Figure 2: Cheshire and Merseyside CYPMH Pathway
All young people accessing specialist community CYPMH services should have a CNEST tool completed to Identify any unmet needs. Clinicians should work across all agencies to share information and meet young person and family needs. If a young person is HIGH risk of admission on CNEST, they should be discussed at the local Gateway meeting.
Multi-agency Gateway meetings are held in each place across Cheshire and Merseyside to meet the needs of young people who have moderate to severe mental health difficulties and/or high levels of risk of self-harm and suicide and are:
- at risk of admission to Tier 4 CAMHS
- awaiting discharge from Tier 4 CAMHS
- delayed discharge from Paediatric wards
- at risk of care placement breakdown
- at risk of custody
Gateway meetings are designed to ensure that the local system takes collective responsibility for the care and welfare of their young people. If the Gateway meeting is not successful at resolving the needs of the young person, the local system can call a resolution meeting. There are several key principles of Cheshire and Merseyside CYPMH Support and Escalation Framework:
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Place-based resolution meetings can be convened when:
- there is significant clinical disagreement about the needs of the young person
- there is no suitable provision available locally for the young person
- there is disagreement about funding for provision for the young person
Place-based resolution meetings involve senior members of the local authority, CYPMH provider, acute trust and health commissioner. It may also include Place Director. For any escalations beyond the Gateway meeting, a risk / benefit form should be completed alongside the SBAR to allow Level 2/3/4 attendees to understand the young person’s needs and associated risks and benefits of different care settings: this should be completed in collaboration with all agencies involved (see Appendix 3).
If significant place-based disagreements about needs, provision or funding continue, an ICB level resolution meeting can be sought by the Place Director. Cheshire and Merseyside ICB cannot direct local authorities or individual provider funding decisions but can facilitate discussions between commissioners and providers. This should only happen in exceptional circumstances.
If significant place-based disagreements about needs, provision or funding continue, and ICB level resolution meeting has not reached a decision, an NHSE NW region resolution meeting can be sought by the Place Director. This should only happen in exceptional circumstances.
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Level 1: Gateway meeting (can be called urgently)
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Criteria for escalation |
Referral process |
Lead Agency |
Membership (may vary) |
Responsibilities of meeting |
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CYP at risk of admission to Tier 4 CAMHS
CYP medically fit for discharge and remaining in the current environment (usually acute ward, A&E, paediatrics, Tier 4) is not in their best interests and is deemed unsafe. |
CNEST – High risk of admission / Red on Dynamic Support Database and SBAR |
Multi-agency (Chair = usually health commissioner) |
Place Based Commissioner LA Social Care – Social Work Manager
Acute Trust – Ward Manager / Matron
Tier 4 AOT Service
Tier 4 LPC (Clinical Case Manager / Commissioning)
Community CYPMH Transitions Teams
Education As above Acute Trust Named Nurse for Safeguarding |
Regular scheduled meetings to discuss CYPs at risk of admission, with a multi-agency response to support needs.
Group agrees shared ownership of risk, with a solution focussed approach.
To agree and implement solutions (ie from formulation and care plan).
To be assured that internal escalations have been undertaken for acute trust, MH, social care.
To understand legal status, capacity/consent, ensure access to advocacy is available. |
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Level 2: Place based resolution meeting
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Criteria for escalation |
Referral process |
Lead Agency |
Membership (may vary) |
Responsibilities of meeting |
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CYP remains in an unsafe/inappropriate environment and there is disagreement about the care pathway or no timely solution available. |
CNEST /DSD / SBAR / risk benefit analysis |
(Chair = usually health senior commissioner/lead) |
The same agencies but more senior members. Place Senior Commissioners / Place Associate Director of Quality LA Director Children’s Services Community CYPMH Trust Associate Director Acute Trust Director / Chief Nurse / HON Tier 4 CAMHS LPC Director (if appropriate) |
Facilitate a discussion and consensus on a clinical formulation if this has not been reached at Level 1.
Ability to make decisions/agree plans that are outside of current service provisions. |
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Level 3: Cheshire and Merseyside Integrated Care Board resolution meeting
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Criteria for escalation |
Referral process |
Lead Agency |
Membership (may vary) |
Responsibilities of meeting |
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CYP remains in an unsafe/inappropriate environment and there is disagreement about the care pathway or no timely solution available. |
CNEST /DSD / SBAR / risk benefit analysis |
Place (chair – usually place director) |
Executive Director of Nursing and Care (ICS) SRO CYPMH ICS Place Director or Associate Director of Quality LA Director Children’s Services / Exec Community CYPMH Trust Associate Director Acute Trust Director / Chief Nurse / HON Tier 4 CAMHS LPC Director (if appropriate) |
To support solutions at place level and ensure that the decision makers are involved from all agencies.
To be assured that there is a clear understanding of the legal status, capacity, consent and rights.
If there are ongoing disagreements about clinical formulation, the Executive Director of Nursing & Care should facilitate a dialogue, involving relevant medical directors.
Recognise themes/ gaps in commissioning.
Notification to NW NHSE Regional Team when Level 3 escalation threshold reached and share plan/agreed solution at this point for assurance. |
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Level 4: Regional NHSE resolution
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Criteria for escalation |
Referral process |
Lead Agency |
Membership (may vary) |
Responsibilities of meeting |
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This should be the exception with all cases resolved at Place or ICB level. |
Email england. |
Place Director |
Key representatives from Level 3 Regional SRO Regional Team |
To be assured that levels 1-3 have been followed appropriately, when all local escalation processes exhausted, but with retained responsibility remaining locally. |