8.1 What the findings tells us about FTB service delivery to date – learning from
the interviews and focus groups
8.1.1 Improving access to mental health support and care
The findings from the interviews and focus groups indicate that overall, there have been some significant improvements in developing access to services for all age groups of children and young people, particularly through the self-referral pathway, PAUSE and the Access Centre, as well as the online portal for self-referral.
It was also suggested that the FTB model has lead to improvements for those requiring the most urgent care, through the Crisis and Home Treatment Teams, (although as the previous chapter described, information from some young people suggests this may have deteriorated over the course of 2017 as FTB has become more stretched and unable to keep up with demand) as well as for older age-groups requiring in-patient care (18-25 year olds).
The factors that are said to have enabled these developments are the investment in these specific elements, and the processes and environments that are in place.
The Primary Mental Health Work Team are seen to be providing important preventative and early interventions and support to children and young people in schools, and to the teaching staff working with them. The current model is felt to be very effective in managing a significant number of children and young people with emerging mental health needs, who otherwise may have accessed services further along the pathway. There is concern that the PMHW team is about to be amalgamated with the Hub teams, and that the current model could be compromised as a result.
Acacia Project for Young Mums, commissioned by FTB, appears to working very well in engaging with those young mothers who might otherwise not access services. With the recent decommissioning of the Family Nurse Partnership (FNP) programme in Birmingham, the outreach and home visiting support offered by Acacia is seen as providing something that is not offered anywhere else. Analysis of its referrals to date indicate that the service is working with a higher level of complexity than originally expected and the outcomes achieved suggest a model of early intervention and support that is achieving positive improvements in the confidence and resilience of the target client group.
8.1.2 Assessment of progress in addressing other priority areas identified in the Birmingham case for change
From the data gathered through the focus groups and interviews, it is possible to conclude that FTB has made headway in improving access to services as noted above. However, given the concerns about long waiting times and signposting out, it is much less clear whether the model is offering seamless provision for 16-18 year olds
It would seem likely from the reports of long waiting lists that these will include for condition specific services for 16-18 year olds such as ADHD.
Rates of DNAs have not been highlighted as a concern - but young people have talked of feeling that they no longer trust FTB and that they have disengaged with the service; we have also received reports of families paying for private counselling such is their level of dissatisfaction with the FTB offer of treatment.
Poor patient experience is suggested by the various concerns that have been reported to us outlined in the previous chapter. Obviously these data are based on a small number of young people but some issues were reported consistently across seven different settings and from young people not known to one another.
With regard to dissatisfaction within referring agencies i.e. primary care, interviews with GPs from some of the top referring GP practices have revealed a mixed picture of some improvements but also concerns, for example about information sharing (e.g. letters arriving very late and/or missing important information about medication or care), of GPs being ‘dumped on’ to prescribe rather than specialists taking responsibility for this and of concerns of insufficient monitoring of patients (of all ages) by specialist health service providers.
These interviewees have noted that possibly the crossover of care for those aged 16-18 is now easier with FTB although major changes or improvements are not yet evident and from their perspective, it does seem that whilst children and young people may be assessed quite quickly, they then seem to wait a long time for any treatment to start.
These interviewees have also encountered difficulties being able to identify and talk to the named consultants for young people they may have referred and confusion about signposting of young people to a wide range of different VCS services. One interviewee, working closely with the university sector also noted the loss of the previous much more tailored service for this client group and the need to explore with FTB how this might be addressed going forwards.
This interviewee also reported that Extended Share Care Agreements (ESCAs) very rarely arrived with young patients from FTB and that these are important in cases where for example the monitoring of lithium may be required. It was also noted that this GP practice had experienced FTB requesting ‘holding prescriptions’ for young people whilst they waited for an appointment to be arranged in FTB.
8.1.3 Barriers to Progress
Barriers to progress are seen to largely arise from the following key factors:
The lack of ability to recruit and retain substantive staff members, compromising capacity and inducing raised levels of stress amongst the workforce, and feeling of increased risk and reduced safety within the service.
Needing to run the services through a high number of agency staff and locums, who often move on quickly, therefore having an impact on consistency of approach and care.
A perceived lack of investment in the original community CAMH teams, in terms of time and funding is leading to issues around capacity to meet demand, and in the application of the CAPA model, which with proper implementation, could help flow through the system.
Concerns about the paucity of provision for children under 14, especially as there has been a reduction in the VCS, an increased demand on Hub teams, and an identified gap in support for newly emerging mental health needs in this group.
The reduced leadership and management capacity affecting the ability to support staff through the change process and to bring the teams together to negotiate and agree processes and interfaces. This in turn is contributing to low staff morale and a difficulty in
working together on the development of the service culture to enable fit with the FTB model, and confidence in it.
Poor data collection and recording systems that are difficult to access and don’t provide a consolidation of the information required at a strategic, operational and clinical level, to support effective provision and review of services.
The overcrowded physical environment within which clinical support is offered is not felt to be conducive to engagement with service users, especially in the younger age- groups.
8.1.4 Key factors to help mobilisation and identified gaps
Participants were able to offer very little in terms of solutions to the challenges they have highlighted. They felt that a focus on developing a skilled and substantive workforce is a priority, along with robust leadership and management of both the transformation and operationally would help overcome a number of the issues they identified.
In addition, they felt that a pathway for young people with Personality Disorder was a gap that needed consideration. Stakeholders in the second round of focus groups reported that they were working on developing one, which needs formalising, however, it needs liaison to be agreed along the pathway and between teams. The main concerns were that these young people are being managed in home treatment, but this can escalate and they can become in- patients. They also frequently attend A&E.
Participants suggested that PAUSE should be replicated in the South – on this basis, the recent introduction of Pop-Up PAUSE (one already at the Lighthouse and a further planned in Longbridge) are welcome developments.
An innovation staff would like to see in the future is a shared care record, for more automated booking whereby all diaries are viewable and time slots can be booked to suit the young person/family at the time of asking. People need to know exactly when they will be seen, not receiving the message “the health exchange will contact you.”