Clare Anderson, a Clinical Nurse Specialist in the CAMHS Crisis and Liaison Team in Durham & Darlington in the North East of England explains how they overcame challenges of culture and caseloads to transform mental health crisis care for children and young people.
In early 2014 I was happily working as a clinical nurse specialist in a community Child and Adolescent Mental Health Services (CAMHS) team when a colleague, Michelle Trainer, asked if I might be interested in a secondment to help set up a CAMHS crisis service. It piqued my interest because emergency mental health care was something we struggled to respond to as a community team with waiting lists and busy caseloads, which left children and young people in distress waiting too long for urgent support.
The vision was very simple; to provide open access, early intervention and high quality support to young people experiencing a mental health crisis. The aim was to respond quickly, see the young person wherever they may present, and support them to resolve the crisis or access appropriate ongoing support.
Sceptics warned us that if we offered open access, allowing anyone to refer to us including the young people themselves, we’d be inundated and overwhelmed. Their predictions were unfounded. Most of our referrals are appropriate and the rest can be easily signposted.
We ‘went live’ in May 2014 with a very small team, having agreed to launch even though we were not yet fully staffed. It meant we relied on very enthusiastic staff who were willing to do over and above usual working hours to get us going but this culture of ‘can do’ set the scene for our team dynamics.
Our ethos is to think about what we can do to help rather than in terms of what ‘doesn’t fit’ our remit. Having minimal criteria, i.e. so long as you are under 18 and experiencing a mental health crisis we will help you, has allowed us to flexible and creative. We can see young people wherever it is convenient to them and utilise community resources more flexibly. We work closely with 3rd sector groups to provide support traditional CAMHS struggle with, due to capacity. A young person recently said she considered our approach to be ‘unconventional’ – I take this as the compliment it was intended to be as the ongoing ‘conventional’ care she has received has been unsuccessful in helping her move forward and she has struggled to engage.
Running initially as a pilot, our nurse-led service cut response times from 18 hours to an average of 90 minutes though we aim to see someone within an hour, wherever they present. The benefits have also been felt by our trust, with reduced overnight beds and less pressure on A&E through being able to assess young people quicker in and outside of the hospital. Of course, we also provide support for blue-light colleagues, conducting joint assessments, which have proven to be very effective in developing joint care plans.
Our biggest early challenge was recruitment – people rarely come with experience of children and young people’s mental health or experience of managing risk in the community. Being a very small team we needed people to ‘hit the ground running’ as it was difficult to offer development posts. We overcame this by recruiting nurses from different backgrounds with varying knowledge and expertise which provided each shift with a collective set of skills. Michelle and I were on-call at all times to offer advice and support and ‘fill any gaps’. We’ve learned so much from each other and I’m extremely proud of the skilled team we have become.
Our wisest move was spending time getting to know our partner agencies, not in strategic meetings but by visiting colleagues ‘on the ground’. I learnt that the strategic benefits of having a cuppa with people you are going to work alongside cannot be underestimated. Our relationships with police, social services emergency duty team, schools, adult mental health teams, community CAMHS teams, amongst others is excellent and this benefits the young people we work with. Joint assessment and planning is frequent and essential. As a whole emergency care team we are each involved with, and committed to, the work of the Crisis Care Concordat.
Our second wisest move was recruiting a fantastic secretary who has single-handedly collated the statistical data we needed to prove the service was having an impact. Sharing this with commissioners and stakeholders has directly influenced the support we have had to develop the service further.
Two years (and a bit) on, it is thanks to the support of our commissioners that we are recruiting to extend the service to a 24/7 model. This will ensure young people’s access to support and intervention does not end at 10pm every evening. We are also hugely excited to be getting vanguard funding to extend into intensive home treatment. This will certainly plug the gap between the crisis response we provide and the wait that young people experience for ongoing treatment. We’re very confident we’ll be able to avoid some young people coming into secondary mental health services at all by providing a short-term intensive intervention to prevent deterioration.
We have been excited to be asked to speak at national conferences, help other areas deliver their services and we’ve won a number of awards for our work. Not bad for a little spot in the North East of England!
The ‘On the Edge’ young people’s manifesto on the wall of our team office states that ‘we have to get worse before we can get better – help us early so we can avoid things getting so bad’. Hopefully with our approach of active and creative engagement, open access for young people in a mental health crisis and (soon to be) capacity to provide intensive home treatment, we can continue to really make a difference.
She is a paediatric nurse with Tees Esk & Wear Valleys NHS Trust and helped develop the Crisis & Liaison service from its conception in May 2014. She has been involved in developing national guidelines for emergency care of young people with mental health problems. She has also visited other areas of the country to share the Durham model and help shape newly developing CAMHS crisis services. She has worked in various clinical settings including acute paediatrics and Accident & Emergency before spending the majority of her career in CAMHS.