Download Referral Guidelines for Doncaster GPs

Guidance for GPs on Referral of Children & Young People with
Emotional Wellbeing Issues, Neurodevelopment Issues and
Neurodisabilities
Referrals to Universal Services, Routine CAMHS and Urgent CAMHS referrals
*denotes facility for self-referral
#SAFEGUARDING
– for all of the presenting issues below, GPs should show curiosity and enquiry into the
child’s home environment and association with behaviour(s), as well as parenting capabilities with regards to
mental health, substance misuse and domestic abuse. Please consider with EVERY issue if there are any
safeguarding concerns. If so, whether TAC and CAF are required and liaise with the child’s Health
Visitor/School Nurse to progress the matter further.
Where there are emergency safeguarding concerns please contact Child Protection, R&R: 01302 736636 or
01302 737777
Issue
Symptoms/presenting problems
Point of contact:
Behavioural
Difficulties#
Poor behaviour at home only (including anger outburst, tantrums, etc.)
*Family Support Evidence
Based Interventions visit:
http://www.doncasterchildre
nandfamilies.info/ifss.htm
click on the map at the
bottom of the page to
identify who to talk to about
making a referral.
*Health Visitor (0-4 years) or
School Nurse (5+ years) (see
School Nurse Pyramid or HV
directory for contact details)
School Nurses can also be
contacted by (non-secure)
email:
CYP&[email protected]
hs.uk
*Local Children’s Centre:
01302 862 116
Other information:
Doncaster Family
Information Service http://www.doncasterchildre
nandfamilies.info/
Poor behaviour at school only
*School Learning Mentor
directly or via School Nurse
(see School Nurse Pyramid or
HV directory for contact
details) School Nurses can
also be contacted by (nonsecure) email:
CYP&[email protected]
hs.uk
DMBC Educational
Psychology Service
Referrals in writing or over
the phone.
Address:
Educational Psychology
Service
Doncaster Council
Civic Office
Waterdale
Doncaster
DN1 3BU
Phone: 01302 737291
Severe behaviour in both home & school
Community Paediatrician
(SPOA - use new referral
form)
*Family Support Evidence
Based Interventions visit:
http://www.doncasterchildre
nandfamilies.info/ifss.htm
click on the map at the
bottom of the page to
identify who to talk to about
making a referral.
*Local Children’s Centre:
01302 862 116
Eating
Disorders#
Low level eating issues – will only eat certain foods
Monitoring of BMI by GP or
School Nurse (see School
Nurse Pyramid or HV
directory for contact details).
School Nurses can also be
contacted by (non-secure)
email:
CYP&[email protected]
hs.uk
Public Health Dieticians
Nutrition and Dietetic
Department
Doncaster Royal Infirmary
Armthorpe Road
Doncaster
DN2 5LT
Phone: 01302 366666 ext.
4110
Low level eating issues and physically unwell also
Acute paediatrics via Choose
& Book or by letter to
Booking Team via email:
[email protected]
or fax: 01302 647073
– encourage open referrals
(rather than to a named Dr)
for all general (Acute)
paediatric clinics.
Anorexia Nervosa:
• Weight loss, or lack of weight gain, leading to weight at least 15%
below expected
• Weight loss is self-induced by avoidance of “fattening foods”
• Self-perception of being too fat, with fear of fatness
• Endocrine changes (e.g., amenorrhoea)
Bulimia: Persistent binge & purge behaviour

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CAMHS (Routine).
If in doubt about urgency of
referral contact our duty
team who are available until
5pm. After 5pm refer to A&E
who will refer to CAMHS out
of hours.
Body Mass Index 18.5 – 25 (normal)
Body mass percentage less than 85% of that what it should be
A constant focus on food, dieting and exercise.
Insistence on having meals separate from the family.
Feeling stressed when unable to exercise.
Increasing social withdrawal, frequent weighing and frequent trips to
the toilet immediately after meals.
For both:
 A normal Body Mass Index (BMI) of between 18.5 – 25:
BMI = weight (kg)/height (m) 2

A Body Mass Percentage of less than 85% is a concern (this
measurement is preferred over BMI):
Body Mass Percentage = Actual BMI x 100/Median BMI (for age and
height)
Suggested tests to be taken prior to referral:
i.
Height, weight, blood pressure (lying and standing).
ii.
Blood test investigations. (Findings suggestive of a suspected eating
disorder.) 







Full Blood Count (Mild leucopenia or thrombocytopenia from
malnutrition; Anaemia from malnutrition or gastrointestinal
losses)
Urea and electrolytes# (Hyponatraemia from excess water
intake; Hypokalcaemia from vomiting; Metabolic alkalosis
from vomiting)
Random blood glucose (Rarely low)
Calcium, phosphate and magnesium (Hypocalcaemia,
hypomagnesia and hypophosphataemia – uncommon)
Liver Function Tests (Slight elevation from malnutrition,
albumin normal unless very chronic)
Follicle stimulating hormone (FSH) leutinising hormone (LH)
and oestradiol (Suppressed FSH and LH-oestradiol usually
low)
Vitamin D (Low from malnutrition)
Haematinics-iron studies, B12 and folate (If indicated-low
from malnutrition)
#

May also be raised due to dehydration.
BMI below 18.5
Acute paediatrics via Choose
& Book or by letter to
Booking Team via email:
[email protected]
or fax: 01302 647073
– encourage open referrals
(rather than to a named Dr)
for all general (Acute)
paediatric clinics.

Anxiety
/Disorders#
If any other concerns about physical health status
Worrying about specific situations e.g.,
 separation anxiety
 anxiety around exams
 moving schools etc.
CAMHS (Urgent) - If after
5pm send to A&E who will
refer to CAMHS out of hours.
* Learning Mentor or
equivalent role in school
directly or via School Nurse
(see School Nurse Pyramid or
HV directory for contact
details)
School Nurses can also be
contacted by (non-secure)
email:
CYP&[email protected]
hs.uk
Jigsaw (Age 11-19). Referral
form on request, please
contact: 07786198675 or
07917031899 or email:
[email protected]
or [email protected]
If you are a System one user
you will find a copy of it on
the system and can task it to
a member of the team.
Severe, persistent anxiety
 Panic attacks
 Attachment disorders (If diagnosed)
 Severe and disabling phobias (Social and specific phobias)
CAMHS (Routine)
GPs should absolutely not prescribe anti-depressants to patients before they
have been assessed by CAMHS. There are clear processes and guidelines that
CAMHS follow when prescribing, all young people need to have –
 A mental health assessment
 Brief intervention
 High Risk Assessment team meeting for a request for Psychiatric
Assessment
 Psychiatric Assessment to decide whether medication is
indicated-or CBT without medication
 Trial of medication if young person and family agree
 Titration of medication to therapeutic levels as per Maudsley
Prescribing Guidelines, with particular care to be taken during the
titrating of Fluoxetine (first line choice for young people)
Mood Disorder
or Depression#
Low mood, not impacting on daily life and no risk evident (no suicidal thoughts
or self-harm).
*Learning Mentor or
equivalent role in school
directly or via School Nurse
(see School Nurse Pyramid or
HV directory for contact
details). School Nurses can
also be contacted by (nonsecure) email:
CYP&[email protected]
hs.uk
Jigsaw (Age 11-19). Referral
form on request, please
contact: 07786198675 or
07917031899 or email:
[email protected]
or [email protected]
If you are a System one user
you will find a copy of it on
the system and can task it to
a member of the team.
Persistent low mood. (Only refer if symptoms present for at least 2 weeks)
 Physical symptoms – poor sleep (or early wakening) or loss of appetite
and weight. (Only refer if symptoms present for at least 2 weeks)
 Cognitive symptoms inc. pervasive negative thoughts (Only refer if
symptoms present for at least 2 weeks).
 Loss of interest/Social isolation/withdrawal seen at home and school.
(Only refer if symptoms present for at least 2 weeks)
 Suicidal thoughts without planned intent (discuss urgency of referral
with team)



Post-Traumatic
Stress Disorder#
Deliberate Self
Harm#
Suicidal thoughts with planned intent REFER URGENTLY.
Suicidal thoughts without planned intent (discuss urgency of referral
with team)
Previous attempts to end life
Symptoms following an event extremely traumatic to the individual, continuing
longer than three months following event.
 Avoidance of reminders of the traumatic event.
 Persistent anxiety.
 Repeated enactment of reminders of the traumatic event.
 Intrusive thoughts and memories – e.g. nightmares.
 Sleep disturbance.
 Hypervigilance.

Presenting with maladaptive coping strategies but less
severe/frequent/recent.
Always discuss case with duty team to help guide urgency
 Presenting with maladaptive coping strategies (e.g. self-cutting and
where recent occurrence).
Obsessive
Compulsive
Disorder (OCD)#
Relationship
Difficulties#


Repetitive, intrusive thoughts, images or behaviour affecting daily life
& activity.
Obsessions/compulsions causing functional impairment (not if
diagnosed with ASD)
General relationship difficulties
CAMHS (Routine)
CAMHS (Urgent) if after 5pm
refer to A&E who will then
refer to CAMHS out of hours
CAMHS (Routine)
CAMHS (Routine)
CAMHS (Urgent)
CAMHS (Routine)
*Learning Mentor or
equivalent role in school
directly or via School Nurse
(see School Nurse Pyramid or
HV directory for contact
details) School Nurses can
also be contacted by (nonsecure) email:
CYP&[email protected]
hs.uk
Jigsaw (Age 11-19). Referral
form on request, please
contact: 07786198675 or
07917031899 or email:
[email protected]
or [email protected]
If you are a System one user
you will find a copy of it on
the system and can task it to
a member of the team.
Persistent patterns of abnormal functioning in interpersonal relationships.
*Family Support Evidence
Based Interventions visit:
http://www.doncasterchildre
nandfamilies.info/ifss.htm
click on the map at the
bottom of the page to
identify who to talk to about
making a referral.
*Anti-bullying Officer directly
or via School Nurse (see
School Nurse Pyramid for
correct contact details)
Suspected
Autism
Spectrum
Disorder (ASD)#
Where family dynamics are fractured and conflicts unresolved.
CAMHS (Routine)
If requesting an ASD assessment or concerns following diagnosis
Community Paediatrician
(SPOA - use new referral
form)
If diagnosed with ASD and where there is an underpinning concern about a
mental health problem
CAMHS (Routine)
Other information:
Autism Spectrum Information
Centre, phone: 01302 737
493 or Email:
autisminformation@doncast
er.gov.uk
Aiming High for Disabled
Children, phone: 01302 862
332 or email:
aiminghighbusinessunit@don
caster.gov.uk
Suspected
Attention
Deficit
Hyperactivity
Disorder
(ADHD)#
For children suspected of ADHD and under 7 years of age or concerns following
diagnosis.
Community Paediatrician
(SPOA - use new referral
form)
Psychosis or
suspected
psychosis#
Criteria for Routine / Urgent referrals – Always discuss with duty team to assist
decision making re urgency.
 Active symptoms inc. paranoia, delusional beliefs & abnormal
perceptions, (hearing voices & other hallucinations). Fixed, unusual
ideas.
 Negative symptoms inc. deterioration in self-care & social & family
functioning.
CAMHS (Routine)/CAMHS
(Urgent)

If child over 16 refer to early intervention in psychosis team.
*Early Intervention in
Psychosis Team. Referrals in
writing or over the phone.
Address:
Jade Centre
Askern Road
Bentley
Doncaster
DN5 0JR
Phone: 01302 821410
Conduct
Disorder#

Very severe and persistent behavioural problems, at home, school
and in the community, and unresponsive to parent training.
If school related – preferable for school/ Educational Psychologist to
make referral with relevant background information.
CAMHS (Routine)
Gender Identity
Disorder#

Initial exploration of issues
*School Nurse (see School
Nurse Pyramid or HV
directory for contact details).
School Nurses can also be
contacted by (non-secure)
email:
CYP&[email protected]
hs.uk


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Strong, persistent cross-gender identification.
Persistent discomfort in gender role.
Above causing impairment in social, family and school functioning.
CAMHS (Routine)

Refer to Community Paediatrician in first instance.
Community Paediatrician
(SPOA - use new referral
form)


Excessive fatigue
Unexplained medical symptoms
CAMHS (Routine)
Chronic
Fatigue/
Somatisation
Disorder#
Bereavement
response#

Within three months of bereavement
 If child is experiencing significant distress following death that has
occurred within traumatic circumstances e.g., suicide.
*Cruse Bereavement Care
Referrals in writing or over
the phone.
Address: 109 Thorne Rd
Doncaster
South Yorkshire
DN2 5BE
Phone: 01302 814 647
After three months of bereavement
 If child is experiencing significant distress following death that has
occurred within traumatic circumstances e.g., suicide.
CAMHS (Routine)
Enuresis or
complex soiling# Moderate
Mild to Severe
*Health Visitor (0-4 years) or
School Nurse (5+ years) (see
School Nurse Pyramid or HV
directory for correct contact
details). School Nurses can
also be contacted by (nonsecure) email:
CYP&[email protected]
hs.uk
*Community Clinics for
Children with Constipation,
Soiling , Nocturnal Enuresis
by self-referral –
Sandringham Road Health
Centre; Fridays weekly,
09.00am-12.00
Bentley Children's Centre;
Tuesday fortnightly,
9.00am-12.00
Denaby Springwell Centre;
Wednesday fortnightly,
13.30-17.15
Orchard Centre Moorends;
Tuesday fortnightly, 13.3017.15
Overdose#
Refer to Tier 3 CAMHS service
CAMHS (Urgent)
Substance
Misuse#
excluding
alcohol
Refer to Young People’s Drug and Alcohol Service
*Better Deal
Referrals in writing or over
the phone.
Address: New Beginnings
Marshall Avenue
Balby
Doncaster
DN4 0QP
Secure fax: 01302 571261
Phone: 01302 571260
Teen
pregnancy#
Tier 1 support as part of Family Nurse Programme
*Family Nurse Partnership
Referrals in writing or over
the phone.
Address: Sprotbrough Clinic
Melton Road
Sprotbrough
DN5 75B
Phone: 01302 786 982
Sexual abuse
People who have been sexually abused or raped can have different feelings or
reactions to their situation:
 Having bad dreams or nightmares
 Imagining that everyone knows what has happened
 Feeling ugly or dirty
 Having problems concentrating
 Trying or wanting to hurt yourself
 Feeling like running away
 Feeling ashamed
*Doncaster Rape and Sexual
Abuse Counselling Service
(DRASACS) Referrals in
writing or over the phone.
Address:
DRASACS
PO Box 470
Doncaster
DN1 3XW

Cerebral Palsy#
Thinking it is your fault

Concerns from parents e.g., visual problems, hearing problems,
feeding problems, epilepsy etc.

Urgent medical needs
Phone: 01302 360421
Referral required to Child
Protection – R&R
Phone: 01302 736636 or
01302 737777
Community Paediatrician
(SPOA - use new referral
form)
Acute paediatrics via Choose
& Book or by letter to
Booking Team via email:
[email protected]
or fax: 01302 647073
– encourage open referrals
(rather than to a named Dr)
for all general (Acute)
paediatric clinics.
Downs
Syndrome#
Any physical issues e.g.,
 cardiovascular problems
 hearing problems
 visual problems etc.
Check practice notes – all
children with Downs
Syndrome should be under
surveillance by a community
paediatrician. If not then
refer to
Community Paediatrician
(SPOA - use new referral
form)
Motor &
Language
Issues#
Any concerns from parents/ Health Visitors /Nursery staff around delays e.g.,
 not walking by 18 months
 not babbling by 12 months (check hearing first)
 regression etc.
Community Paediatrician
(SPOA - use new referral
form)
Physical
disabilities#
E.g.,
Community Paediatrician
(SPOA - use new referral
form)



Achondroplasia
Neurofibromatosis
any concerns following an accident or meningitis
Process to be followed for CAMHS referral:1. In order to effectively triage a referral, please provide the contact telephone number for the patient.
2. Referrals will be acknowledged within 5 working days, with the aim to have an initial appointment within 28 working days
of receipt of referral. Urgent referrals are seen within 24 hours. If available, a copy of the Common Assessment
Framework (CAF) should also be provided and parent/carer/patient permission demonstrated.
3. Following Initial Assessment – Needs are identified & where appropriate a management plan communicated to the referrer.
Where appropriate, referrals may be signposted to other services but only where patient contact details and consent is provided
with the referral.
CAMHS Referrals should be sent with the patient and/or family’s consent and using the agreed CAMHS referral form, or provide the
required referral information in your letter (see ‘CAMHS Referral Checklist’) to:- The Duty Team, Doncaster Child & Young People’s
Mental Health Service, Unit 3, Balby Court, Carr Hill, Balby, Doncaster DN4 8DE. Tel: 01302 304070 Fax: 01302 304077
DO NOT REFER
Do not refer if not stated in the above list. If in doubt please discuss with the CAMHS Duty Team (available until
5pm).
Out of Hours CAMHS clinician criteria:
Access to CAMHS clinicians outside of office hours (i.e., Mon- Fri, 9am-5pm) will be considered using the current criteria for ‘urgent’
assessments during office hours, i.e.:
•
Children and young people expressing suicidal thoughts
•
Self harm- which may have required minimal medical intervention, but not requiring admission to a paediatric ward
•
Rapid weight loss and a low BMI
•
Symptoms of psychosis (hallucinations, delusions etc) causing distress
o
If a child or young person presents to Accident and Emergency having taken an overdose/ self-harm which requires medical
attention anyone under the age of 16 years of age should be admitted to the paediatric ward as per NICE guidelines
Access to CAMHS clinician:
Young people below the age of 16 years:
Access to the CAYPMHS clinician will be made via the locality crisis team and assessments will be completed within the local hospital
environment. The member of staff undertaking the assessment will be responsible for informing the appropriate CAMHS team of
each case and transfer information to ensure on-going care delivery as needed.
The CAMHS clinician will be encouraged to discuss the case and assessment with the medical director or other consultant psychiatrist
on their return work.
16-18 year olds:
Crisis and Home treatment teams would provide assessments and support to young people aged 16-18 years out-of-hours via the
same access route as adult services currently have in place per locality. The CAYPMH team would provide assessment for people
under the age of 16 years and complete joint assessments with people aged 16-18 years with more complex presentations.
The criteria for joint assessments for 16-18 yr olds is to be developed between CAYPMHS and Crisis teams
•
Dual diagnosis- mental health and ASD/ ADHD/ LD
•
Complex safeguarding issues
•
Looked after children with complex social situation
Lead Consultants
Lead GP
Date Approved:
Review Date: