Salford PCT
2nd Floor
St. James House
Pendleton Way
Salford
M6 5FW
6th October 2003
Tel: 0161 212 4843
Fax: 0161 212 4856
Email: Harry.Golby@salford-pct.nhs.uk
Dear Colleague
Update to Salford Child and Adolescent Mental Health Services
(CAMHS) Strategy
Please find enclosed an update to the Salford CAMHS Strategy. The original
Salford and Trafford Strategy was written in 1998 and this document
considers developments in national policies and guidance, provides a Salford
specific focus when describing existing services and lists actions that need to
be undertaken in the short / medium term.
Salford Children’s Services Planning Forum is the forum that has an overview
of all developments relating to children, young people and transition into
adulthood and ensure consistent and cohesive implementation of a Salford
Children’s Strategy. That strategy aims transform the lives of Salford’s
children’s, their families and communities through effective partnership built
on inclusion and empowerment. CAMHS represent an important aspect of
the overall Children’s Strategy. More work is required before Salford has a
CAMHS strategy that meets the vision of the Children’s Services Planning
Forum. Much of this work will focus on better understanding the approaches
used in schools and across the community to promote good mental health
and agreeing how to maximise their contribution.
In the meantime this strategy update will be used locally to agree short /
medium term actions and to inform the City Council’s Health Scrutiny
Committee, the Joint (PCT / Social Services) Executive Commissioning
Forum and the Greater Manchester Strategic Health Authority.
Yours sincerely,
Harry Golby
Head of Children’s Commissioning
Salford Primary Care Trust
Encs.
(see attached distribution list)
Copies to:
Paul Woltman, Assistant Director (Children’s Services), Community & Social
Services Directorate, Salford City Council
Edna Robinson, Chair of Salford Children’s Services Planning Forum & PCT
Chief Executive
Alan Campbell, Chair of Salford Joint Executive Commissioning Forum
Nick Clawson, Associate Director – Clinical Strategy, Greater Manchester
Strategic Health Authority
Members of Salford CAMHS Strategy Group
Hilary Wensley, Head of (Adult) Mental Health Commissioning, Salford PCT
THE MENTAL HEALTH OF
CHILDREN & YOUNG PEOPLE
OF SALFORD
UPDATE TO CAMHS STRATEGY
OCTOBER 2003
FINAL (VERSION 3)
1
INTRODUCTION
Good mental health is a key component of a healthy active life. A child or
young person with good mental health is more likely to fulfil their full potential
later in life. There is evidence of an increase in poor mental health amongst
children and young people over the last three decades, particularly amongst
those who are at risk of social exclusion. The aim of this strategy is to
describe the actions to be undertaken to maintain and improve the mental
health of children and young people in Salford.
The strategy is written in four sections:
 ‘context’ describes this strategy’s place in terms of national and local
plans for services that will improve outcomes for children and young
people; common themes for the development of services fall out of this
section.
 ‘need’ provides an overview of the mental health needs of children and
young people in Salford.
 ‘services’ describes some of the existing services in Salford (this
section does not attempt to comprehensively describe all services – it
focuses on a few that may be particularly relevant.)
 ‘actions’ lists what has been done recently and what else needs to be
done to address the development themes locally.
2
CONTENTS
1
Introduction
2
Contents
3
Context
3.1
Scope of Strategy
3.2
National Context
3.3
Local Context
4
Need
4.1
Needs Assessment
4.2
User Views
5
Services
5.1
North West Children’s Taskforce Model – PREVENTION
5.2
4 Tier Model - INTERVENTION
5.3
Description of Some Salford CAMHS services
5.4
‘Dyson’ Model - PATHWAYS
5.5
Investment in Salford CAMHS
6
Actions
6.1
Recent Progress
6.2
Actions to be Undertaken
3
CONTEXT
3.1
Scope of the Strategy
This strategy has relevance to all children and young people in Salford,
whether they are resident in the area, looked after by Salford Social Services,
registered with a Salford GP, go to a Salford school or are placed in an
independent sector special school. It applies to them from when they are
born to the point that they are no longer receiving ‘children’s services’ and
their care, where appropriate, has been handed over to adult services (in the
vast majority of cases children and young people are aged 0 –19.) It applies
when the child or young person is well and are trying to maintain their mental
health, when the first signs of a mental health issue is recognised (whether
this by the child themselves, a family member, friend or professional),
throughout the period that they are receiving an intervention to improve their
mental health, until they no longer require that service either because their
mental health has been restored or because they have passed through
transition into adult services.
3.2
National Context
Green Paper ‘Every Child Matters’
The government’s vision for children and young people can be summarised in
the five outcomes described in the new Green Paper ‘Every Child Matters’,
these are:
 being healthy: enjoying good physical and mental health and living a
healthy lifestyle
 staying safe: being protected from harm and neglect
 enjoying and achieving: getting the most out of life and developing the
skills for adulthood
 making a positive contribution: being involved with the community and
society and not engaging in anti-social or offending behaviour
 economic well-being: not being prevented by economic disadvantage
from achieving their full potential in life.
This vision sets considerable challenges if the agencies across the education
/ health / social care spectrum are going to help all children and young people
achieve their full potential, particularly those children who are at risk.
Children’s National Service Framework ‘Getting the Right Start’
Emerging Findings
One element of the NSF emerging findings relates to the mental helath and
psychological wellbeing of children and young people. The key themes in the
document are:
 commissioning: effective, high quality, joint commissioning arrangements
across health, social services and education

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

partnership: joint provision of services and smooth transition between
services across health, education, social care, youth justice and voluntary
agencies
developmentally appropriate care: clarity about the age range CAMHS
serve and better transition to adult mental health services
evidence based practice, training and a skilled and competent
workforce: matching skills and competencies of workforce across whole
CAMHS service to local need
service composition: ensuring services have the appropriate critical
mass of staffing and supporting infrastructure (e.g. appropriate IT, admin,
buildings, etc.) to be sustainable
access: ensuring services are managed and delivered in a way that the
children and young people who need them can access them
user views: enabling service users and their families / carers can
influence the services that are offered
audit and outcomes: routinely collecting and using information that
demonstrates the effectiveness of services
Other Developments
The Green Paper and NSF builds on a number of other relevant publications
and strategies:
 Keeping Children Safe - the response to Lord Laming’s report which
highlighted a failure of the relevant agencies to intervene early enough, in
a properly co-ordinated way, to prevent the death of Victoria Climbie
 Getting the Right Start: The National Service Framework for Children and
Young People which is being developed and will describe a 10 year plan
for services, including CAMHS, to meet new standards for services
 The Kennedy Report into the children’s heart surgery at the Bristol Royal
Infirmary which highlighted the importance of designing children’s services
from the child’s point of view
 Quality Protects - a programme to improve services for some of the most
vulnerable children in our society – those who are looked after by local
authorities; considering issues such as placement stability, support for
care leavers, children and young people’s participation, partnership
working and services for particular groups of children (e.g. disabled, ethnic
minorities, refugees, etc.)
 Youth Justice Board which provides expert advice on prevention of
offending amongst young people through earlier provision of multi agency
support for families and juvenile sentencing reforms
 Full Service Schools which will bring together services previously provided
from different location, onto a single site – the local school, for example
health education and promotion, housing, teenage pregnancy, crisis
intervention and community policing advice
 Sure Start, Sure Start +, Teenage Pregnancy Grant which provide extra
resources to improve the multi agency response to the needs of young
parents and young children in deprived areas. These developments bring
significant extra resources to Salford, for example in 2003/4 Salford’s Sure
Start revenue allocation is £2925k, Sure Start+ £118k and Teenage


Pregnancy £135k. Some of the services provided through these
developments will help maintain and improve the mental health of children
and young people for example additional speech therapy, reading skills
projects, domestic violence services and sex and relationship advice
services.
Salford Children’s Fund brings an investment of £5.5m to the deprived
areas of the city over a five year period, in order to promote and develop
preventative services for 5-13 years olds. Over 60 different projects are
being supported and are to be externally evaluated. Most , if not all, of
these projects have a role in maintaining and improving the mental health
of the children and young people who are involved, 5 specifically target
this area – Circle Time Training, Young Runaways, Triple P, Child Witness
Support and Pyramid Clubs.
Education legislation such as the Special Educational Needs and
Disabilities Act which promotes the inclusion of all young people
Many of these strategies were brought together in relation to CAMHS in
Health Service Circular / Local Authority Circular HSC 2003/003: LAC (2003)2
‘Child and Adolescent Mental Health Service (CAMHS) Grant Guidance
2003/04.’ This document described increased allocations to councils,
alongside increases to PCT’s baseline allocations, to deliver ‘comprehensive
CAMHS services’ in every locality by 2006. A comprehensive CAMHS
service is described in several ways:
 Underpinning principles to inform the commissioning and delivery of
services
 Range of services to meet the full range of users needs
 Workforce and training to ensure the skills and competencies required
to deliver the service are available
 Organisational arrangements to ensure CAMHS services and their
interfaces with other services are effectively managed.
In total in the next two years in addition to its current ‘core’ allocation Salford
(City Council and PCT combined) will receive in excess of £550,000
ringfenced funding for CAMHS services. Other sources of funding are
available through Children’s Fund, Sure Start, Education Authority and
schools allocations
National Good Practice in CAMHS
Various publications (e.g. Department of Health (November 2002) What’s
New: Learning from the CAMHS Innovation projects, Alexander T. (November
2002) A Bright Future for All: Promoting Mental Health in education, Meltzer
H., Gatward R., Goodman R., Ford T. (2000) The mental health of children
and adolescents in Great Britain, Roberts H. (2000) Barnardo’s: What works
in reducing inequalities in Child Health, Ashton C. (2001) Promoting
Children’s Mental Health within Early Years and School Settings, Audit
Commission (1999) Children in Mind: child and adolescent mental health
services) reveal that effective CAMHS services have a number of
characteristics in common, including:



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


Strategy. Child and adolescent mental health data shows strong
inequalities, where poorer children are more likely to experience high
levels of mental distress. It is crucial that the overall direction of CAMHS
relates closely to the strategies of other agencies working with children to
improve their life chances. A clear set of aims and objectives should be
articulated, to identify the opportunities for reducing inequalities through
joint work where it would add value. Monitoring frameworks are necessary
to identify areas of local progress. The NSF will provide a source of good
practice standards against which services will need to be monitored.
Partnership working. Clear and consistent leadership is needed to
develop co-ordinated and integrated approaches. Effective CAMHS have
strong relationships with local education authorities, schools, social
services and other parts of the health service. In addition, there are
numerous opportunities for joining up with the voluntary sector and
Connexions. These partnerships should be formed at strategic levels,
through established high-level mechanisms; they should also exercise
their ability to influence agendas to promote well-being for young people
more generally. Multi agency approaches are very effective and should be
developed. Therefore, partnerships should be developed at operational
levels; for example, CAMHS should offer advice, training and support to
partner agencies working with young people and their families.
Accessibility. CAMHS must be accessible for young people; they should
operate at times when young people are able to use them, and in locations
that are not intimidating or difficult to find. Similarly, different models
should be used, including outreach, which take the service out to young
people, especially for those in communities that have not always benefited
from statutory provision.
Appropriateness. A range of services should be made available
depending upon the needs of young people and the realities of their lives.
It should be recognised that they, and their families/carers, have diverse
cultural, social and individual needs (for example child from black and
ethnic minority communities). Different interventions are necessary to
meet diverse needs - taking into account the range of experiences which
might indicate poor mental health - including therapies, advice and
support.
Acceptability. CAMHS should provide non-stigmatising environments,
which welcome young people, where staff members respect their diversity
and difference.
Involvement and participation. Young people, their families and their
carers should be systematically and meaningfully involved in the design,
implementation and evaluation of services.
Adequate resources. CAMHS services should be adequately resourced,
using benchmarks and evidence of good practice as means of assessing
appropriate funding. Given the multi agency nature of the work, funding
should be provided from a range of sources.
3.3
Local Context
Salford
Salford is a medium sized metropolitan area within Greater Manchester with a
population of around 215,000 of whom approximately 20.4% are aged under
16. In common with many other urban communities with an industrial heritage
there are pockets of very high levels of deprivation across Salford with nine of
the twenty wards falling within the lowest 10% of wards nationally in the Index
of Multiple Deprivation 2000. Five of the inner city wards have a child poverty
index score higher than 66.4. Educational attainment within the city is below
the national average but rising.
Children’s Services Planning Forum
Local organisations have committed to work together to achieve the best
outcomes for children and young people. This work is overseen by the Local
Strategic Partnership and within that framework the Children's Services
Planning Forum, which is chaired by the PCT Chief Executive, works to 5 key
aims for children in Salford:





to live in nuturing and well supported families
to have high levels of achievement and aspirations
to live in, and make a positive contribution to, a community which they
respect and which respects them
to be able to access relevant and welcoming services
to grow up healthy and to minimise the impact to their potential of any
health disadvantages, illness or disability
The CSPF is made up of representative of all the agencies that deliver
services for children across the city. This includes the voluntary sector, as
well as the statutory agencies, which has an equally important role in shaping
and delivering services.
Integrated Children’s Services
Salford’s application to become a Children’s Trust Pathfinder Site is a clear
statement of the vision to develop integrated services across health / social
care / education. Integrated services are expected to achieve easier access
through a single point of entry, joined up assessment to reduce the need for
children and families to retell their story and better links between services to
ensure there are no gaps in provision. Although the application to become a
pathfinder was unsuccessful the City Council and Primary Care Trust are
continuing to take this work forward. This will be via a phased approach
initially through the creation of a joint commissioning function and then by a
gradual roll out of integrated services for children, young people and families.
CAMHS services are one area where health, social services, education and
independent / voluntary sector services all have a contribution to make, so will
be a fundamental part of Salford’s integrated children’s services. The
CAMHS services, services for sick children and services for disabled children
need to be integrated.
The re-configuration of Salford’s children’s health services presents an
opportunity to implement the necessary changes within Salford’s CAMHS
services. Royal Manchester Children’s Hospital, which provides secondary
(district) and tertiary (specialist) health services for Salford’s children and is
the base for the Tiers 2/3 CAMHS team (see Section 5.2), is to close in 2008
and tertiary services to transfer to the central Manchester site. In response
Salford PCT is planning a development of community based children’s health
services building through the local investment finance trust (LIFT)
redevelopment of community based facilities. The Pendleton LIFT centre will
act as an important resource for Children’s Services across Salford and will
be the base for the Tier 2 /3 CAMHS services. New hospital based services
for children will also be developed on the Hope site as part of the Salford
Health Improvement for Tomorrow (SHIFT) private finance initiative.
The Education and Leisure Directorate work within a framework which
promotes the empowerment of children and young people, their parents /
carers and all learning settings. All teams within the Directorate from Early
Years to the Youth Service, supports a capacity building strategy based on
delegating resources to those working with children and young people,
providing advice, guidance and training to those partners and challenging
expectations and practice. While all teams contribute to this strategy, the
Inclusion and Access Division provides a specific focus on supporting
vulnerable young people in Salford.
In promoting good mental health all primary, secondary and special schools
have a vital role within the CAMHS strategy. The specific teams working with
children / young people, parents / carers and learning settings includes
educational welfare, educational inclusion, educational psychology and SEN
support.
The existing children’s division of Community and Social Services will be part
of the Salford’s integrated children’s services. The initial focus will be around
developing a common Identification Referral and Tracking system for Salford
underpinned by a single assessment process. Initiatives such as Sure Start,
Children’s Fund, Connexions will mean an increasing emphasis of
preventative work within these services over time.
4
NEED
4.1
Needs Assessment
Summary


A quarter of Salford’s population is aged 19 or under.
Around 4000 children or adolescents are likely to have some form of
mental disorder in Salford


Around 270 looked after children in Salford will have some form of
mental disorder.
Five of the six wards in Central locality are in the top 2% most deprived
child poverty wards in the country.
Younger People
Just over a quarter (25.8%) of the population of Salford is aged 19 and under.
In absolute terms, South locality has the largest population of people aged 19
and under. According to the 2001 Census approximately 19,500 people aged
19 and under lived in South locality, compared to around 13000 in both West
and Central locality and 9000 in North locality.
Central locality has the highest percentage of the population aged 19 and
under (26.9%) and North Locality the lowest percentage of population aged
19 and under (24.1%). Figure 1.
Figure 1: Localities - percentage aged 19 and under
Localities - percentage of population aged 19 and under
27.5
Source: ONS - Census 2001
Percentage of locality population
27.0
26.5
26.0
25.5
25.0
24.5
24.0
23.5
23.0
22.5
Central locality
North locality
South locality
West locality
At an electoral ward level, Kersal (33.9%) has the highest percentage of
population aged 19 and under. Along with Kersal, Little Hulton (30.3%),
Broughton (29.7%), Winton (29.5%) and Irlam (28.5%) are the five electoral
wards with the largest percentage of population aged 19 and under.
Prevalence Of Mental Health Disorders In Children And Adolescents In
Salford
The ‘mental health of children and adolescents in Great Britain’1 states that
among children aged 5–15 years, 9.5% had some form of mental disorder.
5% had clinically significant conduct disorders; 4% were assessed as having
emotional disorders (anxiety and depression) and 1% were rated as
hyperactive. The ‘less common’ disorders (autistic disorders, tics and eating
disorders) were attributed to half a per cent of the population.
If these prevalent rates are applied to the Salford population aged 5 to 19 it is
estimated that around 4000 children and adolescents will some form of mental
disorder, 2150 conduct disorders, 1700 emotional disorders, 430 hyperkinetic
disorders and 215 less common disorders (Table 4).
Table 1: Estimated numbers of children and adolescents in Salford with
mental health problems (from national prevalence rates)
5-10
any 1400
Prevalence of
mental disorder
Conduct disorders
780
Emotional disorders: 560
Anxiety
525
Depression
35
Hyperkinetic
255
disorders
Less
common 85
disorders
11-15
1600
5 to 19
4085
910
810
675
260
200
2150
1720
1634
387
430
88
215
Prevalence Of Mental Health Disorders In Looked After Children
The “Mental health of young people looked after by local authorities in
England”2 estimates the prevalence of mental disorder among looked after
children to be 45%, a rate over four times higher than that for young people
generally.
37% of looked after children will have a clinically significant conduct disorder,
12% emotional disorder and 7% of looked after children will have a
hyperkinetic disorder. A further 4% of looked after children will have a ‘less
1
Meltzer H, Gatward R. The mental health of children and adolescents in Great Britain.
ONS. 1999
2 Meltzer H, Corbin T, Gatward R, Goodman R, Ford T. The Mental Health of young people
looked after by local authorities in England. ONS. 2003.
common’ disorder (such as pervasive developmental disorders, tics and
eating disorders).
If these prevalence rates are applied to the population of looked after children
in Salford it would mean that approximately 270 looked after children in
Salford will have some form of mental disorder. About 220 will have a
clinically significant conduct disorder, 70 will have an emotional disorder and
40 will have a hyperkinetic disorder and around 25 looked after children will
have one of the less common disorders.
Table 2: Estimated numbers of looked after children and adolescents in
Salford with mental health problems (from national prevalence rates)
Prevalence of any mental disorder
Conduct disorders
Emotional disorders:
Hyperkinetic disorders
Less common disorders
5 to 19
270
220
70
40
25
Autistic Spectrum Disorders (ASD)
Understanding of ASD is developing. It affects at least, 60 per 10,000
children under 8 years, of whom 10 to 30 have narrowly-defined autism. This
national increase in prevalence is replicated in Salford. It is a developmental
disorder in which the presentation varies with age and, in any one individual,
varies over time. By adulthood about one third of individuals with ASDs have
developed epilepsy.
The association of ASDs with learning disability is not well understood and the
risk of low IQ in ASDs may be lower than previously thought. Diagnostic
instruments are being developed which mean more children and adolescents
without learning disabilities are being identified on the autistic spectrum.
Nevertheless a substantial number of children and adolescents with identified
ASDs have learning disabilities. Many of these present with atypical ASDs,
and there is a significant association with “challenging behaviour”.
The high correlation between ASDs and learning disabilities means that this
will have implications for all LD camhs provision, particularly as in combination
these present a higher risk of challenging behaviours.
Risk Factors
Factors which increase the risk of developing mental health problems in
childhood include:
 Family poverty
 Family discord or separation
 A parent with mental illness
 Parents who misuse drugs
 Chromosomal or other genetic abnormalities






Brain damage in the child
Physical, emotional or sexual abuse (including bullying or racism)
Severe trauma
The child having a learning disability, language or communication
problem.3
Being a looked after child
Chronic physical illness, especially that which includes physical
disability and damage to the central nervous system
These are risk and not causal factors. The extent to which any child
experiencing these risks goes on to suffer a mental health problem will
depend on a complex range of interactive issues.
Child poverty
Family poverty has been identified as a risk factor in developing a mental
health problem.2
The Index of Multiple Deprivation 2000 (IMD 2000) measured derivation
across six domains using a basket of indicators. Overall, Salford is the 28 th
most deprived local authority in the country out of 354 local authorities.
The Child Poverty Index score formed a part of the overall deprivation
measure. In Salford, child poverty scores are worse than overall deprivation
scores. Of 8414 electoral wards nationally, Ordsall was ranked the 12th most
deprived ward in terms of child poverty. Blackfriars (21 st), Pendleton (54th),
Broughton (135th) and Langworthy (153th) are in the top 2% of the most
deprived child poverty wards. Additionally, Little Hulton (276th), Winton
(479th) and Weaste and Seedley (656th) are in the most 10% of child poverty
deprived wards.
With five of the six wards in Central locality being in the top 2% most deprived
child poverty wards in the country, this is by far the most deprived locality in
Salford.
Educational attainment
The prevalence of mental disorders among children increases with a
decrease in the educational level of the interviewed parent. 15% of children
of parents with no educational qualifications had a mental disorder compared
with 6% of those whose parent had at least a degree level qualification. 4
Department of Health. Child health in the community – a guide to good practice. NHS
Executive.1996.
2 The University of Liverpool. Health Prospects for Young Citizens of the North West. A
Special Report for the Regional Director of Public Health. 1998
4 Meltzer H, Gatward R. The mental health of children and adolescents in Great Britain.
ONS. 1999
3
Taking the population as a whole, central locality has the highest percentage
of residents with no qualifications (37.7%). West locality has the lowest
percentage of residents with no qualifications (31.7%).
Lone parent households
The ONS survey ‘the mental health of children and adolescents in Great
Britain’4 states that the children of lone parents were about twice as likely to
have a mental health problem than those living with married or cohabiting
couples: 16% compared to 8%.
Across the whole of Salford, 8.6% of households are those with lone parents
bringing up dependent children compared to 6.5% of households in England
and Wales.
Localitities: Percentage of lone parent households.
Lo c a lit ie s - pe rc e nt a ge o f lo ne pa re nt ho us e ho lds
12
Percentage of households
Sour ce: ONS - Census 2001
10
8
6
4
2
0
Central locality
4.2
North locality
South locality
West locality
User Views
There is a history of productive user involvement in adult mental health
services. User involvement in Salford CAMHS services is much more patchy.
Involving children and young people in the development of services for them
is a key principle underpinning the work of the Salford Children’s Services
Planning Forum and is becoming a key action area for all services to take
forward. Through the Children’s Services Planning Forum the resource and
intelligence within the city will be joined up to create a comprehensive strategy
for involvement. Part of this will include the appointment of a worker to take
the lead on developing local capacity for involvement work around health
services. This individual represents a resource local CAMHS services will
utilise.
4
Meltzer H, Gatward R. The mental health of children and adolescents in Great Britain.
ONS. 1999
42nd Street (see section 5.1) was commissioned by Salford West Primary
Care Group in 2000 to understand the mental health needs of young people in
West Salford. (The project worked with young people aged 14 – 25.) The
original remit was expanded to reflect the creation of Salford PCT in 2001 and
the report ‘Under Pressure’ reflects the views of young people from across
Salford. The report identified a number nationally recognised social factors
that affect young people’s mental health needs (e.g. family life, abuse, crime,
education, discrimination, drugs, etc.) and some that seemed to be of
particular relevance to young men in Salford (e.g. macho masculine identities,
poor economic opportunities and changing economic roles.) Some of the
strategies these young people used to cope with these stresses (e.g.
substance use and misuse, self harming and suicidal activity) may further
exacerbate their mental health needs. The report made a number of
recommendations relating to existing services:
 Establish peer support / mentoring system, including face-to-face and
Internet services
 Increase range of flexible, young people friendly support services (e.g.
out of hours, drop-ins, outreach and services sensitive to disability,
gender, sexual identity and ethnicity issues
 Improve access to range of therapeutic and other support services as
an alternative to / alongside medication
 Establish a city-wide multi-agency training programme around CAMHS
for statutory and generic workers
And some proposals for new services:
 System to promote young people’s participation in the development of
services
 Further research into the needs of specific groups
 A CAMHS co-ordinator for Salford with a remit around mental health
promotion
 Drop in Tiers 1-3 services, services with a focus on young men’s
needs, interventions suitable for those wishing to start work
 Supported housing / rehab centres facilitating independent living of
young people needing residential / inpatient care and a residential
crisis centre for young people.
In addition the Victims of Crime Partnership has involved young people in
considering issues around domestic violence. One of the key messages
coming out of this work is the desire for more counselling in schools.
Some of these issues have already been addressed (see next section on
Services) others need to be picked up in the actions falling out of this
document.
5
SERVICES
This section describes some current CAMHS services in Salford. A variety of
models have been used to provide an overview of CAMHS services, each
focuses on different of the overall provision and adds richness to the
description of CAMHS services in Salford. It is not possible to describe every
service in detail but a few have been highlighted where they are of particular
relevance / interest.
5.1
North West Children’s Taskforce Model - PREVENTION
The North West Children’s Taskforce’s guide for commissioners of CAMHS
services published in early 2003 represented CAMHS services through the
model below:
There are clear links between this model and the 4 tier model (see section 5.2
– children with lower levels of need will tend to access lower tier services.
However as the models have been developed from different starting points
(one based on need, one based on the way the workforce is organised) it is
not clear exactly how well they map together. For example do / should all
children in the mental health difficulty category receive Tier 2 services or do /
should some receive Tier 1 and some Tier 2 as well.
All Children /
young people
Risk factors
but not
problem yet
100%
Mental health
difficulty
20%
Mental health
problem
10%
Mental /
psychiatric
illness
? 2%
Universal
Services
MH Promotion
(and some
primary
prevention)
Children and
Young People
at Risk –
Targeted
Services
Primary
Prevention &
Early
Intervention
(and some
secondary
prevention)
Secondary
Intervention
and
Prevention
(and some
tertiary
prevention)
Tertiary
Intervention
and
Prevention
A strength of this model is that it describes services from the perspective of all
children and young people, highlights the importance of the promotion of good
mental health for children and young people and the fact that most children
and young people who receive a mental health ‘intervention’ will receive it
from their families, friends, communities and universal services (e.g. schools)
rather than from targeted or specialist CAMHS services.
5.2
4 Tier Model - INTERVENTION
A 4 tier model for CAMHS services was described in Together We Stand
published by the Health Advisory Service in 1995. This model describes each
service by considering by whom and how it is provided, with children and
young people with more severe problems requiring input from a higher tier of
service:

Tier 1:
Represents teachers, social workers, voluntary agencies
and primary healthcare staff, etc.



Tier 2:
Represents CAMHS professionals (clinical psychologists,
psychiatrists, nurses and other mental health workers) working as
individuals with particular children and their families.
Tier 3:
Represents CAMHS professionals working in teams to
deliver a multi-professional response to an individuals needs
Tier 4:
Represents highly specialised services such as inpatient
facilities
This is the nationally recognised model for CAMHS and allows comparison
between Salford and other areas and a common language which reflects the
concept of the graduated response used in education.
5.3
Description of Some Salford CAMHS Services
PREVENTION
In Salford there are a range of services that fall within the CAMHS health
promotion / prevention remit, many of these are funded through the Salford
Children’s Fund and a few are described below:
World Wide Web
Information around issues related to young people’s mental health is available
on the World Wide Web, much in a form that is accessible to young people.
www.ru-ok.com is a site that has been developed by mental health
professionals locally and aims to help teenagers assess their strengths and
weaknesses and access advice.
Bullying Policies
A survey of primary and secondary schools across England showed bullying
is widespread with 44% of children reporting they had been bullied at some
point and 27% reporting they had bullied others. It is slightly more common
amongst boys than girls and decreases with age. Bullying can involve
physical, mental or indirect (e.g. via gossip, emails, text messages, etc.)
abuse. Victims may be reluctant to attend school and are often absent. They
may be more anxious and insecure than others and being bullied may lead to
anxiety, depression, loneliness and lack of trust in adult life and in extreme
cases attempted suicide. Victims may present a variety of symptoms to
health professionals, including fits, faints, vomiting, limb pains, paralysis,
hyperventilation, visual symptoms, headaches, stomachaches, bed wetting,
sleeping difficulties and sadness.
Much of the work to tackle bullying is being driven nationally but led locally by
schools. ‘Don’t suffer in Silence’ an anti-bullying pack has been circulated to
all schools and offers practical advise on developing schools anti-bullying
policies, through awareness raising and consultation, policy implementation,
monitoring and evaluation. The pack promotes a range of good practice for
example exploring issues within circle time, building ‘circles of friends’ around
vulnerable pupils, setting up support groups, pupil volunteer ‘befrienders’,
mediation by peers and adults, counsellor based services, assertiveness
training and involving parents at various stages.
Behaviour Education Support Teams (BEST)
BEST teams have been set up as part of Salford’s Behavioural Improvement
Programme which is part of the national strategy to reduce street crime. Set
up in 4 secondary schools and their feeder primaries, multi-agency BEST
teams offer intensive support to pupils, their teachers and families who are at
most risk of non-attendance or exclusion from school. One member of these
teams is a CAMHS professional and has a specific role about enabling
appropriate access to CAMHS services.
Triple P Parenting
Parents have a strong influence on their child’s educational development,
behaviour and mental health. People learn how to be parents from their
families, their community, the media and occasionally from people who work
in children’s services (e.g. GPs, health visitors, teachers, social workers, etc.)
Currently a number of parenting techniques are taught by different staff in
Salford (for example Webster Stratton and Parent Survival courses (used by
the Child and Adolescent Mental Health team), Hanen (used by speech
therapists), etc.) Processes such as participatory appraisal carried out with
the public in a number of areas across the city (e.g. Seedley, Langworthy,
Ordsall, Kersal and Charlestown) have shown Salford’s parents want
themselves and their families to receive consistent parenting advice.
The Children’s Fund in Salford has commissioned the PCT to lead a two year
project that aims to trial a single, coherent parenting strategy, Triple P, within
one area of the city (surrounding the schools that the Behaviour Education
Support Teams work with.) Triple P is a comprehensive early intervention to
support parenting and intervene effectively in the management of childhood
behaviours. There are 5 levels of Triple P, level 1 provides all parents with
basic parenting information and subsequent levels provide progressively more
advice to parents and is increasingly targeted towards families with higher
levels of concern and difficulty about their child’s behaviour. The Salford
project will trial the use of the first 3 levels (the Webster Stratton programme
will continue to be used for the highest level of need.)
The project will entail understanding current parenting activity, identifying
training needs, training staff in the Triple P approaches and then delivering
Triple P parenting. Evaluation of the project is being led by the Clinical
Psychology Research Department of Manchester University the evaluation
will consider the value of using the Triple P approach in Salford. In addition
the project will identify the barriers to using Triple P to provide a single
coherent parenting strategy across the whole of Salford.
To inform the evaluation of this project, teachers asked over 400 children to
get their parents to complete questionnaire on their behavioural and emotional
adjustment. Over 2/3 of the questionnaires were returned (60% from girl’s
parents, 70% from boy’s) and this high response rate is felt to reflect the
importance of the issue to parents and the approaches the researchers used
to incentivise the children to take part.
Salford Foundation – Pyramid Clubs
Salford Foundation works to improve links between the business and
education sectors of the city. Since its inception in 1991 the Foundation has
developed and now runs a wide variety of volunteer schemes for example
mentoring, Millenium Volunteers, New Deal mentoring for job seekers, peer
mentoring in high schools, etc.
A new scheme has recently been launched – Pyramid Clubs. This is a
preventative approach targeted at 7-8 year olds. 10 primary schools within
Salford have signed up to take part and professionals and parents will screen
children to identify those who could be at risk of developing mental illness
(e.g. low self-esteem, poor social skills, stressed, etc.) 10 children in each
school will be invited to join a Pyramid Club which will be run by trained
volunteers and, through fun and play, help the children develop confidence,
friendships and coping skills.
There is evidence that such approaches can
improve the children’s well-being later in life.
INTERVENTION
Tier 1 in Salford
In common with other areas Salford Tier 1 servcies are delivered by a variety
of agencies:
Health:
GPs, health visitors, school nurses, community paediatricians,
A&E staff, hospital doctors
Social Services: Residential units, fieldwork teams, foster carers
Education: High school counsellors, teachers, educational welfare service,
education psychology service, special schools. 4 high schools in Salford also
have recently put in place multi-agency Behaviour Education Support Teams
which will provide early intervention for pupils who are showing signs of
emotional behavioural problems or who are at risk of developing mental
health problems.
Other:
Youth Offending Teams, Drug & Alcohol Teams, Charitable,
Voluntary and Independent Sector Services
There are also a number of more targeted Tier 1 services in Salford:
ADD/ ADHD Family Support Centre – this is a charitable centre based in
Little Hulton, Salford, which provides various services for families of children
with attention deficit disorder and related syndromes from Greater
Manchester. The services provided include advice, resources (books,
video’s, etc.), trips and activities, group work, solicitors clinic, etc.
Pro-Contact – Salford has the only Pro-contact centre in the North West of
England. This relatively new independent service provides opportunities for
supervised contact between children and parents who have been separated
potentially as a result of offences which have been dealt with through the legal
system. In addition to facilitating safe contact the service may provide
assessment of needs and therapeutic intervention such as parenting,
counselling and anger management.
Relate – this is a charity that aims to support people to build better
relationships through the provision of counselling services. In addition to
counselling and psycho-sexual therapy services Relate provides a young
person’s service to help young people come to terms with family break-up and
re-organisations.
Crossroads – this charity provides support to carers of dependent adults and
children. In Salford it provides a well developed service, for example
domiciliary respite care as well and activities, for children with chronic health
conditions and challenging behaviours, co-ordinated with provision by all
statutory agencies.
Brief Intervention Team – this service provides a short-term, intensive
solution focused approach for families in crisis with children at risk of being
excluded from school or looked after by the Local Authority. The service is
staffed by employees of the Local Education Authority and Social Services
who use a clinic based approach, engaging with young people and families to
look at how change can be effected.
Tier 2 in Salford
Most referrals from Tier 1 services to CAMHS Tier 2 / 3 services are from
GPs, school nurses and social workers. A significant proportion of the
children and young people will be known to other services, all should be
known to education services, and may have a variety of related needs. The
CAMHS professional will often need to discuss cases with the referrer to
ensure the CAMHS response is in line with the clinical priority of the CAMHS
issue.
The services are primarily provided by clinical psychologists, but are also
provided by psychiatrists, child psychotherapists, nurse practitioners and child
mental health practitioners. The treatment / intervention used is based on the
assessment of the child and their family’s needs and can include individual
work with the child and the family, parent training and parenting groups. Core
services are provided at the RMCH site however several projects have been
funded which provide Tier 2 services in other settings, for example outreach
work in Little Hulton, Lower Broughton, Ordsall and Eccles, Life Start
parenting courses in a community setting for hard to reach families in a Sure
Start area, clinical psychology input to the Diana team for home nursing of
children with life limiting illnesses and school based services for children of
refugees and asylum seekers (funded through Action for Children in Conflict.)
Tier 3 in Salford
Salford Tier 3 services are accessed by the same means as Tier 2 services.
Tier 3 is delivered by psychiatrists, clinical psychologists, child
psychotherapists, child mental health practitioners and nurses. The services
comprises a comprehensive assessment and multi disciplinary intervention
which is usually more intensive and / or for a longer period of time than for
Tier 2. Specific elements of the service include referral onto more specialist
services (e.g. early onset of psychosis, severe anorexia), the day unit (with
CAMHS, education and social work input) and a 24hour on-call rota for
emergencies.
The Salford Therapeutic Advisory Referral Service for Looked After Children
(STARLAC) improves access to Tiers 2 / 3 CAMHS services for looked after
children and extends the consultation / training / support given to local foster
carers and children’s residential units.
Tier 4 for Salford
Tier 4 services are commissioned on a large population basis, Salford’s
services are commissioned as part of the Greater Manchester provision. NHS
Tier 4 services in Greater Manchester include:
 ward 15, Booth Hall Hospital, Central Manchester and Manchester
Children’s University Hospitals NHS Trust (for children under the age of
15)
 McGuiness Unit, Prestwich Hospital, Bolton, Salford and Trafford Mental
Health Trust (for 13 –18 year olds)
 Salford Social Services also provides the Barton Moss secure unit for
young offenders.
Health / social care and education agencies have recently developed a tripartite funding protocol to place children and young people usually outside the
area in independent sector provision if local services cannot meet their needs.
5.4
The ‘Dyson’ - PATHWAYS
The ‘Dyson’ model, see below, was based on a model developed through the
Salford Health Investment for Tomorrow project and has been developed to:
 describe all services (including health / local authority / voluntary
sector) that are available to children and adolescents from Salford with
mental health problems
 concentrate on the connections between the services
 be tested / challenged by services (initially the CAMHS strategy group)
 be used as a planning tool to help identify gaps and duplication.
This model highlights the importance of understanding CAMHS as a whole
system of services that need to work together as children and young people
move from one part to another. It highlights the importance of the training /
consultation / liaison role of the Tier 2 / 3 CAMHS professionals to assist the
development of appropriate skills and competencies such that Tier 1 services
can manage children and young people with low level needs and can quickly
assess and identify those few who have high needs and need a more
specialist input. The model also highlights the variety of routes into different
services and the potential for children and young people to be stuck or going
round in circles if there are not clear pathways into appropriate services for
them – the ‘Dyson’ effect.
Understanding the Dyson Diagram
The model is a graphical representation of current CAMHS in Salford. A few
examples of different services are listed in each category and links between
the categories are shown. Broadly speaking services towards the bottom of
the diagram represent ‘higher end’ services. The size of a box does not
represent the importance of that service, the numbers or needs of its users or
the resources it requires and the size of the arrows does not represent the
numbers of referrals from one part of the system to another.
Current CAMHS Services in Salford (Version 2.1) – the ‘Dyson’ model
Universal Services (mainly
open access)
e.g. School Counselling, Social
Work, 42nd Street, www,
Parenting Groups, Anti Bullying
Specialist
CAMHS
Intake
Meeting
Clinical Child Psychology
e.g. Outpatient services, Clinics, Day
Unit, STARLAC
CAMHS Psychiatry
e.g. Outpatient services, Clinics, Day
Unit
Tier 4 e.g. McGuiness Unit, Booth Hall, Independent Sector
Outrach Services, Training, Networking & Liaison
Outreach Services, Training, Networking & Liaison
Targeted Services
(mainly limited access)
e.g. ADD / ADHD Centre,
Crossroads, Brief Intrvntn Team,
Relate, Pro-Contact
Refe
rers
e.g.
GPs,
Soci
al
Work
ers
Authorities across the country are investing in Identification, Referral and
Tracking schemes to improve co-ordination between partner agencies who
are working with vulnerable children, young people and their families. A key
element of this investment relates to the development of integrated IT
systems. In Salford the system will be underpinned by the Family Action
Model. This model aims to enable vulnerable families who fall below the
threshold for social work intervention to access co-ordinated multi-agency
services. Locality based FAM co-ordinators have been recruited and one of
these will take a lead on ensuring CAMHS services are linked into this
development.
The CAMHS strategy group has agreed clear pathways into services need to
be developed for children who are:
 disabled
 looked after
 having special / additional educational needs
 at risk of abuse or living with domestic violence
 in transition
 in a highly mobile families
 a young offender
 gay or lesbian
 in a family that is breaking up or having suffered a bereavement
 a carer
 having learning related difficulties
 out of education
as well as those who have a diagnosed mental illness.
The national CAMHS mapping exercise indicates that nationally 48% of Tier 2
/ 3 staff time is spent in direct clinical contact, 20% on consultation,
supervision and training and 22% on admin and case management. Salford
CAMHS staff consult, train and liase with the following services:
Social Services
 All residential
units
 Fieldwork
teams
 Foster carers
 Brief
Intervention
Team
Education
 Most high
schools
 Educational
Welfare
 Education
Psychology
 Special
Schools
Health
 Health visitors
 School nurses
 Community
paediatricians
Other
 Youth
Offending
Team
 Young
Person’s
Substance
Misuse Team
The Salford CAMHS tier 2/3 team also has strong links with the Manchester
University Department of Child & Adolescent Psychiatry. These links mean
staff are supported in a wide range of clinical research, training placements for
psychiatrists, clinical psychologists, nurses and social workers are provided
and various other education and training activities are developed and
undertaken.
Resources Invested in Salford CAMHS
Due to the range of services that make up a comprehensive CAMHS service and the range of sources of funding it is difficult to
identify the resources that are invested in Salford CAMHS services in their entirety. The table below provides some figures:
Commissioning
Organisation
PCT – Core
Contracts
Service Provider
Service
Central Manchester and
Manchester Children’s
University Hospitals
NHS Trust
PCT – Non-NHS
Salford City Council
Small Grants
Jewish Society
Making Space
Crossroads
After Adoption
Homestart
Reserves
Contribution to out of
area placements
STARLAC
Cornerstone
Crossroads
42nd St
STARLAC
Psychiatry –outpatients
Psychiatry – inpatients
Psychiatry – day care
Psychology
Outreach
STARLAC
Diana Nursing
Child Protection
ADD Centre
Project Smile
Family Support
ADD Centre
-
PCT – Joint
Finance
PCT –Packages
of Care
Social Services –
Core
CAMHS
Funding
£000s
326
27
74
365
103
141
12
9
18
15
13
5
18
21
Notes
Figures are estimates of
02/03 outturn. Accuracy of
activity and costs needs to be
clarified.
Figures are 02/03 outturn
Figures are 02/03 outturn
67 Figures are 02/03 outturn
40 Figures are 02/03 outturn
Development
Grant
Education
Authority
Children’s Fund
Total
Child Psychotherapy
Cornerstones
42nd St
ADD / ADHD Centre
Packages
Inclusion and Access
Division
Projects specifically
targeting mental health
Educational Psychology,
Education Inclusion, SEN,
Educational Welfare
Circle Time Training
Young Runaways
Triple P
Child Witness Support
Pyramid Trust
10
15
12
12
6
470 This is a cautious estimate of
the time these teams spend
dealing with CAMHS issues
29 Figures are 2003/4
97 allocations
115
27
36
6
ACTIONS
6.1
Recent Progress
A number of actions for Salford were identified in the 1998 Salford and
Trafford CAMHS Strategy, this section outlines recent progress against these
actions:
Action
Progress
6.1.1.
Ensure that the development of a
Preventative Strategy for
Children & Young People in
Salford, and the roll-out of the
Children’s Fund takes full
account of the CAMHS agenda,
especially tiers one and two
Continue to develop training for
first and second tier staff
A written prevention strategy is
being developed taking account
of CAMHS issues.
Prevention Strategy / Children's
Fund coordinator is member of
CAMHS Strategy group.
6.1.2.
Focus on the further
development of services to meet
the needs of vulnerable groups
including children looked after
and young offenders.
The Local Authority will focus its
increased grant on these areas
including such steps as the
development of STARLAC,
Cornerstones, and 42nd Street to
ensure a range of responsive
and supportive services.
STARLAC social worker post in
post.
Cornerstones worker in post.
YOT has link worker from core
CAMHS service.
Multi-disciplinary support is being
offered to EBD schools and pupil
support units.
6.1.3.
In addition, the Local Authority
will review the needs of an
increasing number of children
and young people looked after
who present very challenging
behaviour and cannot be cared
for in a group. This is leading to
an increasing number of
placements with one-to-one
supervision.
Tri-partite funding panel
established to consider how best
to meet the needs of children
with extreme complex needs.
6.1.4.
Contribute to ongoing
consideration of meeting the
educational needs of children
with learning disability (including
autism and ADHD) and
strengthening multi-agency
responses to their needs.
The ADHD Centre is working
with the LEA in this area.
6.1.5.
Enhance the diversity of skills
Child psychotherapist in post.
and therapies available, such as
increasing the availability of child
psychotherapy and play therapy
6.1.6.
Establish CAMHS After Adoption
support
Will be taken forward using
Adoption Support grant
6.1.7.
Support voluntary organisations
and partnerships which are
contributing to service delivery
and support especially for young
people with emotional
difficulties.(e.g. 42nd Street,
Cornerstones, local ADHD
Support Group)
Links to Asylum Seeker team
and Education services noted.
Several voluntary sector
providers are supported through
links with core CAMHS services
and the Strategy Group
6.1.8.
Put in place steps to ensure that
the development of services is
based on evaluation of existing
services. (Although some
services are evaluated with
inclusion of those using services
in many areas of need and
provision we are not currently
able to identify outcomes for
CAMHS provision.
We have some good examples of
individual project evaluation
following on from the provision of
training but have not yet created
a single process for all CAMHS
services.
We will aim to use an evaluation
group with user involvement in
the future.
6.2
Actions to be Undertaken
The actions the CAMHS Strategy group have identified as needing to be
undertaken are listed below. A CAMHS co-ordinator is to be appointed by the
PCT and Social Services to facilitate moving forward these actions.
6.2.1.
6.2.2.
6.2.3.
Action
 detail
Multi-agency commissioning arrangements
 terms of reference / membership of CAMHS strategy group to
be reviewed
 possibility of a practitioners communications sub-group to be
considered
 CAMHS co-ordinator to be appointed
Information systems
 Tiers 2 / 3 IT systems to be developed
 Tiers 2 / 3 developments to link with Salford IRT work
Clarify funding arrangements for CAMHS budgets
 Tiers 2 / 3 / 4 funding to be clarified to inform CMMCUHT /
Salford PFI developments
 Future of joint finance budgets to be clarified
 Plans for investment of extra allocations to be firmed up
6.2.4.
6.2.5.
6.2.6.
6.2.7.
6.2.8.
6.2.9.
6.2.10.
6.2.11.
6.2.12.
6.2.13.
6.2.14.
Develop user involvement role within commissioning cycle
 Element of extra allocation to be delegated to young people
 Young people to be involved in service performance
management / quality monitoring
Ensure Tri-Partite Funding Protocol (and other out of area
placements) inform commissioning cycle
 Apparent gaps in service provision which lead to out of area
placements to be clearly articulated
 Needs of children and young people with complex mental
health problems to be articulated
 Multi agency service model to be developed
Child protection
 CAMHS input into Salford child protection arrangements to be
agreed
Supporting Tier 1 service
 Tiers 2 / 3 support to be developed as other services develop
(e.g. substance misuse service, ADHD service, LD service,
etc.)
Transition
 Scope of Tier 2/3 services to be reconsidered alongside
national guidance
 Transition protocol to be agreed and implemented between
CAMHS and Adult Mental Health services
Clear pathways
 Articulate clear pathways through Salford services for ‘at risk’
groups
 Develop Family Action Model
Access
 Ease access to CAMHS services for children and young
people in PRUs
Workforce
 Benchmark Salford CAMHS service workforce profile against
national models to understand potential gaps
 Agree CAMHS service models with wider workforce especially
considering role of speech therapists
Pendleton Centre Design to be agreed
 Work to be underpinned by future service model for Tier 2 / 3
CAMHS service
 Special consideration to be given to service model
underpinning the Day Unit
Opportunities for Tier 4 to be maximised
 CMMCUHT and BSTMHP capital plans to be considered
together
Current hospital school service to be re-provided
 Role of school currently in providing services for children for
whom no other local education service is suitable to be
considered
 Plans to be developed to meet the need
6.2.15.
6.2.16.
6.2.17.
6.2.18.
6.2.19.
6.2.20.
Future inpatient ward provision
 Service model for CAMHS provision to paediatric inpatient
services at Hope Hospital to be agreed
Learning Disability Service
 Develop integrated learning disability service, monitor and
agree future development plans across agencies
ASD
 Agree need / service model for services, link to LD service
developments
ADD / ADHD
 Agree need / service model for integrated service with
voluntary sector and education
Parenting
 Implement Triple P project and consider wider lessons for
Salford
Early Intervention in Psychosis
 Develop Salford services in line with regional and national
guidance
The table overleaf indicates how the above actions relate to the key themes
coming out of local and national strategic vision.
Theme
Action
Multi agency commissioning
arrangements
Information systems
Budget clarification
User involvement
Tri-partite funding protocol
Child protection
Supporting Tier 1
Transition
Pathways
Access
Workforce
Pendleton centre design
Tier 4 Opportunities
Hospital School Service
Inpatient ward provision
Learning Disability Service
ADD / ADHD
ASD
Parenting
Early Intervention in Psychosis
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