A. The SEMH strategy vision

There is a clear-shared intention to adopt a whole system approach to developing and transforming the support for children and young people’s mental health and wellbeing. Fundamental to this approach is the importance of partnership working and that social and emotional mental health becomes ‘everyone’s business’ in the same way as safeguarding has become ‘everyone’s business’ across Portsmouth.

We want all children and young people in Portsmouth to enjoy good emotional wellbeing and mental health. The ways in which we will achieve this vision is by:

• Establishing a clearly understood needs-led model of support for children and young people with social emotional mental health difficulties, which will provide access to the right help at the right time through all stages of their emotional and mental health development.
• Ensuring that children and young people have access to a range of early help in supporting their emotional wellbeing and mental health needs which will prevent difficulties escalating and requiring specialist mental health services.
• Supporting professionals working with children and young people to have a shared understanding of social emotional mental health and to promote resilience and emotional wellbeing in their work.

B. Our local picture

A summary of the changing needs in Portsmouth

Over the past 12-months young people, their families and the services they access have seen unprecedented challenges brought about but the coronavirus pandemic. Already increasing identification of SEMH needs have seen a steep upward trajectory, in line with nationally reported trends.

• The proportion of children with SEN and a primary need of social, emotional or mental health continues to be higher than the national average and slowly increasing.
• The wait times reported by core and extended CAMHS continue to increase (now 15 and 27 weeks respectively).
• The eating disorder service offer continues to be strong, meeting access targets.
• The MHST offer has been positively received, with increasingly strong school engagement. Referrals have been uneven as a result of the pandemic but continue on an increasing trajectory.
• Since the establishment of the psychiatric liaison service within the hospital emergency department we have seen an increasing number of presentations. Although recent data would suggest a small decline during summer months. Response times by the service have been impacted upon due to recruitment and accommodation challenges.
• Initial data and feedback demonstrate a positive start to the implementation of a youth work offer alongside the psychiatric liaison services. This is being delivered by a third sector partner, No Limits.
• The growing complexity of presentations has been noted by services including CAMHS. This is partly due to late presentation for many young people having been aware from education settings.
• Families report good service support once accessed; but increasing frustration with wait times, access criteria and information sharing.
• We have seen a positive impact following the introduction of Kooth in January 2021. Registration and access figures are high.
• Referrals for neurodiversity assessment in CAMHS and CPMS continue to rise, along with the awaiting times. This is focus of a significant piece of system-wide change to test a new ND profiling tool and bring together a multidisciplinary ND team.

Assessment of local need including inequalities and vulnerable groups

Portsmouth is a unitary authority with an estimated population 212,800 in 2020; this is forecast to increase to 218,300 by 2027 . Children in the city face significant challenges around deprivation with approximately 24% of children in the city living in poverty (the England average is 20%). However, in some areas of the city, the proportions are much higher, for example, in Charles Dickens ward, 46% of under-16s are growing up in poverty.

Portsmouth’s children and young people are predominantly of white ethnic origin (82.4%). A sizeable proportion are not of White ethic origin (i.e. 17%), with larger ethnic minorities being Bangladeshi and African.

Key findings – Children and Young People’s Needs Assessment 2018: (Estimates are based on modelled data)

• About 1,000 (3.7%) 5 to 16 year olds are affected by emotional disorders with anxiety being the most frequent, followed by depression.
• About 420 5-16 year olds have severe ADHD.
• Around 206 5-9 year olds and 58 9 to 10 year olds have an autism spectrum disorder.
• An estimated 16 10-19 year olds have a diagnosed eating disorder, though many more will demonstrate ‘disordered eating’ behaviours.
• Social, emotional and mental health difficulties is the most common primary need for those with Special Educational Need (SEN) support (24.7% of Portsmouth pupils with a statement or Education Health and Care plan).
• Portsmouth has a significantly higher than national rate of hospital admissions for self-harm. An estimated 8.9% of 16 to 24 year olds have self-harmed in their lifetime (equating to 3,209 young people in Portsmouth).

Schools data

In the January 2021 census there were 1,181 children and young people in reception to year 11 with EHCP’s. 228 of these pupils had a primary area of need recorded as SEMH. There were a total of 26,213 children and young people in Reception to Year 11, in state-funded Portsmouth schools.

We know locally that children with Social Emotional Mental Health needs are disproportionally represented amongst those with poor attendance and high levels of exclusion.

Data from PHE shows that across England the percentage of secondary school pupils with SEN identified as having a primary need of social, emotional or mental health (SEMH) expressed as a percentage of all school pupils in 2020 was 2.67%. This was significantly higher than in recent years. The proportion in Portsmouth is higher than the national average with 3.68%. The proportion across the South East is 2.63% with Southampton (4.05%,) and the IOW (3.42%).

Amongst the primary school age category, the recent trend has also increased with a prevalence across England of 2.45% in 2020.
Portsmouth’s proportion is 3.1% with Hampshire being 2.36%, Southampton (3.73) and IOW (3.08).

Stakeholder feedback – key messages from SEMH pathway review

• Frustrations from families, schools and services with the length of time it takes for a child to be seen by CAMHS; frustrations with having to jump through unnecessary hoops and a belief that mental health service thresholds are too high.
• Parents report frustrations with having to repeat themselves to different services, feeling there was a lack of communication between services and a need for the system to be more joined up.
• A parent likened navigating the system to ‘wearing a blindfold to bake a cake’. This was a particular challenge for minority communities, parents do not know who to call or speak to.
• When families receive SEMH related support it is reported as ‘good’ and children felt ‘listened to’. Families spoke very highly of the support from MABS and reported that it was very helpful and non-judgmental. It was reported that CAMHS support is good.
• Schools, services and parents report a challenge with deciding which pathway is best and navigating the system. There is a lack of understanding about the continuum of SEMH support.
• Colleges are reporting significant recent increases in MH presentations and struggle with the capacity to manage volume of referrals and lack mental health expertise across their teams.
• Lack of understanding amongst professionals around LGBTQ+ identities and a lack of trusting relationship between young people and school staff.
• CAMHS report challenges with the system wide understanding of thresholds and the capacity and confidence of professional/ services to deliver interventions relating to SEMH.
• Broadly speaking GP’s sometimes struggle to untangle what the issues might be for young people and families and they don’t always have the awareness of what support is available locally.

Performance summary and service data

Kooth
The Kooth platform for Portsmouth launched in January 2021. Take up by young people started very well:

• 426 registrations in quarter 4 (2020 -21)
• 452 registrations in quarter 1 (2021 – 22)
• Over 400 professionals and parents/carers have attended the KOOTH webinars.
• 15-year-old girls are the predominant group accessing Kooth, which mirrors the national picture.
• BME registrations accounts for 16.5% of all registrations, in line with the 16% of young people who identify as BME in Portsmouth.
• There has been an increase in quarter 1 with more young people using the chat and counselling offer.
• 100% of young people would recommend Kooth to a friend with 91% saying they got what they were looking for.

MHST referrals
The numbers of MHST referrals have been steadily rising month on month, which is expected as the teams become better established across the schools system. Of those referrals triaged 76% were accepted for assessment, we anticipate this figure will improve as schools better understand the MHST criteria and scope.

2021	Jan 21	Feb 21	Mar 21	Apr 21	May-21	Jun 21	Jul 21
Sum of Referrals	27	29	82	34	44	51	76

MHST have introduced a school engagement tracker which gives a breakdown of referrals by individual schools. The tracker, which is monitored by the MHST steering group, also highlights how embedded the teams are in those schools and what they are doing to improve the partnership.

Core CAMHS – Referrals to CAMHS single point of access:

2018-19	Apr-18	May-18	Jun-18	Jul-18	Aug-18	Sep-18	Oct-18	Nov-18	Dec-18	Jan-19	Feb-19	Mar-19	Total
Sum of Referrals	103	159	152	144	86	134	162	193	137	169	140	164	1743
2019-20	Apr-19	May-19	Jun-19	Jul-19	Aug-19	Sep-19	Oct-19	Nov-19	Dec-19	Jan-20	Feb-20	Mar-20	Total
Sum of Referrals	122	150	153	151	82	118	165	149	112	140	133	92	1567
2020-21	Apr-20	May-20	Jun-20	Jul-20	Aug-20	Sep-20	Oct-20	Nov-20	Dec-20	Jan-21	Feb-21	Mar-21	Total
Sum of Referrals	43	49	90	111	59	123	156	173	131	90	106	132	1263

The CAMHS waiting lists at the start of August 2021 are:

• CAMHS SPA first appointment wait time is 15 weeks with 112 young people waiting (target for first appointment is 5 weeks)
• 8 week wait for brief interventions – 16 young people are waiting
• Demand has increased for duty calls which has impacted SPA completing first appointments. They are also not able to open up fully and are still operating COVID safe practice in the building.
• Current wait time for first appointment with extended CAMHS is 27 weeks with 238 young people waiting (target for is 18 weeks)
• ND assessment – 214 young people waiting. The longest wait is 74 weeks with an average of 39 weeks

Eating disorders
Demand for eating disorder support has started to significantly rise locally in line with regional/national trends with 33 young people in Qtr 1 2021/22 compared to 10 in Qtr 4 2021/22. The eating disorder charity BEAT reported an 81% increase in contact across all helpline channels with a 139% surge in online group attendance. Kooth report a sharp increase in eating difficulty presentations in under 18’s since the start of the pandemic.

There are currently 58 young people on the eating disorder caseload. We continue to meet the national access standards for eating disorders with 100% of urgent referrals being seen within 5 working days and 100% of routine referrals being seen within 20 working days in Qtr 1 of 2021/22.

	2019/20				2020/21				2021/22
	Q1	Q2	Q3	Q4	Q1	Q2	Q3	Q4	Q1	Q2	Q3	Q4
Urgent
Number seen within 1 week	0	7	9	5	14	12	5	5	3
Total Completed Cases	0	9	9	5	14	12	6	6	3
% Seen within Timescales		78%	100%	100%	100%	100%	83%	83%	100%
Routine
Number seen within 4 week	1	1	3	1	1	1	2	4	30
Total Completed Cases	1	1	6	8	1	5	2	4	30
% Seen within Timescales	100%	100%	50%	13%	100%	20%	100%	100%	100%
Total
Number seen within 4 week	1	8	12	6	15	13	7	9	33
Total Completed Cases	1	10	15	13	15	17	8	10	33
% Seen within Timescales	100%	80%	80%	46%	100%	76%	88%	90%	100%

Paediatric Psychiatric Liaison

CAMHS liaison continue to experience staffing pressures due to recruitment and COVID related issues, which is affecting their ability to deliver a full comprehensive service. It’s expected the service will be at full capacity in October 2021.

The No Limits service is now well established with the youth worker provision. Data in quarter 1 2021/22 highlights No Limits supported 89 young people in the emergency department.

100% of the young people who had contact with an emergency department youth worker rated the support they received as excellent or very good.

Feedback from paediatric staff has also been very positive with awareness being high (90%) and 100% of staff said the service was available when called upon.

‘We have really valued their support with patients, especially with signposting to services and linking them into resources. They’ve also been very effective at supporting patients who are distressed in the department without a parent present, as clinical staff aren’t always able to spend prolonged periods of time with each patient due to clinical demand.’

National Access Indicator
We just missed out on meeting the national access target (35%) for 2020 – 2021. Our final year rate for 2020/21 was 34.25%. The collective figure for HIOW was 40%. Work is underway to enable school nursing to flow their emotional health related work to the MHSDS. No Limits will be flowing activity as from September 2021. One of the difficulties we have locally in meeting the national access target is that the approach our CAMHS local authority offer takes; supporting the network to support the young person, a ‘team around the worker’ approach. As this work isn’t direct one to one work with the young person it doesn’t count towards the target.

C. SEMH Partnership, Integration and I-Thrive

Partners across Portsmouth are fully signed up to the SEMH strategy and have a very successful Portsmouth Education Partnership which brings together LA maintained schools, academy providers, the council and health partners.

Good social and emotional mental health for children and young people and closing the gap around inequalities is a key priority for Portsmouth and is a golden thread running through our strategies and plans. We have a strong track record of excellent partnership working through a long-established set of Children’s Trust arrangements. The SEMH Partnership includes:

• Portsmouth CCG
• Portsmouth City Council
• Solent NHS Trust
• Co-production groups – parents and young people
• Portsmouth Hospitals Trust
• Primary care
• Voluntary and community sector agencies
• Early years, schools and colleges

Integration, Integration, Integration – What does it look like?

• Integrated, whole-system SEMH Strategy, service design, service delivery and micro-commissioning
• Joint working and signposting between strategies (e.g. Children’s Public Health Strategy)
• Shared posts across agencies – Council, CCG and Solent NHS Trust
• Dozens of multi-agency steering groups within the Children’s Trust structure
• Several multi-disciplinary teams
• Joint Business Plans – Council, CCG and Solent NHS Trust

We use a relationship-based approach to promote and develop SEMH so that all children and young people can flourish in our local community. This approach recognises the importance of:

• Putting relationships first where a sense of belonging and connection, respect and value, support and compassion is fostered
• Promoting and developing SEMH for all – nurturing and developing resilience and strengths as well as supporting need
• Understanding children/young people within the contexts of relationships and wider factors
• Understanding SEMH as communicating a need rather than a problem taking a non-judgemental and empathetic approach
• Applying trauma informed and attachment aware approaches with children and young people with the most complex needs relating to social and emotional wellbeing and mental health
• Ensuring all approaches and interventions are evidence-based
  Working within a collaborative process
• Recognising the need to promote and support wellbeing and resilience within the work-force

Coproduction
Partners across the Portsmouth system have set coproduction at the heart of improvement and transformation work. The Partnership aim to work in coproduction wherever possible in order to achieve the best outcomes for those who make use of our services. This includes individual, operational and strategic co-production. Representatives from Portsmouth Parent Voice, Dynamite (young people’s group) and Portsmouth Parent Board are all represented on both the Strategic partnership and sub-groups.

The coproduction strategy can be found in Appendix B.

D. Thrive demand modelling

The I-Thrive framework is being used to support system-wide change. Portsmouth is transforming its approach to children and young people’s emotional wellbeing and mental health by aligning itself with the Thrive model. The framework is an approach to supporting all children and young people’s emotional wellbeing. We know that the influences on a child mental health are varied and each and every individual in a community has a role to play in helping young people to stay emotionally healthy.

All our service and pathway developments will follow these principles.

Principles	Description
Common language	Provides a shared language which everyone can understand.
Needs led	Approach based on meeting needs regardless of diagnosis.
Shared decision making	Children, young people and their families are experts in understanding their needs.
Proactive early intervention and prevention	Enabling the whole community in supporting mental health and wellbeing.
Partnership working	Working together to support and improve mental health is vital – ‘everybody’s business’.
Outcome informed	Shared understanding of what we are trying to achieve and understanding early if it is not working.
Reducing stigma	Reducing together the stigma that surrounds mental health.
Accessibility	Advice, help and risk support available in a timely way for the child, young person or family, where they are and in their community.

To help us as a system understand how many children and young people (CYP) have emotional health needs and the level of their need we have used the findings of the national Thrive programme to identify what the potential demand might be in each of the Thrive clusters. The authors of the Thrive elaborated report (an update on 2015 of the original Thrive paper) indicate that 80 to 90% of young people can be said to be Thriving. Of the remaining 10-20% of young people:

• 30% fall into the Getting Advice cluster
• 60% fall into the Getting Help cluster
• 5% fall into the Getting More Help cluster
• 5% fall into the Getting Risk Support cluster

The population estimate indicates there are 40,050 children and young people aged 5 to 19. These weightings have been applied to the local population of young people in Portsmouth and the results are set out below.

	%	Number
estimated young people thriving	80%	32050
estimated getting advice	6%	2400
estimated getting help	12%	4800
estimated getting more help	1%	400
estimated getting risk support	1%	400
Total aged 5-19	100%	40050
Total not “Thriving”	20%	8000
Population source: ONS 2018-based subnational projection for 2020 rounded to nearest 50; and percentages from Table 1 of Warrington’s THRIVE cluster report

We have decided to base the modelled data on the assumption 80% of children and young people are thriving. The reason for us using this more conservative projection is that the prevalence figures this modelling is based on would be out of date with the known rising demand for children’s mental health support.

When reviewing our service data alongside the modelled data we know that there are currently large numbers of young seeking specialist support in the getting more help section as opposed to the numbers needing support in the getting advice and getting help sections. This reinforces our plans to provide greater access to self-help and early help support which in turn will prevent difficulties escalating and requiring specialist mental health services.

It’s estimated that roughly 8,000 of children and young people in Portsmouth are not thriving and would benefit from some form of social emotional mental health support. Our plan is to continue comparing this modelled data with service data which will give us a better understanding for what demand would be in each THRIVE cluster.

E. Expected outcomes and measures of success

The SEMH Partnership have agreed a system-wide scorecard that will provide a picture of both service improvement and impact for young people. This seeks not only to measure performance where necessary, but moreover to inform the system about where positive outcomes are seen and where focus should be given to make further strides forward for young people. The scorecard groups data under 4 areas; quantity, quality, impact and feedback. This helps the system to understand whether we have sufficient resources, whether we are delivering high-quality provision that is impacting on young people’s outcomes and draws on user and provider feedback for continuous improvement.

The SEMH Strategy targets nine key outputs and outcomes, which will positively impact on young people long-term:

1. Reduced exclusions from school
2. Improved attendance at school
3. Reduced referrals into alternative provision
4. Good response times for young people’s SEMH support
5. Reduced number of inappropriate referrals to CAMHS
6. Reduced demand to specialist CAMHS
7. Reduced self-harm attendances and admissions
8. Reduced prevalence of mental ill-health including anxiety, self-harm, low mood and eating disorders
9. Increasingly skilled and confident workforce, able to promote emotional well-being and respond to emotional distress and mental ill-health

Measures of success based on national expectations

• Eating Disorder service recovery – we will continue to see over 95% of children and young people referred to CAMHS Eating Disorder services as urgent cases within 1 week.
• Eating Disorder service recovery – we will continue to see over 95% of children and young people referred to CAMHS Eating Disorder services as routine cases within 4 weeks.
• Access 0-18 – we will meet the national access standards targets for children and young people estimated to have a mental health disorder for 2021/22.
• Access 18-25 – we will achieve or exceed the national access targets for increased uptake of mental health services by 18-25 year olds each year from 2021/22.
• We will achieve or exceed 90% of young people being assessed within 5 weeks of assessment by the end of 2021-22.
• We will achieve or exceed 90% of young people starting treatment within 18 weeks of assessment by Nov 2021.
• We will reduce Autism Assessment waits from 74 weeks to 42 weeks by April 2022.

F. COVID-19 and likely impact on emotional and mental health

The SEMH partnership has considered, as a result of the COVID-19 pandemic, the likely impact and presentation of mental health difficulties within the population as a whole. We are focusing on how we reshape the system to meet an anticipated increase in demand for mental health support for children and young people as lockdown eases and children return to school and their peers.

The short-term (year one) plan in this Strategy including our response to COVID-19. ‘New’ or increased anticipated needs as a result of COVID-19 include the following:

• Separation anxiety
• Anxiety of release from lockdown/virus fears
• Isolation from peers and loss of routine
• Trauma experienced in lockdown
• Worries about exam cancellation and moving into next phase of education
• Self-harm
• Bereavement and loss
• Anxiety with transition
• Sleep hygiene
• Potential rise in eating difficulties
• Later identification of emerging needs
• Increased incidence of adverse events such as domestic violence and child abuse

G. SEMH strategy – 10 key objectives

1. Secure strong early attachment in the first 1000 days of life
2. Provide high quality advice, guidance and self-help
3. Develop the children and young people’s workforce
4. Improve early help and develop digital solutions
5. Improving wellbeing and resilience in education
6. Improve mental health support for LAC and care leavers
7. Improve the support for specific groups of vulnerable children and young people
8. Develop CAMHS services to meet demand
9. Prevent suicide and its impact on children, young people and families
10. Improving our local knowledge and performance management

H. Deliverables (2021 – 2023)