A complex systems approach to young peoples mental health
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This provides a summary overview of some of the areas of work we are leading in Hertfordshire to build a complex systems approach to mental health of children and young people
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A complex systems approach to young peoples mental health
- 1. www.hertfordshire.gov.ukwww.hertfordshire.gov.ukwww.hertfordshire.gov.uk Creating a Systems Approach to Young Peoples’ Mental Health Hertfordshire County Council www.hertfordshire.gov.uk
- 2. www.hertfordshire.gov.uk Hertfordshire – an overview
- 3. www.hertfordshire.gov.uk The size of our system: 540+ schools • 600 named mental health leads in Herts (note – some schools have 2) • Whole School Approach • Kitemark • Stonewall Education Equality Index ranking • School Health Champions • Student Organised conferences (4 per annum) • Pastoral Leads Network • Exam Stress “PH Approach” training
- 4. www.hertfordshire.gov.uk Young people tell us…. More education is needed in schools Parents, friends, schools, and GPs are key people that help us! We need to remove the fear/stigma associated with seeking support Be flexible with appointments Offer us choice and a range of therapies Make our treatment based on need Be friendly approachable and compassionat e
- 5. www.hertfordshire.gov.uk • Galea’s 7 principles of population health systems • Responding to Morbidity alone insufficient • The CAMHS system is important, but it’s only a part of it • Resilience, Resilience, Resilience • Make Settings and People Salutogenic • Change social norms and culture Why systems approaches?
- 6. www.hertfordshire.gov.uk The Herts Childrens Outcomes Framework
- 7. www.hertfordshire.gov.uk • Map system and identify must dos • All 11 Councils have elected member Mental Health Champions and Senior Officer Champions • Reporting to Health and Wellbeing Board • Responsibilities distributed – Drugs and Alcohol Board – Children and Young People MH and Wellbeing Board Running it…
- 8. www.hertfordshire.gov.uk The 20 System Must Dos beyond the basics of running MH Services Good parenting Suicide prevention Maternal mental health Relapse prevention Whole school approaches Support recovery Primary school Physical & mental health Support school aged CYP Unmet needs Adult resilience Liaison psychiatry Workplace Smoking cessation Early identification Stigma & awareness raising Reducing loneliness Major incident trauma Alcohol & Drug issues Bereavement
- 9. www.hertfordshire.gov.uk Hertfordshire – our CAMHS system journey • In 2015 we commissioned an independent review of Hertfordshire CAMHS system. It found: – a system that provided excellent provision, but lent itself to crisis management – concerns about access to services and waiting times, in particular from children and young people – A system that was often fragmented, with a reliance on NHS professionals – Concerns that CYP were often treated in isolation from environmental and family factors • A strong need to change and transform
- 10. www.hertfordshire.gov.uk What did we need to change to improve? • Develop a continuum of provision, from prevention, to early help through to specialist • Seeing the whole child, young person and /or family • Flexible proactive delivery of services • Creative, timely, evidence-based interventions (with an emphasis on early intervention) • Increasing resilience of CYP, promoting good emotional health and wellbeing, reducing stigma • Outcome focused services – goal-based outcomes • Better partnership working and greater transparency - A significant need to change as a system, rather than in isolation
- 11. www.hertfordshire.gov.uk Our Ambition…. It is the ambition that CAMHS is: • A system, rather than a service, that can operate across organisational boundaries through a shared vision to reduce duplication and provide access to the right support, including self-help where appropriate. • Responsive to need, where children, young people and their families are placed at the centre to improve outcomes. • Is based on continuous improvement, using evidence to support best practice and practice improvement
- 12. www.hertfordshire.gov.uk Our Ambitions…. • Development of an alliance between HPFT, HCT, HCC to: – Work together and not in isolation – Integrate pathways that can operate across organisational boundaries to ensure seamless transitions and flow for CYP – Develop a digital offer to families that promotes engagement and self-management – Referral mechanisms that are responsive to need – Share accountability – Joint outcomes and performance measurements
- 14. www.hertfordshire.gov.uk Our vision Range of Services delivering evidence based interventions to CYP and families
- 15. www.hertfordshire.gov.uk What have been our successes across 20 areas We have improved the provision across the system
- 16. www.hertfordshire.gov.uk What have been our successes CAMHS workers embedded into services 2 x Strategic Leads for Mental Health In Schools Kite mark developed to facilitate whole school approach Pastoral leads networks Mental Health Champions across the system Multi-agency suicide prevention plan Multi Agency CYP Emotional wellbeing board Collaborative commissioning arrangements
- 17. www.hertfordshire.gov.uk We still have challenges! • Further developing work around prevention of mental ill health, and early help with emotional wellbeing • Increasing demand for provision • Integrating provision in the face of diminishing budgets • Clarity, shared understanding, and consistent language, from the wider workforce is needed on promoting emotional wellbeing amongst all young people • Ensuring strategic direction is operationally delivered • Priority in future commissioning intentions across CYP landscape
- 18. www.hertfordshire.gov.uk • We have a set of pastoral leads networks established across the county on mental health • There is one in each district, with 67/80 secondary schools regularly engaging and attending meetings. • These meetings enable a whole school approach to mental health as they – sharing of best practice, – shared problem solving, – from key partners that are able to support schools with the mental health of their pupils. Secondary School Pastoral Lead Networks
- 19. www.hertfordshire.gov.uk 540+ schools • 600 named mental health leads in Herts (note – some schools have 2) • Whole School Approach • Kitemark • Stonewall Education Equality Index ranking • School Health Champions • Student Organised conferences (4 schools) • Pastoral Leads Network • Exam Stress “PH Approach” training
- 20. www.hertfordshire.gov.uk • launched recently • two schools have already successfully completed the process (The Priory in Hitchin, and Hitchin Girl’s School). 2 being assessed Schools MH Kitemark
- 21. www.hertfordshire.gov.uk Young Commissioners and Takeover Challenge.
- 22. www.hertfordshire.gov.uk How Hertfordshire is making conversations about mental health relevant for boys and young men www.justtalkherts.org Talking shows strength
- 23. www.hertfordshire.gov.uk 1) OBJECTIVES OUTCOMES Raise awareness of mental health amongst young people esp boys • 20 million social media impressions (2018 and 2019 campaign weeks) Challenge stigma and normalise conversations about mental health • 530+ contributors talking about mental health • Several male role models speaking openly and sharing coping strategies Increase consistency of mental health language and messages • 20+ partners using consistent campaign messages, branding and toolkits Increase the number of young people using healthy coping strategies • 4% reduction in 12-13 year old boys keeping worries about their mental health to themselves • Boys more likely to talk to others if worried about school work Equip schools and other agencies with tools to promote mental health and wellbeing • 75+ local primary schools, secondary schools and colleges supporting #JustTalk
- 24. www.hertfordshire.gov.uk MORE THAN A CAMPAIGN 1) Boys and Men - Making Mental Health Accessible for all: Guidance document produced for mental health services and commissioners Practical, achievable ways to make it easier for boys and men to access and engage with mental health services 2) Social Media agreement Shared multi-agency agreement for social media activity relating to mental health Focus on positive, hopeful messages Consistent language and meaningful messages Agreement around communications relating to suicide, linked to a media charter for suicide reporting 3) Partnership work Just Talk network has enabled joint commissioning opportunities Co-delivery between partners and sharing of resources Increased awareness across all partners of the work of other agencies Work with sport and physical activity providers, including mental health training
- 25. www.hertfordshire.gov.uk Young peoples’ film competition Over 25,000 views in just one week and an ongoing resource for the campaign
- 27. www.hertfordshire.gov.uk How Hertfordshire is making conversations about mental health relevant for boys and young men www.justtalkherts.org Talking shows strength THANK YOU!
Editor's Notes
- Hertfordshire is located just to the north of London, covering an area of 634 square miles, with a population of around 1,2M (2017), making Hertfordshire one of the most densely populated shire counties in England. Approximately 269,296 (2017) children and young people under the age of 18 live in Hertfordshire. This is 23% of the total population in the area. The ONS predicts an overall increase in Hertfordshire’s 0-19 population of 11.3% between 2018 and 2027 compared with 5.7% for the same age group nationally. The increases in Hertfordshire are particularly pronounced in the 10-14 age group (13.6% growth projected) and 15-19 age group (24.2% growth projected). There are 534* schools in Hertfordshire, of which: 417 primary, 80 secondary, 26 special and 7 education support centres. *the secondary figure includes 2 all through schools and 4 middle schools, and the primary figure includes nursery schools, first schools, infant schools etc.. Additionally there are a number of independent schools. The quality of education in Hertfordshire is highly regarded and pupil attainment is very strong when benchmarked against national performance – Ofsted As at 31 March 2018 there were: 5053 children in need (all cases open to children’s social care), a rate of 188 per 10,000 compared with a 2018 national average of 341 and 2018 statistical neighbour average of 304 522 children subject to a child protection plan, a rate of 19 per 10,000 compared with a 2018 national average of 45 and statistical neighbour average of 44 890 children looked after, a rate of 33 per 10,000 compared with a 2018 national average of 64 and 2018 statistical neighbour average of 50.8 CP data (numbers) March 2018 - 522 CLA March 18 - 890 CiN March 18 (all open cases including those above) 5053 Profile of CLA 84.4% of 10-16 year olds in Foster Care % of CLA exiting care to SGO 13.5% % of CLA exiting care to adoption in the 13% 2.1% of children in Hertfordshire schools have a statement of special educational needs or Education, Health and Care Plan, compared to 2.9% in England. Health outcomes across Hertfordshire are good with low rates of infant mortality and teenage conception compared with the national and eastern region averages. Hertfordshire also has one of the lowest proportion of children who are obese in both reception (20% compared to 22.6% nationally) and year 6 (28.9% compared to 34.2% nationally). From the most recent prevalence data from NHSE we can assume that approx 23,000 of our CYP would benefit from a CAMHS service. Service ratings: Longstanding and well embedded joint commissioning arrangements for CAMHS across the county council and two CCGs HPFT - strong NHS Foundation Trust with a ‘Good’ CQC rating provide Tier 3 CAMHS HCT – Community Trust with ‘Good’ CQC rating providing some tier 2 CAMHS A children’s Service that was rated as Good in our recent Ofsted inspection
- Our YP also had a voice in what matters to them in looking at how we transform our services.
- In 2015 ; following feedback from our families, our professionals and our communities we commissioned a review by the Centre for Mental Health in 2015 ; The review found that, whilst the system delivered excellent provision by knowledgeable and dedicated professionals it was also; a system that lent itself to crisis management – not enough being done at the earliest point to address emerging concerns and a reliance on NHS as the experts a strong voice of concerns from children and young people regarding waiting times A system that was fragmented – causing confusion for both families and professionals – and a lack of ownership across partners A system that system that often fixated on diagnosis – rather than need, including any environment factors that may be influencing, for example looking at the ‘whole family’ approach in addressing concerns We knew that we needed to change. But we needed to do this in partnership, to move from a fragmented system to one that works together. By driving change though our Health and Wellbeing Board has ensured systemic approval for change, endorsed by members. It is not an LA agenda, a NHS agenda, or any one else's agenda – it is a system agenda to improve the emotional wellbeing and mental health across communities
- Taking stock from the 2015 review, we sought to transform by developing a CAMHS system that would EMPOWER professionals, parents, members and their communities to recognise the part we all have to play in children and young people’s emotional and mental health. This is a significant culture change from the idea that mental health is just the responsibility of NHS Specialists. We have done this through workforce development, training, education and communication to promote and improve, knowledge, confidence and resilience. To address how we move from a system that responds to crisis to one that seeks to support emotional and mental health concerns the earliest point across the CAMHS system has been the development of a continuum of provision that can be accessed quickly at an appropriate level of need and that will offer support to a child / young person or the system around them for as long as it is required. We have developed our training and assessments to ensure we are seeing the whole child, young person and /or family not just the presenting issues or diagnosis; hearing what has brought them to need and seek help and addressing this; considering environmental factors, including the impact on the wider family, or the impact the mental health of a parent is having on the resilience of the whole family. Applying a flexible and proactive delivery of services that empowers children, young people and families to own their journey and be able to fully participate as equal partners, working in partnership to deliver support that is right for them. A range of creative, timely evidenced based intervention and approaches delivered across all partners within the CAMHS system for example the voluntary sector, schools, public health, the LA or community volunteering to provide a holistic package of support that meets the needs identified and values the views of others System wide recognition of the importance of shifting the focus from specialist interventions to one of improved resilience and self awareness in our children and young people population, promoting good mental health and wellbeing and reducing stigma. This has been driven H&WB board, across partners and services to embed systemic change. Outcome focussed services that concentrate on goal based outcomes that are meaningful to the child or young person that could be supported by consistency of outcomes measures – through our outcome bee framework and reported across the continuum to measure progress and effectiveness of resources.
- Taking stock from the 2015 review, we sought to transform by developing a CAMHS system that would EMPOWER professionals, parents, members and their communities to recognise the part we all have to play in children and young people’s emotional and mental health. This is a significant culture change from the idea that mental health is just the responsibility of NHS Specialists. We have done this through workforce development, training, education and communication to promote and improve, knowledge, confidence and resilience. To address how we move from a system that responds to crisis to one that seeks to support emotional and mental health concerns the earliest point across the CAMHS system has been the development of a continuum of provision that can be accessed quickly at an appropriate level of need and that will offer support to a child / young person or the system around them for as long as it is required. We have developed our training and assessments to ensure we are seeing the whole child, young person and /or family not just the presenting issues or diagnosis; hearing what has brought them to need and seek help and addressing this; considering environmental factors, including the impact on the wider family, or the impact the mental health of a parent is having on the resilience of the whole family. Applying a flexible and proactive delivery of services that empowers children, young people and families to own their journey and be able to fully participate as equal partners, working in partnership to deliver support that is right for them. A range of creative, timely evidenced based intervention and approaches delivered across all partners within the CAMHS system for example the voluntary sector, schools, public health, the LA or community volunteering to provide a holistic package of support that meets the needs identified and values the views of others System wide recognition of the importance of shifting the focus from specialist interventions to one of improved resilience and self awareness in our children and young people population, promoting good mental health and wellbeing and reducing stigma. This has been driven H&WB board, across partners and services to embed systemic change. Outcome focussed services that concentrate on goal based outcomes that are meaningful to the child or young person that could be supported by consistency of outcomes measures – through our outcome bee framework and reported across the continuum to measure progress and effectiveness of resources.
- Taking stock from the 2015 review, we sought to transform by developing a CAMHS system that would EMPOWER professionals, parents, members and their communities to recognise the part we all have to play in children and young people’s emotional and mental health. This is a significant culture change from the idea that mental health is just the responsibility of NHS Specialists. We have done this through workforce development, training, education and communication to promote and improve, knowledge, confidence and resilience. To address how we move from a system that responds to crisis to one that seeks to support emotional and mental health concerns the earliest point across the CAMHS system has been the development of a continuum of provision that can be accessed quickly at an appropriate level of need and that will offer support to a child / young person or the system around them for as long as it is required. We have developed our training and assessments to ensure we are seeing the whole child, young person and /or family not just the presenting issues or diagnosis; hearing what has brought them to need and seek help and addressing this; considering environmental factors, including the impact on the wider family, or the impact the mental health of a parent is having on the resilience of the whole family. Applying a flexible and proactive delivery of services that empowers children, young people and families to own their journey and be able to fully participate as equal partners, working in partnership to deliver support that is right for them. A range of creative, timely evidenced based intervention and approaches delivered across all partners within the CAMHS system for example the voluntary sector, schools, public health, the LA or community volunteering to provide a holistic package of support that meets the needs identified and values the views of others System wide recognition of the importance of shifting the focus from specialist interventions to one of improved resilience and self awareness in our children and young people population, promoting good mental health and wellbeing and reducing stigma. This has been driven H&WB board, across partners and services to embed systemic change. Outcome focussed services that concentrate on goal based outcomes that are meaningful to the child or young person that could be supported by consistency of outcomes measures – through our outcome bee framework and reported across the continuum to measure progress and effectiveness of resources.
- Hertfordshire is located just to the north of London, covering an area of 634 square miles, with a population of around 1,2M (2017), making Hertfordshire one of the most densely populated shire counties in England. Approximately 269,296 (2017) children and young people under the age of 18 live in Hertfordshire. This is 23% of the total population in the area. The ONS predicts an overall increase in Hertfordshire’s 0-19 population of 11.3% between 2018 and 2027 compared with 5.7% for the same age group nationally. The increases in Hertfordshire are particularly pronounced in the 10-14 age group (13.6% growth projected) and 15-19 age group (24.2% growth projected). There are 534* schools in Hertfordshire, of which: 417 primary, 80 secondary, 26 special and 7 education support centres. *the secondary figure includes 2 all through schools and 4 middle schools, and the primary figure includes nursery schools, first schools, infant schools etc.. Additionally there are a number of independent schools. The quality of education in Hertfordshire is highly regarded and pupil attainment is very strong when benchmarked against national performance – Ofsted As at 31 March 2018 there were: 5053 children in need (all cases open to children’s social care), a rate of 188 per 10,000 compared with a 2018 national average of 341 and 2018 statistical neighbour average of 304 522 children subject to a child protection plan, a rate of 19 per 10,000 compared with a 2018 national average of 45 and statistical neighbour average of 44 890 children looked after, a rate of 33 per 10,000 compared with a 2018 national average of 64 and 2018 statistical neighbour average of 50.8 CP data (numbers) March 2018 - 522 CLA March 18 - 890 CiN March 18 (all open cases including those above) 5053 Profile of CLA 84.4% of 10-16 year olds in Foster Care % of CLA exiting care to SGO 13.5% % of CLA exiting care to adoption in the 13% 2.1% of children in Hertfordshire schools have a statement of special educational needs or Education, Health and Care Plan, compared to 2.9% in England. Health outcomes across Hertfordshire are good with low rates of infant mortality and teenage conception compared with the national and eastern region averages. Hertfordshire also has one of the lowest proportion of children who are obese in both reception (20% compared to 22.6% nationally) and year 6 (28.9% compared to 34.2% nationally). From the most recent prevalence data from NHSE we can assume that approx 23,000 of our CYP would benefit from a CAMHS service. Service ratings: Longstanding and well embedded joint commissioning arrangements for CAMHS across the county council and two CCGs HPFT - strong NHS Foundation Trust with a ‘Good’ CQC rating provide Tier 3 CAMHS HCT – Community Trust with ‘Good’ CQC rating providing some tier 2 CAMHS A children’s Service that was rated as Good in our recent Ofsted inspection
- Whilst we have achieved a lot we know we cannot rest on our laurels – we need to keep the momentum to have a system of continuous improvement. Our key focusing for the coming months will be further work on our pathways to ensure that CYP move seamlessly through the system, without the need to keep retelling their story. We know that this is key for our young people, for them to be able to meet with the right person, who knows their story and is able to support them. We are a big county and a big system, and there is much more to do with regard to support at the earliest point across the children’s system. We want to explore the no wrong door approach and the vision of a single front door – we currently have a children’s services front door and a CAMHS single point of access so we need to see how this can work better as a system. We know that parents and CYP want good and relevant information and forms of support available to them digitally, and are looking at ways that we can achieve this. And we have been selected as one of the trailblazer areas for the new Mental Health teams as part of the Green paper recommendations.
- Following the 2015 CAMHS review, there have been notable improvements in the support offered to children and young people with regard to their mental health and emotional wellbeing. This was noted in 2017 by the Care and Quality Commission (CQC), who chose Hertfordshire as one of the 10 Health and Wellbeing areas to be part of a national thematic review of services for children and young people’s mental health. By working together to support children, young people and their families at the earliest opportunity, has enabled a more joined up and systemic approach to service delivery. We now have a shared ownership and a whole system approach across the CAMHS system, from the H&WBB, to multi agency CAMHS meetings, for example the Childrens and young people Emotional Wellbeing board which has responsibility for delivering the programme of improved change across the system. These strong partnerships have been the drivers in embedding systemic change and support joint commissioning arrangements to ensure services can be delivered holistically, addressing many of the wider determinants of poor mental health. This has also supported a more visible focus on emotional wellbeing and mental health throughout commissioning arrangements, particularly with regard to provision that delivers family support. Through joint working and partnership arrangements, services have made great strides to implement system wide, joined-up approaches to address the needs of children, young people and their families and improve their mental health and emotional wellbeing at the earliest opportunity A range of provision has been developed and commissioned to supporting all children, young people and their families to have improved, timely access to information, advice, and guidance and, where necessary, interventions or support to enable them to develop and maintain positive emotional wellbeing, demonstrate healthy behaviours and feel more resilient and empowered to cope with the day to day adversity and stress that they may experience. This ‘earliest’ provision is delivered by trained professionals from across the system including the LA, Schools, family Support workers and youth workers, allowing NHS professionals to work with CYP who are need more specialist interventions and treatment. Prevention is the earliest form of intervention. By empowering Hertfordshire’s children and young people with positive messages and guidance on healthy life choices, it enables improved resilience and the potential for them to make informed choices to support, and take ownership for, their own positive emotional wellbeing. For example, Public Health’s Just Talk campaign works to empower boys and young men to have the confidence to talk about their emotional wellbeing without stigma or fear of judgement by normalising the conversation. Our CWP workers work across with CYPF who are experiencing low mood or anxiety issues, and deliver support to parents through emotional wellbeing master classes, giving them strategies to manage their CYPs emotioanl health. We have commissioned Kooth – an online counselling and emotional well-being platform for children and young people, accessible through mobile, tablet and desktop and free at the point of use. Manned by trained professionals we have approx. XXXXX CYP in Herts accessing this service.
- Following the 2015 CAMHS review, there have been notable improvements in the support offered to children and young people with regard to their mental health and emotional wellbeing. This was noted in 2017 by the Care and Quality Commission (CQC), who chose Hertfordshire as one of the 10 Health and Wellbeing areas to be part of a national thematic review of services for children and young people’s mental health. By working together to support children, young people and their families at the earliest opportunity, has enabled a more joined up and systemic approach to service delivery. We now have a shared ownership and a whole system approach across the CAMHS system, from the H&WBB, to multi agency CAMHS meetings, for example the Childrens and young people Emotional Wellbeing board which has responsibility for delivering the programme of improved change across the system. These strong partnerships have been the drivers in embedding systemic change and support joint commissioning arrangements to ensure services can be delivered holistically, addressing many of the wider determinants of poor mental health. This has also supported a more visible focus on emotional wellbeing and mental health throughout commissioning arrangements, particularly with regard to provision that delivers family support. Through joint working and partnership arrangements, services have made great strides to implement system wide, joined-up approaches to address the needs of children, young people and their families and improve their mental health and emotional wellbeing at the earliest opportunity A range of provision has been developed and commissioned to supporting all children, young people and their families to have improved, timely access to information, advice, and guidance and, where necessary, interventions or support to enable them to develop and maintain positive emotional wellbeing, demonstrate healthy behaviours and feel more resilient and empowered to cope with the day to day adversity and stress that they may experience. This ‘earliest’ provision is delivered by trained professionals from across the system including the LA, Schools, family Support workers and youth workers, allowing NHS professionals to work with CYP who are need more specialist interventions and treatment. Prevention is the earliest form of intervention. By empowering Hertfordshire’s children and young people with positive messages and guidance on healthy life choices, it enables improved resilience and the potential for them to make informed choices to support, and take ownership for, their own positive emotional wellbeing. For example, Public Health’s Just Talk campaign works to empower boys and young men to have the confidence to talk about their emotional wellbeing without stigma or fear of judgement by normalising the conversation. Our CWP workers work across with CYPF who are experiencing low mood or anxiety issues, and deliver support to parents through emotional wellbeing master classes, giving them strategies to manage their CYPs emotioanl health. We have commissioned Kooth – an online counselling and emotional well-being platform for children and young people, accessible through mobile, tablet and desktop and free at the point of use. Manned by trained professionals we have approx. XXXXX CYP in Herts accessing this service.
- We know this is not without our challenges – We need to further develop our early help offer, though evidence based interventions to deliver both efficiencies and improved outcomes for our CYPF. A new strategy for promoting mental health and preventing mental ill health in CYP is under development, coordinated by Public Health, but with input from the wider system, young people and parents Demand for services is both increasing and changing and we need to be responsive whilst being realistic Budgetary pressures mean we need to look at how we do things in the future – whether we look to integrating provision or aligned provision, we need to more with less and find the most effective and efficient way to do it. Consistent language and increasing a basic understanding of how to promote mental health is a core priority and a remaining challenge. Just Talk aims to address this by ensuring partnership work and shared resources. The new mental health strategy will also be focused on increasing clarity and transparency, and enabling more effective sharing of best practice. There is a articular need to ensure we are reaching those groups at a higher risk of mental illness including Children looked after, young carers, and LGBTQ. Ensuring that the strategic direction can be operationally delivered and maintaining the everybody’s business message across the whole CAMHS system particularly at early intervention and prevention.