B LACKPOOL CAMHS ADHD P ROFESSIONAL S TAKEHOLDERS EVENT 6 March 2018 - - PowerPoint PPT Presentation

BLACKPOOL CAMHS ADHD PROFESSIONAL STAKEHOLDERS EVENT

6 March 2018

PROGRAM

 Housekeeping  Schedule  Agenda

Session 1: 9:15 AM ( morning session), 1:10 PM ( afternoon session) Context of meeting Service user feedback ADHD Diagnostic Assessment Break 10:20Am( morning session), 2:30 PM ( afternoon session) Session 2: 10:30 ( morning session), 2:40 PM ( afternoon session) Diagnosis and Post diagnostic care Feedback and close

WHY ARE WE HERE?

 Quality improvement of ADHD service provided by Blackpool

CAMHS

 Improve quality: What can we do better with what we have?  Integrated working :work different NOT additional work

Some changes may need additional work initially as part of CHANGE but overall becomes lean, efficient and effective for service user and staff

WHAT ARE WE NOT GOING TO FOCUS ON

 what is out of scope of the current service: although if sufficient

need/case demonstrated discussions maybe help as part of formal discussion: including any new business case/collaboration

 Neurodevelopmental /LD/ASD  Additional resources/staffing  Training , Transition, medication/pharmacological Treatment of

ADHD

ADHD DIAGNOSTIC ASSESSMENT: VASU TO LEAD THIS . NEED SOMEONE TO COUNT NUMBERS WHEN HANDS LIFTED: CAN DELETED QUESTIONS FROM SLIDE. VASU WILL BRING

QUESTIONS SEPARATELY ON PAPER

 Brief Interactive viewpoints/session: check beliefs/myths about ADHD ,

evidence or guidance Some examples below

 ADHD exists/not  ADHD mental health condition?  Who should diagnose? CAMHS/paediatrics/any other  Diagnostic assessment requires: 2 appointment/multiple assessment  Assessment can be done by single clinician/MDT  ADHD a chronic condition should be seen on par with child with

diabetes

WHY DO THIS NOW: CONTEXT

 Referrals to CAMHS: increase in numbers over years* Dave  Staff recruitment difficulties 1.8 WTE Psychiatrist/medical staff Vacancy (

total consultant 2.8 WTE for the team) since February 2017 ( 1 WTE vacancy since August 2016)

 Independent Nurse prescriber left post: ADHD nurse appointed: awaiting to

complete Nurse prescriber training: impact prescribing for consultant National drivers and local drivers

 CAMHS Transformation agenda: Increase age CAMHS up to 19 years:

demand increase by 25-30% for ADHD alone

 NICE guidelines  Greater Manchester Commissioning guidance ADHD  SEND

THE DEMAND FOR ADHD IN BLACKPOOL

 Children and young people under the age of 20 years make up almost

23% of the population of Blackpool

 the proportion of children living in low income families is significantly

higher, at 32%, than the England average at 20%.

 The number of children in care is also significantly greater with 164, as

• pposed to 60 per 10,000 for England.

 Under 18 conceptions are more than twice that of the England average

at 43.8 for every 1,000 pregnancies whilst the rate of teenaged mothers is almost twice that of the England rate at 1.6%.

 There are 25% of new mothers who smoke at the time of delivery

compared with 10.6% on average elsewhere.

WHAT DOES THIS MEAN FOR ADHD SERVICES IN BLACKPOOL

 Population Children : Blackpool CCG 5-15 years 15,000: up to 19

years 23,000

 If we apply rule of 1% severe ADHD prevalence :up to 15 years

:150 children. 5 % calculation 750 children

 Up to 19 years service age increased : 1% 200-230 children,5% 1150

implications

 Currently not identifying all severe ADHD  What do we do with those that are not severe/Hyperkinetic

disorder?

CURRENT DATA SET BLACKPOOL CAMHS APRIL 2017-12 FEB 18

 Total Referrals to CAMHS via single point access: 794  Active/open cases at CAMHS 31/1/18 :738. ADHD coding 95Number of

referrals for psychiatrist within CAMHS for ADHD assessment : 100

 Approximate time to receive diagnosis of ADHD after referral: current:

about 1 year* Dave

 Number of patients with diagnosis of ADHD open to CAMHS on

treatment : 150

 Number of patients on waiting list awaiting diagnosis of ADHD: 30

Current waiting times to access psychiatrist in CAMHS appointment 9 months( May 2017) Numbers on waiting list 45 Probable ADHD on waiting list 30

WHAT HAVE WE DONE SO FAR?

 Journey started 2016( not just fire fighting)  Scoping/ Audit: Case note audit neurodevelopmental needs, ADHD monitoring

review of 25 new ADHD assessments completed by medics Sep 2016 : 50% attachment difficulties , 25-30% had comorbidities of learning difficulties, ASD, sleep problems.

• parenting. 20% concerns around experience of trauma/bullying, sensory difficulties, and

emotional dysregulation and anger issues. This did not take into account specify impact

• f ADHD on self-esteem and mental health diagnosis

 Team discussions and shared, ways of managing ADHD diagnostic and post

diagnostic interventions

 Pilot ADHD diagnostic MDT within CAMHS from January 2018  Discussion and involvement with other key developments: CAMHS transformation,

ASD pathway

 Recruitment of Psychologist : Neurodevelopmental role : pilot 1 year  Discussion with Fylde and Wyre CAMHS : sharing practice, sharing ideas for

innovative, effective ways of working

 service user feedback 2/3/2018

ADHD: GIVING FAMILIES A

VOICE...

Our aims:

• To find out about the experience of families and children who have

received a diagnosis of ADHD from Blackpool CAMHS.

• To give families a voice
• To enable service users to shape the development of our new ADHD

service

WHAT WE DID:

• Collecting feedback along patient/parent journey (questionnaires,

interviews, focus groups).

• Parent Support Group Feedback Discussion – Assistant Psychologist -

last hour of the last session.

• Two service user events, one for parents, one for young people and

children in March 2018.

• Run by Assistant Psychologist, Senior Clinical Psychologist, CAMHS

Practitioner, Consultant Psychiatrist

• 2.5 hours session and 3 hour session.

I like meeting other parents, I don’t feel isolated and alone anymore

What do you like about attending the Parent Support Group?

We really like learning more about medication, I had no idea what it was or why it was helping

9 sessions was enough

The time and location is good, I can drop the kids off at school then come straight to the group. It’s a pain going home to come back out again This time is for me and gets me out of the house

I’ve made friends and exchanged numbers I liked listening to other parents ways of coping with behaviour and swapping strategies

Marilyn invited me to the group, she reassured my worries and encouraged me to attend

What do you dislike about attending the Parent Support Group?

I’ve finally found a place for support and now the course has finished, I’m isolated again I’d rather just use name badges, I’m a private person and will tell people about my life in my own time

I struggled to do the homework, I wanted to do it but its too chaotic when I get home

I don’t like introducing myself, it makes me feel like a child

Some people didn’t want to talk, just listen but felt like they had to so stopped coming No one looks at paper- based information anymore – I just lose it or bin it

A PARENTS JOURNEY…

Inattention, concentration, speech and language Primary School:

Behaviour became

• worse. Difficult to

manage

MDT Meetings SHINE 1:1 support Change of school assessments

GET TO CAMHS AND EVERYTHING WILL BE OK HES GETTING WORSE HES GETTING WORSE

WHAT IS ADHD?

I like knowing there’s someone over the phone to help

What was good about the ADHD pathway?

Vasu and Andrea ring me often to check how I am and how we’re getting

• n

They’ve helped me through difficult times in my life

It helped having someone from CAMHS go into school to speak to them I finally felt listened too I was told what all the assessments were for

I think I’ve had a good experience in CAMHS I enjoyed the Parent Support Group

What was not so good about the ADHD pathway?

I found the MDT discussions intimidating. I felt pushed into going along with decisions I didn’t agree with I got upset because nobody was listening to me I’m not given the time to process things I had to pass on information to professionals about stuff I didn’t understand The fight of getting a diagnosis has made me dread having to go through it again with my daughter I felt my child wasn’t getting the support he needed at school I was watching my child get worse. I felt so helpless I don’t have the confidence to ring CAMHS to ask for

• help. I don’t want to bother

them

What suggestions do you have for improving the service?

A parent drop in group would be

• good. A place I can go to ask

questions or get more ideas from parents More Marilyn’s! Everyone needs a Marilyn in their life

Don’t call it parenting! Call it “ADHD support for parents”

Leaflet design: Its ok to just come and listen

• No pressure
• It’s a choice
• Can opt out at any time

Digital information/advertisement Contact/MDT cards (purse) More ADHD education and awareness in GPs

What suggestions do you have for improving the service?

A parent drop in group would be

• good. A place I can go to ask

questions or get more ideas from parents More Marilyn’s! Everyone needs a Marilyn in their life

Don’t call it parenting! Call it “ADHD support for parents”

Leaflet design: Its ok to just come and listen

• No pressure
• It’s a choice
• Can opt out at any time

More colourful/eye- catching resources/materials Digital information/advertisement Contact/MDT cards (purse) More ADHD education and awareness in GPs

 Parents helped design a poster to put up in the waiting room for

the next group – changed group name to “ADHD support for parents” – felt it was important to get across that parents don’t have to talk in the group if they don’t want too – its ok just to come and listen – no pressure – want it to be clear that it is a choice – can opt out at any time (further distancing itself away from a traditional parenting course)

CURRENT ADHD DIAGNOSTIC PATHWAY BLACKPOOL CAMHS( CREATE FLOWCHART,NICOLA TO DO )

STAKEHOLDER OPINION/DISCUSSIONS

 Pre-referral  Referral information  assessments

PRE-REFERRAL AND REFERRAL

What do we do now? No standard requirement of information for ADHD Generic CAMHS referral form Varied amount and quality of information available at time of referral Duplication of information Clinician and administrative time spent requesting and collating information

OPTIONS

Continue to do what we do If ADHD assessment requested: can additional information be sent by referrer with referral: e.g. screening questionnaires( parent and teachers), school/educational psychology reports, developmental or paediatric assessments

Interactive discussions : what to stakeholders think? Any

• ther advantage/disadvantage

Final vote for/against( make sure key referrers like GP, SENCO, school nurse, educational psychologist present if we go for voting option)

OPTION 2: PRE-REFERRAL COMPREHENSIVE INFORMATION?

 decreases delays in processing

referral and quicker entry to ADHD pathway

 Helps identify professional

involved and interventions tried

 Identify complexity and

comorbidity

 Increased workload for referrer  Too many questionnaires for

families/teachers to complete

 Causes delay at point of referral  Raising

parental/carer/professional expectation of ADHD diagnosis and inability to address other issues unless diagnosis ruled in or

• ut

Advantage: difficulties

Interactive session: support for not so severe ADHD /concerns present

 What do we have available ?  Are there any other resources we can access?

ADHD : NICE GUIDANCE

mental health services for children, young people and adults and child health

 should form multidisciplinary specialist ADHD teams and/or

clinics for children and young people and separate teams and/or clinics for adults. These teams and clinics should have expertise in the diagnosis and management of ADHD, and should:

 provide diagnostic, treatment and consultation services for people

with ADHD who have complex needs, or where general psychiatric services are in doubt about the diagnosis and/or management of ADHD

ADHD ASSESSMENT

What does NICE recommend

 Full clinical and psychosocial assessment  Developmental and psychiatric history  Observer reports  Mental state examination  Not based just on rating scales and observational data  Person’s needs: coexistent conditions, social , family, educational

circumstances, physical health

 Parent/carer’s mental health assessment

WHAT DO WE OFFER

 Screening questionnaire Snap questionnaires (parent, school), young person:

self rating*

 School generic information form  Comprehensive assessment: Structured clinical and psychosocial interview :

choice, partnership. May include additional individual play/interview sessions

 School observation*: not all cases, usually by AP, but can be

CC/psychologist/psychiatrist

 Qb test  Screening for any other difficulties: social communication, conduct disorder,

LD, tics, attachment: parent questionnaires, observation

 Medical history and examination

THE ADHD DIAGNOSTIC MDT PILOT: JAN 2018

 MDT : psychiatrist, clinical psychologist, occupational therapist,

ADHD nurse

 MDT Meets once per month to discuss cases  case can be referred to MDT at any point in time:

referral/choice/partnership

 Once MDT agrees clinical indications present for ADHD

assessment: started on care pathway for assessment

 Parent information session to obtain consent and inform

parent/young person details of process of assessment and signpost to information on ADHD

WHAT IS WORKING WELL

 Comprehensive clinical assessment  Observation of child by different clinicians in different settings  Screening, identification of social , risk, child and parental mental

health needs

DO WE HAVE ALTERNATE SOLUTIONS FOR ASSESSMENT

 Specialist ADHD trained practitioner assessment at choice  Specialist ADHD assessment at partnership  Specialist ADHD team assessment after referral to ADHD MDT:

complete all information and initial observation in 2.5 hour session by 2 staff ( may include psychiatrist)

 Further additional assessments ( developmental, school

• bservation, Qb test) based on complexity/need

SPECIALIST ADHD TEAM

Better quality of information/assessment Decrease in time for assessment Easier to capture: Needs assessment ,Mapping of journey,gaps Opportunities to train, recruit , research and audit in specialist team Develop local expertise in diagnosis and post diagnostic intervention Use wider pool of practitioners or even

• ther assessment models ( e.g. Healios):

e.g. paediatric staff Easier to integrate with wider Neurodevelopmental pathway if developed/commissioned Saves capacity of generic CAMHS practitioner to focus on mental health interventions

Dependent on specialist practitioners in post: risks if vacancy, concerns of competency Loss of skills for generic clinician Managing capacity for CAMHS due to loss of sessions( spurious) Different waiting times for ADHD/mental health( is this already not so) Barriers to access mental health support /intervention if required( internal referral/wait) High caseloads for clinician in ADHD MDT: risk, limitation on what can be care coordinated

Advantage

Disadvantages

Post diagnostic flow chart

WHAT INTERVENTIONS DO WE PROVIDE POST DIAGNOSTIC

 Medication, education about ADHD: clinic based : limited: signpost

resources

 Liaison with school: needs and case based  Child: emotional regulation, relaxation, sleep, healthy lifestyle

advice

 Family :IY parenting, family therapy, ADHD parent support group  Access to mental health support if other mental health needs

identified e.g. anxiety, low mood

 Sensory screening, cognitive  Signpost: ASD, intellectual disability, OT

GAPS/DIFFICULTIES

 Sleep clinics: detailed sleep evaluation , advice and reviews  Parenting support :variable: individual/needs based  Parenting support groups: previously run, now restart: uptake(

numbers, brief feedback)

 Individual child: education about ADHD, social skills, ADHD

focused intervention( NICE)

DIFFICULTIES SPECIFIC TO TREATMENT ADHD WITHIN BLACKPOOL CAMHS : MEDICATION

 Andrea : present what she does  How role is changing  Changes made by herself in the role to manage and help

psychiatrist demand

PSYCHIATRIST CAPACITY ISSUES

 Vasu to add  Proposed model of change

 Summary of guidance and checking what other service offer  < 5 yrs  ADHD support

MAPPING WHAT OTHER SERVICES OFFER

 School/education  School nurses  SENCO  SEN  Educational psychology  Social care  FIN  Behaviour support team

NEXT STEPS

 Our work/plans in progress