Effective integration between agencies in order to support children and young people is a key principle in the THRIVE framework for system change (Wolpert et al., 2019). Thank you to Dr Paul Wallis, Director of Psychological Services at the Central Manchester University Hospital Foundation NHS Trust for speaking to us about the development of their Integrated Access and Care Pathways.
What was the problem you were trying to solve?
Central Manchester University Hospitals NHS Foundation Trust (CMFT) provide child and adolescent mental health services (CAMHS) for Manchester and Salford. The move towards Integrated Access and Care Pathways (ICP) in Manchester and Salford — inspired by CYP IAPT and the THRIVE Framework — was undertaken to overcome a number of internal and external challenges common to CAMH services. With limited resources and funding, the demand for a wide range of services for children and their families has continued to outstrip what’s on offer. This has necessitated a move away from the traditional way of delivering services towards more integrated pathways that can guarantee the delivery of the highest quality services whilst also ensuring that patients and their needs are put first.
The overriding ambition of the ICP agreement has been to implement a uniformity and standardization of treatment, while also aiming to drive up efficiency to address the financial concerns, address the delays, and successfully cope with the demand. In Manchester and Salford, this has been achieved by bringing together specialist CAMHS services with 250 staff spread across over half a dozen sites that operate to deliver treatment to young people who suffer from varying levels of mental health difficulties. By forging cross-agency partnerships and bringing together key stakeholders, the ICP transformation of service delivery has been able to enhance the referral and communication systems between sites, leading to the creation of more standardized services. This effort ensures that young people and families do not fall between the gaps by receiving variable levels of care.
With a focus on multi-disciplinary working, and by offering integrated pathways for treatment of complex conditions, Manchester and Salford’s ICP offers an example of how to reduce barriers both for the patients and for those delivering the services between sites.
What are the Integrated Access and Care Pathways?
The ICPs act as a “one house” model, or umbrella for providing services. This is achieved by bringing together community outreach, intervention, and signposting in an evidence-based fashion with a focus on easing the transition into more specialist systems and helping children to get help (and more help) as they need it. We make sure that from getting advice, to getting help and more help, and to getting risk support, that the transition is made a lot easier for the patient than previously. Underpinning the entire effort is a system that works to ensure that staff in all localities are equipped with strong and robust training around risk management, and systems are in place to escalate risk cases.
While the approach to integrating services and easing referrals in Manchester and Salford has been widely regarded as successful, development continues to be ongoing and iterative.
“We make sure that from ‘Getting Advice’, to ‘Getting Help’ and ‘Getting More Help’, and to ‘Getting Risk Support’, that the transition is made a lot easier for the patient than previously.”
— Dr. Paul Wallis, Director of Psychological Services, CAMHS
What approach did you take to developing the pathways?
The approach was based on good practice guidance with a focus on developing quality relationships with partnership agencies. Cross-agency work was paramount. These partnership relationships have been established to ease referrals into more specialist services, and follows recommendations put forward in the Future in Mind report, which called for a comprehensive, whole-system response. The report highlights the need to make it easier for children and young people to access high quality mental health services when they need it.
In addition, Manchester and Salford CAMHS have aligned their thinking to meet the outcomes put forward by Every Child Matters and have adopted the principles of the ‘One Team – Place Based Care model’ and the THRIVE Framework. By aligning their services with the THRIVE Framework, Manchester and Salford can continue to assure a seamless whole-school and person-centred offer across mainstream and special education extending from nursery to further education.
The evidence tells us that treating different and specific health issues separately will not tackle the overall wellbeing of this generation of young people. Commissioners understand the importance of supporting teachers to support children in the school setting. Going forward, the aim is to make sure that there is a named lead in Manchester and Salford CAMHS for each school and a number of commissioned targeted/specialist teams will be created based on a community outreach model. The new model aims to address the lack of parity in the current emotional health support provided in schools which was highlighted in the CAMHS review.
“Cross-agency work is paramount.”
How do the pathways align with Manchester and Salford’s i-THRIVE plans?
The ICPs have enabled Manchester and Salford services to become more THRIVE-like with their focus on improved internal operations. More recently, they’ve also shifted to the THRIVE Framework’s needs based groupings conceptualization of service delivery, and they are looking to ensure that all of the services within and across their organisational structures are working to implement THRIVE principles.
There is now a plan to expand the ICPs even further with a focus on linking together a wider range of external agencies. They already have a number of historical relationships (e.g. they already sit on local CAMHS partnership boards and have strong links to local authorities, including all the specialist schools and the adoption board) but their continued expansion will guarantee children and young people a smoothness of transition from signposting to accessing a referral to getting the help and support they need. The connections across local authorities also enable the CAMHS in Manchester and Salford to deliver a THRIVE-like model of care, which focuses on a multi-agency approach to risk support and providing connection to a full range of services.
As Manchester looks to the future they are looking to recommission and universalise their schools service to all schools in the region. In the past, Manchester commissioned school services to nine high schools. This effort was focussed on providing access to in-school psychologists in order to promote resilience and skills-training within schools. This program also sign-posted into CAMHS and more specialised services. A new expansion effort will aim to include many of the principles established in their previous efforts, with a focus on providing information, training, better signposting and direction to people within CAMHS.
Additional external changes will involve the further development of specialised referral pathways with partner agencies: Early Intervention Psychosis Service, Drug and Alcohol Service (Eclypse), MIND, Youth Offending Service, Place2be and the Sexual Assault Referral Centre.
Current partnership boards are interested in redefining their remit to become the vehicle for implementing the THRIVE Framework. This move is largely led by a team of staff at CAMHS who are intent on developing a better model of care around early intervention. Following the THRIVE Framework’s principles, the model will focus on offering advice for self-help and direct people to getting help. They are also hoping to partner with local authorities to build their skill base and highlight the importance of evidence-based interventions. Internally, the team is continuing to think about how they can better support staff with varying levels of supervision and continuing to upskill newer members of staff. Perhaps most importantly, they are also trying to look at how to move away from the current situation where all risk seems to reside within specialist CAMHS. In order to accomplish this, their future plans involve looking into how agencies can collaboratively manage risk by partnering with other services so they become more confident in addressing risk.
THRIVE is at the forefront of the commissioners’ minds around the partnership tables in Manchester and Salford. The THRIVE Framework helps to frame the discussion and helps commissioners establish a coherent cross-agency offer for what families and individuals can expect. The commissioners are very keen to drive the offer forward and bring partners together to ensure consistency. THRIVE provides a framework for us to ensure things don’t fall through the gaps.
“THRIVE provides a framework for us to ensure things don’t fall through the gaps.”
In order to drive sustainable change, however, investment in early intervention, self-help and online materials will have to be considered. Moreover, one of the potential issues for implementation and becoming more THRIVE-like (especially for the Getting Help and Getting More Help needs groups) is that funding will be needed to: expand a wide-array of agencies, grow the workforce, improve training in CYP IAPT, and expand evidence-based interventions.
How have the new integrated pathways affected service users?
In terms of breaking down barriers and enhancing the referral process, the situation for service users has improved markedly. However, it’s difficult to entirely quantify the ways in which the broader strategic claims listed above translate to a better lived experience. Nevertheless, questionnaire data is routinely collected to provide a running audit of services and all concerns are flagged and addressed by the services. To date, the feedback has demonstrated that clients are satisfied overall with the services they’ve received.
How have the new integrated pathways affected staff?
The vast majority of staff are on board with the principle of improving experiences for service-users. While changes initially led to a degree of resistance and unsettlement among staff members, staff went on to grow increasingly supportive. The growing support and acceptance was motivated by a number of early adopters who acted as champions for internal change. To date, staff are much more on board and accepting of the need for a degree of standardised practice around risk assessment and data management. Staff are also more aware of good quality data management, which includes outcome measurement, continuous monitoring, and participation feedback.
How have the pathways enabled a needs-based approach to care for service users?
This is one aspect that was largely pre-existing in the CAMHS services well before CYP IAPT and the THRIVE Framework came along. To the extent that a needs-led model is about actively hearing and responding to needs and wants of young people and their families, there has been a long history of using a formulation of this in the collaborative approach to assessing and treating young people in Manchester. Where THRIVE improves on this is by providing a framework and an opportunity to think about expanding efforts across a whole system — especially as it relates to the need for improvement in ‘Getting Advice’.
For internal and outreach purposes, a needs-led approach is part of the core training for staff. This is sustained by offering a very clear supervision policy that enables staff to continue their training with a trained supervisor. The vast majority of practitioners are now using this formulation.
How have services been redesigned to enable delivery of the integrated pathways?
Services have worked collaboratively in the past, but the internal systems now allow for them to work together more effectively as part of a larger organisation reaching across a number of services. To encourage and enable collaboration, there is now a number of forums to bring people together to work more closely. In terms of external improvement, THRIVE helps CAMHS and partner agencies to think more strategically about working together in Manchester and Salford, bringing together professionals across sectors. The THRIVE Framework forms the backdrop for a re-invigorated conversation across agencies. The hope is for this to drive a cross-border fertilization of THRIVE ideas.
What was done at a senior leadership level?
Senior managers and clinicians from all levels have been involved in the strategic and commissioning meetings over many years. The early years services, as well as others, liaise with appropriate people within each sector. Clinical leads have a presence at monthly and bimonthly boards to influence and contribute to discussion around service improvement.
How have the integrated pathways been evaluated?
Since a lot of the development has been iterative without a clear date on which something new was implemented, it is challenging to have a clear a pre- and post- comparison. On the whole, the majority of feedback has indicated that the systems are working smoothly together. For example, a commissioned report on mental health services in Manchester looking particularly at adult mental health services was clear that the vast majority of agencies were satisfied with the CAMHS in Manchester and Salford. In addition, a number of commissioned reviews have endorsed our approach. In the future, additional ways to gather service-user and partner-agency feedback about the implementations will need to be tested.
If you would like to find out more information, please contact Dr Paul Wallis, paul.wallis@CMFT.nhs.uk
Written September 2016.