Post on 03-Jul-2020
1 Modelling THRIVE –Warrington
THRIVE: Adopting a new model of practice THRIVE is described by its originators as “a radical shift in the way that services are conceptualised and
potentially delivered”.1 Rather than adopting the tiered approach that determines need in relation to
types of service provision, the THRIVE model tries to identify “resource-homogenous groups ... who
share a conceptual framework as to their current needs and choices.” In doing so, it creates four
“clusters” or “groups” of types of young people with mental health issues among the wider population
in the community who are “thriving”. These groups are:
Getting Advice
Getting Help
Getting More Help, and
Getting Risk Support
The THRIVE model is set out diagrammatically below.
Figure 1: The THRIVE model
1 THRIVE Elaborated, Anna Freud Centre and The Tavistock and Portman NHS Foundation Trust,.2015, p.6
Thriving
2 Modelling THRIVE –Warrington
The groups – or “clusters” as they will be termed in this report – are intended to be distinct in relation
to:
The needs of the young people in each group
The skill mix required to work with the young people in each cluster
The dominant metaphor used to describe the needs of young people in the cluster (for instance
whether young people are described in terms of ill-health or needing support)
The resources required to work with young people in the clusters
It is important to note therefore that the clusters do not focus on diagnostic need – that is, “There is no
one-to-one relation between severity or type of problem and grouping.”2
The authors describe the clusters thus:
Getting advice: one to three contacts and ending by mutual agreement. This level of support is
sufficient to normalise behaviour and provide reassurance
Getting help: children and young people who benefit from goal-focused, evidence-based
interventions with clear aims
Getting more help: children and young people who would benefit from extensive long-term
treatment which may include in-patient care or extensive out-patient care
Getting risk support: children and young people who are unable to benefit from evidence-based
treatment but remain a significant concern or risk, including those who routinely go into crisis or
don’t make use of help
Thriving: all those children and young people who do not need individualised mental health
advice or support. This population is supported by prevention and promotion initiatives
As outlined above, the THRIVE model (or framework as the authors refer to it) conceptualizes five
needs based groupings for young people with mental health issues with children and young people
being grouped according to their needs.
2 Ibid., p,9
3 Modelling THRIVE –Warrington
Current provision and THRIVE The following section seeks to understand the level of demand for children and adolescent mental
health provision in Warrington CCG areas and therefore what the potential demand might look like in
each of the THRIVE clusters. Using data provided by the CCG, current caseload information has also
been mapped using the THRIVE authors apportions for differing clusters.
Total young people’s population
For the purpose of the mapping exercise the population total has been taken from information provided
by Warrington CCG. Population estimates for 2016 suggest that the total of children and young people
in Warrington aged naught to 17 inclusive is 44,823.
Prevalence data for mental health issues among children and young people in the UK is vastly out of
date – the occurrence of mental health issues in children and young people was last surveyed nationally
in 20043. It was identified that one in ten children and young people aged 5 – 16 had a clinically
diagnosed mental health disorder4.
There is very little data regarding specific age groups and the prevalence of mental health issues, the
Mental Health Foundations report, “Fundamental Facts about Mental Health 2015”, identifies the only
research into preschool age children as dating from 1993, where it was estimated that the prevalence
for behavioral difficulties was 10%5. Furthermore, data from the 2014 Adult Psychiatric Morbidity
Survey: Survey of Mental Health and Wellbeing, suggests that the prevalence of mental health issues
amongst young women aged 16 to 24 has increased dramatically over recent years with one in 4 16-24
years olds (26%) reporting common mental disorder symptoms compared with 9% of males in the
same age category6. However, what the research does show is that mental health prevalence increases
with age.
Public Health England has produced a Children and Young People mental health and wellbeing tool kit,
which collates and analyses a wide range of publically available data. Within this dataset is prevalence
data for the estimated prevalence of any mental health disorder. This is a percentage of the GP
3 Mental health of children and young people in Great Britain, 2004
4 Figures taken from http://www.youngminds.org.uk/training_services/policy/mental_health_statistics 26/09/2016
5 https://www.mentalhealth.org.uk/sites/default/files/fundamental-facts-15.pdf, pg 31, 07/11/2016
6 http://content.digital.nhs.uk/catalogue/PUB21748/apms-2014-exec-summary.pdf, pg 8, 07/11/2016
4 Modelling THRIVE –Warrington
registered population aged 5-16. A profile has been created for each CCG. Figures provided for
Warrington CCG estimate the level of prevalence at 8.9% 7 Thus for the purpose of this report,
instances of mental health among children and young people have been estimated as 8.9% of the
population of young people aged naught to 17 a total of 3,989.
Chart 1 provides a breakdown of the population by age groups and an estimated prevalence for each
group and the overall total.
Chart 1: Young people population for Warrington by age groups and estimated prevalence
NHS England has introduced a new indicator, the objective of which is to improve access rates to
mental health services for children and young people. The overall objective is for at lest 35% of children
and young people with a diagnosable mental health condition to receive treatment from an NHS
7https://fingertips.phe.org.uk/profile-group/mental-
health/profile/cypmh/data#page/0/gid/1938132753/pat/46/par/E39000026/ati/19/are/E38000194, accessed 12/1/17
5 Modelling THRIVE –Warrington
funded community mental health service. NHS England has set out a five year national trajectory for
CCGS8.
From a reading of the THRIVE Elaborated report (an update on 2015 of the original THRIVE paper), the
authors indicate that 80 to 90% of young people can be said to be Thriving9.
Of the remaining 10 – 20% of young people:
30% fall into the Getting Advice cluster10
60% fall into the Getting Help cluster11
5% fall into the Getting More Help cluster12
5% fall into the Getting Risk Support cluster13
These weightings have been applied to the local population of young people. The results are set out at
Table 1.
The results from Table 1 indicate that somewhere between 4,482 and 8,965 falls into one of the clusters
in which some form of mental health intervention would prove beneficial (i.e. the population that is not
Thriving).
8 https://www.england.nhs.uk/wp-content/uploads/2015/12/joint-technical-definitions-performance-activity.pdf (accessed 12/1/17)
9 THRIVE Elaborated, Wolpert et al, 2015, p.17
10 Ibid, p.19
11 Ibid, p.21
12 Ibid, p.22
13 Ibid, p.23
6 Modelling THRIVE –Warrington
Table 1: Total Warrington young people’s populations by THRIVE clusters
Predicted % in
groupings: 90% of
young people
thriving
Number Predicted % in
groupings: 80% of
young people
thriving
Number
Thriving 90 40,341 80 35,858
Getting Advice 3 1,345 6 2,689
Getting Help 6 2,689 12 5,379
Getting more help 0.5 224 1 448
Getting Risk
Support
0.5
224
1
448
Total 100 44,823 100 44,823
Current CAMHS provision and THRIVE Using data provided by Warrington CCG, it is possible to provide an estimate of the numbers of young
people who may fall into each of the THRIVE clusters. Both CCGs reported that there are issues around
data collection and the information available about who is attending the services.
Current CAMHS caseload – THRIVE author weightings
The weightings as developed by the authors of THRIVE were used to develop a picture of what the
current CAMHS caseload might look like when described in terms of THRIVE clusters.
Warrington
For Warrington, the analysis is based on data for the year ending March 2016. Information was
available for three services, CAMHS Tier 2, CAMHS Tier 3 and St Josephs which provides services for the
CCG. The total recorded treatment population for Warrington in 2015/16 was 1,641. This equates to
some 4% of the agreed population of young people in the area, or some 37% of those what may benefit
from mental health support.
7 Modelling THRIVE –Warrington
Table 2 shows the treatments population for 2015/16 apportioned using the THRIVE authors
weightings.
Table 2: weightings per cluster and applied to current treatment population in Warrington using THRIVE authors weightings
Predicted % in groupings Current treatment population
Getting Advice 30 492
Getting help 60 985
Getting more help 5 82
Getting risk support 5 82
Total 100 1,641
Table 3 compares the current recorded treatment population with the prevalence figures as outlined in
Table 1. As explained earlier, the current treatment population equates to 37% of those who may
benefit from some support.
Table 3: weightings per cluster for Warrington – comparing the prevalence where 90% are Thriving and current treatment population
Expected prevalence figures using 90%
who are THRIVING
50% of expected
prevalence
Current treatment
population
Getting Advice 1,345 673 492
Getting help 2,689 1,345 985
Getting more help 224 112 82
Getting risk
support 224 112 82
Total 4,482 2,241 1,641
8 Modelling THRIVE –Warrington
As outlined in the section above, NHS England has introduced a new target aimed at improving access
to mental health services for children and young people. Warrington CCG has been provided with an
access target of 1,192 by the end of March 2018. This figure falls within the 50% of expected prevalence
as outlined in Table 3. The target is part of a five year national trajectory for CCGs where the target will
reach 35% of prevalence by 2020. Any plans for the commissioning of services should take this increase
into account as the target will increase year on year.
As the THRIVE model is based upon the assumption that between 80% and 90% of the population as
‘Thriving’ the decision has been made not to include any analysis that relates to the new target and how
it would look against the THRIVE model as the information is not comparing like for like.
Furthermore, the current data collection does not match the definition of treatment as per the new
target, where treatment is defined as “at least 2 contacts (including indirect contacts) in relation to the
same referral”.14 Going forward, the CCG will need to ensure that any data collection is robust in order to
support the new access target. Anecdotally, the CCG is closer to meeting the target than their data analysis
suggests, and the THRIVE mapping indicates that almost half of those may need some support are
accessing services, however it is not possible to identify where clients are being counted multiple times.
Allocation of financial resources
Within the most recent edition of the THRIVE model, the authors have developed an “algorithm” which
seeks to allocate young people and families to the THRIVE groupings. The authors reviewed 15 existing
NICE guidelines (11 specifically for children and four for adults but with reference to children) and used
these to assigns children and young people in mental health services to three categories in the THRIVE
framework, namely:
Getting Advice,
Getting Help, and
Getting More Help
Within each of these three categories (Getting Advice, Getting Help, Getting More Help) the authors
identified subcategories corresponding to NICE guidelines to develop a more in-depth picture of the
profile of each category. The needs based groupings as devised by the authors are set out below.
14
https://www.england.nhs.uk/wp-content/uploads/2015/12/joint-technical-definitions-performance-activity.pdf, Pg. 40 (25/01/17)
9 Modelling THRIVE –Warrington
Table 4: THRIVE needs based groupings
Getting advice
Getting help Getting more help
Neurodevelopmental assessment
Signposting and self-management
ADHD
Depression
Conduct Disorder
Anxiety Disorder
Autism Spectrum
OCD
GAD/Panic Disorder
PTSD
Self-harm
Psychosis
Eating Disorders
Potential BDP*
Post-traumatic stress disorder
* Borderline personality disorder
The above information is useful for any future service specifications as it will allow the CCGS to align
their services with the THRIVE model to ensure NICE guidelines are met and thus data analysis can also
be consistent.
These needs based groupings relate to the payments system groupings which are closely aligned to the
THRIVE model. The payments systems attempt to capture a more complete picture of the work done
by clinicians and develop a system by which payment is determined by need. As identified in the
THRIVE Elaborated report, the algorithm did not fit neatly with actual resource use. However, the
authors provide a predicted percentage of resource use for a typical service.
10 Modelling THRIVE –Warrington
Table 5: Predicted resource use for needs-based grouping from payment systems project analysis
Predicted % resource use for a
typical service
Informal confidence range for
predicted resource use
Getting Advice 24% 20%-29%
Getting Help 59% 53%-65%
Getting more help 16% 13%-22%
Total 100% --
It should be noted that these predictions are only based on face-to-face work as the data quality for
indirect work was too poor and also no data was known about the overall cost of staff, thus each
contact was treated as equal resource use. Furthermore, the authors also state that the confidence
interval is not precise.
In addition to these predicted resource use percentages, the authors provide a hypothetical allocation of
resources to the THRIVE clusters. This hypothetical allocation takes into consideration the above
analysis (based on the payments systems) but also assumes “resource use that follows tighter allocation
to clusters and includes hypothesised use of groupings not addressed in the payments systems work
11 Modelling THRIVE –Warrington
but core to THRIVE: thriving and risk support.”15 Thus, Table 7 details the hypothetical resource use as
defined by the authors.
Table 6: Hypothetical resource use in NHS outpatients CAMHS after implementing THRIVE
Needs based groupings Hypothetical % resource use
(direct appointments only)
Hypothetical % overall
resource use
Getting advice 10% 8%
Getting help 66% 56%
Getting more help 16% 14%
Getting risk support 8% 7%
Thriving n/a 15%
Total 100% 100%
For the purpose of this report, a financial model has been created using the THRVE authors hypothetical
allocation across the four clusters (Shown in column two in Table 7). Based on discussions with the
Commissioning Manager for Warrington CCG a projected spend for 2016/17 has been agreed as the
basis for the model. The services included in the total baseline figures are;
CAMHS
15
Ibid, pg. 16.
12 Modelling THRIVE –Warrington
St Josephs
An uplift based on previous years spend
Tier 3 CAMHS
Tier 2 CAMHS
Thus, Graphic 1 is based on a spend of £2,158,995.
Graphic 1: Allocation of resources using the THRIVE authors hypothetical allocation based on projected spend for 2016/17.
13 Modelling THRIVE –Warrington
For the purpose of the modelling exercise, the cost of School Health, Health visiting and the family
nurse partnership has been excluded from the calculations. The majority of these services will fall
within the Thriving cluster, possibly with the exception of the work of the family nurse partnership,
however at this time it has not been possible to get a breakdown of each service. It should also be
noted that the total does not include any funding for those with neurodevelopmental conditions.
One other element of funding has been excluded from the analysis. From the beginning of February
2017 Warrington CCG has commissioned a service for Eating Disorders totalling £177,960. Whilst this
spend forms part of the overall budget for emotional health and well-being, due to the contract starting
in 2017 this amount of funding is now committed to the service and has not been used as part of the
modelling exercise. The contract is due to run for 3 years. It should also be noted that a further element
of spend has been committed to fund a nurse prescriber for the ADHD pathway totalling £52,750,
including on cost.
External funding elements
Significant levels of investment are made in children and young people’s emotional health and well-
being services by non-NHS organisations (particularly Local Authorities). For the purpose of this report
Warrington CCG has identified a number of services which fall within the remit of being Local Authority
funded services which provide an element of support for emotional health and wellbeing in children and
young people. These are:
Risky Behaviour Pathways
Drug and Alcohol Pathway
The Risky Behaviour Pathway – Service overview
This service is delivered by Warrington Youth Service to all Warrington high schools to deliver educative
and effective workshops to all year 7 and year 10 pupils. These workshops include the following topics
Resilience, Smoking, Relationships, CSE, Drugs, Cannabis use, Exam Pressure, Sexting and
Pornography. The workshops are followed up with a 6 week drop in session that is delivered from our
Mobile Youth Bus these are more informal sessions and youth workers use interactive activities and
14 Modelling THRIVE –Warrington
discussions to deliver issue based work such as C card deliver, drug and alcohol interventions, wellbeing
talking kits and IAG.
Youth workers are trained to identify any young people they feel maybe at risk or are in need of further
support from our service. All schools are aware of the work we deliver and the pathways into our service
for young people requiring further support.
The Youth Service currently delivers at Orford Youth Base, Warrington Youth Café and across the town
in the evening using the Mobile Youth Bus resource. There are also 4 intensive group work sessions that
are referral based. These include GLYSS the LGBTQ group at the youth café, UFI – supporting
vulnerable young people who have experienced isolation, bullying, LDD , Girls Group intensive group
work for young women, Bike and Brew – intensive bike project for young people aiming to learn new
skills build confidence and self-esteem.
Drug and Alcohol Pathway
This service offers Tier 3 support to young people aged 11 to 19 with problematic drug and or alcohol
issues. Warrington Borough Council youth workers use 1-1 interventions that strengthen young
people’s resilience to substance misuse. Youth workers prioritise developing positive relationships to
support young people to engage in meaningful activities such as positive leisure time or sport and work
with young people to achieve realistic goals around their substance use. WBC Youth workers provide
psychosocial, harm reduction care plans focussing on goal settings, solution focussed outcomes and
family. All 1-1 support is delivered on a voluntary basis and is based on the consent of the young person
to engage.
The associated spend for these services are detailed in Table 8 below.
Table 7: Non-NHS services which provide emotional health and wellbeing support annual spend
Service Commissioner Annual Spend
Risky Behaviours Team Public Health £167,000
Drug and Alcohol Pathway Youth Service £67,000
Total £234,000
15 Modelling THRIVE –Warrington