‘Building psychologically informed Forensic CAMHS’ Dr James Millington

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Dr. James Millington on ‘Building psychologically informed Forensic CAMHS’.

Recorded on 19 April 2018 at the North West ACAMH Branch as part of a conference on Conduct Disorder.

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Dr. James Millington is a HCPC registered Consultant Clinical and Forensic Psychologist and Lead Psychologist for Specialist CAMHS at Greater Manchester Mental Health NHS Foundation Trust. He is an Associate Fellow of the British Psychological Society (BPS) and the Child and Adolescent Representative on the BPS Division of Clinical Psychology, Faculty of Forensic Clinical Psychology Committee. James has worked for the NHS for over twenty years mainly within adolescent forensic mental health services. His clinical role includes leading the psychology teams within adolescent inpatient services, the secure estate within the North West of England, and the newly established Forensic CAMHS North West. Dr Millington contributes to practice development through various professional and service networks and via publication projects, teaching, and presenting.

Transcript

Dr. James Millington – Thank you for inviting me. Some of the slides you may have seen before because I know some of you have been at recent events to do with our services. We have a range of services that my Trust are involved in, and I’ll explain those as we set out what’s available in the northwest as well.  I think it’s important, first of all, to explain why I think it’s vital that we see specialist CAMHS as a real opportunity to pioneer a whole lot of different practise and be quite brave. We can use specialist CAMHS as a way to also challenge adult practise. There are some parallel commissioning processes happening within the adult world that are perhaps that little bit easier to do across the services for children. It also means we can challenge the ways in which adult mental illness models or adult models [inaudible 00:01:17] disorder may be understood better with a developmentally informed approach, an attachment and trauma approach.

So within the system for children and young people that are involved with the criminal justice system, we know it’s quite dynamic; it’s politically… it’s on the news all the time. If it’s not foreign affairs or Donald Trump, it’s going to be about children or crime or education, mental health, social services. We also know that in the past few years, there’s been some recent high profile cases, not enough services, children that can’t be found a hospital bed moved to different parts of the country. Because we’re talking about a small group, those in, I suppse, a securer state now, we’re talking about 800 to 900 children. Five, ten years ago, we were talking about 3,000 children. And they’re often placed in a range of different settings. Some of those places having their problems as well. So that’s half a high school of kids across England. We should be able to manage that number a lot better than thousands and thousands of children and do something a bit bold with a smaller amount of money than what it takes to do with adults.

Investing in children, not as difficult politically as saying we’re investing a whole lot of money in offenders, even though we should do that one as well. We’ve been hearing about early intervention and there’s still a great need to intervene early with children and young people, even if they are in a locked setting and approaching 18. We’ve still got an onus to divert them from a very fixed pathway that can be really difficult to move off once they enter adult services, and all the different ways the narrative changes about how they are responsible to them. But also, I’m a psychologist, so I’m bound to say part of the solution is going to be about a really good formulation and understanding about what’s going on, and that formulation is something that has an impact in practice, rather than get too caught up about all the different disorders of conduct and all the different diagnoses.  I’m not anti-diagnosis in any way. I have a 14-year-old boy with autism. It’s very much important to have his diagnosis otherwise we wouldn’t get the services that we now complain about [laughter].

So there are lots of drivers for change. The past five years, I’ve been involved in a range of different things through the Clinical Reference Group to do with of these forensic CAMHS services. And it’s been a long time to get to the point where these new services are starting to start up. There’s a complicated tree of things that are happening, so the Five Year Forward View, that’s a mental health [inaudible 00:04:40] programme, part of that is the Children and Young People Mental Health Transformation programme. One branch of that is the Health and Justice Specialised Commissioning Workstream, and that itself is split into other work streams.

So I’m going to explain a little bit about what we’ve got in the northwest. So we have adolescent medium and low secure units. We have the Gardener Unit based at Prestwich, [inaudible 00:05:07] medium secure unit for boys. If we look at medium secure units for children across the country, there’s Newcastle, which has boys and girls, us in Manchester that has boys, Birmingham, boys and girls, London, boys, Southampton, boys and girls. So if you are a child in the northwest and you need a medium secure unit, you might [inaudible 00:05:32] have a bed in a 12 unit in Manchester. If you’re a girl in the northwest, the nearest units are Newcastle and Birmingham. If you need a low secure unit, there is one, Cheadle Royal, for girls. And if you need a low secure unit if you’re a boy, I think the nearest commissioned one is Middlesbrough. So part of what NHS England are trying to do is make sure that we have some regional parity and you don’t have to go 200 miles to find a bed.

There’s a similar issue in other types of services like the prison services and where children are detained under criminal justice legislation. So in the northwest, we have Barton Moss as, I think, the one remaining place where children are detained, remanded or sentenced. It’s 27 bed in there, takes boys from the age of ten. If you are older than that and you might need a [inaudible 00:06:39] nearest ones are Wetherby in Yorkshire or Werrington near Stoke. So again, if you are a boy in the northwest and you happen to be detained in custody, you could be going to a completely different region of the country, and that’s a challenge for those links with family, with services, both in terms of how to [inaudible 00:07:01] when you’re there or how they can get involved with the planning for when you return. That makes it a bit difficult. Ideally, I would rather have… if you’re going to lock up children, smaller, regional, secure children’s homes are going to be better than four big prisons dotted around the country miles from anywhere.

FCAMHS is another service that has started up, and some of you will have been at our launch last week. FCAMHS… We existed in a previous guise as the FACTs team until the 1st of October last year. And now we have this new commission, a much broader service specification, different thresholds, more money, a bigger team, and we cover the northwest. FCAMHS Northwest is open. Referrals are free. You can send me an email and we’ll send you a referral form, and we’ll want to respond quickly within five working days to whatever your concerns are. Myself and Kenny are speaking later as part of the FCAMHS team.

The next branch is about Secure Stairs. Secure Stairs is… I suppose across the 20 settings in England where children are locked up… This can mean criminal justice secure children’s homes or welfare Secure Children’s Homes. So we have St Catherines in St Helens, which is a welfare Secure Children’s Home, so the children there are going to be detained under secure orders of the Children Act, rather than criminal justice legislation. Twelve beds, mostly girls, often quite a significant history of CSE or trauma. Secure Stairs will involve recruiting psychologists to work in each of these settings. So currently at Barton Moss there’s an inpatient psychologist to do with  the mental health team; that’s a day a week. Through Secure Stairs we’ll be recruiting full-time psychologists just to work there to do a whole range of different work in terms of formulation, formulation based care plans, putting in new staff, working   with the senior management team to make sure that the entire place is psychologically informed. I’ll talk mostly about Secure Stairs and the ideas behind it. We’ll be doing the same at Barton Moss and the same thing will be happening in all the different places. So I think the YOIs will have a greater challenge, far more children and young people there, that bit older, because you have to be 15 to go in a YOI, and you’re working with prison officers and with really different staffing numbers than at children’s homes, so it’s hard to know whether the greatest gains are going to be in the YOIs or much more achievable in for Secure Children’s Homes.

One of the new things about FCAMHS and Secure Stairs is that there will be an intensive evaluation of it. The Anna Freud Centre have been commissioned to do the evaluation of FCAMHS and Secure Stairs, and we’ll… Well, myself and Kenny are in Birmingham tomorrow at a national event to hear more about how the Anna Freud Centre want to evaluate it. But if we’re not doing what we should be doing by the commissioners and by the Anna Freud Centre we’re not going to get commissioned again. But we’ve got a bit of wiggle room as we try to work out exactly what it is that they want us to be doing over the next 12 months at least.

So there’s a lot going on. The other thing that I should mention is that the medium and low secure inpatient units have only recently last month had their service specifications published, and hopefully that will open up the commissioning framework at some point, so services might be retendered. They might look again at where regionally low and medium secure units should be, and maybe those that just have boys will be expected to do some revamping so they can take girls as well.

Okay, so improving the securer state, multiple complex needs, not just one domain, so not just mental health, lots of persistent problems, lots of severe problems, all the standard interventions haven’t worked or they’ve not been able to access them, a lot of high risk behaviours to themselves, to others, from others, complex management difficulties, often is often seen as high risk, high harm, high vulnerability.  Traditional regimes don’t seem to be enough. We know from [inaudible 00:12:21] mental health common histories are long term antisocial behaviour, high risk behaviours, complex trauma, early attachment problems, and at risk of being diagnosed as adults as PD or maybe even [inaudible 00:12:40] psychopathy, depending on what kind of culture will exist when they hit 18.

 

Often seen as problems within systems, consume a lot of resources, burn out a lot of staff, get moved around places, often as a way of managing them or giving each unit a break. But you can imagine if you already have a lot of attachment trauma problems the fact that people don’t want you there is not going to really help either. And they are really surviving it. But this is a lot of [inaudible 00:13:15] to survive in these places. They don’t often present with, even in inpatient services, as having a clear mental illness or a single diagnosis that can really explain what’s going on. I’ve listed some acronyms there and, obviously, the kids I’ve had them all, [inaudible 00:13:41] in the way that their difficulties are categorised, and a lot of horrible stigmatising labels are put on them.

And I’m mindful as well as how often you’re working with staff that come from different types of service, so we’ll get a lot of our staff at the inpatient unit that have come from our Forensic Services, and we get a lot of staff that have come from CAMHS services, and in the middle there’s this unique area of experience that draw from both but know which is baby, which is bathwater in their kind of knowledge and how they apply it. So we’ve got to fend off an awful lot of ways that some staff will respond, react to some of the behaviour that they see, and some of it gets too easily dismissed as, well, they’re bad, PD, they’re not ill, we don’t need to care for them in the same way. Increasingly, we can also see how if you don’t understand some of the relational security aspects of working with them, you’re going to miss a whole lot of good practice that come from Forensic Services.

It’s a real challenge to recruit at the moment, particularly those that have good quality experience in this specific area. So what we see is difficulties re-emerge, get re-played, intensified as children get older into adolescence. Some of the behaviours are not tolerated as well. You might start to find the things that the things that they do get reported to the police a lot more. That may or may not be a good thing. It’s a real dilemma sometimes as to whether we should make sure that everything’s reported to the police and investigated promptly… Maybe consequences and other services could be made available… or whether we’re unnecessarily criminalising children. And there is costs and benefits there for each case. Often the outcomes are really depressingly similar despite a whole load of different, complex and difficult beginnings and that can be really frustrating. It’s really difficult to move children on to a setting from hospital that’s going to meet all their needs. And then they often get stuck because there’s nothing there for them that will manage everything and then you miss the clinical window of discharging somebody and they will just get worse, and then they will feel like a burden, and then problems will emerge.

Services still seem quite patchy. [Inaudible 00:16:47] services, it seems like we’re almost starting again with every case to find out what have they got available in their local area; it can be different. So what’s available in South Cumbria is different to Manchester to Liverpool to Cheshire to Lancashire.  Some of our kids in the medium secure unit have come from different parts of the country, which makes it even harder to try and transition somebody back to the community.

My observations: often things are too [inaudible 00:17:17] driven, too simplistic; interventions are often prescribed; a single modality. Really tear my hair out when I get a referral to [inaudible 00:17:28] management. I have to use my own case training skills to calm myself again before I respond. We often blame and locate problems within the child. I’m even aware of how trust invests a lot in the recovery [inaudible 00:17:48], recovery model. I don’t think that’s really appropriate for children to make them responsible for dealing with what’s happened because it puts a lot of pressure on them, blames them for their problems.

We offer an intervention on the level that they’re responsible for their own problems, missing the whole systemic context, and that’s vital. That’s absolutely vital. We don’t often have a shared developmental understanding.  Seeing these kids as mini adults is a mistake. There’s no rationale for how we’re doing what we’re doing, but it’s left to almost individual adults to have their own values to come up with some kind of parenting culture. Consequences are, if you have that approach, there’s a lot of organisational trauma within complex things. It can really burn out staff teams.  It can lead to a lot of defensiveness and reactivity, sickness absence problems, restrictive practises, punishing reactions, and ultimately, the kids pick up on all of this, they don’t feel safe, and therefore will carry on doing the behaviour [inaudible 00:19:07]. A lot of [inaudible 00:19:10] disciplines come in with their own perspectives and missing that fundamental understanding of how the service, the unit will operate as a whole. A lot of conflict within the system between the services as you in and out of them, back to the community. Home, prison, home, somewhere else, different part of the country, start again. That confusing experience really just [inaudible 00:19:48] justifies some of the difficult beginnings and the impact on behaviour. We end up having quite a problem within settings as well, and therefore things often get worse and the mental distress becomes more difficult. How do you cope? How do you feel emotionally? It becomes more difficult to [inaudible 00:20:08], relationships break down and problems just increase and you end up just having somebody for a while, make it worse, then pass them on.

There’s a range of complications that come out of the BPS. This one in particular, I think, is really influential, and there’s a couple of authors that have written about psychologically informed trauma in [inaudible 00:20:37] parents with children.  So I’d recommend this paper and some other publications that are coming out of BPS. The What Good Looks Like, a very practical… certainly shaping what myself and my psychology team are doing. Basically, a psychologically informed environment. We are able to provide that missing overarching framework, that model of care. And that’s coming from a developmentally informed [trauma]. We emphasise that it’s the relationships between staff, the every day interactions that’s going to be a key agent for change. It’s not going to be the half an hour of CBT a week with me that’s going to change everything; it’s going to be the rest of the week. The models of parenting that we see, and what we’d like to have is our staff as therapeutic parents I would like to have as [inaud osterhaus to prioritise, which is a bit more difficult, which is a bit more difficult when you use those kind of terms for a prison officer than it is for a support worker, but the rationale is the same.  We’ve got to balance the nurturing, caring parenting aspect with the predictable structure and the routine, and get the balance right. If you miss either of those, then often the dynamics are difficult. If you end up being too nurturing, too caring and you end up too over involved, too rescuing, too emotional, you’re not going to be as effective. If you end up with too much structure, too much routine, too cold, too aloof, you’re not going to do the predictable, caring, supportive work, and you’ll be too avoidant. And the different attachment patterns will bring in different staff, and ultimately, that causes an awful lot of splits in staff teams, and therefore, you need this whole systems approach, and not give them therapy to deal with the fact that you haven’t got the system right.

So you do need a well-supported staff team.  They need to be equipped with a lot of psychological knowledge, [inaudible 00:22:52] and have a culture that emphasises support and the safety. So physical and emotional safety is key for any further interventions. If you haven’t got that you can’t build on the work later on. There won’t be that many reasons for, I suppose, a psychologist to do the type of high-level psychological therapy that only a psychologist can do.  The rest of it is [inaudible 00:23:21] all the different levels. What we try to do as a group of psychologists, working in all our different settings… So my role covers our inpatient units and supporting the psychologists there, the psychologist [inaudible 00:23:40] reach teams and supporting those at St Cath’s. And we’re recruiting currently… The job advert’s out now for psychologists working through Secure Stairs and through FCAMHS.

So what we would like to do is promote a lot of values and visions about psychologically informed services, helping them to have oversight and support, supervised practice, formulation leading to [inaudible 00:24:04] practice, support staff to do their difficult work. We describe and develop a philosophy of care. We help maybe slow down thinking, have a transparent, defensible practise, different to defensive practise, which is more about covering your back and worrying, added some critical thinking to systems. Absolutely encouraged my group to question and challenge and not tolerate anything that they think is wrong. I do that [inaudible 00:24:37] upstream and as systemically as possible. Lean on a lot of content and delivery of training. I do all of that staff support. It’s not about counting how many units of CBT or [inaudible 00:24:51] therapy that we’ve done in a week to evaluate our work.

So being trauma informed, Karen Treisman wrote a book last year. I think this is a really good quote from that book. It’s in your packs, but it applies to more than just a single type of therapeutic approach. It’s a whole systems way of working. We should be able to recruit to that model, train in to that model, lead in a way that facilitates trauma informed organisation. Some of the spinoffs that we’ve been able to do in our trust are post incident debriefs. That’s led to a whole load of involvement with all sorts of things, including after the Manchester attack last year. And if we can do that kind of trauma aware support for our staff, we’re likely to be able to retain and recruit and have better outcomes for the children.

So Secure Stairs. Secure Stairs is an acronym. I won’t go through these in detail, but it talks about staff and skill sets programme to retention training, emotionally resilient staff able to remain child centred, emotionally challenging behaviour, cared for staff, supervision and support, understanding across the establishment, child development, attachment, trauma, and other key theories, not just those that are at the coalface, doing all the direct work with the kids, but all the way through, including the managers, get it as well. Their management style and their policies and practice is all informed by us.  So we have a reflective system able to consider the impact of trauma at all levels, both for the kids and for the organisation. Again, every interaction matters, so every conversation, every game of pool you have, every good morning, every joint group is part of the therapy.

The Stairs bit is slightly more complicated. It involves scoping the presented situation, highlighting the problems, so starting to formulate really, coming up with targets, so I suppose a plan is formed by that formulation, looking at what starts things off, what might trigger a problem, doing different interventions, reviewing and re-evaluating in collaboration, and that could be with the young person, with the residential staff, home managers, parents, other agencies, and maintaining change as we start to see it starting to work.

So just a little bit on formulation, so I think this is not clear. I suppose as a psychologist, I should know a bit more about formulation, but I did have to go and look it up, and find different definitions. So first thing I thought was that bit between assessment and before intervention. That’s vague. I think somebody would see formulation a bit diagnosis with a few other adjectives, but it’s probably a lot more than that. We might talk about risk formulation or case formulation or a psychological formulation that’s related to a particular therapy. That might be a challenge for how it gets applied in the services if we need everybody to have done a diploma in schema therapy in order to understand what psychologists is talking about then we’re going to not get very far. I understand it as an explanation.  I think this one is probably most simplistic: formulation is just a way of describing problems and ways out of them. It’s a joint effort between you and the psychologist to try and understand the good reasons why you’re struggling with the stress of feeling stuck. But we’re working with complex kids, so that might be too simplistic.

Now I’ve taken these, even what I said about PD before, this is from the National Offender Management Service working with offenders with PD in Brooklyn and highlighting managers involved in the environment. So I think some of these explain actually in decent language what I think complex formulation might involve. So formulation is an organisational framework for producing generally the narrative that explains the underlying mechanism of the presenting problem and proposes hypotheses regarding action to facilitate change. Or case formulation is a theoretically based concise explanation or conceptualisation of information obtained from diverse sources that offers a hypothesis about the cause and nature of the presenting problem, and provides a framework to developing the most suitable management or treatment approach.

So there are things that we might want to have as a checklist to include in formulation, something we’ll be working at within FCAMHS as well, so if we agree on consultation we might need to think about what standards we put into our letters. So it’s got to have clarity of purpose based in sound theory. It’s got to be clear, whether it’s an initial formulation, perhaps when somebody is about to arrive in the service, rather than one that involves a couple of months of assessment. It counts the development of history, patterns of behaviour, provides an explanation of the problem. It’s organised, considers attachment relationships set in context. It connects information and processes hypotheses about triggers. It’s collaborative.

These ten standards for a clinical case formulation come from a paper by Stephen Hart, who’s behind some of the adult [inaudible 00:31:10] risk assessment tools. Sorry, this appears a bit small, but it should be in your packs. A lot of this is for adults.  I think the thing that differs is this one, diachronicity. Diachronicity is the extent to which the formulation ties together relevant information about the past, present, and the possible futures of the client. Much more difficult to do with a child, with a young person, whose existence is very dynamic and changing all the time or whose brain is still developing or patterns of behaviour, patterns of offending still developing, their mental health, distress, mental illness might still be formative as well.   So it’s much harder to anticipate fixed patterns of behaviour and experience with children, given that they’re likely to have to move on to something at 16 anyway.

So we might want to think about how we use different scenarios in order to explain what’s going on, what we should do about it. But you can use these as a ten-point checklist for your quality of any formulations that you do. We’re likely to see more and more of this come out, so rather than [inaudible 00:32:23] it does a formulation exist, does a risk assessment exist, we might want to move to [inaudible 00:32:29] to check for the quality of the formulation that came out of that process. So the key elements, stability of placement relationship is paramount. There’s not always an easy answer to what helps, so diagnosis, simple model of therapy, a way of understanding is the answer. We need this multi-systemic, multifactorial formulation. We’ve got to be aware of the parallel processes and how the staff will pick up the trauma and then start to act in traumatic ways. We’ve got to look after our staff. We’ve got to get the day-to-day care right. That should be the basis of every intervention and the primary focus of support.  Interventions should be driven by the formulation and start where the child is at. So it’s got to be developmental.

So one of the… I suppose an example of that is the structure and routine for a 16 year old might actually involve needing to do a lot more help to get them up, might need to do a lot more in the evening to help them settle at night. It might be a bit weird, but you might have to read to them at night-time, and help them have a routine and not be so standoffish. You might want to read with them. I’m not suggesting we infantilise teenage boys, but you’ve got to work at the level that they’re at. Every interaction matters; we’re all therapists the carer is the expert; the one in front of them is the expert. Really the professionals are the supporters and the advisers. So a lot of it is kind of… It sounds really basic child development in terms of how we parent in these complex things, but it’s not straightforward.  We’ve got to recognise all the different ways attachment patterns and trauma impact on us, where the gaps are, maybe focus on some key staff that just don’t get it, maybe recruiting staff that do; that’s going to take a lot of them. I think we’ve got to develop what we do for these kids from an adult mental illness model. There’s far more going on that those things won’t touch. I’m not suggesting that there always should be dismissed at all, but we’ve got to get the other stuff right first. If we don’t do that, we’re not going to make much change. They’re not going to develop in the way that we would want them to. We’re not going to prepare them for the community or returning to normal relationships on the outside, not going to change their offending behaviour, their [s.l. risk to society 00:35:23].

Okay, so where we are at now, as I’ve said, the new patients [s.l. specs 00:35:30] for inpatient services are out. We eagerly await when we can re-tender or bid for more local provision for the northwest. FCAMHS Northwest is open. Please do get in contact and refer. Speak to myself and Kenny today. We’re going to be commissioned. We don’t know quite how that will happen yet.  We know that we’re going to want to work with YoungMinds as well, so we’ve got the voice of the children. Secure Stairs for recruiting, and hopefully that will make a difference across the country. We are mindful that there’s a lot of money going in at this top end, perhaps particularly psychology. That’s great, but we’re also aware that we haven’t quite seen the funding or the protection of existing services within those lower tiers. So I would certainly endorse that we need to invest far more in CAMHS and schools, SENs, ring fence that funding, stop it being leached out to be put in other budgets.

I’ll leave you with a couple of misquotes before we take any questions. I think it was Nelson Mandela said something like… far more eloquently than I’m about to… Civilised society is judged by how it treats its children. The second thing I’m going to misquote, Dostoyevsky: civilised society can be judged by how it treats its prisoners. So a really civilised society should be judged on how it treats its children prisoners. We’re starting to get a little bit better, but hopefully we’ll have a lot more in place in the coming years, and if these things are a success, that should have an impact in terms of how we treat our adult prisoners as well. And then if we can get some of these ideas working within those secure settings, hopefully that means that they’ll be influencing beyond these locked settings.

Finally I’m co-editor of a book about educating children in secure accommodation. It should be out this year and a lot of it’s based on working with academics and practitioners working in these locked environments, in hospital, Secure Children’s Homes, secure training centres, prisons, the PRUs, all sorts of places. Thank you. Happy to take questions.

Speaker 2 – Thank you. I really enjoyed the presentation. I think, in my experience, part of the history of the [inaudible 00:38:13] much better at evaluating is how the mother of [inaudible 00:38:17] the moment she became pregnant, what happened in that house previously, what happened [inaudible 00:38:22] and in the first year. It’s that first year establishing the trusting relationship versus the mistrust relationship. And if you don’t find out how this happened, then you’re stuck at that developmental level of one or two as a 16 year old in a traumatic situation will revert back to that. And another key factor is if they’ve experienced any… especially [inaudible 00:38:47] experience will have been escalated to abandonment, and they may [inaudible 00:38:49] if not given that chance so that they can still not make an attachment. So there needs to be an evaluation assessment during that period of time. Also from six months to about three and half to see whether it’s secure attachment versus insecure because that will completely change how you approach these kids.  You’re essentially [inaudible 00:38:54] single [inaudible 00:38:56], so everything [inaudible 00:38:58] based on their earliest memories.

Dr. James Millington – No, I agree. I think most of the time I know we generally take care to make sure that we get developmental history and starting with the parents and conception and pregnancy and go from there. I wonder how much that kind of effort we might see in adult services. I think often when you’re handing over to adult services you see them look at under 18 as just one big [s.l. lump 00:39:48] that they’re not monitoring in [s.l. contact 00:39:49] services. So yes, it’s absolutely vital. I know that there’s other public health initiatives to look at adverse childhood experiences. I know that we’re seeing a lot of requests for training for things like attachment trauma and how we move from explaining maybe the origins or [inaudible 00:40:12] and how that might manifest itself in our interactions with them later on. There’s an awful lot in that explanation, which leads to very different ways in which our staff can understand where that sweary attack is coming from and what triggers it. That’s been a vital part of how we trained our staff, so yes, I absolutely agree with you.

Speaker 2 – I think… sorry, just to pick up on what you were saying, that is an absolutely standard part of our developmental history, the whole thing. The first year we’re taught about it.

Dr. James Millington – Anyone else. Okay? Thank you very much.

Speaker 3 – Can you just please summarise a bit for FCAMHS? Because everyone’s here form the northwest and I know you are doing a big launch and information but…

Dr. James Millington – FCAMHS, yes. NHS England have commissioned FCAMHS across England where previously we existed in local CCG packages and then the FACTs team covered of all the UK and Ireland, Northern Ireland. Over the years, we’ve, I suppose, shrunk down into a much more regional service anyway, but we’ve always recognised that there’s a great need for FACTs as it was, and FCAMHS in it’s new model now. So this new money is set up in 13 different regional Forensic CAMHS services and Wales has its own FACTs team now. Northern Ireland has its own different services, and Scotland. We will take referrals from pretty much anyone, so you don’t have CAMHS involvement. You don’t necessarily have to have a [s.l. doctor’s 00:42:08] involvement. A lot of emphasis will be on prevention. We will go anywhere in the northwest to where you are, apart from North Cumbria, which is covered by the northeast service.

I suppose we have different ways in which we can get involved. We like to do it quickly. We can do a consultation, [inaudible 00:42:36]. We can get involved directly and see the young person and family, do an extended assessment if that’s what required. We can have ongoing involvement, so that could be an intervention [inaudible 00:42:51] most important team involved, which are working with the child and family over the setting where they’re in. We might also have, I suppose, less referral based for the [inaudible 00:43:04] work, so we might be able to respond to requests for training. I know I’ve got a meeting planned to work with SENCO at the PRU in Bury and we’ll be looking at how we can pick up the needs from those kind of services as do what do they require. Are there [inaudible 00:43:23] staff or are they managing the violence or sexual health behaviour or intervent risks, which are significant. We’re working with Prevent perhaps, police, so all sorts of services. We’ve got an emphasis on transition as well, so we take referrals under the age of 18 and probably working with cases until we can hand them over properly. We’ve increased our team by… Well we’ve doubled to myself, psychologist, Kenny, the psychiatrist, and we’ve got another psychologist part-time, art therapist, clinical nurse specialist, mental health practitioner at advanced level, an assistant psychologist that’s helping with our evaluation and outcomes, and supporting the clinical work.

What it’s going to go, I would hope it would expand, and our role in terms of our stakeholder engagement could mean that we’re well placed to find out where the gaps are, go back to commissioners as part of the collaborative clinician model and suggest that there’s nothing there, they’ve got a really good model, fund that, [inaudible 00:44:42] health.  We can’t solve all problems, but we’ll try and respond to anything that comes through.

 

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