Havering LSCP
H
a
v
e
r
i
n
g
L
S
C
P
Mental and
sexual health
provisions for
Havering
Children
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1
S
c
r
u
t
i
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y
o
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t
l
i
n
e
This Scrutiny will
“explore provision, access to and use of early help services for children with mental and sexual
health concerns “
Scrutiny method
National picture overview
Havering data from
•
Interviews
•
Data analysis
•
Documentary analysis
Reporting Timeline
Draft presentation for consultation (4
th
December)
Feedback on the draft to
Jennyjoypearce@gmail.com
by 18
th
December 2023
Final version for sign off and action plan HSCP: 6
th
February 24
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2
Young People and mental health: the national context:
Young Minds accessed 2023
•
Under 18s referred to
Child and Adolescent Mental Health Services
(CAMHS)
risen by 53% since 2019
, escalating to over 1.2 million in
2022, (
data from NHS Digital
1)
•
Young people face a
unique combination of challenges
:
consequences of the pandemic, the cost of living crisis and academic
catch up, taking a toll on their mental health.
•
Over half (53%) of young people told Young Minds that
worries about
money
were impacting their mental health, and over a quarter (28%)
are still feeling the
impact of the pandemic
.
•
The lack of any
concrete mental health workforce planning
means
waiting lists in much of the country are longer than two years.
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3
National picture : ethnicity
•
Black young people
are 10 times more likely to be referred to CAMHS via
social services, rather than via the GP, compared to White young people
(Kapadia et al, 2022).
•
A new policy briefing from the
Money and Mental Health Policy
Institute
shows that people from minoritised ethnic groups are
disproportionately affected
by the economic and social determinants of
poor mental health. This includes low income, social exclusion and racism
•
NHS England has launched its first ever
anti-racism framework
for mental
health trusts and providers across the country. The new
Patient and Carer
Race Equality Framework (PCREF)
aims to support organisations to be
actively anti-racist, requiring them to implement concrete actions to
reduce racial inequalities.
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4
National picture: First port of call, the role of GPs in early support for young
people’s mental health (Young Minds / Children's society National research 2023)
•
GPs are a significant source of support for young people’s mental health across
the country
.
•
GPs provide significant levels of support in primary care while young people
waited for specialist services.
•
Young people said seeing their GP made a positive difference in their journey to
mental health support.
•
GPs have varying degrees of confidence and knowledge in supporting young
people with their mental health, creating what amounts to a postcode lottery
•
Some young people also reported negative experiences associated with going to
see their GP about their mental health, as well as barriers to accessing support.
•
GPs voiced frustration about the discrepancy in early support available across
different local areas: often a lack of services for signposting
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5
Havering data: referrals to CAMHs
April 22-23 : 14,262 total contacts. NB: these are not unique numbers of young people
and include repeat contacts
•
42.1 % of referrals from GPs (largest referrer);
•
22% from unknown ‘other’;
•
11% from schools;
•
9% for self;
•
Small numbers from school nurses, YOT, community paediatric service and A&E
In each month, approximately
•
90% remained active cases;
•
28% discharged following professional advice;
•
13% no further treatment appropriate;
•
17% referred to other specialist services
Did not attend appointment ranging from 16 to 22% (NB: this could be for valid
reasons (inappropriate referral for e.g. but qualitative data says ‘not attending’ is not a
reason for closing case of those who are in need)
NELFT have a robust ‘was not brought policy’ that helps them manage when
children do not attend appointments
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6
National and Havering data comparisons
Drawing on
Children and Young Peoples Mental Health Annual Benchmarking report
2022/23. NHS Benchmarking Network, 2023
And
Havering CAMHs April 22 to 23 : NELFT Havering CAMHs
Warning: comparison between Havering and national data is not always
reliable because of reporting methods
(H= Havering; N= National )
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7
H
a
v
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r
i
n
g
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o
n
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l
d
a
t
a
Acceptance rate for assessment : 100% H, 78% N (NB : We do not have data of
cases accepted following assessment. This is needed to review appropriate uptake)
Gender : approximately 50% split both Havering and National
Havering investing
more for each contact
•
Cost of service per contact: H= £479; N mean = £341
Havering
shorter waiting times
than national average
•
referral to 1
st
appointment : H = 2 weeks, N mean= 10 weeks
•
1
st
to 2
nd
appointment : H= 14 weeks, Nat= 21 weeks
Havering
seeing more young people face to face
Non face to face contacts delivered 28% H , 41% Nat mean
Havering has a ‘
looked after children pathway
’ which has a 4 week referral to
treatment pathway compared to the generic 16 weeks
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8
H
a
v
e
r
i
n
g
c
h
a
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n
a
l
d
a
t
a
(
2
0
2
2
-
2
0
2
3
)
Community workforce lower than national average
:
•
78.3 (H) 122.9 (N)
Is data impacted by workforce availability i.e. Lower than national
average referral because lower than average workforce?
•
Referrals to community services:
1372 (H) 4997 (N)
•
Community CAMHs cases:
616 (H) 3656 (N)
•
Patients on case load per 100,000:
1824 (H) 2094 (N)
•
Contacts delivered per 100,000:
14,531 (H) 20,701 (N)
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9
E
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10
C
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Y
o
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P
e
o
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=
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)
Data from Specialist mental health services in Havering is absent in the
NHS benchmarking data.
This includes
•
general admissions adolescents (13 to 17 years) ;
•
data on ethnicity and gender of children in inpatient services;
•
services for children on the autism spectrum;
•
children with ADHD;
•
children with eating disorders;
•
data from CAMHs forensic services.
DRAFT: Not for circulation
11
Havering Mental health support in schools
•
NHS England funding for three ‘mental health school support teams’:
A preventative offer with a whole school approach; fostering change
in attitude on mental health. Run groups for parents and children.
•
This initiative needs supporting and developing as evidences good
outcomes
•
Only got 8 school nurses against a backdrop of increased demand.
•
The cohorts of concern are Missing, CSE, CCE : these young people
are unlikely to go to GP or to a specialist service. Need access to
services during school holidays. Activity based projects are at
capacity, some with waiting lists
•
Havering Psychological services: ‘Wise up project’ : need to explore
uptake by young people
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12
E
a
r
l
y
h
e
l
p
a
n
d
G
P
p
r
i
m
a
r
y
c
a
r
e
Proactive outreach to early help: CAMHS primary mental health teams
alongside education colleagues have invited Early Help, Early Years
team to join consultations
The CAMHs Home treatment team: is well received and reflects
creative thinking.
GPs are aiming to expand support for children not meeting CAMHs
threshold:
A recent exercise run by one GP has been in offering protected
appointments (about 12 appointments) for adolescents. Of these 10 of 12
young people who attend present mental health issues: 50% to 60% need input
from CAMHs. The GP offers support to these cases while they are on the waiting
list. It is recommended that this protected time for adolescents is rolled out
across other GP surgeries.
GPs tend to use websites to find early intervention services.
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13
E
a
r
l
y
H
e
l
p
a
n
d
G
P
p
r
i
m
a
r
y
c
a
r
e
(
c
o
n
t
i
n
u
e
d
)
GPs developed a resource of ‘star workers’ to see and triage and signpost
children with mental health problems to services. This Pilot was not funded,
but NELFT provided the staff. Young people were seen within 2 to 3 weeks,
supporting up to 66% of attendees receiving early help and avoiding the
need for them to go onto CAMHS waiting list (or to come off a CAMHs
waiting List if already on one) It is recommenced this is extended across at
least 3 of the 4 PCN footprints in early 2024.
There is need for improved feedback to GPs following a child being
discharged from a CAMHs service. GPs can play a role in preventing repeat
referral into CAMHs if they are aware of the discharge
Havering has not fully adopted ‘I thrive’ : there is a recognised need for a
culture shift within The Trust : recognising the importance of effective early
intervention.
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14
Sexual Health
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15
National Picture
UK Health Security Agency (UKHSA)
•
26% increase in STI diagnoses among young people aged 15 to 24 since
2021.
•
392,453
sexually transmitted infections
(STIs) reported in England in
2022 –
•
a 24% rise on the previous year.
•
50% increase in
gonorrhoea
since 2021.
•
24% increase in
chlamydia
since 2021 (despite no increase in testing)
•
15% increase in
syphilis
since 2021.
•
8% increase in number of consultations at sexual health services since
2021.
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16
Nuffield Trust : Teenage Pregnancy 2023
Between 2007 and 2021, the under-18 conception rate in England and Wales
decreased by 68%,
•
from 42 per 1,000 women to 13 per 1,000 women
The number of abortions decreased by 67%
•
21,494 in 2007 to 6,999 in 2021
The most recent year, however, saw a small increase in both the rate of under-18
conceptions and number of abortions
.
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17
National Picture (continued )
UK Gov STI and Screening report 2022 (updated 2023)
•
People of
black ethnicity had the highest diagnosis rates of STIs
amongst all ethnic groups, although this varied among the black
ethnic groups.
•
Previous research found, when compared to all other ethnic groups,
there were
no unique clinical or behavioural factors
explaining the
disproportionately high rates of STI diagnoses amongst people of
black Caribbean ethnicity
•
this ethnic disparity in STIs is therefore likely
influenced by
underlying socio-economic factors .
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18
Havering: Teenage pregnancy
See accompanying Power point overview of data from Havering Sexual Health ‘Needs
assessment’ Spring 2023 : specifics regarding young people
•
Over the past 20 years, the teenage pregnancy rates for females under 18
year and under 16 years have decreased in Havering, (following regional
and national trends)
•
2020 data shows that Havering still has a higher rate of both under 18 and
under 16 years conception rates than both London and England. (Under 18
(12.5 per 1,000) and under 16 (1.7 per 1,000)
•
Improvements are evident: Havering now ranks 8
th
of 33 London local
authorities for under 18 years conception/1,000 whereas was 3
rd
in 2020.
•
But, Havering second out of the 33 local authorities for under 16 years
conception/1,000.
•
Learning from strategies implemented in similar local authorities may be
useful in tackling these higher rates.
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19
Conceptions and STIs
See accompanying Power point overview of data from Havering Sexual Health ‘Needs
assessment’ Spring 2023 : specifics regarding young people
Short acting hormonal contraception is the chosen method in Havering. Need to
understand reticence for longer term methods
The e-service appears to continue to be a preferred service: the number of test kits
ordered online has not reduced since the face to face clinics have been
reintroduced.
Although …
•
emergency hormonal contraception (EHC) is available for free at any GP, SRH service and
family planning clinics,
•
two pharmacies are contracted to provide free EHC specifically for 13 to 25 year olds with the
aim of increasing access to sexual health to reduce unintended pregnancies
•
there is one day a week Family Planning service at Queens hospital
…it is rare for a young person to attend these provisions and there is
a recognised
lack of sexual health services accessible to young people in Havering
Royal London sexual assault hub at The Royal London: there is a sexual assault hub
Linked with ‘Tiger Light’ Barnardo's service for children who have disclosed abuse.
Tiger light in 8 London boroughs, Havering has access to its services
DRAFT: Not for circulation
20
T
h
e
N
H
S
B
H
R
U
T
S
a
f
e
g
u
a
r
d
i
n
g
T
e
a
m
There is a Sexual health and safeguarding advisor in Safeguarding Team,
NHS trust :
•
see young people,
•
link with social workers ,
•
follow up on safeguarding concerns:
•
provide health promotion, advice, sex and the law,
•
also treat some patients for STIs;
Would like to ‘get the word out more’. Would like to do outreach: are
trained, skilled , and ready to do outreach but not commissioned to do
this.
DRAFT: Not for circulation
21
D
a
t
a
p
r
o
v
i
d
e
d
b
y
B
a
r
k
i
n
g
,
H
a
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r
i
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a
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d
R
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d
b
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g
e
U
n
i
v
e
r
s
i
t
y
H
o
s
p
i
t
a
l
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22
Safeguarding Team | Corporate Division data for 2023
Barking, Havering and Redbridge University Hospitals NHS Trust
NB: data system has a complex coding formula so figures may be less than actual e.g. a LAC is only coded once
on registration. So may have been coded as LAC in the previous year but not on attendance last year.
DRAFT: Not for circulation
23
V
u
l
n
e
r
a
b
i
l
i
t
y
f
a
c
t
o
r
s
The overarching factors perceived by colleagues that contribute to
rates of teenage pregnancy in Havering are
•
childhood vulnerability:
•
Child sexual exploitation
•
Child Criminal Exploitation,
•
discrimination against LGBT and Trans young people
•
Racism
•
poverty
DRAFT: Not for circulation
24
S
o
m
e
o
f
t
h
e
s
e
i
s
s
u
e
s
a
r
e
b
e
i
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g
a
d
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r
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s
s
e
d
t
h
r
o
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g
h
t
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e
J
o
i
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t
S
e
x
u
a
l
a
n
d
R
e
p
r
o
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H
e
a
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t
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S
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r
a
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g
y
f
o
r
N
o
r
t
h
E
a
s
t
L
o
n
d
o
n
(
2
0
2
4
–
2
0
2
9
)
High-level five-year goals for SRH have been agreed for the NEL system including :
•
Reverse the trend of increasing STI diagnoses by preventing and reducing the onward transmission of STIs
•
Increase knowledge and choice around reproductive health for NEL residents, with increased uptake of the most reliable
forms of contraception, especially LARC
•
Reduce the number of unplanned and teenage conceptions.
•
Reduce the number of abortions and repeat abortions, learning from the
Tower Hamlets model
.
•
Reduce demographic inequities in sexual health activity and outcomes where they are known or identified in the future.
•
Ensure that principles of ‘Universal Proportionalism’ run through all of our work on SRH over the next five years,
prioritising our most vulnerable and high risk residents wherever possible.
•
Overall incidence of STI diagnoses has increased year-on-year in NEL boroughs following the Covid pandemic, with most
cases seen in residents aged under 25 years. This strategy calls for a renewed focus on STI prevention across the whole
NEL system of providers – especially gonorrhoea and syphilis among GBMSM and C&G among under 25s – with emphasis
on increasing use of condoms, enhancing Partner Notification (PN) and increased levels of repeat STI screening for high-
risk groups at a regional level in line with BASHH guidance
•
Teenage conceptions, often unplanned, can have long-term negative consequences for young women and society as a
whole, with many (33%) resulting in termination. The partnership between specialist sexual health services and
Termination of Pregnancy Services (ToPS) is therefore crucial.
In Tower Hamlets, these services are already aligned in a
Women’s Hub model, and the data shows that this has had a positive impact on outcomes
: in 2021, the legal abortion
rates in Tower Hamlets were 41% lower than NEL average. All partners behind this strategy are therefore committed to
replicating the Tower Hamlet’s model across NEL as part of the nation-wide roll-out of Women’s Hubs2.
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25
Looked After Children
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26
LAC National picture: DfE : Children Looked after in England 2023
Numbers LAC entry to and exit from Care have increased –
•
the number of CLA starting during the year has increased by 6% - to 33,000
•
and the number of CLA ceasing during the year increased by 5% - to 31,680
Many of the changes explained by the large increase in unaccompanied
asylum-seeking children (UASC).
•
UASC have increased by 29%, following the 37% increase seen last year.
•
they are a distinct cohort with specific characteristics: generally male, aged 16+
years.
Nuffield Family Justice Observatory 2023
‘
Using data combined across the 5 years, White children account for 78% of
children in care proceedings. Children from Mixed or multiple ethnic groups
were the second most frequently reported group at around 11% of children
’
DRAFT: Not for circulation
27
T
h
e
H
a
v
e
r
i
n
g
C
o
n
t
e
x
t
•
The ‘Cocoon’ is celebrated: essential place for LAC: to be maintained and
supported
•
Mental Health Nurse and LAC nurses to continue to attend Cocoon: this could be
developed to include GP and sexual health advisor attendance
•
LAC ask for consistency of relationships in school and placement: LAC nurses /
those who do LAC health review assessment try to maintain consistency so the
young person gets to know the nurse.
•
The LAC Nurse team has had a low turnaround of staff: this is to be commended
as it creates consistency and facilitates relationship building
•
LAC nurses would benefit from seeing information of content from SDQ:
(strengths and difficulties questionnaire) done by LA (about 80% of LAC children
do the SDQ with school and foster careers).
•
Half of LAC live in borough and half out of borough accommodation: means there
is constant need for continued communication across boroughs
DRAFT: Not for circulation
28
Generic themes from scrutiny of sexual and
mental health provision
DRAFT: Not for circulation
29
R
e
l
a
t
i
o
n
s
h
i
p
b
a
s
e
d
s
u
p
p
o
r
t
Interviews for this scrutiny reiterate the importance of relationships
between practitioners in multi agency contexts and between
practitioners and children and young people
Interviewees suggested :
•
Targeted multi agency networking opportunities:
•
Creating spaces for multi-agency teams to be co-located:
•
mental and sexual health services integrated into other services as
primary prevention;
•
GPs working with PSHE; having a clinic in schools
DRAFT: Not for circulation
30
I
n
f
o
r
m
a
t
i
o
n
s
h
a
r
i
n
g
•
Speed dating events: highlight what each agency is doing. Helps improve
evidence base.
•
Multi agency working:
•
Best e.g. is work on obesity reduction through whole school approach and community
intervention: draw on this for example to follow re mental and sexual health
•
Need to advance
multi agency decision making
about where a child placed.
Jointly assuring ourselves of the placement
•
ICB to ICB communication
: checking if the placement for a young person is the
right one with the right resources: Often done in an emergency without health
matching the provision with needs. This becomes more complicated when
instigated by other ICBs outside NELFT.
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31
Young People’s Voices
DRAFT: Not for circulation
32
Young People’s Voices : Sexual and mental health issues
N.B. Thanks to the Havering Safeguarding Young Advisors
•
Personal hygiene : Sanitary products (free sanitary products)
‘having like a food bank for personal hygiene
stuff – when I have a limited budget food takes priority’. Having Well-being care packages.
•
Sexual Health: need more young person friendly outlets to provide sexual health advice, condoms etc.
•
Young person friendly information on what happens when you have a sexual health test – some young
people expressed anxiety of not knowing what would happen, with some telling of ‘horror stories’ they had
heard
•
Taking us to the doctors
‘Living with a foster carer means that they help us with this, but it is hard to get an
appointment and sometimes we don’t bother saying anything because we know that by the time we get an
appointment the problem would have probably gone or got worse
’.
•
Our older young people shared that ‘
it can often take a lot of mental energy to make any appointment, and
when you’re not in a good place, I don’t have the energy.
•
Another young person shared how prioritising video calls to care leavers would be useful.
•
Relationship with others:
‘you know when I called you after my blood test because I just needed to talk to
someone about it …. That’s what everyone needs, someone to talk to. For Care Leavers we often have no-
one to be our cheer leader, our workers are often not available in that moment, and may not find a call about
a blood test important’.
•
Stopping Bullying, including online bullying.
‘we all know the things to do if we’re being bullied online, stay
off Social Media and that, but it’s hard and it doesn’t make it go away’
.
•
We want Self Defence courses
DRAFT: Not for circulation
33
Q
u
a
l
i
t
a
t
i
v
e
d
a
t
a
f
r
o
m
Y
o
u
n
g
S
a
f
e
g
u
a
r
d
i
n
g
A
d
v
i
s
o
r
s
:
y
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Feedback from young safeguarding advisors …
•
Essential need for local sexual health service
: we need more than one venue, need something on Harold Hill
and Romford: young people may not be able to travel, may not want to explain to parents where they are
going.
•
It Needs to be trauma informed
and sensitive to sexual health problems emerging from sexual and criminal
exploitation
•
Relationships
with people you know and can trust are important
•
The previous
‘drop in’
sexual health service in Queens Hospital before covid was popular
•
Is It possible to have an
outreach bus
for sexual health?
Essential themes are that services need to be local, relationship
based, trauma informed involving youth participation
DRAFT: Not for circulation
34
Recommendations
Blue sky’s thinking
•
Having a room in schools for school nurses, youth workers, GPs,
mental health and sexual health practitioners:
•
What's Ap number for access to young people for mental and sexual
health issues: advertise the number for young people to use.
•
Sexual health service and mental health online: a lively active website
with materials schools can access and use: posters and QR codes for
further info on line about services
DRAFT: Not for circulation
35
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Between 20 and 25% had been sexually harassed
just over 30% felt that people being violent to each other was a problem in their area
48% gave lower scores about being happy at home
Just over 4% felt they were discriminated against because of their sexuality; 10% felt they were
discriminated against because of their race, skin colour or where they were born ; 18.5% had
experienced bullying
52% felt often, some of the time or occasionally lonely
57.9% seek and/or receive support from GPs and specialist services for drug related problems //
33.8% for sexual health and relationships problems
Essential themes: sexual harassment and bullying and violence is a problem, a substantial
minority note they experience discrimination and many are looking for support with drug use,
sexual health and relationships
DRAFT: Not for circulation
36
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1. Havering Mental and Sexual Health services review content of this scrutiny and create an
action plan for their service development in response
2. Havering CAMHs: review
•
unique numbers of CAMHS contacts to accompany data including repeat referrals;
•
the policy regarding ‘did not attend’ to assure themselves that young people needing a service but
unable to take it up are being reached;
•
data of cases accepted or declined following assessment
•
with ‘early help’ suitable referral to primary care services for those not meeting CAMHs threshold
•
With ICB and NHS England the data regarding lower community service uptake compared to
national average to assess if this is due to lower investment in community child mental health
services in Havering, this to include review of commissioning of services for children’s mental and
sexual health in light of this report ;
•
accuracy of data regarding ethnicity and CAMHs take up and considering questions of
disproportionality ;
•
the current process for communication with GPs and consider improvements in feedback
following CAMHs assessment and following child discharge from CAMHs services GP network to
work with Schools create an action plan noting links with Havering Education Strategic Partnership
to review primary care (GP) engagement with schools and create proactive strategy for closer
working methods
•
The existing good work of mental health support teams and support the growth of this
DRAFT: Not for circulation
37
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3. ICB with Havering LSCP undertake
•
case audit of communication between ICBs and children's services on transfer of LAC placements into, within and out
from Havering to extract learning for future improvements
•
improve referral pathways from GPs to early help through continuing activities from the ‘Star worker’ pilot across at
least 3 of the 4 PCN footprints in early 2024.
•
and by fully adopting ‘I Thrive’.
•
a review to initiate extension of ‘protected GP appointments for adolescents’ across all Havering GP practices.
4. LSCP Health leads to ensure all health practitioners informed of key messages from NHS England anti-racism framework:
Patient and Carer Race Equality Framework (PCREF)
5. CAMHs (see recommendation 2) and Children sexual health services and In Care Council look at data showing
disproportionality within their data and confirm strategy of action to address this
and ensure that their policies regarding
outreach to global majority children and LGBTQ+ and Trans young people are up to date
6. Health leads and commissioning services look a the small number of school nurses in Havering and propose ways of
improving health input into schools
7. The LSCP focus on Trauma informed practice and relationship based practice is welcomed. It should be continued in
training and strategy interventions from services addressing young people’s mental health and sexual health needs
R
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c
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m
m
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8. The ICB, NHS England and the LSCP leadership could consider developing a Hub
and spoke model for sexual health services creating accessible locations in Havering
for young people to access sexual health services. This could draw on learning from
the Tower Hamlets Women's hub and spoke model. This must address the lack of
sexual health services accessible to children and young people in Havering. The
development of sexual health services for children and young people in Havering
need to consult closely with the NHS safeguarding team to draw on and potentially
extend commissioning of their services into outreach provision. It could also look to
extending use of and accessibility to ‘Tiger Light’ service.
9. The Cacoon is a celebrated service that should be protected and extended with
further collaboration between mental, sexual health services and primary care
including GPs
10. The important feedback from children and young people into service
development through consultation exercises and through the young safeguarding
children advisors is to be promoted with service development underpinned by
young peoples views and perspectives
This draft document outlines the scrutiny of mental and sexual health provisions for children in Havering, exploring access to early help services. It also discusses the national context of young people's mental health, including challenges and disparities in service provision.
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Mental and sexual health provisions for Havering Children Havering Havering LSCP LSCP DRAFT: Not for circulation 1
Scrutiny outline Scrutiny outline This Scrutiny will explore provision, access to and use of early help services for children with mental and sexual health concerns Scrutiny method National picture overview Havering data from Interviews Data analysis Documentary analysis Reporting Timeline Draft presentation for consultation (4th December) Feedback on the draft to Jennyjoypearce@gmail.com by 18th December 2023 Final version for sign off and action plan HSCP: 6th February 24 DRAFT: Not for circulation 2
Young People and mental health: the national context: Young Minds accessed 2023 Under 18s referred to Child and Adolescent Mental Health Services (CAMHS) risen by 53% since 2019, escalating to over 1.2 million in 2022, (data from NHS Digital1) Young people face a unique combination of challenges: consequences of the pandemic, the cost of living crisis and academic catch up, taking a toll on their mental health. Over half (53%) of young people told Young Minds that worries about money were impacting their mental health, and over a quarter (28%) are still feeling the impact of the pandemic. The lack of any concrete mental health workforce planning means waiting lists in much of the country are longer than two years. DRAFT: Not for circulation 3
National picture : ethnicity Black young people are 10 times more likely to be referred to CAMHS via social services, rather than via the GP, compared to White young people (Kapadia et al, 2022). A new policy briefing from the Money and Mental Health Policy Institute shows that people from minoritised ethnic groups are disproportionately affected by the economic and social determinants of poor mental health. This includes low income, social exclusion and racism NHS England has launched its first ever anti-racism framework for mental health trusts and providers across the country. The new Patient and Carer Race Equality Framework (PCREF) aims to support organisations to be actively anti-racist, requiring them to implement concrete actions to reduce racial inequalities. DRAFT: Not for circulation 4
National picture: First port of call, the role of GPs in early support for young people s mental health (Young Minds / Children's society National research 2023) GPs are a significant source of support for young people s mental health across the country. GPs provide significant levels of support in primary care while young people waited for specialist services. Young people said seeing their GP made a positive difference in their journey to mental health support. GPs have varying degrees of confidence and knowledge in supporting young people with their mental health, creating what amounts to a postcode lottery Some young people also reported negative experiences associated with going to see their GP about their mental health, as well as barriers to accessing support. GPs voiced frustration about the discrepancy in early support available across different local areas: often a lack of services for signposting DRAFT: Not for circulation 5
Havering data: referrals to CAMHs April 22-23 : 14,262 total contacts. NB: these are not unique numbers of young people and include repeat contacts 42.1 % of referrals from GPs (largest referrer); 22% from unknown other ; 11% from schools; 9% for self; Small numbers from school nurses, YOT, community paediatric service and A&E In each month, approximately 90% remained active cases; 28% discharged following professional advice; 13% no further treatment appropriate; 17% referred to other specialist services Did not attend appointment ranging from 16 to 22% (NB: this could be for valid reasons (inappropriate referral for e.g. but qualitative data says not attending is not a reason for closing case of those who are in need) NELFT have a robust was not brought policy that helps them manage when children do not attend appointments DRAFT: Not for circulation 6
National and Havering data comparisons Drawing on Children and Young Peoples Mental Health Annual Benchmarking report 2022/23. NHS Benchmarking Network, 2023 And Havering CAMHs April 22 to 23 : NELFT Havering CAMHs Warning: comparison between Havering and national data is not always reliable because of reporting methods (H= Havering; N= National ) DRAFT: Not for circulation 7
Havering successes compared to national data Havering successes compared to national data Acceptance rate for assessment : 100% H, 78% N (NB : We do not have data of cases accepted following assessment. This is needed to review appropriate uptake) Gender : approximately 50% split both Havering and National Havering investing more for each contact Cost of service per contact: H= 479; N mean = 341 Havering shorter waiting times than national average referral to 1st appointment : H = 2 weeks, N mean= 10 weeks 1st to 2nd appointment : H= 14 weeks, Nat= 21 weeks Havering seeing more young people face to face Non face to face contacts delivered 28% H , 41% Nat mean Havering has a looked after children pathway which has a 4 week referral to treatment pathway compared to the generic 16 weeks DRAFT: Not for circulation 8
Havering challenges compared to national data (2022 Havering challenges compared to national data (2022- -2023) 2023) Community workforce lower than national average : 78.3 (H) 122.9 (N) Is data impacted by workforce availability i.e. Lower than national average referral because lower than average workforce? Referrals to community services: Community CAMHs cases: Patients on case load per 100,000: Contacts delivered per 100,000: 1372 (H) 4997 (N) 616 (H) 3656 (N) 1824 (H) 2094 (N) 14,531 (H) 20,701 (N) DRAFT: Not for circulation 9
Ethnicity and CAMHs : Ethnicity and CAMHs : (Barking & Dagenham, Havering and Redbridge Joint needs assessment 2021) (Barking & Dagenham, Havering and Redbridge Joint needs assessment 2021) T The ethnicity categories as recorded are open to interpretation of meaning. That said, Asian and Black young people appear to be under represented and white young people appear to be over represented. Ethnicity as recorded CAMHs case load (30/09/23) Havering population: GLA Ethnic Projections in Barking & Dagenham, Havering and Redbridge ./ Joint Strategic Needs Assessment Profiles : Havering 2022 Asian 70 (3%) 7.6% Black 89 (3.9%) 6.8% Mixed 110 (4.8%) 3.5% Not known 449 (19.8%) 0% Other 46 (2%) 0.7% White 1502 (66.2% ) 74.6% (81.5% including other white ) Total 2266 DRAFT: Not for circulation 10
Children and Young Peoples Mental Health Annual Benchmarking report 2022/23. Children and Young Peoples Mental Health Annual Benchmarking report 2022/23. NHS Benchmarking Network, 2023 (H = Havering, Nat= National ) NHS Benchmarking Network, 2023 (H = Havering, Nat= National ) Data from Specialist mental health services in Havering is absent in the NHS benchmarking data. This includes general admissions adolescents (13 to 17 years) ; data on ethnicity and gender of children in inpatient services; services for children on the autism spectrum; children with ADHD; children with eating disorders; data from CAMHs forensic services. DRAFT: Not for circulation 11
Havering Mental health support in schools NHS England funding for three mental health school support teams : A preventative offer with a whole school approach; fostering change in attitude on mental health. Run groups for parents and children. This initiative needs supporting and developing as evidences good outcomes Only got 8 school nurses against a backdrop of increased demand. The cohorts of concern are Missing, CSE, CCE : these young people are unlikely to go to GP or to a specialist service. Need access to services during school holidays. Activity based projects are at capacity, some with waiting lists Havering Psychological services: Wise up project : need to explore uptake by young people DRAFT: Not for circulation 12
Early help and GP primary care Early help and GP primary care Proactive outreach to early help: CAMHS primary mental health teams alongside education colleagues have invited Early Help, Early Years team to join consultations The CAMHs Home treatment team: is well received and reflects creative thinking. GPs are aiming to expand support for children not meeting CAMHs threshold: A recent exercise run by one GP has been in offering protected appointments (about 12 appointments) for adolescents. Of these 10 of 12 young people who attend present mental health issues: 50% to 60% need input from CAMHs. The GP offers support to these cases while they are on the waiting list. It is recommended that this protected time for adolescents is rolled out across other GP surgeries. GPs tend to use websites to find early intervention services. DRAFT: Not for circulation 13
Early Help and GP primary care (continued ) Early Help and GP primary care (continued ) GPs developed a resource of star workers to see and triage and signpost children with mental health problems to services. This Pilot was not funded, but NELFT provided the staff. Young people were seen within 2 to 3 weeks, supporting up to 66% of attendees receiving early help and avoiding the need for them to go onto CAMHS waiting list (or to come off a CAMHs waiting List if already on one) It is recommenced this is extended across at least 3 of the 4 PCN footprints in early 2024. There is need for improved feedback to GPs following a child being discharged from a CAMHs service. GPs can play a role in preventing repeat referral into CAMHs if they are aware of the discharge Havering has not fully adopted I thrive : there is a recognised need for a culture shift within The Trust : recognising the importance of effective early intervention. DRAFT: Not for circulation 14
Sexual Health DRAFT: Not for circulation 15
National Picture UK Health Security Agency (UKHSA) 26% increase in STI diagnoses among young people aged 15 to 24 since 2021. 392,453 sexually transmitted infections (STIs) reported in England in 2022 a 24% rise on the previous year. 50% increase in gonorrhoea since 2021. 24% increase in chlamydia since 2021 (despite no increase in testing) 15% increase in syphilis since 2021. 8% increase in number of consultations at sexual health services since 2021. DRAFT: Not for circulation 16
Nuffield Trust : Teenage Pregnancy 2023 Between 2007 and 2021, the under-18 conception rate in England and Wales decreased by 68%, from 42 per 1,000 women to 13 per 1,000 women The number of abortions decreased by 67% 21,494 in 2007 to 6,999 in 2021 The most recent year, however, saw a small increase in both the rate of under-18 conceptions and number of abortions. DRAFT: Not for circulation 17
National Picture (continued ) UK Gov STI and Screening report 2022 (updated 2023) People of black ethnicity had the highest diagnosis rates of STIs amongst all ethnic groups, although this varied among the black ethnic groups. Previous research found, when compared to all other ethnic groups, there were no unique clinical or behavioural factors explaining the disproportionately high rates of STI diagnoses amongst people of black Caribbean ethnicity this ethnic disparity in STIs is therefore likely influenced by underlying socio-economic factors . DRAFT: Not for circulation 18
Havering: Teenage pregnancy See accompanying Power point overview of data from Havering Sexual Health Needs assessment Spring 2023 : specifics regarding young people Over the past 20 years, the teenage pregnancy rates for females under 18 year and under 16 years have decreased in Havering, (following regional and national trends) 2020 data shows that Havering still has a higher rate of both under 18 and under 16 years conception rates than both London and England. (Under 18 (12.5 per 1,000) and under 16 (1.7 per 1,000) Improvements are evident: Havering now ranks 8th of 33 London local authorities for under 18 years conception/1,000 whereas was 3rd in 2020. But, Havering second out of the 33 local authorities for under 16 years conception/1,000. Learning from strategies implemented in similar local authorities may be useful in tackling these higher rates. DRAFT: Not for circulation 19
Conceptions and STIs See accompanying Power point overview of data from Havering Sexual Health Needs assessment Spring 2023 : specifics regarding young people Short acting hormonal contraception is the chosen method in Havering. Need to understand reticence for longer term methods The e-service appears to continue to be a preferred service: the number of test kits ordered online has not reduced since the face to face clinics have been reintroduced. Although emergency hormonal contraception (EHC) is available for free at any GP, SRH service and family planning clinics, two pharmacies are contracted to provide free EHC specifically for 13 to 25 year olds with the aim of increasing access to sexual health to reduce unintended pregnancies there is one day a week Family Planning service at Queens hospital it is rare for a young person to attend these provisions and there is a recognised lack of sexual health services accessible to young people in Havering Royal London sexual assault hub at The Royal London: there is a sexual assault hub Linked with Tiger Light Barnardo's service for children who have disclosed abuse. Tiger light in 8 London boroughs, Havering has access to its services DRAFT: Not for circulation 20
The NHS BHRUT Safeguarding Team The NHS BHRUT Safeguarding Team There is a Sexual health and safeguarding advisor in Safeguarding Team, NHS trust : see young people, link with social workers , follow up on safeguarding concerns: provide health promotion, advice, sex and the law, also treat some patients for STIs; Would like to get the word out more . Would like to do outreach: are trained, skilled , and ready to do outreach but not commissioned to do this. DRAFT: Not for circulation 21
Data provided by Barking, Havering and Redbridge University Data provided by Barking, Havering and Redbridge University Hospital Hospital DRAFT: Not for circulation 22
Safeguarding Team | Corporate Division data for 2023 Barking, Havering and Redbridge University Hospitals NHS Trust NB: data system has a complex coding formula so figures may be less than actual e.g. a LAC is only coded once on registration. So may have been coded as LAC in the previous year but not on attendance last year. Number of children attended Sexual Health Services under 18 166 Under 16 27 How many children present that are known to be LAC 3 How many CSE toolkits have been completed 76 Children under 13 0 DRAFT: Not for circulation 23
Vulnerability factors Vulnerability factors The overarching factors perceived by colleagues that contribute to rates of teenage pregnancy in Havering are childhood vulnerability: Child sexual exploitation Child Criminal Exploitation, discrimination against LGBT and Trans young people Racism poverty DRAFT: Not for circulation 24
Some of these issues are being addressed through the Some of these issues are being addressed through the Joint Sexual and Reproductive Health Strategy for North East London (2024 Joint Sexual and Reproductive Health Strategy for North East London (2024 2029) 2029) High-level five-year goals for SRH have been agreed for the NEL system including : Reverse the trend of increasing STI diagnoses by preventing and reducing the onward transmission of STIs Increase knowledge and choice around reproductive health for NEL residents, with increased uptake of the most reliable forms of contraception, especially LARC Reduce the number of unplanned and teenage conceptions. Reduce the number of abortions and repeat abortions, learning from the Tower Hamlets model. Reduce demographic inequities in sexual health activity and outcomes where they are known or identified in the future. Ensure that principles of Universal Proportionalism run through all of our work on SRH over the next five years, prioritising our most vulnerable and high risk residents wherever possible. Overall incidence of STI diagnoses has increased year-on-year in NEL boroughs following the Covid pandemic, with most cases seen in residents aged under 25 years. This strategy calls for a renewed focus on STI prevention across the whole NEL system of providers especially gonorrhoea and syphilis among GBMSM and C&G among under 25s with emphasis on increasing use of condoms, enhancing Partner Notification (PN) and increased levels of repeat STI screening for high- risk groups at a regional level in line with BASHH guidance Teenage conceptions, often unplanned, can have long-term negative consequences for young women and society as a whole, with many (33%) resulting in termination. The partnership between specialist sexual health services and Termination of Pregnancy Services (ToPS) is therefore crucial. In Tower Hamlets, these services are already aligned in a Women s Hub model, and the data shows that this has had a positive impact on outcomes: in 2021, the legal abortion rates in Tower Hamlets were 41% lower than NEL average. All partners behind this strategy are therefore committed to replicating the Tower Hamlet s model across NEL as part of the nation-wide roll-out of Women s Hubs2. DRAFT: Not for circulation 25
Looked After Children DRAFT: Not for circulation 26
LAC National picture: DfE : Children Looked after in England 2023 Numbers LAC entry to and exit from Care have increased the number of CLA starting during the year has increased by 6% - to 33,000 and the number of CLA ceasing during the year increased by 5% - to 31,680 Many of the changes explained by the large increase in unaccompanied asylum-seeking children (UASC). UASC have increased by 29%, following the 37% increase seen last year. they are a distinct cohort with specific characteristics: generally male, aged 16+ years. Nuffield Family Justice Observatory 2023 Using data combined across the 5 years, White children account for 78% of children in care proceedings. Children from Mixed or multiple ethnic groups were the second most frequently reported group at around 11% of children DRAFT: Not for circulation 27
The Havering Context The Havering Context The Cocoon is celebrated: essential place for LAC: to be maintained and supported Mental Health Nurse and LAC nurses to continue to attend Cocoon: this could be developed to include GP and sexual health advisor attendance LAC ask for consistency of relationships in school and placement: LAC nurses / those who do LAC health review assessment try to maintain consistency so the young person gets to know the nurse. The LAC Nurse team has had a low turnaround of staff: this is to be commended as it creates consistency and facilitates relationship building LAC nurses would benefit from seeing information of content from SDQ: (strengths and difficulties questionnaire) done by LA (about 80% of LAC children do the SDQ with school and foster careers). Half of LAC live in borough and half out of borough accommodation: means there is constant need for continued communication across boroughs DRAFT: Not for circulation 28
Generic themes from scrutiny of sexual and mental health provision DRAFT: Not for circulation 29
Relationship based support Relationship based support Interviews for this scrutiny reiterate the importance of relationships between practitioners in multi agency contexts and between practitioners and children and young people Interviewees suggested : Targeted multi agency networking opportunities: Creating spaces for multi-agency teams to be co-located: mental and sexual health services integrated into other services as primary prevention; GPs working with PSHE; having a clinic in schools DRAFT: Not for circulation 30
Information sharing Information sharing Speed dating events: highlight what each agency is doing. Helps improve evidence base. Multi agency working: Best e.g. is work on obesity reduction through whole school approach and community intervention: draw on this for example to follow re mental and sexual health Need to advance multi agency decision making about where a child placed. Jointly assuring ourselves of the placement ICB to ICB communication: checking if the placement for a young person is the right one with the right resources: Often done in an emergency without health matching the provision with needs. This becomes more complicated when instigated by other ICBs outside NELFT. DRAFT: Not for circulation 31
Young Peoples Voices DRAFT: Not for circulation 32
Young Peoples Voices : Sexual and mental health issues N.B. Thanks to the Havering Safeguarding Young Advisors Personal hygiene : Sanitary products (free sanitary products) having like a food bank for personal hygiene stuff when I have a limited budget food takes priority . Having Well-being care packages. Sexual Health: need more young person friendly outlets to provide sexual health advice, condoms etc. Young person friendly information on what happens when you have a sexual health test some young people expressed anxiety of not knowing what would happen, with some telling of horror stories they had heard Taking us to the doctors Living with a foster carer means that they help us with this, but it is hard to get an appointment and sometimes we don t bother saying anything because we know that by the time we get an appointment the problem would have probably gone or got worse . Our older young people shared that it can often take a lot of mental energy to make any appointment, and when you re not in a good place, I don t have the energy. Another young person shared how prioritising video calls to care leavers would be useful. Relationship with others: you know when I called you after my blood test because I just needed to talk to someone about it . That s what everyone needs, someone to talk to. For Care Leavers we often have no- one to be our cheer leader, our workers are often not available in that moment, and may not find a call about a blood test important . Stopping Bullying, including online bullying. we all know the things to do if we re being bullied online, stay off Social Media and that, but it s hard and it doesn t make it go away . We want Self Defence courses DRAFT: Not for circulation 33
Qualitative data from Young Safeguarding Advisors: young people and sexual health Qualitative data from Young Safeguarding Advisors: young people and sexual health Feedback from young safeguarding advisors Essential need for local sexual health service: we need more than one venue, need something on Harold Hill and Romford: young people may not be able to travel, may not want to explain to parents where they are going. It Needs to be trauma informed and sensitive to sexual health problems emerging from sexual and criminal exploitation Relationships with people you know and can trust are important The previous drop in sexual health service in Queens Hospital before covid was popular Is It possible to have an outreach bus for sexual health? Essential themes are that services need to be local, relationship based, trauma informed involving youth participation DRAFT: Not for circulation 34
Recommendations Blue sky s thinking Having a room in schools for school nurses, youth workers, GPs, mental health and sexual health practitioners: What's Ap number for access to young people for mental and sexual health issues: advertise the number for young people to use. Sexual health service and mental health online: a lively active website with materials schools can access and use: posters and QR codes for further info on line about services DRAFT: Not for circulation 35
Comments in The Havering Well being survey 2023 (10 schools, year Comments in The Havering Well being survey 2023 (10 schools, year groups 8 and 9, 2,287 students) groups 8 and 9, 2,287 students) Between 20 and 25% had been sexually harassed just over 30% felt that people being violent to each other was a problem in their area 48% gave lower scores about being happy at home Just over 4% felt they were discriminated against because of their sexuality; 10% felt they were discriminated against because of their race, skin colour or where they were born ; 18.5% had experienced bullying 52% felt often, some of the time or occasionally lonely 57.9% seek and/or receive support from GPs and specialist services for drug related problems // 33.8% for sexual health and relationships problems Essential themes: sexual harassment and bullying and violence is a problem, a substantial minority note they experience discrimination and many are looking for support with drug use, sexual health and relationships DRAFT: Not for circulation 36
Recommendations Recommendations 1. Havering Mental and Sexual Health services review content of this scrutiny and create an action plan for their service development in response 2. Havering CAMHs: review unique numbers of CAMHS contacts to accompany data including repeat referrals; the policy regarding did not attend to assure themselves that young people needing a service but unable to take it up are being reached; data of cases accepted or declined following assessment with early help suitable referral to primary care services for those not meeting CAMHs threshold With ICB and NHS England the data regarding lower community service uptake compared to national average to assess if this is due to lower investment in community child mental health services in Havering, this to include review of commissioning of services for children s mental and sexual health in light of this report ; accuracy of data regarding ethnicity and CAMHs take up and considering questions of disproportionality ; the current process for communication with GPs and consider improvements in feedback following CAMHs assessment and following child discharge from CAMHs services GP network to work with Schools create an action plan noting links with Havering Education Strategic Partnership to review primary care (GP) engagement with schools and create proactive strategy for closer working methods The existing good work of mental health support teams and support the growth of this DRAFT: Not for circulation 37
Recommendations continued Recommendations continued 3. ICB with Havering LSCP undertake case audit of communication between ICBs and children's services on transfer of LAC placements into, within and out from Havering to extract learning for future improvements improve referral pathways from GPs to early help through continuing activities from the Star worker pilot across at least 3 of the 4 PCN footprints in early 2024. and by fully adopting I Thrive . a review to initiate extension of protected GP appointments for adolescents across all Havering GP practices. 4. LSCP Health leads to ensure all health practitioners informed of key messages from NHS England anti-racism framework: Patient and Carer Race Equality Framework (PCREF) 5. CAMHs (see recommendation 2) and Children sexual health services and In Care Council look at data showing disproportionality within their data and confirm strategy of action to address this and ensure that their policies regarding outreach to global majority children and LGBTQ+ and Trans young people are up to date 6. Health leads and commissioning services look a the small number of school nurses in Havering and propose ways of improving health input into schools 7. The LSCP focus on Trauma informed practice and relationship based practice is welcomed. It should be continued in training and strategy interventions from services addressing young people s mental health and sexual health needs
Recommendations continued Recommendations continued 8. The ICB, NHS England and the LSCP leadership could consider developing a Hub and spoke model for sexual health services creating accessible locations in Havering for young people to access sexual health services. This could draw on learning from the Tower Hamlets Women's hub and spoke model. This must address the lack of sexual health services accessible to children and young people in Havering. The development of sexual health services for children and young people in Havering need to consult closely with the NHS safeguarding team to draw on and potentially extend commissioning of their services into outreach provision. It could also look to extending use of and accessibility to Tiger Light service. 9. The Cacoon is a celebrated service that should be protected and extended with further collaboration between mental, sexual health services and primary care including GPs 10. The important feedback from children and young people into service development through consultation exercises and through the young safeguarding children advisors is to be promoted with service development underpinned by young peoples views and perspectives
