Lincolnshire CAMHS

Action
Under Future in Mind reforms, NHS clinical commissioning groups (CCGs) had until December to publish plans for transforming child and adolescent mental health services (CAMHS). As the lead commissioner for CAMHS, Lincolnshire's children's services were able to take the driving seat in this process, a role delegated by the county's four CCGs.

The authority stuck with Lincolnshire Partnership NHS Foundation Trust as its provider and worked with the trust to develop the new model, shaped by consultation with 55 professional groups including school leaders, GPs and social workers. The trust remodelled its CAMHS workforce, expanding it from 96 to 110 full-time equivalent posts, helped by £1.4m a year of government funding over five years.

Chief commissioning officer Sally Savage says Future in Mind provided the framework for enabling Lincolnshire young people "to access help in a variety of ways, as quickly as possible", which is what they said they needed. In addition, schools play a crucial role. "Children spend most of their time at school, and learning and talking about mental health there is really important to reduce the stigma," she says. "So is being able to access help there."

The new model, operational since April, is built upon a new package of support to schools and other universal services. A Professional Advice Line (PAL) enables staff such as teachers, school nurses and health visitors to discuss mental health concerns with CAMHS about children they are working with, and get advice on what to do. Professionals other than doctors and social workers have to use this line before making a referral, enabling children to get the right support early enough to prevent problems escalating, as well as quickly identify those who do need specialists. "Staff can talk to a CAMHS worker and say: ‘I'm doing x, y and z,, and the worker will either say: ‘you're doing great, here are a couple of other things you can try,, or ‘you've done all you can, this is probably a referral,," explains Savage. She says the line has been "very well used" by school staff, but less so by GPs.

Schools also receive mental health training from CAMHS, sometimes triggered by PAL staff observing a need for support with a particular issue such as self-harm, through the volume of calls received. Savage says schools can find it "really difficult" to identify mental health issues in children whose behaviour they find challenging.

So as part of its "pre-CAMHS" provision, the authority is commissioning support charity Family Action to deliver a behaviour outreach support service for all state schools from September. It will help staff identify these pupils, needs and find the right approaches, working alongside staff or directly with the child.

Non-urgent CAMHS referrals now have a halved waiting time of six weeks. After assessment, they are looked after by "core CAMHS", through 11 evidence-based and outcomes-focused "pathways" for conditions such as anxiety, depression, self-harm and trauma, as well as attachment disorders, learning disabilities and harmful sexualised behaviour.

Each pathway outlines the interventions a young person can expect, the frequency of contact and the anticipated treatment time, adapted to his or her needs. This replaces the previous system of young people being allocated to differing tiers of service where young people often "get stuck", Savage explains.

Young people in crisis, such as those in hospital following suicide attempts or self-harm, get 24-hour help from the CAMHS, Crisis and Home Treatment Team, which responds to emergencies within four hours by phone and 13 hours in person. Team members provide intensive, time-limited treatment to prevent hospital admissions, or to enable earlier discharge for those already admitted. The team works alongside the new Eating Disorder Service, providing round-the-clock rapid response, psychiatric and medical assessment, followed by psychological interventions, home treatment and family support.

Specialist support with reduced waiting times is provided for vulnerable groups, including looked-after children, care leavers, young offenders and victims of abuse or exploitation. Looked-after children are seen within four weeks and their carers provided with advice and support.

Savage says CAMHS is working towards young people being able to refer themselves. Services are more accessible through extended hours at Lincolnshire's four CAMHS hubs and through "satellite" clinics, in community centres, children's centres and schools.

Impact
PAL received 313 calls between 21 April and 13 June. "I had been stuck and didn't know what else to do to help the young person, so I called PAL and the CAMHS professional was very helpful in providing advice on further strategies," says one professional. Another commented: "Before the line existed, I struggled to know who and where to obtain mental health advice from, but now it's very easy."

The crisis team had 175 accepted referrals and 350 appointments in April and May. The Eating Disorder Service had 55 accepted referrals and 116 appointments.

One young person helped by the crisis team is 17-year-old Sarah, who had used the previous service for many years, with several hospital admissions. The team assessed Sarah in hospital, when she was suicidal, a role that would have previously been carried out by the adult crisis team. Sarah did not want hospital admission, and the crisis team was able to agree a safe plan for home treatment, visiting Sarah daily over the next five weeks. Once she had decided to engage, her mental health started improving significantly, enabling the daily visits to reduce to phone calls, then being discharged from the crisis team.