Children and Young People's Mental Health Services

There must be a clear strategy and plan on reducing the proportion of young people remaining on the inpatient unit for more than 60 days. The plan must include: • promotion and development of effective alternatives to an inpatient admission, including provision through social care and education; • rapid and appropriate access to therapeutic support on the inpatient unit; • the ability to ensure a rapid discharge from hospital with ongoing intensive support in a community setting. a Commissioners and providers including lead providers within a collaborative must develop alternatives to admission for young people who are likely to escalate behaviours on admission and can be managed in the community. This must be a jointly owned plan with all commissioners working together. b Commissioners and providers must enable multiagency working, in particular with social care and education to enable ongoing community support in a social/educational environment that will foster engagement with the community therapeutic process. c Clinicians and commissioners must develop locally agreed clinical outcomes to use as the guiding principle behind discharge. These outcomes must link to the Impact Framework. d Commissioners including lead providers within a collaborative must promote a guiding principle of discharge being linked to agreed clinical outcomes rather than an arbitrary LoS. e Commissioners and lead provider/s of an NHS-led provider collaborative to monitor LoS using stratification of LoS rather than average LoS. f Commissioners and lead provider/s of an NHS-led provider collaborative to monitor readmission rates.

Clear therapeutic models must be present on each unit, concordant with available NICE guidance, for the most common reasons for admissions. The model requires identified clinical interventions including frequency, intensity and expected outcomes. These models should be accurately staffed and link to the funding model for the unit. a Each provider to review the service offer requirements of the service specification. b Each provider to assess care provision against published NICE guidance on depression in CYP (NG134), the recommendations on referral in crisis and challenging behaviour in NICE's guideline on psychosis and schizophrenia in CYP (CG155), and the recommendations on inpatient and day patient treatment in NICE's guideline on eating disorders: recognition and treatment (NG69).

A blended model of commissioning for inpatient units should be considered and commissioned based on the provision of therapeutic models and outcomes, not a cost per bed day model. a To develop an outcomes-based service specification linking to the resourcing of the unit. b Linking to recommendation 17. The service specification should include requirement on data collection for diagnosis, reason for admission, interventions offered and patient reported outcome measures.

There must be a focus on avoiding escalation in presentation and behaviour of young people in GAU to prevent avoidable admissions to PICU. All PICU admissions should be subject to careful collective review to identify if any opportunities to avoid the PICU admission were missed. a For each trust/IH provider to identify a profile of young people requiring PICU admissions. b For each trust/IH provider to identify the most common reasons for escalation to PICU. c Each trust/IH provider to implement plans to reduce reasons for escalation to PICU. d Each trust/IH provider to ensure effective staff training is in place. e Each trust/IH provider to ensure an appropriate environment is provided.

All provider organisations must focus on reducing the incidence of restraint, prone restraint, and seclusion and should: • Ensure levels of restraint in the CYP inpatient population are no higher than in the adult inpatient population. • Have a clear plan in place to reduce incidents of restraint and seclusion. Improvement activity should be based on benchmarking with peers aiming for milestones year on year to achieve a position in the top decile. a All NHS and IH providers must have a clear QI plan in place to address restraint and seclusion with an aim to reduce incidents of restraint by at least 10% year on year. The plan must include an aim to improve data collection on restraint episodes.

When requiring a Mental Health Act assessment, CYP must be assessed by clinicians with the right skills in a child appropriate environment. a Improve the national offer on support and training on reducing restrictive practices in CYP inpatient services. Ensure that there is an appropriate therapeutic environment to support the development of psychological formulation and de-escalation interventions.

Commissioners, including lead providers within a collaborative, must ensure that there are effective protocols in place so that when a social need, rather than medical, is present there is a clear and understood pathway to follow which operates both in and out of hours. a Commissioners and providers must develop a clear, commissioned, multiagency pathway.

The crisis and urgent care pathways, including inpatient admissions, must be seamless with consistent treatment plans, objectives, and care coordination. In most circumstances, this will require the community care coordinator remaining as the main point of contact and driver of care regardless of the crisis, urgent care or inpatient setting the patient is within. There must be a robust preadmission assessment process including input from the inpatient unit, crisis services, community team and when necessary the local authority. The aim of the assessment process should be to avoid admissions if at all possible. a Providers to review the CRAFT model and implement a similar model of community engagement of young people within the crisis pathway. b To review the contracting arrangement for crisis services and community services to allow the implementation of the new model. c Provision of training for community staff to ensure staff are skilled to implement new model. d Providers to review the learning from CETRs within their trust and ensure that any learning is implemented.

Commissioners must ensure that young people are admitted within their natural clinical flow, recognising that there may be patient choice or specific clinical needs to admit outside. This should be in line with the national CYPMH Competency Framework. a Commissioners including lead providers within a collaborative to undertake bed modelling with the use of an appropriate modelling tool.

There must be an effective and sufficiently resourced CYP urgent & emergency mental health pathway based on local needs and with effective data collection to drive QI. The pathway, as indicated in the Long Term Plan, will operate 24 hours a day, seven days a week. It will combine crisis assessment, brief response, and intensive home treatment functions. a To drive continued investment, including re-investment into: • An urgent and emergency response. To ensure the urgent and emergency mental health pathway combines crisis assessment, brief response and intensive home treatment functions. • Linking to recommendation 11, ensuring that there are effective processes and policies linking the urgent and emergency services to the intensive community intervention services.

Individual providers and commissioners must ensure there are evidence-based crisis avoidance, specialist intensive community support teams to provide treatment to high-risk young people with the aim of avoiding them entering a crisis. a Invest in evidence-based crisis avoidance, specialist intensive community support teams. These teams must be multiagency in nature. b There must be ongoing evaluation and sharing of best practice as services are developed at a local and national level. c Providers must enable effective coding of these services and ensure the flow of data from these teams to the MHSDS.

The urgent and crisis care pathways, including those for eating disorders and neurodevelopmental disorders, must work across physical and mental health organisations in a seamless and effective way with a recognition that best outcomes are not always achieved in a mental health setting. a The role of A&E and paediatric wards to be clearly identified, through commissioned arrangements, within the urgent and crisis care pathway. b Where specialist paediatric input is required, such as within the eating disorder pathways, there is identified and commissioned paediatrician input. c For A&E and paediatric staff to access appropriate training such as the training developed by Healthy London Partnership.

Recruitment and retention of skilled staff must be a focus for all inpatient units. Data on staffing levels, vacancy rates, turnover and agency use for all urgent care and inpatient services should be collected at NHS-led provider collaborative level to support sharing of best practice and enable the challenges to be addressed as a systems issue. It is clear that there is a direct relationship between shorter LoS and more staff. a A clear unit-level recruitment and retention programme needs to be in place that links with trust programmes. b Consider national collection of routine workforce data for all CYP inpatient and community services. c Sharing of best practice through NHS-led provider collaborative events.

Trusts, commissioners and lead provider/s of an NHS-led provider collaborative should, taking into consideration national training initiatives, develop a local workforce strategy to support delivery of the Long Term Plan with a focus on staff skills and competencies rather than professions. a Development of a local workforce strategy shared across the NHS-led provider collaboratives. The workforce strategy should identify the gaps in national training and fill these with local training offers.

The additional needs and reasonable adjustments for young people with autism and/or learning disabilities, who are experiencing a mental health crisis, must be identified and managed in all settings. Services must ensure that: a There is effective and high-quality training for staff in autism. b As already indicated within the Department of Health Building Notes, outpatient and inpatient environments are adaptable to the sensory needs of young people with autism. c Inpatient units' crisis services and intensive community support services ensure the availability of specialist assessments and care for young people with an autism spectrum condition diagnosis or suspected autism spectrum condition. d Effective digital solutions to promote communication are made available.

All adolescent inpatient units and crisis services must improve the use of QI programmes to drive high quality care. a For QNIC to strengthen the role of QI within their standards. b All providers to meet the QNIC standards for QI. c Consider the development of a national improvement collaborative on a topic that is a shared quality concern across adolescent inpatient units. d To identify a national forum for adolescent inpatient units which can host QI resources, successes, and learning.

All NHS commissioned services must have effective data collection processes to understand the reason for acceptance into a service, interventions offered and outcome of interventions. This data must be flowed to the MHSDS. a Local data collection of reason for admission, intervention offered to be implemented. b This data must be collected and analysed at an NHS-led provider collaborative level.

A national approach to a definition of diagnosis/reason for admission should be developed through the CYPMH policy team/Specialised Commissioning team/NHS digital and adopted by all services. a Paired outcome measures must be implemented within all services. b Development of nationally accepted SNOMED-CT codes. c Implementation and use of diagnosis SNOMED-CT codes.

Trusts and IH providers to be encouraged to invest in IT infrastructure for adolescent inpatient units. All inpatient patient-focused meetings must have the option of videoconference access. a To ensure that their digital strategies include a specific focus on adolescent inpatient unit infrastructure. b To ensure each adolescent inpatient unit has a clinically-led initiative to increase videoconference access for carers, patients and the wider community team. Implementation monitored at NHS-led provider collaborative operational level.

There must be effective governance and advocacy systems in place in all CYP mental health inpatient units to ensure that young people are able to speak up should they be exposed to inappropriate practices. a Individual inpatient adolescent units to ensure governance and advocacy systems are in place. b Ensure that systems are co-designed with young people. c Patient experience measure included in routine collection. d Young people able to contribute to service design evaluation and audit. e Ensure that there are processes in place, so the patient voice is clear within care planning. f Reasonable adjustments should be put in place to ensure children and young people with LDA access advocacy proactively.

Reduce litigation costs by application of the GIRFT programme's five-point plan. a Clinicians and trust management to assess their litigation claims covered under Clinical Negligence Scheme for Trust (CNST) notified to the trust over the last five years. b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests, and SI/PSI and where a claim has not already been reviewed as SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all staff in a structured format at departmental/directorate meetings (including MDT meetings, and morbidity and mortality meetings where appropriate). e GIRFT clinical leads and regional teams to share with trusts examples of good practice where it would be of benefit.