Overview and Scrutiny Response by MikeJenny


Overview and Scrutiny Committee
 CAMHS in Cheshire Response

           May 2007

 Produced by Cheshire CAMHS
     Commissioning Board
1.      Context

     a) What factors influence poor mental health in children
        and adolescents?

     There are many factors that can influence a child or young persons
     emotional development. Below are some examples, although this list is by
     means comprehensive.

              Poor Attachment in early years
              Environmental factors such as Social Deprivation
              Domestic Abuse
              Personal or Parental Drug and Alcohol Misuse
              Having a learning disability
              Being a young carer
              Being a Young Offender
              Parental mental and physical health issues
              Being a looked after child
              Family breakdown
              Difficult transitions i.e. between primary and secondary school
               and at 16 into adult life

     b) Are those factors prevalent in Cheshire?

The majority of children and young people in Cheshire grow up to be healthy.
Family, friends, the resources that they hold within themselves and services in
the community such as nurseries, health visitors and schools offer enough, to
help them build the necessary confidence and resilience to do Ok. However,
this is not the full picture. What we know from National statistics is that mental
health problems are relatively common in children and young people.

The following information sets out the demographic background and rates of
prevalence for mental disorder in children and young people and taken from
the Cheshire CAMHS Needs Assessment Data 2007/08.

The demographic data has been sourced from data provided by the Office for
National Statistics (ONS) from the 2001 Census, and the prevalence data is
taken from the ONS report 'The Mental Health of Children & Adolescents'

According to the ONS 2005 Mid-year estimates, there were 101,900 Children
and Young People aged 5 to 16 living in Cheshire. The National CAMHS
Needs Assessment Data 2007 / 08 uses this most recent ONS survey data to
predict the prevalence rates shown below

These prevalence rates apply only to this age band. The total population aged
less than 18 is 155,010. This represents 22% of the total population of

Number of children aged 0 to 16 year olds with some
type of mental disorder' (9.6%): = 9800
Gender differences at ages 5 to 10 are as follows:
Girls (5.1% x 23610) population: 1200
Boys (10.2% x 24930) population: 2500

Between the ages of 11 and 16 the rates for both sexes are higher:
Girls (10.3% x 25760) population: 2700
Boys (12.6% x 27600) population: 3500

Of these, the following prevalence of specific disorders is indicated, a
young person may be experiencing more than one disorder:

       Type of disorder            Boys (5-16)        Girls (5-16)       Total (5-16)
Conduct Disorders                3900              1900               5800
Emotional Disorders              1600              2100               3700
Being Hyperactive                1400              200                1600
Less common disorders            1000              390                1390

Using the above data we can make a reasonable assumption that if we have
a relatively stable population of 155,000, young people aged 0-18 residing in
Cheshire then we can expect to have approximately 9,800 young people aged
0 -16 experiencing some type of mental health difficulty at any one time.

Of these 9,800 children and young people a small number will need access to
acute/specialist services for treatment of conditions such as severe
depression. The remaining children will need less specialist support with their
emotional health and well-being and their needs can be often be met within
other services such as through counselling or other therapeutic interventions
i.e. a teacher offering respectful curiosity and an opportunity for a young
persons to talk about any problems.

In relation to 16 – 18 year olds the expected prevalence rates are more
complex to predict due to the available research papers. However the
‘Maudsley Discussion Paper No.4 by Robert Goodman’ suggested some
expected prevalence rates for the ’16 to 17’ age group. ‘Connexions Cheshire
& Warrington’ Management Information Data for June 2007 shows that the
current population young people aged 16 to 17 is 18,012 (8821 Females and 9191
Males). Using this research we can predict the following rates:
    1% of 16 to 17 year old Girls with Anorexia Nervosa, therefore in
     Cheshire we could expect to see 88 female, young people
    4% of 16 to 17 year olds with Depression, therefore in Cheshire we
     can expect to see 720 young people
    15/10,000 of 16 to 17 year olds with Psychosis, therefore in Cheshire
     we can expect to see 27 young people

The Maudsley paper also suggests that of all 3 to 4 year olds 3% will have
moderate and 1% severe pre school mental health difficulties. Therefore in
Cheshire we can expect to see from a total population of 0 to 4 year olds of
36,100 (ONS Regional Statistics 2003) 1,083 Children with moderate and 361
with severe, pre school mental health difficulties.

In addition to the above needs analysis we can utilise other pieces of valid
research such as the below to help us plan and commission effective mental
health services.

Utilising the ONS 2005 Mid-year estimates in conjunction with the 1994
Health Advisory Service publication ‘Together We Stand’ this then provides
an estimate of the number of children we should be expecting to see
presenting across our four tiered mental health framework, see below:

               % Total 0-18         Number of Children & Young
               population              People presenting
  Universal         15%                          22,000

  Targeted          7.5%                         11,000

 Specialist         2.5%                          3700

   Acute           0.47%                          690

Other data

Other data we currently hold regards levels of emotional health and well -
being in our population are based around expected prevalence and
presentations we see within our services.

    In 2005/6 2099 Children aged 0-19 were referred to Health delivered
     Specialist Child and Adolescent Mental Health Services. This is
     approximately 21% of the total number of young people we would be
     expecting to be experiencing mental health problems in Cheshire and
     is approximately 1.4% of the total population of 0-18 year olds
 Children’s Services tell us that in the 2006 census there were 567
  young people in Education ‘statemented’ as having Behavioural,
  Emotional and Social Difficulties (BESD), as their primary need.
  Additionally there were 1161 children and young people with learning
  difficulties 298 with Severe and 863 with Moderate Learning Difficulties,
  while 335 of these children and young people are on the Autistic
  Spectrum. These figures do not take into account pre school age
  children who are not statemented and 16 to 18 year olds.

 Cheshire CAMHS Needs Assessment Data 2007/08 suggests that
  Cheshire will have a total, in the region of 2,500 children and young
  people aged 0 -18 with learning disabilities, of whom around 275 will
  have severe learning disabilities. While 9.6% of 0-16 year olds will
  have mental health problems at some time this increases to
  approximately 40% for those children and young people with learning
  disabilities. It is higher still for those with severe learning disabilities.

    Over one in three children and adolescents with a learning disability in Britain
    (36%) have a diagnosable psychiatric disorder. Children and adolescents with
    learning disabilities are over six times more likely to have a diagnosable
    psychiatric disorder than their peers who do not have learning disabilities.
    The Mental Health of Children and Adolescents with Learning Disabilities in Britain
    Eric Emerson
    & Chris Hatton January 2007

 The latest Children in Need Census (a snapshot of social services’
  cases during one week in February 2005) showed that parent / carer
  mental illness was a factor in 12% of social services’ open cases

 In Cheshire CAMHS Needs Assessment Data 2007 / 08 there were
  500 Looked After Children as of the 31st March 2005. Of these there
  were 50 children and young people in residential care, 360 with foster
  carers and 40 placed with their parents.

    One recent study sought social workers' views on the mental health of a group of
    foster children. Eighty per cent of these children were considered to require treatment
    from a mental health professional (Phillips, 1997). McCann et al (1996) showed that
    two-thirds of children looked after by an Oxfordshire local authority had significant
    psychiatric disorders

    This would equate to a total of 191 children across all these settings
    who may experience some type of mental disorder. There were 30
    'other' looked after children, including children in lodgings, for whom
    there are no prevalence rates.

   There were 20 Adopted Children in Cheshire CAMHS Needs
    Assessment Data 2007 / 08.

 26 Looked After Children and Young People aged 0-19, were
  engaged with Specialist CAMHS on the 1st October 2006
 190- 200 Looked After Children & Young People had engaged with
  Cheshire Multi-Professional Support Teams in 2005/2006,
  approximately 40% of the total Cheshire looked after population.

 In Cheshire CAMHS Needs Assessment Data 2007 / 08 there are 501
  young people on the caseload of the Youth Offending Service.

    Dolan found that 25% of juvenile offenders aged 10 to 17 appearing
    before Manchester Youth Court had had recent contact with
    psychology or psychiatric services. If applied to the same age range on
    the YOT caseload this produces a prevalence of 130 individuals who
    may have had recent contact with CAMHS.

    Vermeiren et al provide prevalence rates for the population aged 12 to
    17 for specific disorders. When applied to the YOT caseload this
    provides the following estimates:

    Conduct Disorders (53%)                                        270
    Hyperkinetic Disorders (19%)                                   100
    Substance Abuse (24%)                                          120
    Depression (14%)                                               70
    Psychotic Symptoms (4%)                                        20

    The number of young people aged 10 - 17 in Cheshire CAMHS Needs
    Assessment Data 2007 / 08 is 70,510. The proportion of this population
    on the caseload of Cheshire CAMHS Needs Assessment Data 2007 /
    08 YOT is significantly less than 1%.

 For some children in Cheshire the Transition between the Primary and
  Secondary Phase of Education can often prove to be a complex
  difficult time, acting as a catalyst for mental health problems in Children
  and Young People. Therefore work is underway to target further
  Primary Mental Health resources in this area.
Nottingham Children’s Services looked at the experience of 1000 children and young
people in
their schools the report found that:

"Sixty five per cent of primary school children rate their school experience as positive
whereas this drops by more than half to 27 per cent at secondary school. Satisfaction
with school is a crucial component of our children’s personal development"


 Autism - If the prevalence rate found by ‘Special Needs and Autism
  Project’ were applied to the child (5-16) population of Cheshire CAMHS
  Needs Assessment Data 2007 / 08 this would estimate 1200 cases.

 Approximately 7% of adolescents will harm themselves at some
  point and 20% will think seriously about it [Andrews and Lewinsohn
   1992]. Approximately 2% to 4% of adolescents will attempt suicide
   [Young Minds 2002], and 40% of those who survive a first attempt will
   repeat it [Wright and Richardson]. 7.6 per 100,000 15-19 year olds will
   complete suicide [Young Minds 2002].

   These rates would approximate to the following for the population of
   young people aged 15 to 19 inclusive in Cheshire CAMHS Needs
   Assessment Data 2007 / 08.

   Attempted Suicide                     850 to 1700
   Completed Suicide                     30

 Cheshire Domestic Abuse Partnership continues to evidence the
  incidence and impact of domestic abuse on children and young people
  in the county and to commission and co-ordinate service development
  to meet their needs.
   Children living with domestic violence are twice as likely to experience mental ill
   health and to live with carers who experience mental ill health and are nine times
   more likely to live with carers who abuse alcohol.

   Consequences of living in households where domestic abuse is repeatedly
   perpetrated include:
   behavioural issues, absenteeism, ill health, bullying, anti-social behaviour, drug and
   alcohol misuse, self-harm and psychosocial impacts. Growing up in a violent
   household is also a major factor in predicting delinquency. (Safeguarding Children in
   Education, DfES 2004)


   Incidents attended by police = 8307
   children present             = 7545
   repeat incidents             = 31%
   repeat victimization         = 29%
   repeat perpetration          = 33%

   April – Dec 2006 (9 months)

   Total No. Women supported                                 306

   Total No. Children supported                              328

   Total no of children aged 11-19 supported                   92

c) What do we know about the mental health of children
   under 5, ages 5 to 11 and ages 12 to 16 in Cheshire?
Using the National prevalence data we can expect to see 9800 children and
young people 'with some type of mental disorder' in Cheshire. The following
numbers give us some indicator of prevalence with age groups:

Gender differences at ages 5 to 10 are as follows:
Girls (5.1% x 23610) population: 1200
Boys (10.2% x 24930) population: 2500

Between the ages of 11 and 16 the rates for both sexes are higher:

Girls (10.3% x 25760) population: 2700
Boys (12.6% x 27600) population: 3500

It is difficult to say what is happening in relation to infants mental health as we
do not currently record any county wide statistics for this age group and the
CAMHS Needs Assessment Data 2007 / 08 does not provide us with any
expected prevalence rates.

However the previously mentioned Maudsley paper does suggests that of all
3 to 4 year olds 3% will have moderate and 1% severe pre school mental
health difficulties. Therefore in Cheshire we can expect to see from a total
population of 0 to 4 year olds of 36,100 (ONS Regional Statistics 2003) 1,083
Children with moderate and 361 with severe, pre school mental health

    d) Are there sections of the Cheshire community that are
       particularly vulnerable?

Cheshire is seen as a relatively prosperous area. The vast majority of
residents like living here (92%) and feel they have a good quality of life (94%).
Cheshire is economically successful; its gross value added (GVA) per head is
the highest in the northwest, while unemployment has been consistently lower
than the national average.

However, the countywide picture masks significant pockets of deprivation and
fails to recognise the many individuals, groups and communities who are
vulnerable or who have particular needs. The most significant concentrations
of disadvantage can be found in West Chester, Central Ellesmere Port, West
Crewe, and parts of Winsford and Northwich. Other smaller concentrations of
deprivation exist in wards such as ‘Colshaw Farm’ estate in East and the
‘Lache’ estate in West.

Eleven of Cheshire’s 442 Super Output Areas1 (SOA’s) fall within the top 10%
most deprived areas in England as measured by the Index of Multiple
Deprivation, a further twenty-eight fall within the top 20%.

  Super output areas are the new sub-ward level of geography which the government is using
to analyse data at a local level, the average population of a super output area is 1,500
44 of Cheshire’s 177 rural SOA’s fall in the top 20% of SOA’s nationally in
terms of remoteness from key services and barriers to housing.

The black and ethnic minority population make up 3% of the total population
(Cheshire Current Facts and Figures 2004) and are not significantly
associated with disadvantaged areas. In terms of population, 22% of the total
black and ethnic minority population of Cheshire live in deprived SOA’s
compared to 19% of the overall population.

It is also worth noting that the occurrence of severe psychiatric conditions
such as Psychosis are not linked to social deprivation and can occur in any
strata of society. However first episodes of psychosis are usually first seen in
14 to 35 year olds. This has lead to the establishment of ‘Early Intervention
into Psychosis Teams’ Nationally.
e) Is mental health getting better, getting worse or staying
   the same? What is this judgement based on?

In trying to understand what is happening within our population regards
mental health we are faced with some challenging questions. How do we
measure mental health? Do more people accessing mental health services
mean there are more people with problems or does it mean our services
are more accessible and readily used? A similar picture exists around
Domestic Abuse.

We can look at expected prevalence rates utilising the CAMHS needs
assessment tools and compare these with numbers of young people
accessing our Mental Health Services. This would suggest we are only
seeing 57% of the young people that need specialist help, within our
Specialist Tier 3 CAMHS teams. These expected prevalence figures do
need to be treated with some caution, as they are only a ‘guide’ to what
might be happening within our population. However this does highlight the
possible level of unseen demand that may still exist.

In response to this issue the CAMHS Commissioning Board has made
investments into earlier intervention through the expansion of Primary
CAMHS teams. These teams will undertake training and consultation with
staff in Universal services such as Schools, Connexions and the Voluntary
Sector. The teams will also undertake limited direct work with Children and
Families. This we hope will have a significant impact on levels of
identification and early intervention.

Alongside this we have also jointly commissioned www.kooth.com, which
provides free online access for 11-19 year old young people in Cheshire to
counselling and other support services.
2.     Commissioning

     a) Who commissions services for child and adolescent
        mental health and from whom?

CAMHS in Cheshire is commissioned through a multi agency commissioning
board. Funding for our Comprehensive CAMHS come via the Local Authority
and the two Primary Care Trusts; ‘Central and Eastern’ and ‘West Cheshire’

Services are commissioned from a number of providers, these include:

      Cheshire & Wirral Partnership Trust – Our main provider of Primary
       and Specialist CAMHS
      West Cheshire PCT i.e. West Cheshire Primary CAMHS
      Cheshire Children’s Services i.e. Multi - Professional Support Teams
       for Looked After Children
      The Voluntary Sector i.e. Counselling organisations such as Relate
       and Visyon
      Private providers i.e. Xenzone who provide www.kooth.com

     b) What information and factors influence commissioning

The Cheshire CAMHS Commissioning Board members share a vision of a
Comprehensive CAMHS fro Cheshire, which informs our work, this is:

We believe that all children and young people have the right to be healthy,
happy, and safe; to; be loved, valued and respected; and to have high
aspirations for their future.

It is also our aspiration that every child in Cheshire should be Mentally
Healthy and have equality of opportunity to develop the emotional skills they
will require to make a successful transition to adult life’.

Alongside this aspiration a number of other factors influence Commissioning
decisions. National and Local Priorities guide us around the development of a
Comprehensive CAMHS service:

        National Plans and Priorities               Local Priorities
      Every Child Matters – Outcomes       Cheshire Children and Young
      Framework                            Peoples Plan

      Strategic Health Authorities
      ‘CAMHS Self Assessment Matrix’
    National Service Framework for
    Children - Standard 9

    National Institute of Clinical
    Excellence (NICE) guidelines

The National Service Framework for Children, Young People and Maternity
Services; Standard 9 – ‘The mental Health and Psychological Well-being of
Children and Young People’ October 2004, states a Comprehensive CAMHS
must incorporate the following:

    Children and young people are able to receive urgent mental health
     care when required, leading to a specialist mental health assessment
     where necessary within 24 hours or the next working day.
    Child and adolescent mental health services are able to meet the
     needs of all young people including those aged sixteen and seventeen.
    All children and young people with both a learning disability and a
     mental health disorder have access to appropriate child and adolescent
     mental health services.
    The needs of children and young people with complex, severe and
     persistent behavioural and mental health needs are met through a
     multi-agency approach. Contingency arrangements are agreed at
     senior officer levels between health, social services and education to
     meet the needs and manage the risks associated with this particular

These measures have been adopted by the Cheshire CAMHS Commissioning
Board to provide the template for both the County-wide CAMHS strategy
document and to inform the two Primary Care Trusts and The Local Authority
in how they commission Mental Health Services.

Additionally the Strategic Health Authorities ‘CAMHS Self Assessment Matrix’
has also been used in conjunction with the NSF Standard 9 for Children,
National Institute of Clinical Excellence (NICE) guidelines and the Every Child
Matters Framework to inform the development and commissioning of mental
health services in Cheshire.

Alongside these National and Local priorities an understanding of the local
needs of Children and Young People is utilised to influence the development
of needs led services, such as Primary CAMHS and www.kooth.com

   c) As a result of what is being commissioned, is there
      anything that is not being done?

   Opportunities that still exist:
      Further integration and collaboration of services
      To continue to develop the capacity of our Comprehensive CAMHS
        to ensure we can provide a responsive and high quality service
           Explore the feasibility of a Children’s Trust Model for CAMHS
           A single assessment process and care pathway across Children’s
            Services that supports those Children and Young People with
            Behavioural, Emotional and Social Difficulties.
           All agencies working towards NICE Guidelines
           To establish a local champion i.e. MP or Council Member for
           The development of SEAL’s in Secondary Schools
           To establish clear pathways into early intervention CAMHS services
            such as Primary CAMHS

          d) Are levels of resources going up, going down or
          staying the same? How does this compare with similar
          local authority areas?

   Funding for CAMHS comes from two main sources:

              The Local Authority via the DFES CAMHS Grant Monies and
               through Children’s Services - Education
              The two Primary Care Trusts ‘West’ and ‘Central & Eastern’
               from re-current CAMHS monies and also from the DOH CAMHS
               Grant (non-recurrent monies)

Local Authority CAMHS Grant Allocations 2006/7 & 2007/8 Comparison
with other similar Authorities:

  Local Authority   2006/7         2007/8
Cambridgeshire          549,734        560,733
Cheshire                734,348        749,035
Cumbria                 537,526        548,279
Derbyshire              745,342        760,261
Gloucestershire         635,839        648,667
Hampshire              1,278,170     1,303,735
Leicestershire          687,378        701,127
Northamptonshire        808,271        824,441
Nottinghamshire         713,549        727,820
Oxfordshire             649,545        662,536
Somerset                514,487        524,783
Staffordshire           810,250        826,460
Suffolk                 708,107        722,276
Warwickshire            536,127        546,852
Wiltshire               438,861        447,978
Worcestershire          573,086        584,550
                                                                                             PCT Allocations to CAMHS
                                                                                                    2004 - 2008

                Note: PCT funding allocations to Cheshire & Wirral Partnership Trust show a year on year increase of investment in CAMHS. Non re-current DOH
                CAMHS Grant Monies have in 2007/8 been re-instated and have also become part of the re-current PCT CAMHS funding.

Cheshire and Wirral Partnership NHS Trust

Cheshire CAMHS Uplifts


1. The values below represent the actual in year income received rather than additional allocations year on year

2. An exercise is on going to sign off contracts that will identify overall allocations by PCT

3. The values below represent additional allocations relating to 10% uplifts only.

                                                 2004 / 2005                                     2005 / 2006                                  2006 / 2007                                     2007 / 2008
                                       04 / 05           05 / 06                       04 / 05           05 / 06               04 / 05       05 / 06   Central Bundle               04 / 05           05 / 06
PCT                                Allocation        Allocation       Total        Allocation        Allocation    Total   Allocation    Allocation              Loss   Total   Allocation        Allocation    Total
Cheshire West                              37                  0        37                 54                  0     54            54             0                0      54             0                  0      0
Ellesmere Port & Neston                    30                  0        30                 32                  0     32            32             0                0      32             0                  0      0
Western                                     0                  0          0                 0                  0      0             0             0                0       0            86               127     213

Total                                      67                  0        67                 86                  0     86            86             0                0      86            86               127     213

East                                       34                  0        34                 34               101     135            34           101              (59)     76             0                  0      0
Central                                    81                  0        81                 81               144     225            81           144             (101)    124             0                  0      0
Central and Eastern                         0                  0          0                 0                  0      0             0             0                0       0           115               245     360

Total                                     115                  0       115                115               245     360           115           245             (160)    200           115               245     360

Total Cheshire CAMHS                      182                  0       182                201               245     446           201           245             (160)    286           201               372     573
3.      Partnership/Strategy

     a) Are there partnership arrangements in place to tackle
        poor mental health in children and adolescents?

     As stated previously Cheshire’s Comprehensive CAMHS is commissioned
     through a multi-agency board. Representation from Health (Provider and
     PCT Commissioner’s), Education, Social Care, Children’s Fund, Youth
     Offending, Connexions, Youth Services and the Voluntary Sector.

     b) Is there an overarching strategy in place?

     A strategy has been in place between 2003/6 and a new strategy is in
     development for the period 2006/9

     c) What arrangements are there for governance and
        accountability across the partnership?

     Accountability to the strategy is a shared responsibility of the CAMHS
     Commissioning Board. However ultimate responsibility to budgets is with
     the Local Authority in relation to the DFES CAMHS Grant and with Central
     and Eastern PCT and West Cheshire PCT for the DOH CAMHS monies

     d) Who owns the process and takes the lead?

     The process of strategy development and subsequent commissioning is
     undertaken in parallel with establishing appropriate governance
     mechanisms and measures of accountability. Services commissioned
     either by the Local Authority or the PCT’s have performance management
     measures in place. These measures are reviewed through the CAMHS
     Commissioning Board via tools such as the CAMHS Self Assessment
     Matrix and other established performance indicators.

     e) How does CAMHS contribute to the "Being Healthy"
        outcome in the Every Child Matters framework?

     Development of Comprehensive CAMHS in Cheshire sits firmly within the
     ‘Cheshire Children & Young Peoples Plan’ under the section focusing on
     ‘Being Healthy’. The objectives set out within the Children & Young
     Peoples Plan’ directly relate to the work streams identified within the
     Cheshire CAMHS Strategy. The CAMHS Commissioning Board believes
     that a Comprehensive CAMHS service will contribute to:

      Improving the emotional health and well-being of children and young
       people will lead to improved physical health
      Increasing resilience and coping skills in children and young people
 Developing greater emotional literacy in young people
 The reduction of Children and Young People described as ‘a child in
  need’ and those requiring care orders
 Healthier and Happy Children leading to a happier and more settled
  Children’s workforce i.e. reduced stress in the teaching profession
 Earlier identification and intervention in mental health issues,
  supporting the preventative agenda
 Healthier, happier and safer communities
 A reduction of Children and Young People described as ‘a child in
  need’ and those requiring care orders

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