicalinterventions alongside medication• a youth-centred and flexible approachwith an emphasis on effectiveengagement of young people throughoutreach and joint working with otheragencies• expertise to treat the range of mentaldisorders presenting in this age group18• flexibility around age boundaries18• access to a range of services to helpyoung people achieve independence,including education, employment andhousing• in-reach to primary care, which offersholistic health care, family practice andearly detection of problems.This model has been shown to improvetransitions for young people withpsychological development disorders,such as autistic spectrum conditions andattention deficit disorders, who are wellknown to experience discontinuity and,in some cases, discontinuation of helpand support when they reach age 16and whose quality of life is consequentlypoorer than that of many young peoplewith longstanding physical healthconditions.20The Bridge ProjectWest Midlands Strategic Health Authorityprovided a grant through its innovationsfund to explore models of deliveringhigh quality care to vulnerable adolescentsthat enhance their experience of transitionand improve their outcomes. Twoinnovative models of transitional carehave been developed in the region tocompare outcomes:• protocol-driven transitional care inSandwell CAMHS• a dedicated transitional worker inCoventry CAMHS, part of the Coventryand Warwickshire Partnership Trust.Both trusts serve socio-demographicallyand ethnically diverse population groupswith high levels of need. Recent CAMHSreviews in both areas have identified carepathways for 16–18 years old as priorityfor service improvement. The projectwill also conduct a one-year prospectiveevaluation to track the care journey,service experience and clinical outcomes ofall young people who make the transitionfrom CAMHS to adult services. The twomodels will be compared for clinical andcost-effectiveness to find out if employinga dedicated transitional worker offersbenefits over and above protocol-basedtransitional care.Transition protocols The lack of consistent protocols fortransition remains a significant barrierto effective practice. Research showsgreat variation in the level of detailon operational procedures involved intransitions: some protocols make veryspecific and clear recommendationson what clinicians should be doing;others make only general statements,such as advising adherence to the CareProgramme Approach (CPA) guidelines.21,22Current good practice indicates thatprotocols should:• promote person-centred planning• enable continuity of care• offer flexibility in decision-making• have sufficient detail in theoperational procedures to ensureefficacy and consistency.Guidance for commissioners of transitions services 11
  13. 13. What would a good transitions service look like? (continued)Commissioning toolsA number of evidence-based toolsexist to support and inform effectivecommissioning of transitions services.Self-assessmentThe NMHDU/NCSS Transitions Actionplanning tool (http://www.chimat.org.uk/selfassessmenttools) is based onthe HASCAS Transitions Standards. Itis a web-based self-assessment tool forcommissioners and services to self-assesskey aspects of transition and identifyparticular gaps and actions.Joint strategic needs assessmentCommissioning for transitions can onlybe effective if commissioners understandthe level of need at local level. Includingtransitions as part of the CAMHS andAMHS elements of the joint strategicneeds assessment (JSNA) will informeffective commissioning of the transitionalprocess. The National Mental HealthDevelopment Unit has produced a toolkitfor commissioners on conducting JSNAsfor mental health.23PersonalisationThe National Mental Health DevelopmentUnit has also produced a good practiceguide, Paths to Personalisation,24on howto make personalisation a reality for peoplewith mental health needs (including youngpeople). It contains information aboutwhat personalisation means for mentalhealth services, examples of what makespersonalisation work, and advice andinformation about good practice.The optimum transitions teamThere is no consensus as to the preferredmodel for an optimal transitions teamand no one-size-fits all configuration.This is because the optimal model andconfiguration will depend on localcircumstances, including local need,geography and the configuration of otherrelated services.OutcomesThe quality outcomes of a transitionsservice should include:• numbers of patients lost to services• duration of untreated psychosis• continuity of health and social carefor particularly disadvantaged groups(such as those with Autism SpectrumDisorders, looked after children andyoung people with learning disabilities)• reduced numbers of young peopleplaced out-of-area because of lack oflocal transitions services.12 Practical Mental Health Commissioning
  14. 14. Supporting the delivery of the mental health strategyThe Joint Commissioning Panelfor Mental Health believesthat commissioning that leadsto the effective planning andmanagement of the transitionof young people from CAMHSto AMHS, including theinvolvement of young peopleand their carers in the transitionprocess, will support thedelivery of the mental healthstrategy,1by contributing tothe following shared objectives.Shared objective 2:More people who developmental health problems willhave a good quality of life– greater ability to managetheir own lives, stronger socialrelationships, a greater senseof purpose, the skills theyneed for living and working,improved chances in education,better employment rates, and asuitable and stable place to live.Improved transitions services will ensurethat young people with mental healthproblems are able to move to adultservices that meet their needs and will leadto better provision for young adults withADHD or ASD so that their quality of lifeand life chances are significantly enhanced.Shared objective 3:Fewer people with mentalhealth problems will dieprematurely, and more peoplewill physical ill health willhave better mental health.Improved mental health is associatedwith better physical health. Improvedtransition from CAMHS to AMHS shouldresult in long-lasting benefits for theyoung person’s mental health and, asa consequence, physical health.Shared objective 4:Care and support, whereverit takes places, should offeraccess to timely, evidence-basedinterventions and approachesthat give people the greatestchoice and control over theirown lives, in the least restrictiveenvironment, and shouldensure that people’s humanrights are protected.Shared objective 5:People receiving care andsupport should have confidencethat the services they useare of the highest quality andat least as safe as any otherpublic service.Improved transitions services will resultin improved quality of care andtreatment for young people with mentalhealth needs, thereby reducing risk ofdisengagement with services and ensuringcontinuity of care and support througha period of great change in all aspects oftheir life, where the young person is attheir most vulnerable.Guidance for commissioners of transitions services 13
  15. 15. 14 Practical Mental Health CommissioningCAMHS Expert Reference Group Members• Margaret Murphy(ERG Chair)Consultant PsychiatristBrookside Family Consultation Clinic• Sarah BrennanChief ExecutiveYoung Minds• Raymond Brookes-CollinsCarer Representative• Anna BurhouseDirector of Strategic Modernisation(Child and Adolescent MentalHealth Service)2Gether Foundation Trust• Jonathan CampionConsultant PsychiatristSouth London and MaudsleyNHS Foundation Trust• Chris FitchResearch and Policy FellowRoyal College of Psychiatrists• Rebecca GoldmanSenior Research AnalystSocial Care Institute for Excellence• Russell JonesDeputy Director for DevelopmentSt Andrews Healthcare• Jo LoughranHead of Children and Young PeopleServices and LearningRethink• Richard MeierPolicy AnalystRoyal College of Psychiatrists• Paul MonksConsultant PsychiatristAdolescent DivisionSt Andrews Healthcare• Kieron MurphyDirector of DeliveryJoint Commissioning Panelfor Mental Health• Kathryn PughChildren and Young People’sIAPT Project ManagerDepartment of Health• Barbara RaymentDirectorYouth Access• Lucie RussellDirector of CampaignsPolicy and ParticipationYoung Minds• Swaran SinghHead of DivisionMental Health and WellbeingWarwick Medical School• Jenny TaylorConsultant Clinical PsychologistHomerton Hospital• Avril WashingtonConsultant PaediatricianHomerton University HospitalDevelopment processThis guide has been written by a groupof child and adolescent care experts.Each member of the Joint CommissioningPanel for Mental Health received draftsof the guide for review and revision, andadvice was sought from external partnerorganisations and individual experts. Finalrevisions to the guide were made by theChair of the Expert Reference Group incollaboration with the JCP’s Editorial Board(comprised of the two co-chairs of theJCP-MH, one user representative, onecarer representative, and technical andproject management support staff).
  16. 16. ResourcesSupporting effective transitions anddevelopment of services for young adultswww.nmhdu.org.ukNMHDU website listing resources theyhave developed in partnership with NCSSand the Social Care Institute for Excellence(SCIE) to support services to improvethe experience of young people who aremoving on children’s to adult services.Provides access to a number of resources,including some listed separately below.Planning mental health services for youngadults – improving transition: a resourcefor health and social care commissionersNCSS/NMHDU (2011)www.nmhdu.org.ukA guide to help health and social carecommissioners of both CAMHS andAMHS understand the importance ofgood transitions and how to translate thisinto positive action through contractingarrangements and commissioning toolssuch as CQUIN.Transitions in mental health care: a guidefor health and social care professionalsYoungMinds (2011)www.youngminds.org.ukA guide to the legal framework written bylawyers and mental health professionalsfor any professional working with youngpeople in transition from CAMHS toadult services. One of a suite of threepublications (see below), it brings togetherin one document the complex array oflegislation, guidance and policy governingtransitions and access to services for youngpeople and their families, and is illustratedwith case studies.Young people’s guide to transitionsYoungMinds (2011)www.youngminds.org.uk/young-people/transitions-guideA companion guide for young people,produced with NCSS and NMHDU,designed to demystify the complicatedprocesses in the transition from CAMHSto adult services and inform young peopleabout their legal rights.Guide to transition for parents and carersYoungMinds (2011)www.youngminds.org.uk/young-people/transitions-guideA companion guide for parents and carers,produced in association with NCSS andNMHDU, and designed to demystify thecomplicated processes in the transitionfrom CAMHS to adult services and informfamilies about their legal rights.Action planning to improve transitionsNCSS/NMHDU (2011)www.chimat.org.ukA web-based self-assessment tool forservice providers and commissioners toassess their baseline position, identifyproblems and develop local action plans.Pathways to effective transition:young people’s mental health(e-learning resources for professionals)NCSS/NMHDU (2011)www.chimat.org.ukA resource for practitioners workingwith young adults or training othercolleagues. Two modules coverdevelopmental and clinical issues foryoung people approaching transitionand help professionals design systemsto improve the transitions process.Social Care Institute for Excellencewww.scie.org.ukThe SCIE website publishes a wealth ofresearch and good practice informationon transitions for young people.Transition: From CAMHS to AMHS– scoping exerciseNCSS (2010)www.chimat.org.ukReport of a study of transition activity andmodels of good practice across the EastMidlands region, including a questionnairefor health trusts.Transition: From CAMHS to AMHS– supplementary reportNCSS (2010)www.chimat.org.ukA practical report setting out ideas forchange arising from a series of workshopsheld in the East Midlands region, plus aself-assessment checklist for providers.Evaluation of provision of mentalhealth services for looked after youngpeople aged 16+ in residential settingsOfsted (2010)www.ofsted.gov.ukA report based on visits to 27 children’shomes in eight local authorities thatexplores how the mental health needs ofyoung people in care aged 16 and overare met, including use of mental healthresources in the children’s homes, goodpractice and problems, and how wellstaff respond to the needs of youngpeople in their care.Guidance for commissioners of transitions services 15
  17. 17. 16 Practical Mental Health CommissioningThe legal aspects of the care andtreatment of young people with mentaldisorder: a guide for professionalsNIMHE (2009)www.chimat.org.ukA guide to the interaction between theMental Health Act, the Mental CapacityAct and the relevant children’s legislation.Consent to admission and consentto treatment: flow chart for 16 and17 year oldsNMHDU (2009)www.chimat.org.ukFlowchart for adult and CAMHS wardssummarising the issues that mental healthpractitioners will need to consider whendetermining the legal authority to admitand treat a young person aged 16 or 17years old. To be read in conjunction withthe NIMHE guide (above).Safe and appropriate care for youngpeople on adult mental health wardsRoyal College of Psychiatrists (2009)www.chimat.org.ukQuality standards to help wards providesafe and appropriate care for youngpeople who require admission to any adultinpatient mental health service.Working together to provide age-appropriate environments and servicesfor mental health patients aged under 18NMHDU (2009)www.chimat.org.ukA briefing for commissioners of adultmental health services and CAMHS tomeet the requirements of the duty forproviding age-appropriate environmentsunder the Mental Health Act 2007.Age-appropriate services:what, why, when and how?NCSS (2010)www.chimat.org.ukPowerpoint presentation on legislativechanges in mental health and implicationsfor children and young people.Systems model for planning ageappropriate environmentsNIMHE (2010)www.chimat.org.ukAn online planning tool withaccompanying guidance on model changesin service provision over a five-year period,considering the consequences in otherparts of the system and also economicimplications.The Junction: what services should bein place to support young people aged16 and 17 years with acute mental healthneeds in Lancashire?Lancashire Care NHS FoundationTrust (2009)www.chimat.org.ukA review of inpatient services by youngservice users in Lancashire, assessedagainst national criteria and withrecommendations for changes to ensuremore appropriate services.Crisis and 24/7 Service developmentin CAMHSNCSS (2006)www.chimat.org.ukReport for the East Midlands Care ServicesImprovement Partnership which identifiedinformation on current service provision;perceived gaps; service models andrecommendations.Mental Health Act ImplementationProgramme: children and young peoplewww.chimat.org.ukAccess to the full range of resourcesdeveloped by NMHDU to help areas meetthe duty to provide an age-appropriateenvironment for all under 18s who requireinpatient mental health care. Includesmany of the resources listed above, as wellas access to ‘train the trainer’ materials onthe legal framework for mental health careof children.Disability equality: fulfilling dutiesfor young people in transitionNational Transition Support Team (2010)www.transitionsupportprogramme.org.ukInformation leaflet published by theNational Transition Support Team (NTST)with support from Scope on what localauthorities and their partners can do toensure they are taking positive action tofulfil their duties to disabled young peopleunder the Disability Discrimination Act(DDA) during the transition to adulthood.Young adults with ADHD: an analysisof their service needs on transfer toadult servicesNaomi Taylor, Amy Fauset, Val HarpinArchives of Disease in Childhood (2010)doi:10.1136/adc.2009.164384http://adc.bmj.com/content/early/2010/06/08/adc.2009.164384.shortA study of the need for transition servicesfor young people with attention-deficithyperactivity disorder (ADHD) who havecontinuing impairment that also reportsthe benefits of specialist nurses workingwith GPs in a primary care setting or adultmental health.
  18. 18. Guidance for commissioners of transitions services 17References1 HM Government (2011). No healthwithout mental health: a cross-government mental health outcomesstrategy for people of all ages.London: Department of Health.2 Bennett, A., Appleton, S., Jackson, C.(eds.) (2011). Practical mental healthcommissioning: a framework for localauthority and NHS commissioners ofmental health and wellbeing services.London: JCP-MH. www.jcpmh.info3 Appleton, S., Pugh, K. (2011).Planning mental health services for youngadults – improving transition: a resourcefor health and social care commissioners.London: NMHDU/NCSS/SCIE.4 Meltzer, H., Corbin, T., Gatward, R.,Goodman, R., Ford, T. (2003). The mentalhealth of young people looked after bylocal authorities in England. London:Office for National Statistics5 Vinnerljung, B., Hjern, A., Lindblad,F. (2006). Suicide attempts and severepsychiatric morbidity among formerchild welfare clients: a national cohortstudy. Journal of Child Psychology andPsychiatry 47(7), pp. 723–733.6 Emerson, E., Hatton, C. (2007). Mentalhealth of children and adolescents withintellectual disabilities in Britain. BritishJournal of Psychiatry 191, pp. 493–499.7 Parry-Langdon, N. (ed.) (2008).Three years on: survey of the developmentand emotional well-being of childrenand young people. Cardiff: Office forNational Statistics8 Stephens, J. (2002). The mentalhealth needs of homeless young people.London: Mental Health Foundation.9 Fazel, S., Benning, R., Danesh, J. (2005).Suicides in male prisoners in England andWales, 1978–2003. Lancet 366(9493):1301–1302.10 Fazel. S., Benning, R. (2009).Suicides in female prisoners in Englandand Wales, 1978-2004. British Journal ofPsychiatry 194: 183–184.11 Lader, D., Singleton, N., Meltzer, H.(2000). Psychiatric morbidity amongstyoung offenders in England and Wales.London: Office for National Statistics.12 Department of Health (2011).The economic case for improvingefficiency and quality in mentalhealth. London: Departmentof Health. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_12373913 Knapp, M., Parsonage, M.(2011). Mental health promotionand mental illness prevention: theeconomic case. London: Departmentof Health. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_12608514 Royal College of Psychiatrists. (2010).No health without public mental health.The case for action. Position StatementPS4/2010. London: Royal College ofPsychiatrists.15 Singh, S.P., Moli, P., Ford, T., Kramer,T., McLaren, S., Hovish, K. et al (2010).Process, outcome and experience oftransition from child to adult mentalhealthcare: multiperspective study.British Journal of Psychiatry, 197(4),pp. 305–312.16 McDonagh, J., Viner, R. (2006).Lost in transition? Between paediatricand adult services. British Medical Journal,332, pp. 435–436.17 NAC Young People’s ReferenceGroup (2009). New horizons: towardsa shared vision for mental health whatyoung people think about the transitionfrom child and adolescent mental healthservices to adult services. London:National Advisory Council. http://nationaladvisorycouncilcmh.independent.gov.uk/downloads/yp-response-final.pdf18 Lamb, C., Hall, D., Kelvin, R.,Van Beinum, M. (2008). Working atthe CAMHS/adult Interface: good practiceguidance for the provision of mentalhealth services to adolescents/youngadults. London: Royal Collegeof Psychiatrists.19 Richards, M., Vostanis, P. (2004).Interprofessional perspectives ontransitional mental health servicesfor young people aged 16-19 years.Journal of Interprofessional Care,18(2), pp. 115–128.20 Royal College of Psychiatrists (2011).Developing services to improvethe quality of life of young peoplewith neurodevelopmental disorders,emotional/neurotic disorders andemerging personality disorder.Occasional paper OP77. London:Royal College of Psychiatrists.21 Singh, S., Moli, P., Ford, T., Kramer, T.,Weaver, T. (2008). Transitions of care fromchild and adolescent mental health servicesto adult mental health services (TRACKstudy): a study of protocols in GreaterLondon. BMC Health Services Research,8, p. 135.
  19. 19. 18 Practical Mental Health Commissioning22 McGrath, B. (2010). Transition fromCAMHs to AMHs – report on the scopingexercise to identify current transitionactivity and models of good practiceacross the East Midlands region.London: NCSS. www.nmhdu.org.uk/silo/files/transition-from-camhs-to-ahms.pdf23 NMHDU (2009). Joint strategicneeds assessment and mental healthcommissioning toolkit: a practicalguide. London: NMHDU. www.its-services.co.uk/nmhdu/en/our-work/mental-health-commissioning-programme/programme-governance/project-1-information-and-data/23 NMHDU (2010). Paths topersonalisation: a whole system, wholelife framework. London: NMHDU.www.nmhdu.org.uk/news/paths-to-personalisationa-whole-system-whole-life-framework/
  20. 20. Guidance for commissioners of transitions services 21A large print version of this document is available fromwww.jcpmh.infoPublished February 2013Produced by Raffertys

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