The National i-THRIVE Programme team caught up with David Eaton, Service Manager of Blackpool Child and Adolescent Mental Health Service (CAMHS), Blackpool Teaching Hospitals NHS Foundation Trust to learn about how he is implementing the THRIVE Framework for system change (Wolpert et al., 2019) in services for children and young people.
What has been your role in implementing the THRIVE Framework and how long have you been working on it?
I am the Service Manager for Blackpool CAMHS, Blackpool Teaching Hospitals NHS Foundation Trust. My role has been to support the implementation of the THRIVE Framework which we are using to move away from the tiered approach. The Pan-Lancashire and South Cumbria Transformation Board is adopting the THRIVE Framework as a way of transforming the emotional health and wellbeing offer across Lancashire and South Cumbria. What is attractive about the THRIVE Framework is that it’s not just a health framework as it brings together other services and agencies enabling a shared language and framework that we can all hopefully sign up to.
The Trust and our CAMHS service are part of a bigger Pan-Lancashire and South Cumbria Transformation Plan. We have been having board meetings and sub-sections of these meetings include different working groups such as the Clinical Reference Group and other working parties who are redesigning our whole CAMHS service across the region to be aligned with the THRIVE Framework. My areas of interest are in the Getting Advice and Signposting and the Getting Help needs based groupings, and prevention and promotion.
I have been involved for some years nationally around the role of the Primary Mental Health Workers (PMHW) in CAMHS and now the new Children and Young People’s Wellbeing Practitioners (CYPWPs) roles. Working with CAMHS providers across Lancashire we have created a Pan-Lancashire service specification for PMHW’s, together we determined how the wider workforce and services would be supported. Predominantly PMHWs have been providing schools support but another service is providing support into primary care. Both approaches have been developing the Getting Advice, Signposting and prevention and promotion agenda. The specification includes the development of other roles including the CYPWPs.
How is implementation of the THRIVE Framework structured in Lancashire?
We have the Midlands and Lancashire Commissioning Support Unit that is supporting local commissioners and providers to transform children and young people’s emotional health and welling services. We have providers from all sectors, children, young people, parents and carers working collaboratively to co-produce and decide how we are going to implement the framework across the region. We are all at different stages and have different resources and provision, so we are learning from and supporting each other. We are collaborating on several workstreams that are aligned with the THRIVE Framework.
The implementation of the THRIVE Framework is becoming more and more talked about but it has taken us a while to ensure we have a shared understanding of the THRIVE Framework and a common language across different agencies. It is a concept that people haven’t been familiar with and there is still more that can be done. A challenge can be defaulting back to the language of tiers and seeing this as only a health issue, but the framework allows a dialogue to start happening so that we can have these conversations and help people see how they fit into the framework and how they can contribute to supporting the emotional and mental wellbeing of children and young people.
Where are you at locally with your implementation of the THRIVE Framework?
The PMHW service specification has helped to articulate what support is going into Getting Advice and Signposting and this continues to drive the agenda. There is support both locally and across Lancashire to get this structure in place and to work with other providers and commissioners. We are now looking at outcome measures and ways in which we can evidence our work through data. For the Getting Help needs based grouping we have been strengthening our contribution to Goal Based Outcomes and evidence based practice partly through Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) and its suggested service changes using Routine Outcome Measures (ROMs). There is also training available on evidence based practice e.g. Cognitive Behaviour Therapy (CBT) and range of other evidenced based interventions that are in the IAPT offer. We are also involved in collaborative participation with service users through our participation strand. We have a group of young ambassadors established in CAMHS called Entwined Minds and we consult and co-produce with them the service redesign that they want to see happening.
We are working on a digital THRIVE Framework offer and have a partnership with a company called Healios. A pilot is underway that offers an online family intervention and CBT from trained therapists via Skype. We are working in partnership with them through funding provided by the Lancashire Transformation Board. This offer will complement our existing therapeutic approaches and a care coordinator in the CAMHS team works in partnership with the Healios therapist. The benefit of Healios is that it supports equitable access and choice by providing access at a time suitable to the family. The pilot is being offered to families through a shared decision making process. There are some inclusion criteria such as having access to the internet for Skype and the type of challenges the family are dealing with. We are continuing to evaluate the pilot and initial feedback from families about digital offer has been very positive.
In addition, there is work taking place on a digital THRIVE Framework solution in the form of a platform where children and young people and their families could find local services based around the THRIVE Framework.
We have been working on our Getting Risk Support offer and have seen an increase with our crisis support provision. We have a service called CASHER, Children and Adolescent Support and Help Enhanced Response, which provides out of hours support. This service offers young people coming in through crisis to our hospital and we are extending this offer into the community through setting up some drop-in facilities. So, a focus for us is out of hour’s crisis response and working across Lancashire and South Cumbria as well as our local providers.
In addition, to supporting multi-agency working we are planning to be part of a train the trainer programme to support the use of Adolescent Mentalization Based Integrative Therapy (AMBIT) across the partnership, as a way of working with services to support young people.
Tell me about the work you are doing in schools to support early intervention?
We have Primary Mental Health Workers within CAMHS who are providing consultation, training, joint work and direct therapeutic work with children and young people. They are also providing mental health first aid training to school staff and other agencies. The PMHW’s offer regular consultation and support sessions in schools to discuss young people who may be starting to experience difficulties or have existing problems. Some fantastic joint working with education staff is taking place such as jointly running groups in schools, supporting staff to do one-to-one work and training, and providing a signposting function either into CAMHS or to other agencies, which is significantly building the capacity of our education workforce in relation to mental health and well-being.
The recent introduction of Trainee Children and Young People Wellbeing Practitioners has complemented the work of the PMHWs, offering support for those children and young people who are starting to experience some difficulties. The CYPWP’s are able to move quickly to offer support or interventions. The feedback from education staff has been very positive. We recognise the vital role and opportunities education staff have in improving children’s emotional health and wellbeing, so we are working alongside them to increase their knowledge, skills and confidence to support the mental health needs of their pupils. We recognise that schools have competing demands on them and often face challenges when offering emotional wellbeing and pastoral support. We have had good feedback so far from individual teachers and pupils about the support that has been put in place through PMWHs and CYPWPs. The challenge is having the capacity to be able to offer this to all schools while not neglecting other services such as social care, the third sector and primary care, as GPs are our biggest referrer. Hopefully the Green Paper and other initiatives will support the expansion of this work.
Which aspects of the THRIVE Framework did you feel were already in place?
We have a number of structures in place across different levels: strategic, service and client level. At the strategic level we have mapped our services, and how each strand contributes to the framework, so the priorities are aligned. The Pan-Lancashire Board as well as providers, have been working on this so that our priorities for the new model fit with the THRIVE Framework, but there is still work to do around engaging other providers, and service users to see how their services contribute to the THRIVE Framework. Our board has representation from all sectors at the strategic level and we have working groups including a Clinical Reference Group that includes a range of clinical and non-clinical staff from all sectors, including third sector, paediatrics, psychologists, psychiatrists, and GPs. We also bring in other agencies to present their work for example, the National i-THRIVE Programme team presented i-THRIVE Grids to the group to encourage people to think about using the grids to enhance young people’s, parents and carers involvement in their care and shared decision making.
Engaging other partners is a work in progress as other services are being invited on board and there are different personnel to accommodate. Currently the structure is there, however processes and ways of communicating are continuing to evolve and improve. We already have a communications strategy, and a communications lead so information can be disseminated across the patch to share learning about our work.
Which aspects of the THRIVE Framework did you feel would be the biggest challenge to achieve for your service?
There are some operational issues that present challenges. For example, in Lancashire we only take referrals for children and young people up to 16 years old in CAMHS. We recognised that this is not in line compared to other areas of the country and there is now a move to increase this to 18 years old. To do this, we need to have an understanding of the demand and capacity in place and make sure services are ready to support this increase in access. We are planning on having a 0-25 year old digital offer that will be aligned with the THRIVE Framework. We have also discussed incorporating a single point of access to all elements of the THRIVE Framework and this is an area that the digital THRIVE Framework pathway could support. Transition between CAMHS and Adult Mental Health Services is also an issue and we are working on the CQUIN to improve this. We want to ensure that this transition happens as smoothly and effectively as possible for young people.
We need to achieve the changes to services though co-production with young people and families, making sure we keep their needs at the forefront. We need to provide accurate and sufficient data for ourselves, commissioners and the Mental Health Service Data Set and make sure there are systems in place to support this. A challenge for us is we have different systems to collect this data from, and are now working with the third sector, so want to be able to evidence how implementing the THRIVE Framework can impact outcomes. We also want to deliver on the access waiting times targets and increase the number of children and young people receiving support. We also want to develop our out of hours and crisis support offer using the THRIVE Framework.
What changes have you made towards becoming more THRIVE-like?
Our Primary Mental Health Worker’s and Children and Young People Wellbeing Practitioners are making a significant contribution to promoting emotional health and wellbeing and Getting Advice and support in schools. We are co-producing our services and working with young people though our CAMHS ambassadors. We are training more of our staff in evidenced based practices and using ROMS. We are discussing the THRIVE Framework regularly in our teams and developing a shared understanding and are starting to create our digital THRIVE Framework offer but there is always lots more to do!
What are some of the barriers you have faced in implementing the THRIVE Framework so far?
There are lots of challenges: operational, strategic and resources. One challenge rather than a barrier to implementing the THRIVE Framework is the need for a common language and a shared understanding of everyone’s contribution to the framework. The danger is people can revert to talking about tiers and that the framework isn’t being used in the way that it was intended. We need to make sure that people don’t think that this is a new tiered model with different language, so it is important that the THRIVE Framework message does not get lost in translation, this will take time to embed. We must check ourselves to make sure that we all understand and are aligned with the THRIVE Framework and its meaning!
We also need to make sure that the services we develop and provide are THRIVE-like. We need to hold a mirror up to other services and keep questioning ‘how does the offer fit with the THRIVE Framework and is the child, young person and their families benefitting?’ It’s essential to have local champions who could keep the THRIVE Framework message at the forefront and make sure that any changes fit with the THRIVE Framework.
What are some of the facilitators you have faced so far in implementing the THRIVE Framework?
The Commissioning Support Unit is taking a lead role in driving service transformation and implementation of the THRIVE Framework forward so we have the strategic message coming from the centre of the partnership. We have providers working together and not in competition under an ethos of collaboration which helps everyone share learning when previously this did not happen.
What has been the area so far that has required the biggest culture change in implementing the THRIVE Framework?
It is difficult to say as we haven’t implemented the THRIVE Framework completely. It is a constant work in process and we are working towards using the THRIVE Framework for how we provide services and support families and young people. There are aspects of this in place already and work is going on to support all of the needs based groupings:
- Thriving: Working in schools to support prevention and promotion of emotional health and wellbeing
- Getting Advice and Signposting: Primary Mental Health Workers and Children and Young People Wellbeing Practitioners in schools providing consultation and supporting young people through self-management. In the future we are looking at having a digital THRIVE Framework offer
- Getting Help: Using Goal Based Outcomes and evidence based interventions – we are working on having a full range of therapies and choices available
- Getting More Help: Increased specialist support for children and young people in the community
- Getting Risk Support: We are looking at extending our out of hours offer and we have good relationships with our social care teams and emergency services. In schools there has been training on CAMHS pathways and self-harm
Have you used any of the i-THRIVE tools from the i-THRIVE Toolkit on the website?
The Clinical Reference Group and board have used the website to understand the framework and to see what tools are available to help support our implementation. We need to make full use of the tools and revisit them when redesigning services with providers.
Do you have any developments you would like highlighted to the i-THRIVE Community of Practice?
I would like to highlight the good practice Getting Advice and Signposting work we are doing by mobilising and supporting PMHW’s and CYPWP’s to work in schools. This also fits with the latest Green Paper recommendations.
What are you focusing on in the next six months?
- We will be focussing on early intervention and prevention in schools by providing Getting Advice and Signposting and increasing this offer into the community.There will be a redesign of CAMHS to improve access to our services by increasing referral age to 18 years old.
- We will continue our co-production and participation work with our young CAMHS ambassadors by strengthening the group and championing their work.
- We will extend our out of hours crisis support offer into the community.
- The Healios pilot will continue, and we will be looking at the feedback and outcomes from it.
- The THRIVE Framework digital offer will continue to develop.
Is there anything you would like to ask the i-THRIVE Community of Practice?
We would like to hear about the Getting Advice and Signposting and prevention and promotion work other sites are doing and to continue to share learning with other sites.
Evidencing the consultation and support that is provided to school staff is vital. We need to demonstrate how this improves access to support and need to be more flexible about what is considered “clinical activity”. All the capacity building work across the children’s workforce through consultation, liaison, training and joint working which is having a huge impact on preventing children and young people from needing more specialist CAMHS services needs to be captured. This information is not well evidenced and is under represented. It has been a constant challenge to get this work recognised and resourced. However, the anecdotal evidence we get from teachers and pupils is that they are getting fantastic support that helps prevent young people from needing to access more specialist services.
Question to the i-THRIVE CoP: “How do sites across the Community of Practice evidence consultation, liaison, training and joint working?”
If you would like to take part in a Q&A to share your experiences in relation to implementing the THRIVE Framework and using the i-THRIVE Approach to Implementation, please get in touch with Bethan Morris at firstname.lastname@example.org.