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