Y Pwyllgor Plant, Pobl Ifanc ac Addysg - Y Bumed Senedd

Children, Young People and Education Committee - Fifth Senedd

07/02/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Hefin David
Julie Morgan
Lynne Neagle Cadeirydd y Pwyllgor
Committee Chair
Llyr Gruffydd
Mark Reckless
Michelle Brown

Y rhai eraill a oedd yn bresennol

Others in Attendance

Angela Hopkins Cyfarwyddwr Interim Nyrsio a Phrofiad y Claf, Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg
Interim Director of Nursing and Patient Experience, Abertawe Bro Morgannwg University Local Health Board
Carl Shortland Uwch-gynllunydd, Pwyllgor Gwasanaethau lechyd Arbenigol Cymru
Senior Planner, Welsh Health Specialised Services Committee
Carole Bell Cyfarwyddwr Nyrsio, Pwyllgor Gwasanaethau lechyd Arbenigol Cymru
Director of Nursing, Welsh Health Specialised Services Committee
Dr Alberto Salmoiraghi Seiciatrydd Ymgynghorol, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Consultant Psychiatrist, Betsi Cadwaladr University Local Health Board
Dr Jane Fenton-May Is-gadeirydd—Polisi a Materion Allanol, Coleg Brenhinol yr Ymarferwyr Cyffredinol
Vice-chair—Policy and External Affairs, Royal College of General Practitioners
Dr Peter Gore Rees Seiciatrydd Ymgynghorol Plant a Phobl Ifanc, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Consultant Child and Adolescent Psychiatrist, Betsi Cadwaladr University Local Health Board
Dr Rob Morgan Swyddog Gweithredol, Coleg Brenhinol yr Ymarferwyr Cyffredinol
Executive Officer, Royal College of General Practitioners
John Palmer Prif Swyddog Gweithredu, Bwrdd lechyd Lleol Prifysgol Cwm Taf
Chief Operating Officer, Cwm Taf University Local Health Board
Liz Carroll Pennaeth Nyrsio, Iechyd Meddwl ac Anableddau Dysgu, Bwrdd Iechyd Lleol Hywel Dda
Head of Nursing, Mental Health and Learning Disabilities, Hywel Dda Local Health Board
Melanie Wilkey Pennaeth Comisiynu ar sail Canlyniadau, Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro
Head of Outcomes Based Commissioning, Cardiff and Vale University Local Health Board
Nick Wood Prif Swyddog Gweithredu, Bwrdd Iechyd Lleol Aneurin Bevan
Chief Operating Officer, Aneurin Bevan Local Health Board
Robert Colgate Cyfarwyddwr Meddygol Cyswllt, Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru
Associate Medical Director, Welsh Health Specialised Service Committee
Rosemarie Whittle Pennaeth Gweithrediadau a Chyflenwi, Cyfarwyddiaeth Iechyd Plant Cymunedol, Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Head of Operations and Delivery, Community Child Health Directorate, Cardiff and Vale University Local Health Board
Rhiannon Jones Cyfarwyddwr Interim Gwasanaethau Cymunedol ac Iechyd Meddwl, Bwrdd Iechyd Lleol Addysgu Powys
Interim Director for Community and Mental Health Services, Powys Teaching Local Health Board
Warren Lloyd Seiciatrydd Ymgynghorol, Bwrdd Iechyd Lleol Hywel Dda
Consultant Psychiatrist, Hywel Dda Local Health Board

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Llinos Madeley Clerc
Clerk
Sarah Bartlett Dirprwy Glerc
Deputy Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:00.

The meeting began at 09:00.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Good morning, everyone, and welcome to this morning's Children, Young People and Education Committee meeting. We've received apologies for absence from Darren Millar and John Griffiths, and Mark Reckless and Julie Morgan will be joining us shortly.

2. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 17
2. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 17

Item 2 this morning is our seventeenth evidence session into the inquiry into the emotional and mental health of children and young people, and I'm very pleased to welcome the Royal College of General Practitioners this morning, in particular Dr Jane Fenton-May, vice-chair, policy and external affairs, and Dr Rob Morgan, executive officer. Thank you, both, for coming this morning. It's good to see you both. If you're happy, we'll go straight into questions. 

If I can just start by generally asking you about the fact that GPs are the gatekeeper of services and often the first point of contact for people with mental health concerns, and you're also the link with other mental health services. Do you think that the expectation that primary care can support and help young people with mental health problems is realistic and achievable?

Yes, from my point of view, I think we should be the first port of call and I think we do provide a very important assist for parents bringing children to perhaps reassure in some instances, but then to subsequently refer on. I suspect, in the question, it's the degree to which that support continues until children can either access more specialist support, or perhaps continue with us for further reassurance.

So, if the expectation of support is to a degree that, perhaps, might go outside our competencies, then it's not going to be achieved, because we'd always try and work within our competencies and recognise that point at which we need more specialist services. Once we refer into specialist services, we're always there in the background anyway, for parental concerns or further assists if people need re-access or further advice. So, I think, in terms of your question, being clear about the extent and the duration of support is important in the context of the child who presents in front of you.

May I just come in? I think that is for children whose parents bring them, but we do have a group of young people whose parents may not present them when they have, perhaps, well-being and mental health issues around their care. And they don't very often come and present to GPs, because getting to the GP can be difficult, and so, from that point of view, the school services are exceedingly important, and enabling children to seek support for counselling for the group of mental health issues that wouldn't be treated by the child and adolescent mental health services is essential.

Also, there is a need for teachers to be able to refer into a route that doesn't involve the GPs, because they have a better or a different understanding of the way that children's behaviour is shown in the classroom. They need to be aware of children who are underperforming because they have mental health issues and be able to advise the child or refer the child to different services. And that may not be the GP type of services, so counselling in the schools is exceedingly important and the school nursing service is very important. So, that can link in either back to the GP or to more specialised services.

09:05

Thank you. One of the things that the committee's heard from young people through our surveys and visits is that their experience of going to the GP about mental health issues shows that the service is patchy. It depends on the individual GP often and the level of expertise or interest they have in mental health. Do you think there are a need for better GP training to ensure that all GPs have the right skills and knowledge to support young people with mental health issues?

I think GPs can always benefit from a little bit more training in lots of things. The trouble is that we have to cover a huge range of things. Mental health is very high on most GPs' agendas. If you don't have specific services where you can send somebody, it is quite difficult to actually engage and feel that you're going to progress them. So, like any service, if you feel that you're stuck and this is a case that you have nowhere to send them to, so you're not feeling that this patient needs CAMHS or antidepressants, but needs talking therapies, and the talking therapies are not necessarily available for the young person, you're stuck with this patient that you can't manage. Now, it may be that some GPs are more skilled in doing some sort of counselling and support for that young person than others, and that is a very personal thing, and it may not involve teaching.

But the other issue—and I'm sorry if I bring it up—is workload pressures. We do know our GPs are very overworked. The whole primary care team is currently overworked, and so having that time to sit with the young person and tease out the fact that they're coming for the fifth time with a sore throat or a bad toe, which you're not quite sure is due to the fact that they have mental health problems, they're being abused at home or they're depressed, or they're being bullied in school, is actually very difficult. So, some of that time pressure could be relieved. And it's not just the GPs; it's the whole team, because, as we start using other people to deal with minor ailments, they need to be able to pull out these frequent attenders and start thinking, 'Why is this child coming again or being sent by their parents or being brought by their parent for some very minor problem, and is there some background—mental health or family problem—that is causing all of this problem?' That is what, when you're pressurised, you don't have time to tease out.

That was going to be the gist of my question, really. When you are a parent with a child, or a child attending by themselves, understanding mental health difficulties is a process, and, therefore, a 10-minute, 15-minute appointment isn't going to address that. You said that it takes many sessions. So, that, actually, is making the problem worse.

It is, but that's sometimes how you pick up that somebody has a mental health problem, because they have come—

So, they're not necessarily referrals; they're actually presenting with something else, physical.

Yes, and in general practice we talk about people who have door-handle problems—so, they've come in, they've done the whole consultation, they've used up the whole time, and you think, 'Well, there's something else going on.' As they go to the door handle, they say, 'By the way, doctor—', and they only say that if you've done well in the other bit of the consultation. Otherwise, they go and see somebody else in the team, and so that's what you have to also be conscious of—somebody is going shopping.

Is that a common term, 'door-handle problem'? Is that something that GPs—

It's a concept, I think, that we'd all recognise. It's the thing that a patient might say on their way out, and patients often have the opportunity to say that, because they've achieved rapport during that short time. I think, on your point about whether that delays things for the individual, I'd probably say not, in my experience. Even though I may have probably spent a short time with someone, I've hopefully, in that short time, built up a bit of trust that allows them to come back next time.

So, you're relying a bit then on primary care services having permanent GPs in practices as well, then, rather than locums, if you're going to build up trust and relationships.

09:10

I think continuity of care is the essence of what we do, and it's difficult for patients if they are faced with a different doctor every time. So, I think ideally, for a new patient, regardless of their age, continuity of care for specific problems is useful.

In terms of the question earlier on about training, I think training is a good idea, and raising awareness is a good idea, but we're all patients, and we probably select those doctors who may have had exactly the same training but suit our personal characteristics—we've built up a bit of a rapport, had some experience of them in the past, though their training qualifications may be exactly the same. So, in terms of young people's experience being patchy, it's very dependent on that interaction between the doctor and the child, or the doctor and the young person, as to how they get on, and training may not come into that.

As part of this inquiry, I get this overall impression of the service. Now, you've painted a clear and what I'm sure is a very real issue around the workload of GPs and the difficulty of actually having the time to spend with some of these young people and children. You've mentioned the importance of school nurses and school counselling services, but, of course, in evidence we've heard that those services are few and far between and it's a diminishing resource. So, how would you characterise the service at the moment, because the overarching impression that I get is that really the service is on its knees and it's diminishing when in fact demand is increasing?

I'd agree with what you're saying. I haven't really seen much change in that impression, despite all the good work that's gone on and trying to revitalise things and put services into schools. We're still having the same discussion amongst ourselves as colleagues as to there not being enough people to meet the increase. And there is an increase in demand, and we're recognising things perhaps a lot earlier than we would have done years ago. There are not enough people to meet that demand in a timely fashion, and that's what it all boils down to in the end: the pressure on waiting times that then spills back onto parental or a young person's anxieties and problems, which subsequently affects their functionality, which brings them back to the GP, who's trying to do the same things as they might have tried to do a month ago. So, yes, the people who are working in the service, I think, are working flat out, but there are not enough of them to meet the demand, I don't think.

So, the bottom line is that, to break that vicious circle, if you like, we need more boots on the ground in different guises.

Simplistically, that's what I feel. You know, I spoke to our primary mental health team this week and I think it's just one person—one whole person. There may be two people doing the job, but it might be one whole person, and that's a lot of work. You can't criticise someone for having a waiting list when there's increased demand but there's only one person to see that demand.

In Wales now, we've got new neurodevelopmental services. How aware are GPs of the new services, and do you have a direct referral route into them?

It's an interesting question. When I thought about this, I thought: what exactly is that, then? But, of course, I do realise what it is, and my understanding and my experience is that we don't particularly have a direct route of referral in, and whilst I might just send a letter off to a local community paediatrician, I realise that isn't the route in and it's actually through the school service. I'm sure that awareness isn't complete across Wales at all. So, I think that development has been quite a quiet development, certainly from my point of view at ground level, and, just speaking to colleagues, I think their experience is quite varied, again, across Wales, and perhaps that understanding that it's actually through the school that you get access into that service isn't perhaps widely known or as accepted as it might have been given the fact that I think it has been going on for quite a while.

So, children and young people are frequently referred to GPs from their schools. Has the Royal College of General Practitioners had any involvement with the new Welsh Government's initiative to ensure specialist emotional and mental health support being more widely available within schools? 

09:15

As far as I know, we haven't been invited to sit on any groups, and we haven't given any evidence to any particular groups, apart from you.

Is the initiative something that either of you are aware of, even if you haven't been officially consulted? 

I did know that there was some review going on, because I did sit on a group looking at transition services from CAMHS, and we weren't discussing the neurodevelopment group. So, they were doing something different and, as far as I know, there was nobody from the royal college of GPs on that group. 

We heard—. Sorry, Chair—

I was just going to clarify that there's a new Welsh Government pilot that is operating in parts of Wales, where they are putting mental health support into schools to try and improve that link there, really. I think that's what the question refers to, rather than neurodevelopmental, really. It's like a pilot, really. 

Because we've heard some, perhaps, complaints or observations from schools that, at least in some instances, schools say they make referrals to GPs for assessment and potential treatment, and those referrals are then bounced back to the school and you each deal with that in your counselling service. Do you see that as a problem? 

I think it is a problem, because the trouble is that sometimes you get a parent that comes in with a child and they say, 'Oh, the school says he's disruptive in class.' When you need that evidence, so you need the evidence from the school in order to actually forward it on to anybody if you were a GP—because you can't just have the mother saying there's a problem; you need the evidence to show what sort of disruption is going on—and actually having some liaison with the school producing those reports—. There used to be at some stage somebody who could do that kind of thing, but sometimes that doesn't seem to happen now. I think it's due to cutbacks in some of the schools. 

I think it is a problem, and it's something that I've had personal experience of, of parents coming from a school and me saying, 'No, no, it's the school that does this now—go back to the school.' So, I think that is a very real experience of children and parents. I think that could easily be solved by perhaps a greater degree of clarity and a well-defined pathway through, perhaps, education, or through some form of advertising, so that everyone is clear on what the system is at this current time, because it changes, and it's changed in my locality in Bridgend. It has changed over the last five years, in that it was through the schools and then back to the GPs. Now, it's, I think, back to schools again. So, I can see that parents are perhaps buffeted a little bit.   

When you have a school and someone's going to the counselling service and they consider there's a mental health issue that needs addressing, should they be allowed to refer that directly to a contact at CAMHS, or should that referral always have to go through the filter of the GP? 

I think it depends on the context of the child. Obviously, it would depend on the degree of confidence in the school counsellor, and the degree of illness in the child. So, obviously, the school, I think, is the best place to make that assessment, and a direct referral through to the primary mental health team is the most expedient way of doing things. As long as you've got trained counsellors in schools—and I'm not sure if that's across the whole patch—there shouldn't be a problem with that. But, any counsellor, there'd always be that little bit of uncertainty where perhaps mental illness is to a degree that might need more specialist services, and as long as the competencies are okay in that counsellor to recognise that then perhaps a direct referral is more appropriate—. If they feel not confident in their competencies, then I'd be quite happy for them to say, 'Go straight up to the GP.' A child that may be hearing voices or threatening self-harm at that moment—if there's not a direct route, a pathway in, I suspect that would be sent to us at the moment, but, if there were better pathways, if there were perhaps more confident counsellors who felt they were working within their competencies, that route is certainly possible.

09:20

Yes, thank you, Chair. I just wanted to ask a few questions around the Mental Health (Wales) Measure that was passed in 2010, which strengthened and expanded mental health services at a primary care level, and I'm just wondering to what extent the CAMHS services across the different health boards are working to the standards that were set by the Mental Health Commission.

I don't have information about all the areas or specific places, but I know—

—that some of the primary care support services didn't have all of their services available for children and young adults because they didn't have suitably trained members of staff to deal with children's mental health as opposed to adult mental health. 

And that's what I was leading to actually, around this criticism that they're not child-centred enough. You believe, or do you—? Is that your experience?

That's my understanding from doctors.

Yes. And how do you think that could be changed? How could we improve that then in terms of the focus on children and adolescents?

Well, we'd need to put in some training for the primary care staff so that they were enabled to deal with children, I think, because a lot of them are adult-trained staff who haven't had the training in children, and so they don't see that they—. Or their licence doesn't enable them to treat children and young adults. 

Okay. During the post-legislative scrutiny of the mental health Measure, you published a paper saying that some GPs refer directly to community mental health services

'because LPMSS are just another assessment'.

So, I just want to ask, really, what concerns you have about the number of assessments being undertaken before patients can access specialist services. 

I think some children do go through a lot of assessments, and I know that—. I can remember one young girl that I had who had, actually, very serious physical problems, and she had mental health problems as part of that, and she had to be assessed to make sure she hadn't an eating disorder, even though she had a muscle-wasting condition, before she would be accepted by the CAMHS service—well, she had depression because she had a muscle-wasting condition, not an eating disorder. So, it can be very difficult when children can't get from one service to another service without being assessed. I don't know whether it has—. That was a few years ago that this particular young girl—

And what impact is that having on the children and the families then? Clearly, it's not—

Well, it doesn't help—if you have to keep taking a child to a different assessment, and that might be at a distance, so you've got travelling time, travelling costs, and you're trying to raise other children, go to work, and all these kinds of things, this can be very disruptive. And, if some of the patients are maybe assessed as in-patients—and there is a limited number of in-patient beds for CAMHS, and, obviously, there's a waiting time for those; those are only for the very seriously ill patients. 

So, you would you say then that the functioning of specialist CAMHS has been disrupted by its inclusion within the provisions of the mental health Measure?

I don't think I can answer that, but I think probably it may have been disrupted. And the CAMHS service is an exceedingly small service. That's one of the problems. So, any change is very disruptive to it. 

Okay. Can I just ask? You mentioned that specialists CAMHS is only for very serious cases, but we know that there's been an issue going on for some time, really, that too many young people who perhaps need support elsewhere are actually referred to specialist CAMHS because there really isn't anything else for them. Are you saying then, from what you've said, that there's a better awareness now amongst GPs of when they should make that referral to specialist CAMHS, and that it's only maybe more appropriate children who are now being referred to that route?

That probably is so, that only the tip of the iceberg are getting to CAMHS. We do have other means, sometimes, of supporting them, but the services, as we say, are limited, and mostly that is things like school counselling. 

Thank you. Good morning. You've stated that GP counselling services aren't available to children and young people. Is that the case across Wales?

09:25

I'm not aware of any area that particularly has that service. Certainly, the primary mental health team can provide brief intervention, and they're very good at that, but, long-term counselling, I'm not aware of that.

I think 18, when they become adults.

Right, and are there any instances where children and young people are being referred to the third sector for counselling?

There's certainly third sector provision. It depends how you might define counselling, but certainly support and perhaps some interventional work with families can happen: Action for Children might be able to provide something. But I think, again, I wouldn't be able to say with any certainty that that exists across the whole of Wales. We're often left with perhaps parents or young people who we would often refer into the early help team, who will invariably take them back through to the schools. We often don't know what happens after that, and that may be because there are generally good outcomes. But I think that the provision of service outside of that pathway is very sparse.

There isn't feedback very often from some of these services to general practice. The other group that I know that does counselling is—Tŷ Hafan does bereavement support for siblings, and I think Marie Curie is now extending their bereavement services to children and families to help support people who have had either recent or past bereavements. That's a subtly different group, but quite an important group, particularly when we're hearing more about young children having bereavement issues around loss not of their parents, but of their grandparents, and often they feel a bit shut out from that grieving process because they're one generation removed.

To what extent are GP services available in Welsh? Not GP services, sorry, GP counselling services, I should have said.

I did try and find some information about that recently, and I don't know.

I don't think it's widespread. There may be more Welsh counselling services up in north Wales than there are in south Wales. But actually getting translation services for counselling is hugely difficult. I have tried it for other languages apart from Welsh, and, once you put a translator in the room, actually, you break that dialogue between the counsellor and the patient, and it's quite difficult apparently.

Do you have any views on how that situation could be improved, how we could increase the level of counselling services being offered in Welsh?

Well, obviously, we'd need to ensure that we have Welsh-language counselling courses, because I think it's really important that the counsellor has experience of doing the counselling in Welsh as well and probably in the regional Welsh—you know, a north-Walian counsellor might not get on very well with a south-Walian patient because of the local dialect issues that may be used in a very personal counselling situation. I don't know what information there is about counselling services or what training services there are in Welsh.

I think it makes sense that, if you're in a very vulnerable position, to be able to communicate in your own language—there's a great advantage to that, in allowing people to really understand what your problems are.

Okay. If I could move on to psychological therapies, frustrations around the waiting times for children and young people to access psychological therapies have been made clear during this inquiry. Is it fair to say that there's been an improvement in the timeliness of assessments for children and young people in primary care but that there continues to be a lack of provision of psychological therapies? Would that be a true comment?

09:30

So, your comment is that people are being seen quicker for assessments but perhaps not getting the subsequent treatment.

There's been an improvement in the timeliness of assessments, but there's a lack of provision of the actual therapies.

I'd probably agree with that to some degree. I think we still, perhaps, would prefer patients to be seen sooner than they are being seen, and in the face of increasing demand, as we were saying earlier, I still think there's significant waiting times and lag times before people get that first assessment. And it's that first assessment that often allows parents to realise that help is at hand and it can take a bit of pressure off a fraught situation. To subsequently then be told there's a waiting list again for counselling—it just doesn't help their confidence in an end to their problem, really.

I think there's a problem for talking therapies across the board, but I think it's probably worse for children and young people, because of the difficulty of having people to provide the services who are child-trained.

And what sort of impact is the restriction in accessing psychological therapies having on GP and local primary mental health support services' ability to manage people with common mental health problems without referring to CAMHS?

I don't think it's a very satisfactory outcome, because what it unfortunately results in is that families will continue to re-attend the GP, who really perhaps can't do anything else apart from support and try to reassure during that time. There's the possibility that that child's illness could escalate to a point where they actually meet the threshold for CAMHS, or in some instances a GP might refer into CAMHS just because it's something else to offer the parent, but CAMHS will invariably return that and say, 'This doesn't meet the criteria: refer back to the primary mental health team', which the parents are already in the system waiting for.

Certainly, there's some anecdotal feedback to us that, even when GPs feel that those criteria are met, the referral comes back subsequently, after some time, to say, 'Doesn't meet our criteria: refer to primary mental health'. I just wonder if there'd be a quicker mechanism of having that referral rejected at an earlier stage so parents and children aren't waiting even longer in a bit of a black hole of referrals without actually seeing anyone.

There are very good systems in adult, both mental health and general health, where e-mail advice, helplines and things like that can direct us very quickly to the right person who can deal with this clinical case. That might be very dependent, in child and adolescent health, on local networks, but it certainly works in adult networks. Those helplines are very much up and running, mental health liaison workers or gateway workers—it's a phone call: 'Okay, where does this person need to go?' But that doesn't really exist, as far as I'm aware, across the patch in Wales.

Again, just on a local level, from a jobbing GP's point of view, there's a helpline in Bridgend that's open during certain times when we can speak, as GPs, as professionals, to the primary mental health team, and that's really useful. But I'm not too sure if that exists across the patch completely, and that might be very staff-dependent. 

Can I just clarify, then, if you're saying that the primary mental health teams can't offer counselling to young people—? But you did say earlier that some young people can be helped by the primary mental health service. What form would that help take, then, if it's not counselling, and we know that they are going to struggle to get access to psychological therapies? What would that service look like for a young person? 

09:35

So, someone who may have a specific, well-defined mental health problem that's just, perhaps, related to one single issue—that problem might be amenable to something called 'brief intervention', so a short series of repeated visits over a short period, to just overcome that one problem. But a child who perhaps has quite a complicated emotional and mental health background is going to need a much longer period of support that we might recognise as more typical cognitive behavioural therapy—you know, just talking therapies, perhaps involving other family members. That does need input over a prolonged period of time, and if the primary mental health team is making assessments as well as trying to offer brief intervention, you can see that system gets very quickly filled up. Does that—?

I was just wondering whether you had any involvement in the development of the new referral criteria for CAMHS in Wales, which is due to be available from the end of this year, I think.

It's strange, listening around the table, we seem to be hearing the same things, aren't we? What you're telling us isn't any different to what we're experiencing. Certainly, I think being involved telling the stories is useful, and sometimes, from a front-line point of view, we might have answers that are a barn door to us, but unless you're in a discussion with a wider team, you may not realise how feasible that is. I suspect you have to be in that discussion to realise that. 

Okay, thank you, Llyr. The next questions are from Michelle on medication.

Thank you. Our predecessor committee raised concerns about the prescribing of antidepressants, ADHD and antipsychotic drugs to children and young people. The Welsh Government tried to address this by issuing a health circular. Has this had the direct desired impact, and has there been a change in the prescription of medication to children and young people since the circular?

When was the date of the circular?

It was issued after the predecessor committee raised concerns about this, and the Welsh Government did some research on it and then issued a circular, so it would have been a few years ago now.

Okay. I'd probably say, to a degree, 'yes', but there are always those instances where you can say, 'Oh, but what about so-and-so? What about this situation?' I think, to be fair, thinking about ADHD treatment and the methylphenidates, things like Concerta, there's definitely been a change, in our awareness, of practice over the last few years: more monitoring and explicit directions around the prescription of quite potent drugs. That would be my own personal experience. I think that has improved. Whether that was due to that circular or not, that's a bit more difficult to say. I think there are still instances where perhaps there might be an expectation of secondary care, primary care, to prescribe drugs that, really, are out of our experience and out of our competency. So, there would always be a bit of reluctance in that, and again, unfortunately, that might have a spin-off for the parents, that they can't access drugs in the locality or in a timely fashion.

I think paramount to all this is patient safety, and it's very difficult for GPs to prescribe drugs to, let's say, perhaps, a parent, who says, 'I've been to out-patients, and this is what they've suggested.' So, I think there is evidence that things have improved, but there may not be a complete watertight experience that GPs may not feel confident prescribing drugs that should really be the responsibility of consultants, and perhaps improving our communication around those drugs might help that.

09:40

Can I just say that I think GPs are probably much more cautious about prescribing some of these drugs to young people because, as paediatricians would like to tell you, children are not just little adults? You have to take into account the developmental issues that are going on with the young people as well, and particularly ADHD—giving a drug is not the only answer. It may be one of the answers, but it should be part of a whole management of the condition for the child rather than just giving them a tablet. It's not a miracle cure; it has to be in a background of other sorts of treatment to manage the condition.

Again, unfortunately, my answer would be that I haven't seen any particular evidence of that, and that may be because teams were working effectively anyway. Thinking of the patients who have severe mental illnesses and who are heavily reliant on secondary care input, that top tier I think are relatively well supported. There may be the odd instance, but it's that lower tier where the difficulties might arise and trying to define, 'Well, who actually fits that group?'

Okay. We know that more and more young people are unfortunately self-harming, and also suicide rates among young people are going up. Can you give us some insight into how confident you feel GPs are when somebody comes to see you saying that either the child says that they're feeling suicidal or have been self-harming, or the parent comes? Are you confident that you've the right pathways then and know exactly what to do about that young person?

I think most GPs probably do feel confident. I think the problem is that the young people don't have the confidence to necessarily come. Their parents may come, but they need to bring the young person, and that doesn't always happen. And I think the teenage group particularly are very shy of going to the GP. Some of that is due to—. In an urban setting it's not too difficult to walk down the road to the GP, but in more rural places you actually have to get to the GP, you have to get past your mother's friend who is the receptionist, you have to get past all those other people in the waiting room, and because your parent has always negotiated the appointments for the GP, you probably don't know the system. So, we need to have a very easy way, which is why I go back and think about school nurses and school counselling services that are accessible for young people and teenagers to get the help that they want in an environment they feel much safer in than coming to a GP surgery, which, let's face it, they've probably only been dragged to when they've had a vaccination or a nasty thing stuck in their ears and their throat because they've had a bad throat. So, it's quite frightening, I think, for young children to come to a GP.

So you don't see that as partly your responsibility, do you, in terms of reaching out? 

It is part of our responsibility, but they're a difficult group to reach. I mean, we've had the same discussion about things like family planning services, which has an impact on their emotional well-being as well. But how do you get to those young people who don't necessarily see you as that friendly, supportive doctor? However friendly and supportive you feel you are, unless they have that relationship with you, which they haven't developed as a little child, because it's always been parentally controlled at the point of either vaccination or being sick, they don't realise that the GPs have this more encompassing, caring job to do for them.

09:45

Okay. I think this is an important point. For instance, I've seen one constituent who took their young teenage daughter to 12 different GPs complaining that they were suicidal before they got a referral. So, are you saying that most GPs do know what to do in that kind of situation, and can you just describe to us what the pathway would be then for a young person who presents with suicidal thoughts or self-harming?

Well, I would try and talk to the young person with their parent, try and maybe talk to them without their parent as well—sometimes that's quite difficult—and then, if they seem to be suicidal, I would make a referral to the mental health for young people, but I'm at a loss to think why somebody would have to go 11 times.

Yes. I think what we are faced with as GPs is that we are gatekeepers. If I were to refer everyone who came into my surgery claiming to be suicidal, either adults or children, that gate would be open much more often than actually I open the gate. It's difficult in that situation to reflect on personal experience, and what you must—

I know, but what I'm trying to get at is what the pathway is. Have GPs got a clear understanding across Wales of what they should do if a young person presents either self-harming or with suicidal ideation?

I'd say 'yes'. And I would say that if you're acutely worried about a child, then that child needs admission, regardless of the age. If you are less acutely worried, you would be referring to and contacting mental health services as urgent referrals, and you'd hope that that would be picked up and responded to within a short space of time. I think your question was about confidence about the pathway, and perhaps that confidence could be shaken by what happens subsequently. What would be common experience amongst GPs is that, if that assessment's been made that perhaps someone doesn't need an acute admission because they may not be psychotically unwell or at direct risk of harm that day, we'd probably be seeing that child the next day, the day after, subsequently the next week, until the secondary care services could actually engage with them. So, I think I'm confident that GPs are recognising—. Obviously there are exceptions, but I'm confident that GPs are recognising those children who have suicidal intent or who are at direct risk of self-harm at that point. I'm confident that they could act appropriately in those circumstances, and my only doubt is about the certainty that it's a consistent response across the patch.

Just on the transition to adult services, clearly, it's not as seamless or smooth as we'd like as often as we'd like. I'm just wondering if you could tell us what role GPs play in that process and particularly in relation to providing continuity and support for children and families.

One of the problems is that, for some of the young people—. There haven't been transition services for attention deficit hyperactivity disorder, for example. It is improving. But somebody who needs specialist services should be referred to adult specialist services rather than to a GP to assume the ongoing management of that care. We should be able to know what is happening and treat the other parts of the patient—so, if they've got physical problems as well as their mental health problems, to have ongoing support and care for those. So, we should know what's happening about the transition, but if somebody is needing specialist care, they need specialist care as an adult as well as as a young person and child. They don't need to be just discharged and for it to be assumed that a GP has the specialist skills to look after them. That, unfortunately, sometimes still happens.

09:50

I think different young people will reach that level of being able to be transferred at different ages, and it would be very patient-dependent. To serve them best, I think there should be an easier transition that a consultant would say, 'Well, we'll see you in three months' time', but that appointment is actually being arranged in an adult service. Whereas what tends to happen is, 'We'll refer you to adult services', they disappear into a black hole and in the meantime there's a continuity of care, which GPs will provide anyway—back to the GP. You'd think that the process could be a lot more seamless, and the clinic appointment could be generated so that the family, the child, knows exactly that, 'Yes, I've got an appointment, and this is the team I'm going to see.' Whereas what we often experience in general practice is, 'Can you see us? Could you prescribe for us because our appointments haven't come through?'

So, in effect, in terms of continuity of service, there isn't any—you're shunted from one service to another. It isn't that seamless sort of process that I thought it was, to be honest.

That would be my impression, and there may be patients who would say, 'Doctor, well, that didn't happen for me', but that would certainly be my impression.

Thank you. Are there any other questions from Members? No? Okay. Well, can I thank you both very much for your attendance this morning, and for answering all our questions? You will receive a transcript to check for accuracy, following the meeting, but thank you very much for your time this morning. The committee will now break until 10 o'clock, but if Members could not rush off, please. Thank you.

Gohiriwyd y cyfarfod rhwng 09:51 a 10:02.

The meeting adjourned between 09:51 and 10:02.

10:00
3. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 18
3. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 18

Welcome back, everyone. Can I welcome the witnesses for our next evidence session on our inquiry into the emotional and mental health of children and young people? We've got a panel of health boards here. I'm very pleased to welcome John Palmer, chief operating officer, Cwm Taf Local Health Board; Melanie Wilkey, head of outcomes based commissioning, Cardiff and Vale University Local Health Board; Rose Whittle, head of operations and delivery, community child health directorate, Cardiff and Vale University Local Health Board; Angela Hopkins, interim director of nursing and patient experience at Abertawe Bro Morgannwg University Local Health Board; and Nick Wood, chief operating officer, Aneurin Bevan Local Heath Board. So, thank you all very much for your attendance this morning. If you're happy, we'll go straight into questions from Members. The first questions are from Llyr Gruffydd.

Thanks, Chair. Good morning. I'm just wondering, maybe to start, if you could tell us what the main changes are that you think 'Together for Children and Young People' has delivered and where you think maybe more progress is required.

Okay, thank you. Do you want me to kick off, colleagues? I think it's probably fair to say that it's been quite a dramatic change and I think a relatively good improvement.

The most important thing, perhaps, has been the implementation of the choice and partnership approach that's now operating across a number of the health board domains. That has had a big improvement for us in terms of performance, so I'd certainly pick that out. I think the second thing is the establishment of referral criteria at a national level, and I think that's beginning to have a significant impact. We now have crisis teams that are appointed across most of our system, and I think that's again having a very big improvement for us. And then, the development of the first episode psychosis service, I think, has been very, very important for us as well.

So, when you bring those four things together, I think we are beginning to see an aggregate improvement in performance across the Welsh system. Certainly, for our network within south Wales, we have seen a significant improvement over the last three years, where you've seen us go from waiting lists that were, at one point, about 3,000 people and now we're looking at waiting lists of about 600, with about 300 patients at the moment over 28 days. That target has changed immeasurably over the last three years, so we've moved from a 26-week target to a 28-day target. So, I think, now, we find ourselves in quite a different position as a result of those aggregate changes that obviously changed our system quite significantly.

10:05

So, where's the progress required then? Because there are a lot of positives, clearly, but there are bound to be a few areas where you think maybe more could be done.

I think there have been, as John has said, some significant issues there around specialist CAMHS and the referral criteria, but where I sit in community child health in children's services, we've got the primary mental health element, and I think there is just something about the whole system working together and making sure that, whilst we've got really good, clear referral criteria for specialist CAMHS now, what we don't actually do is have children that don't quite fit anywhere. I think the challenge, the remaining challenge, really, is to make sure that we've got a coherent pathway that is clear for referrals and actually meets the needs of all children.

I think I would support John's view that the implementation of CAPA and a more lean model of referral into the system has probably been the most progressive element of what we've seen at a health board level in terms of access arrangements and the way in which patients can now access the service. I think, going forward, the challenge we've got to tackle is: where do we refer some of the younger people who are a lower level perspective? We were talking outside about—what we've seen is, consistently now, more children being referred into the primary mental health service. Numbers there are growing rapidly, and it's where we then link them into a more therapeutic and behavioural analysis and counselling, rather than a high-level intervention. What we're now seeing is probably only about 1 per cent to 1.5 per cent of children going into a specialist CAMHS referral. But if you say you've got 100 referrals, and only one or two are going, it's what we are doing with the other children who've got that lower level who require some form of intervention that's probably not necessarily by a clinician, but it may be therapeutic, it may be counselling, it may be talking therapies—all of those things. That's a big challenge now, how we start to scale up some of those services so that we meet the needs in a much more rapid way.

You are asking your own questions now, in effect, because that's where I was going to go, really. How do we do that then? Because, clearly, it's been a key message coming from the evidence that we've received as a committee—this missing middle, if you like, that aren't unwell enough to receive the specialist services, but they need support. I'm not saying there's a vacuum there, but, clearly, there are deficiencies in terms of access to certain services there, so what would you see as your role within that sort of structure?

I think that, just from a Cardiff and Vale community perspective, we have lots of partnership arrangements. So, I think my reflection is that there are lots of services out there for children and young people, providing really good support, but, somehow, the system needs to be more joined up so that you need specialist support for those earlier interventions in order that they feel confident and so that what you don't have to do is then refer on again, if that makes sense, so, it's much more of a system. 

Because referring is the easy answer, in a sense, isn't it? It's, 'Well, I don't know, so I'll have to refer.' We've had evidence from schools around school nurses, school counselling services, all that kind of thing, but, of course, the message we get in that evidence is that those are diminishing resources. They are few and far between, if, indeed, available at all in some places. So, clearly, there's a gap there that needs to be addressed. Would you agree with that?

I think there's a definite consequence of the period of austerity that we've gone through over the last five years. I think you see it written through the evidence that's been put in by each health board that it's very clear we've felt the pinch of reduction in social work capacity, educational psychology and, where local government has been under pressure on its aggregate budget, I think it's unavoidable that pressures go onto the largest budgets. Having said that, I think, again, you'll see in the evidence that's been put in by each of the health boards that there's a good theme of developing partnership working, commitment, through mental health partnership boards, to really work collectively, and some of the stuff that you just mentioned there around school nursing developments and mental health first aid, group activities in school environments—that sort of stuff—is coming through the system. I just don't think it's coming at enough scale, to be frank with you.

If you look at the blend of investment that we've seen come into these sorts of services over the last three years, you see significant increased investment in neurodevelopmental services, which gives you a behavioural angle and a therapeutic angle that then links in to the school system, and that's probably where the biggest connection is between services. You've seen greater resilience come into the specialist CAMHS service, alongside a much increased expectation about performance delivery, so moving from 26 weeks to 28 days. 

We're beginning to see, I think, more grip across all the health boards around our learning disability services, which do have a connection here as well, but there's a lot of work to do on that front. You can see some promising statements of intent on that at the moment, but I think we need to be held to account around resourcing. And then you've got other things like psychological therapies, forensic services having some investment as well. I think if they're an area for us to push in terms of our planning in our integrated medium-term plans, and for further conversations with Welsh Government about areas for resourcing, I do think it's that tier 0 provision that we really need to focus on.

If you look at our general performance now, if you look at the local primary mental health support service, you can see that every system is under pressure on that front, and I think probably Aneurin Bevan have got some of the most developed activity around that space, but we are all trying to improve our performance there. We're using a blunt tool in the main at the moment, which is that we're using waiting list initiatives to ramp up our activity. That's probably not clever enough, really, so I think it's fair to say that tier 0, integration with partnership arrangements into local authorities, wider third sector, is going to be really important for us in the next cycle. But I do think we've built some foundations to be able to get into that over the last three years. 

10:10

So, in Cardiff and Vale, as part of the Together for Children and Young People activity, we commissioned a service from the third sector for early intervention and emotional well-being, and we've seen an increase in referrals into that system. We commissioned it jointly with some of the young people from the youth councils and youth forums across Cardiff and the Vale, and that's had a really positive impact because it's relatively open access. They run group courses on things like living life to the full and emotional regulation, and they offer some one-to-one support, and we're also using it as a little bit as step-up and step-down from CAMHS services. So, I think that we'd like to extend those sorts of services and integrate those better with some of our partner services. And, obviously, we're engaged with the Families First recommissioning now to try and make sure that we're making those links, and that actually what we're doing is not duplicating effort, but making sure that the services that we do provide support each other in the right way. 

One of the other ways that we're looking at this as well, in terms of making sure that the whole system is working for the child, is the area that you touched upon: education. So, in ABMU, via the Western Bay regional partnership, which is multi-agency, and multidisciplinary, we've developed liaison workers. Those liaison workers are providing a really good function because there is somewhere for the school counselling service, for example, to refer a child for a view, rather than just immediately going to a GP referral, which can frequently end up in a very specialist referral into the CAMHS service. So, that system there is looking at what, often, emotional support is needed for the child and the school—the education system as well.

So, we have some liaison workers who are engaged in that work and other liaison workers who are engaged in training. So, they're putting more training and education in, so that school counsellors, teachers, health visitors, school nurses are upskilled again, because this is a new area for them. They went into their career for a particular reason—teaching, for example—and we are now expecting them to engage a lot in psychological assessments and support for children. So, we do need to give them almost a new pack of cards to actually draw from.

So, the liaison service is actually supporting across sectors there, so that anywhere that the child might access, there is an increased knowledge and awareness of the alternative referral routes for support, whether it's into the third sector, as some of my colleagues have described, or whether indeed it is appropriate to refer into a specialist CAMHS service. So, it's about supporting the system as a whole. And I think the Western Bay regional partnership have recognised that that is a requirement, from a multi-agency and a multiprofessional point of view, for that large area where we have quite significant challenges with some of the children, particularly around the Swansea area. 

Melanie mentioned the project in Cardiff and the Vale, the third sector one, and I know that there's a project in Gwent, Changing Minds, which the committee has visited as part of this inquiry. But that's lottery funded and that's coming to an end. Have the other health boards got a third sector partner that they can refer to for that more universal support?

10:15

In Cwm Taf, we've got good integration with the third sector. So, we've got a number of service level agreements in place with third sector supporters, not just on CAMHS, but across the adult mental health arrangements as well. We run to about £700,000 a year spent on those kind of SLAs. So, we do have a broad range of third sector support in place.

Thank you. Good morning, everyone. Evidence given to our inquiry suggests that significant work remains to be done to ensure that health services and education services collaborate and co-operate to support children and young people with mental health and well-being issues. Do you agree with that and what barriers do you think that may be in place preventing that collaboration from taking place?

I think I've probably answered part of that question already. I think if you look at just the aggregate resourcing position, we know that we've had real challenges in recent times in terms of reaching into services that would have traditionally meant that we could protect specialist CAMHS services to a degree, and allow our educational psychology services to deliver in the way that they need to. We also know that we've concentrated a fair degree in developing school nursing models over the last couple of years and there are some promising signs about how they are developing. We know that where, on the neurodevelopmental front, we're delivering group activities into schools with good community linkages, we do tend to get a better sense that we're getting fewer referrals coming through the system, because we're building resilience and we're giving children assets that they can use to perhaps live happier lives in their communities rather than finding themselves in a place of crisis. That's work that we continue to need to scale. I think that, if we were trying to identify areas where we wanted to continue resource and build up tier 0 services, it's going to be around that kind of stuff.

Some of the things we see referred into specialist CAMHS on an increasing basis now are around self-harm and attachment, and they're really not things that we can deal with very well in a specialist CAMHS system. What those presentations do require—and indeed this is what young people tell them themselves—they want peer-group activities, they want locally supported activities, where they're engaging with community nurses and school nurses who they trust and have a relationship with. So, for us, I think it's about building those kinds of services into schools and into communities. So, if we wanted to target a place with our education colleagues, it would probably be around that kind of area. That then allows us to focus on what we can really do in terms of prudent medicine in a specialist CAMHS space.

I think, as well, we need to think about social services as well as education. We've started to look at some specialised services for looked-after children. We've got a very small resource, but that's identified that, actually, we need to be providing some more support in line with our local authorities to provide support for children on the edge of care, making sure that we're retaining and maintaining placements for young people, and so that's an arena that I think that we would really like to get engaged with. Rose can perhaps speak a little bit more authoritatively about the service that we've got. But then it's about how we make sure that we're very clear about the accountability, because you've got professionals involved in this all the way through, who have a specific accountability in line with their profession, so it's very difficult for them to hand over young people, from a safeguarding perspective, if you're accountable for that young person's care. So, we really need to be able to get over some of the information-sharing issues on a broad and more universal scale and then also to be able to really understand that accountability and how we make sure that we are case holding those young people appropriately. 

What's the relationship like generally between education services and health services where it comes to managing a specific child or young person's case, if you like? Is there a dovetail between the services that are being provided and the communication between the two services, so that everything fits together for the child or young person? What happens with that?

10:20

Shall I pick up some of that? Going back to your first question, I think there's a lot of work to be done in linking up the education sector with health around the lower level needs of the child—so, tier 0 or tier 1, whichever we want to call it, really. In Gwent, there's heavy involvement now in a multidisciplinary approach with the £1.4 million investment in a joint health, social care and education initiative around bringing together all of the professionals. We're leading that through our primary care mental health team because they are closer to the schooling groups and the cluster of schools, and they can then draw in the specialist CAMHS knowledge as and when it's required. But I think the majority of cases that they will tend to deal with or tend to work through in a joined-up way will be around the coping mechanisms and emotional intelligence and all of those well-being issues.

We're also working with a cluster of schools in Newport, which is a completely separate project, around bringing the professionals together, because I think one of the things that we've seen through the implementation of the integrated assessment programme is the lack of a dovetail, if you like, around getting that very clear referral and clear understanding of the child's need, which I think has moved forward massively in the last 12 months, but I think there's still a long way to go in really driving that ownership across all of the public sector bodies to make sure that everybody understands what the child needs, and secondly what the treatment plan or what the next steps in the care are. That's where we've got to go next. We've established a process of integrated assessment, and now how do we deliver integrated treatment plans that really are tailored to the individual child's needs? That's the next challenge for us.

I think some of the challenges are the number of schools, the engagement of different schools. In Cardiff, what we've been trying to look at—and Melanie mentioned it earlier around Families First and working with Families First—is to try to move towards a school cluster model that effectively is putting an identified named worker in each school cluster, which I think is similar to what you're describing, in order that you can have an early conversation and avoid the, 'Must have a referral. Must go to the GP.' So, it's the same principle really and, I think, if there's an area for development, that is without a doubt where we need to go to make that system work and support young people where they need to be, really, rather than getting a referral into a clinic appointment or whatever. It's about supporting them where they need the support—in their communities. 

I'd agree with that. I think what we're all looking at—this next phase, if you like—is developing that seamlessness, because the children and the young people, and their parents as well, need to have a very clear route through. We talk about low-level children. That's the area we do need to get into, because actually that's the preventative area. We do want to develop that area with our school colleagues, with local authorities as well. That's where we can make the biggest impact for the future, because we do want to be looking at—. Clearly, we had major issues in terms of the waiting times for some very complex children and young people with mental health issues, and, as we've been able to progress in that arena there, we're all very focused now on the preventative agenda, because what we want to do is to prevent more children and young people ever getting to a stage where they need that complex service. But we have to develop the seamlessness between all the agencies, and certainly between education and health. It's absolutely key. I think the bridge provided there is with the school nursing service, and it's how we support them, because, again, they need a constantly increasing level of knowledge and development themselves to be able to respond to what is a changing picture. We've done a lot of work around the mental health aspects and the mental well-being. We know that we've got emerging and challenging issues now, around emotional well-being and also behavioural aspects. And if we can help to support children to have a greater level of self-esteem and more confidence themselves, they move forward as young people, then, in a more confident way, and we avert some of those risks around a developing mental health condition, which can actually then follow them through life.

10:25

Just a final point on this one, one of the things that the clinical directors have been working on on a national level is the development of specialist CAMHS referral criteria. I think when people usually hear about referral criteria, then they expect that hard gatekeeping follows with that sometimes, and, actually, having seen some of the detail that the clinical directors have been developing and then how that's translating into local working, it's much less a signposting kind of model and much more an enhanced referral kind of model. So, what those referral criteria are trying to do is to make sure that there is good shared understanding across the professional system about the range of services that has now been developed. So, we do have an integrated autism service that is now developing at pace in each of the health boards. We have neurodevelopmental services that are at a scale that we haven't had previously. We've got psychological therapies investment that's gone into our specialist CAMHS service. Our teams need to be very aware of each other when they're dealing with complex patients that are coming to us for referral, so I think that's a good intervention and one that should help with us connecting not just within the health system, but connecting out into the wider public service system as well.

Just before we move on, then, and I bring Mark in, you referred to the referral criteria that are being developed by the clinical directors, but we heard earlier that the GPs haven't had any involvement in that, which does raise questions as to how much of a whole-system approach that is. Have you got any comment on that?

I think, probably, just to say that I think that is a responsibility not just at national level, but at the local level as well. So, I'm pretty sure, in terms of the implementation that's now happening—because it's not complete work—that GPs are being involved. I know for certain that, in Cwm Taf, our GPs have been involved in those conversations, that they've been involved in framing the forms that we're going to use to express those criteria, and, indeed, it's been through our local medical committee. So, we have had oversight from the GP body, officially and formally, if you like. I think that pattern is being followed in other places. So, it might just be a phasing issue, in that it's still work that's ongoing, but of course we'll take that feedback back as well and think about how we make sure that there's a national line on it.

You raised, I think, in the written evidence from Cwm Taf to us, about the national referral criteria to specialist CAMHS and how those were being developed. Is that what you've been talking about just now, with reference to your clinical director? To what degree is this something you're driving in Cwm Taf, or to what extent is it a national initiative, and how are those two knitted together? 

It's a national initiative. So, our clinical directors across Wales with responsibility for specialist CAMHS have been meeting collectively. I think it's quite a self-aware kind of project, in that they realise that we'd had some issues with referral generally and that we needed to be driving more multidisciplinary team working off the back of referrals. So, they've had a proper, I think, professional reflection that has led to that national debate and, now, a national piece of work. The bit that we're in the middle of at the moment is then translating that guidance into local adoption. So, the kind of pattern we would then go through is that we would go into our local medical committee, and we go into our specialist CAMHS senior management team meetings, and we promulgate. And there will be probably some differences from health board to health board about exactly how those referral criteria are applied, but there will be a common core.

Yes. I mean, the GPs we've just had from the royal college of GPs didn't seem to be aware of this initiative from that perspective, and you've referred to knitting in the LMC into that. I sort of understood the LMC had more of a shop-steward-type trade union role for GPs. Is that the appropriate body to be dealing with, rather than the RCGP, in developing this pathway?

10:30

Well, it sounds like we've got more work to do with the college, so we'll have to take that in hand. I think that, certainly for introduction of new referral criteria, the LMC is absolutely the right place to go for that conversation, and it is a conversation that probably usually takes a couple of iterations to get absolutely right. But then, of course, you don't stop in the formal environment because what we all have now across all of our health boards are established clusters with often cluster leads in place, locality clinical directors who are resourced from within core health budgets but who are representing the GP voice in the organisation, working on integrated pathways. So, it's the follow-on work that goes through those kinds of individuals and out into the wider body of our GPs, where we'll be concentrating not just on the mechanism but the culture that we need to have in place to do this work properly.

And how much difference would you expect to see—and I don't know whether others want to contribute as well—across different health boards in terms of what the referral process is and, for instance, what the acceptance rate may be for referrals to CAMHS? Would we expect that to be consistent across Wales or different depending on the health board approach?

So, I would expect the criteria to be the same. Some of how you get into it—the technical mechanisms for making the referral or whether you've got a single point of access, how you take those referrals in—might vary. What is then appropriate for specialist CAMHS, as for the referral criteria, I would expect that to be the same because that's been developed nationally by the clinical directors.

Just to come back on it, if you look at the overall referral figures at the moment—. So, I can speak for the operational element that I cover for ABMU, Cardiff and Vale and Cwm Taf. Current referral rates or acceptance rates are 59 per cent for ABMU, 59 per cent for Cardiff and Vale, 79 per cent for Cwm Taf. Now, I think the referral criteria might bring those numbers down to a degree, but actually I think what it will improve is a more structured referral on to other services. So, bearing in mind that we've got new services developing and growing, like neurodevelopmental services, like the integrated autism service, forensic elements, psychological therapies and so on, I'd want us to be referring on to those in a very structured way. And if you spoke to the clinical directors, what they would say is that they would anticipate doing much more multidisciplinary team working across those services as a result of a more structured referral pathway. 

So, for example, I've got the December figures for Cardiff and Vale. The December figures were 62 per cent acceptance rate into specialist CAMHS. However, most of those young people were referred into other services, so either primary mental health or the emotional well-being service, through a multidisciplinary meeting to determine the most appropriate place for that young person. It was only 13 per cent that there wasn't actually a service for, and that's about some of the gaps that we talked about earlier and some of the behavioural aspects et cetera that don't fall into the mental health and emotional well-being services that we currently provide.

Melanie, you're Cardiff and Vale, and, John, you're employed by Cwm Taf but you are also, I think, able to speak to some degree for Cardiff and Vale and ABMU just now. Can you just clarify how you're working across health boards in that way?

So, Cwm Taf is operationally responsible for Cardiff and Vale, Cwm Taf and ABMU specialist CAMHS and also for the tier 4 service that's run out of Tŷ Llidiard. So, you have either side of me my commissioners for the operational service. So, actually what you've just heard from us is good consistency. So, the aggregate data from the last year is 59 per cent for the accepted referral. So, we've got a monthly variation a little bit up to 62 per cent in the data that Mel's given you.

We had written evidence from Powys in reference to referral rates continuing to rise and this causing various issues or problems for them. Is that something that's consistent? Can we just clarify what the current state of demand is and whether we're still in a situation of significantly and continually rising referral rates?

It's probably not at the volumes over the last two years that it has been over previous years. I'll give you the data straight off the bat. So, ABMU accepted 1,541 referrals over the last year, from 2,612 presentations. That's a 9 per cent volume increase for ABMU. So, that's significant. Cardiff and Vale accepted 1,200 of 2,034, and that was a 1 per cent increase in overall aggregate demand. For Cwm Taf—interesting figures for us. So, we had 1,723 referred in. We accepted 79 per cent, 1,361, but that's 9 per cent down on the previous year.

I think the story within that, if you were to look at what types of patients are presenting, it's undoubted that there's a level of acuity and complexity that's increasing. We tend to see that surfacing through, actually, the tier 4 service, where we are seeing, I think, more demand for complex placements that require maybe an in-patient stay, certainly some kind of quite significant multidisciplinary team working between local authorities, health boards and the specialist CAMHS service thereafter. So, whilst numbers overall, you could say, look fairly static, if you blend them across the overall position there's a lot of challenge within that. Nick, I don't know whether you just want to reflect on your numbers at all.

10:35

Yes, we're seeing a similar pattern where, in overall terms, the numbers are slightly rising, but I think it's the acuity of a certain number of the cases where we're seeing the biggest challenge for ourselves. So, the urgent assessment numbers are going up quite rapidly. Our acceptance of referrals overall is about the same. It's about 50 per cent, and that's been consistent now for 12 months or so. But in urgent assessments we've seen a big increase, and the number of young people then assessed in the system, again, has gone up in overall terms. But referral numbers are not massively increasing and are not causing undue concern in that way. It's the levels of intervention that are required, either at specialist CAMHS or urgent and emergency levels, and what we did, as we spoke about earlier, at that low level with patients who are not accepted by CAMHS—what treatment pathway we can then put them on—is quite key I think.

So, I think that we are seeing a steady increase in primary mental health referrals for children and young people, much more consistently than in CAMHS. We were getting, on average, between 70 and 80 a month, and it's been up over 100 for the last three months, in each month, and that can be quite peaky. So, quite a lot of that is driven by activity and media activity and things like that. So, you might see a couple of steady months, but then you might see a peak up to 120 or 130, and then it drops down. We're talking about relatively small specialist teams, so that makes that profile quite hard to manage.

Thank you. I want to move on now to waiting times. Can I appeal for witnesses to be as concise as possible in their answers, because we've got a lot to get through, please? Julie.

I wanted to ask you about the 28-day target. I just wondered: what are the challenges of meeting that 28-day target?

Shall I kick off with that one? It's been very challenging, I think. Last year, we delivered 100 per cent on the 28-day target across all three health board areas that are within the network that Cwm Taf serves, but we drove a lot of medical activity. So, we had huge numbers of medical follow-ups coming into the next year, and I think I would accept that, as the lead for the service, I probably drove the performance management too hard in a system that wasn't yet mature enough to really deliver that performance level sustainably. So, what we've done this year—and this was always part of the plan—is we've introduced a choice and partnership approach, which is a completely different model of delivering CAMHS services. It's therapeutically led. It generally means that the first appointment has a wraparound with different types of clinicians in the room, not just a consultant lead, and it will be with the family. The conversation, really, there is about the appropriateness of the specialist CAMHS to deliver the outcome that the patient wants. So, it's very much a patient-directed approach to the service. 

So, we've implemented that now, from the beginning of last year, in Cwm Taf, and then, from mid year, in Cardiff and Vale and ABMU. What that has done is start to change the case load that we're holding quite significantly, because it just doesn't fall, therefore, onto the shoulders of the medics; it's a blended approach that is getting different inputs from the professions. We've brought about 50 different types of professionals into the system over the last two years, with the new funding available, which allows us to do the family therapy kind of work.

10:40

I suppose I'm surprised that it's only now that that's been brought in, because it seemed such an obvious thing to do that it's surprising to me that that hasn't been done earlier.

I think that's a fair challenge. But I think if you look at the pattern of mental health service delivery across all domains over the last 10 years, there's been a general movement away from medicalised models towards something that is more blended and therapeutic, less dependent upon pharmacological intervention, and I think CAPA has developed within the body of both the medical and nursing bodies within CAMHS and is now seen as the standard. And we're implementing that as quickly as we can. It runs in four quarterly cycles, so you adjust the job plans of your teams on a quarterly cycle, according to the need of the patients.

As it stands at the moment, as I said earlier, we've got about 600 patients on our waiting list, 300 of those patients are over 28 days across the three areas of the network, but we're confident that we're tracking in to deliver the 80 per cent target at the year end. We might have a couple of challenging areas in that, but the important thing about achieving CAPA is it allows you to balance your system, rather than having a large number of medical follow-ups in the system. So, we feel that, having achieved 100 per cent last year, we'll achieve 80 per cent this year without then finding ourselves with a very difficult follow-up challenge in the new year. So, we hope that we'll stabilise our performance at around the 80 per cent target. 

If you were to look at Nick's model—and Nick can speak for himself, of course—I think we see a model of sustained CAPA actually helping the target to be delivered on an ongoing basis. So, those, I think, are my reflections on performance.

We introduced the CAPA model 18-plus months ago. We had 639 patients at that point who were outside of what would've been the waiting list target, and it took us probably 12 months in order to see and put those patients on a treatment plan. As a result, we've now achieved the 80 per cent standard for the 28 days for probably the last nine out of the last 12 months, and I think the December figure, which I'm not sure has been fully reported yet, is that 88 per cent of patients are seen within 28 days. So, we are confident, now, that we've got a sustainable system, based on the CAPA model, which will continue to deliver the national target of 80 per cent of patients being seen within 28 days.

I think we had the challenge early on and we've invested a lot of time and effort in managing that waiting list and putting in additional resource. We used quite a lot of the additional resources that came into CAMHS to recruit and resource additional staff, so that we could get ourselves on an even keel in terms of the delivery of that. So, yes, it was challenging, but I think we're now consistently delivering a service in a timely way for children and young people across Gwent.

And how confident are you about the accuracy of the statistics for the CAMHS waiting times?

I'm extremely confident of mine, and we manage our patients on an individual basis, and that is reflected in an assessment that is done on a monthly basis, looking at all of those patients, not only on the four-week waiting list, but also on the 26-week waiting list for neurodevelopmental, so we know exactly where they are in the pathway and how many weeks they've waited. There are no hidden backlogs or waiting lists. We're absolutely confident. My briefing for today from my team in AB—literally, I know every patient's time of wait, and that is managed on a weekly basis by the team in the health board.

Because there has been some concern, as you know, about the accuracy of the statistics.

There has been—absolutely. I think we saw, probably two years ago or slightly less, patients waiting over two years to get into the system, and they were becoming hidden in the system. I think we're clear now what we've got. We measure our primary care mental health target, both in young people as well as adults, because, given the volume of adults, the waiting list for children can become hidden. We recognised that about six or eight months ago, and put a piece of work in where we looked—I think it was in Caerphilly, we had 230 children in the primary care service who hadn't been seen in four weeks. They have all now been seen; there's a plan for all of them. So, I think there have been some concerns, but I'm absolutely confident, over the last six to eight months, that these are accurate figures and they accurately reflect the issues. There will always be the odd child or young person who waits longer than that. That may be because of certain individual difficulties, it may be their ability to access an appointment. So, you will always get some outside, but I am confident that we know who they are and that their care is being managed.

10:45

Nick's trumped me now, because I was going to say 'very confident' and he said 'extremely', but I'm very confident. Over the last couple of years, we've all heard the feedback that we had to be sharper around this. The Cwm Taf system that serves ABMU and Cardiff and Vale, as well as Cwm Taf, has migrated onto the Myrddin system over the last 18 months. We are now able to pull click data on a daily basis that shows every single appointment booked, every single patient, the profiles for the rest of the year, their waiting list challenge and so on and so forth. We've also had a number of audit activities to make sure that that migration has been done properly. So, I think we can say very confidently that our data's good.

I'd just pick up on the same point that Nick was making: because our system is a little bit less mature, we're working through the primary care element of our work at the moment, but we have, if you like, exposed those lists, despite the fact that they haven't been driven by a national target, and we've got waiting list initiative activities ongoing in ABMU, Cardiff and Vale and Cwm Taf at the moment to make sure that we've dealt with that underlying issue, if you like, that could, down the line, have an impact on our specialist CAMHS service. So, we feel it's very transparent and the data is well collected.

I think from the ABMU perspective, we obviously receive information that provides reports that break things down very carefully for us into individual areas and treatment areas. But what we also do is we triangulate that information ourselves, because we know that we have areas where we have hotter spots for children accessing services, and in other areas we have perhaps lower numbers of children who are trying to access services. So, as a commissioned service, we received the information from Cwm Taf, but we also triangulate information from our own intelligence within the health board. For example, last week, our quality and safety committee at the health board was receiving a report on the CAMHS services that are provided for ABMU. So, I would say it's very high on all our agendas, so that we are confident that we are managing the children in the most appropriate way, and that, similarly, we are developing the services to meet a changing need, a changing demand, because one of the things we haven't talked about is some of the issues that result in children having emotional concerns, and they can be around things like social media. There are so many aspects now that impact on their health and well-being, and it's how we respond early enough to actually address those needs.

Thank you, Chair. I'm just wondering whether you can confirm that there is now a 24-hour, seven-day-a-week crisis CAMHS service in each of your health board areas.

I think we can say that, actually, we haven't got that service at the moment. So, services, in general terms, are five days, 9 a.m. to 9.30 p.m., and that gives us a degree of coverage. We have been looking at wider coverage models, so we already have an on-call rota that works out of hours, and that's a two-level on-call, with clinical support, so it is there to be called upon. We've been looking at a seven-day model in ABMU, and we have run that through a degree of time. It's been difficult to resource, frankly, in terms of workforce availability, so we're just having a bit of a stock take on that at the moment. But we are thinking about how we might build a business case that would take us to a seven-day service. But we were just reflecting on this earlier, actually, that it's about having an appropriate service for the level of demand that is in the system. So, we as executives would always know if there's a crisis moment over the course of a weekend, and whether there are emergency services that need to be pulled in to support a patient. Those events are not regular. We do find that the service coverage that we have at the moment does mean that, most of the time, we're able to do what we need to do through our crisis service, or through the community intervention teams that have been a feature of our work over the last couple of years as well. So, I think it's an issue we're alive to, and we do need to think about what's the next business case for developing the service further. 

10:50

So, how far away, do you think, is that, potentially, in terms of realising that aspiration, depending on the business case being accepted and everything? You know, you're thinking about it. Are you—? How far away are you from presenting something?

I think we work very strongly in integrated medium-term planning cycles now, so there is a strong annual cycle for us. I don't think we will catch this round of IMTP for putting a major business case forward for changing our crisis services. Remembering that these are quite new services, we're still learning about them, we're still developing them, and we've got a bit of notable practice that we've just been trying out, I think it would be a business case for the next IMTP cycle. So, earliest introduction would be 2019-20.

Okay. So, you recognise therefore—because we've had evidence from people saying that they are concerned about the availability of out-of-hours services, with children inappropriately ending up on adult wards or paediatrics, and other issues around being discharged without follow-up support, and lack of in-patient beds for emergencies. These are all things that you recognise, but you're doing what you can to manage that.

I wouldn't minimise the issue. Certainly, I can think of several occasions over the last two years where we've been called upon as executives to be involved in significant multidisciplinary team discussions to properly place a patient. But actually I'm not sure that the crisis service was the service that was most important in terms of placing those patients. There might be an immediate response that's required, and in general terms we're able to deliver an immediate response. It's what happens, I think, the next day and the following couple of weeks when you're trying to stabilise a patient with multidisciplinary team working. What you're usually looking for in those kinds of cases is some type of placement where you've got a safe and secure environment, whether that's Tŷ Llidiard or a local authority care placement of some kind, and then you're looking for peripatetic services, often the community intensive treatment team, to go out and support that individual in an appropriate way.

So, I think our services now have to be quite flexible to wrap around those individuals. I can think of four incidents over the last two years where we've had to do really intensive work around individuals as a result of an initial crisis presentation that's been out of hours. There'll be ongoing work all the time, but I do feel that we've got to be very proportionate, learn from the pilot activity that we've been doing and make sure that, if we're bidding for serious new moneys to come into CAMHS, we're judicious about that.

Okay. Some of the evidence we've received has said that local primary mental health support services are still quite adult-oriented, and staff sometimes don't have the skills to undertake age-appropriate assessments. Do you think that's the case, and what would you do to address that?

Can I just speak from a Cardiff and Vale point of view? Our local primary mental health service for under-18s is entirely resourced through a children's—it's actually sat within a children's directorate, and all those workers have come through a children's route. So, I know there are differences across the area, but, for us, it's very much a children-focused under-18 service.

I think, as I expressed earlier, we've invested quite a lot of moneys into the local primary health service for children and young people. We invested £156,000 of the CAMHS moneys into that service in the last 12 months and have increased our number of clinicians from six to 11, who are CAMHS-based, into the local primary care mental health service. So, I think there was a recognition that, yes, your point was probably correct, it was adult-orientated. In recognising that, we've sought to use the additional moneys and resource that we've had to put additional services in for children that were specific for children, rather than multi-disciplinary.  

10:55

That's been done over the last six to eight months. 

And, similarly, in ABMU, I spoke earlier about the Western Bay regional approach, and they have a target, obviously, around the CAMHS services now and how we do ensure that it is child-focused, and that the practitioners who are working within the service have the appropriate skills and expertise to actually address the needs of the child.

And how are you ensuring that there is the rapid and early intervention that was intended under the Mental Health (Wales) Measure 2010? 

I think, in terms of the Measure, we all track our performance on the mental health Measure on a very regular basis. It has board scrutiny, so we will lay out all the performance domains of the mental health Measure every month in our executive boards, and at health board level. And, in that, we'll break down the various elements of the mental health Measure that show part 1 assessment, part 1 treatment and part 2 care treatment planning. And then, underneath that, we'll show the CAMHS performance, which is a contributory element of the mental health Measure's overall achievement. So, we are completely transparent and visible about our performance on that front. 

And then, for the primary care element, or the local primary mental health support services element, I think we've all acknowledged that we've had challenges around that performance over recent years, and that we've had to put catch-up activities in—waiting list initiatives, that sort of thing—very recently to get our performance to where it needs to be. Obviously, everyone is in a slightly different position on that front. But I think there's a recognition that we need to continue working at that. The conversations we were having earlier about more investment into tier 0, tier 1, is absolutely the place that we need to focus on as we go forward into the next cycle, and I'd put that ahead of other investments that we'd need to look out for CAMHS.    

So, I think, from Cwm Taf, that just 8 per cent of the overall mental health budget was going into CAMHS. I wonder: do we have any equivalent figures for other health boards represented here?

Our CAMHS spend is £4.1 million, which is up £1 million on the previous year, and if you compare that as a—. Because it's run separately from our mental health service, it would represent around 8 per cent to 8.5 per cent of the core service mental health budget. 

So, we spend in total about £6.4 million on the broadest definition of CAMHS, including emotional well-being, et cetera, and the highly specialised services, and it's around 7.6 per cent of our overall mental health budget. 

And in ABMU we spend about £4.5 million—just over £4.5 million—and that's about 6.2 per cent of the mental health budget. 

I think it's just worth adding that I think we're grateful for the investment that has come into the CAMHS service over the last three years. It has in some terms taken us from a place where we've been regarded, I think, as a cinderella service to something that now is approaching levels of resourcing that are allowing us to get into the other services that we need to put in place to protect specialist CAMHS and make sure it does what only it can do. If you look at the overall Welsh data, it's £45 million going into CAMHS against £310 million for adult mental health. The network with the Cwm Taf service has gone from about £9 million up to now about £12 million, so that's been a significant improvement for us. So, I think it's just worth stating that we've had good support over the last three years to build the base. 

But that £45 million out of £355 million—we're looking at 12.5 per cent, 13 per cent there, which is an awful lot higher than the figures that we've been given for each health board, and the other figures we've got from elsewhere are in the same range. So, I wonder whether John or anyone else might take a lead on this, but could you perhaps assist us in getting consistent local health board numbers that compare to that Wales-wide number—12.5 per cent, 13 per cent—that is a lot higher than what we're being quoted for the individual health boards. Why is that? 

I'd be happy to write to you with a reconciliation on that. 

11:00

Yes. Thank you very much, Chair. I wanted to ask about in-patient provision. And, first of all, how many young people do you have to place out of area?

A fair question. At the moment, it's relatively small numbers compared to where we have been in the past. So, we'd be on an average of three or four out-of-area placements per month. In the past, that would have been in double figures, but since we've had the investment in Tŷ Llidiard, which is the 15-bed in-patient unit—

—and it also has the five intensive beds as well—we've seen out-of-area placements come down very significantly, and I think we could give a very strong picture that those out-of-area placements that we now do make are not about bed capacity. They're almost exclusively for reasons of secure environments or appropriate care being delivered. 

It's about secure environment provision, often for highly complex patients that we're just not able to serve within that environment appropriately. 

We've had four out-of-area placements over the last 12 months for similar reasons to what John has described. I think one of the things that we've implemented as part of our emergency response team is to have a designated CAMHS bed based at our Ysbyty Ystrad Fawr unit as a holding option, so, if there is a patient that needs a particular placement, usually to Bridgend, then, rather than send them out of area, we will hold them in this designated bed until an appropriate bed becomes available, and we've seen that reduce the number of out-of-area placements on the back of that. 

So, these figures of three or four, what was it before? What was the average before?

Before, we were in double figures on a monthly basis, before the unit came into being. There's a demand pattern that runs through the year, so, over the last three years, it's a very clear pattern that we're underutilised from April through to September, and then, from September through to the end of the year, we'll tend to have high levels of utilisation. And, so, for that reason, there have been questions previously about did we need to utilise the beds in a different way during the first half of the year, maybe look at different types of provision around eating disorders, or whatever else. That's normalised a little bit this year. We thought, over the first couple of years, it was that the CIT teams were beginning to be very successful at driving discharge and getting peripatetic support in the communities, so that was taking pressure off the system, and therefore freeing beds within the in-patient environment. As I say, the last six months, we've seen quite a consistent pattern of being usually about 13 beds—we usually have a couple available—but utilisation feels more balanced now, and maybe, again, this is about maturity of the system, the CIT teams, and the in-patient facility coming into balance. But, certainly, we aren't having classic bedblocking kind of problems on a regular basis. That would be a very rare event for us. 

Yes, I was going to ask you about the effect of the CIT teams on in-patient provision. So, you have definitely seen an effect.

We've seen occupancy drop quite considerably across the bed base, and, therefore, that allows us to have that flexibility of use. I don't think there's particular bedblocking now in the system on the back of the introduction of those sorts of services. 

Thank you very much. Well, we've come to the end of our time. Can I thank you all very much for attending? We will write to you with some questions that we weren't able to cover, if that's okay, and you will be sent a transcript to check for accuracy in due course. Thank you very much. The committee will now break until 11:10. Back promptly, please.

Gohiriwyd y cyfarfod rhwng 11:04 ac 11:12.

The meeting adjourned between 11:04 and 11:12.

11:10
4. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 19
4. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 19

Welcome back everyone to our next evidence session. I'm very pleased to welcome our panel, in particular Warren Lloyd, who is consultant psychiatrist and associate medical director and clinical director for mental health at Hywel Dda; Liz Carroll, who is director of mental health and learning disabilities at Hywel Dda; Peter Gore-Rees, who is a consultant child and adolescent psychiatrist and clinical director for CAMHS at Betsi Cadwaladr; Alberto Salmoiraghi, who is a consultant psychiatrist and medical director at Betsi Cadwaladr; and Rhiannon Jones, who is the interim director for community and mental health services at Powys teaching board. So, thank you very much, all of you, for attending. If you're happy, we'll go straight into questions—we've got a lot of ground to cover. I've got Llyr first.

Thank you, Chair. Bore da. I'm just wondering if you could tell us what the main changes are from Together for Children and Young People since it was started about three years ago, and where you think the main challenges still remain.

From a Powys perspective, obviously, Carol Shillabeer, who is the chief executive for Powys Teaching Health Board, is leading the national programme and I think that that, without a shadow of a doubt, has enabled quite a focus on children's and young people's mental health within the health board and also nationally. I think the main focus and the positives have been the national direction, the fact that clinicians in health boards have come together in terms of this agenda, the care pathways that have been developed, and just the focus on the agenda, but also the investment that's followed as a result of that. So, there have been quite a few positives from a Powys perspective.

I think, from a Betsi Cadwaladr perspective, I'd absolutely echo that. I think it's been transformational, certainly in terms of us being able to adopt a whole-system approach that focuses on primary mental health, early intervention and prevention at the same time as enhancing our treatment modules for the more unwell young people and simultaneously looking at the high end of young people who need admission. I think that to be able to take that whole-system approach and at the same time have investment—it's seen the biggest improvements, greater access to services and a real shift towards more preventative work and more early intervention in a really significant way. It's also enabled us to work more effectively with partners, because we've had more resource to do the work we've wanted to do for a very long time. The 'Together for Mental Health' programme has helped us take an overview and work collaboratively with the other health boards.

11:15

You've mentioned that shift to the more preventative approach. Of course, one clear message that we've received back in evidence throughout this inquiry so far is that there is an issue for those who aren't unwell enough to access maybe some of the specialist stuff. There's this tier in the middle who require support but they're not ill enough to maybe access some of the more specialist stuff. So, do you recognise that there's an issue there still, that more could be done? Well, there's always more that could be done, but is that one of the challenges, then? Because I did also ask where you think work is still—

It's both one of the challenges and, without paraphrasing, it's a real opportunity as well. I think it's an area we've made more progress in, in a really remarkable way, with opportunities opening up with education, with GPs, with our local authority colleagues, to work differently. As you say, we can always do more, but I think in some ways that's where we've made the greatest gains.

I was just going to say, in terms of the resilience and building up resilience in young people, I think the variation in working with the local authorities and third sector is probably more of an issue as well, so that we've got parity across services that we can provide within the health board.

I think the focus on the middle has been really positive. I'd agree with colleagues that there's a lot more to do, but this is about, rather than the early intervention stage or the higher end in terms of specialist CAMHS—this is an area where I think we need to be promoting that mental health and well-being is everybody's responsibility, so that it isn't about specialist services, it's about the role of teachers, it's about parenting skills. So, I think that middle bit is the real opportunity for us to take things forward in a more productive way than we have, perhaps, to date. 

So, that'll mean training those people, in effect, and increasing capacity as well, because we've heard that there's a diminishing resource for that tier of people requiring support in terms of lack of sufficiency in relation to school nursing and school counselling services and those kinds of things.

I think it's in terms of the resource allocation and sustaining that resource, but it's also in terms of the training and development, and there are also opportunities to have a more seamless or joined-up approach in terms of the whole system and how we deliver the services, and how we as partners contribute to that in terms of health, in terms of local authority, education, third sector, and our local community. So, I think there's a real opportunity for us to move that forward.

I guess the programme of work to date has been an overdue national conversation about CAMHS and specialist CAMHS, and what it's enabled us to do is to have those conversations with key partners, but more importantly with those who use our services, who have lived experience of our services, and how we utilise those experiences in terms of how we develop our services moving forward across the board, from the tier 0 to tier 4.

Thank you. Evidence given to our inquiry has suggested that there still remains work to be done to foster collaboration and co-operation between health services and educational services in terms of managing and supporting children and young people with emotional health needs. Would you agree with that perception? And if you agree, what barriers do you see in place that should be removed?

I'd certainly agree with that; it's absolutely critical, the joint working between health and education. We've got some really good examples in Betsi Cadwaladr of success in that area. So, for example, we have established a programme to train teachers and pastoral support teams to respond effectively to self harm so they're more able to intervene earlier, and we've worked with the trade unions to establish that as part of the role of teachers, and each of the counties across north Wales is adopting that.

I think one of the barriers for me is the opportunity that we haven't really taken up yet to really engage with the new curriculum in Wales. I think there's an offer there to embed mental health and well-being in the everyday teaching across the curriculum. I don't think we've yet found the right way of doing that. I think there are conversations going on, but I don't think there's an active work stream that says, 'How do we grab this opportunity right now with the curriculum?' It would be more of that barrier to me. Provided the relationships are there within counties between the education authorities and health—I think, certainly in Betsi, there's a willingness to do that and work together.

11:20

I guess we know there have been a number of surveys and reports recently, over the last few years, especially the 'Making Sense' report from Hafal, informed by young people, where they are saying that, actually, having that support within educational settings would be very helpful. One of the challenges for us is in terms of that stigma and discrimination, and how we normalise some of the conversations, make that an everyday conversation and invite people in terms of promoting positive emotional and mental well-being. So, in terms of how we as partners work together, it's also in terms of how we as a society address our conversations in terms of mental health and emotional well-being.

We had that with cancer services years ago and a significant drive in terms of trying to normalise conversation around that. There's a lot of work been done nationally around that, but that's another key area for us in terms of addressing stigma and discrimination for our children and young people: to access services when they need to access services so they get timely input and, hopefully, that will prevent a deterioration or an escalation in the condition, which they need in the specialist end of the services.

I think there is something as well in terms of the whole-system approach. So, we're talking about statutory sectors in terms of education in the local authority and health. But I think there's a whole range of people who can provide pastoral support—all of those elements in terms of the third sector, chaplaincy. I think it is much wider than statutory services, and that's an area that we need to go at a bit more.

How much co-ordination is there between health services and schools in relation to specific individual cases? Is there a good working relationship? Does it dovetail?

Across all of the health boards, we'd be able to demonstrate examples of really good practice. I think it's about how that's spread and normalised across the piece.

And I guess we now have the opportunity to harness some of the innovation across Wales in terms of good practice and how we learn lessons and embed some of those practices locally. But yes, you're right; every health board will have an example, or a number of examples, where we've set out our services—either with primary care or secondary care, or commissioned services with local authorities—to try and improve that joint working and accessibility of services.

The instances of good practice and the instances where health services and education are fitting together well, what steps are being taken to roll those positive things out across your health boards? And what steps are each of you taking to ensure that that dovetailing between education and health is consistent across your region?

There's been a recent allocation of funding in terms of a number of pilots within our health board footprint. There's going to be a pilot within Ceredigion in terms of health and education, and it's the same in Betsi and other parts of Wales. What we're hoping for is that those pilots will trial a number of approaches in terms of how health and education work together, and that we can learn very quickly from those lessons and that hopefully we can roll that out across Wales. That's been very much welcomed, and, for each area, it's about how we use our local resources within an education setting to deliver those pilots, but also to make sure we can demonstrate the outcomes in terms of the measurements and the evidence around the interventions utilised.

They're two-year pilots with national oversight, so there'll be concentration around looking at what the learning is across the three different pilots with that national lead.

I agree. In Betsi Cadwaladr, we have a strategic meeting where we have a representative of the heads of local authorities representing education, together with children's services, so, our overall strategy is lined up. The key thing is that, with these pilots, there is an ability to evaluate. So, we've got quite mature relationships with each of the secondary schools across north Wales, with CAMHS staff going in and offering consultation and advice, and liaising with school counsellors. But the key additional thing for me is that we can now try and evaluate and pull out the very best bits by learning from the pilot.

The reality is that the Social Services and Well-being (Wales) Act 2014 has provided that platform in terms of how health boards and local authorities are working together around the children and young people's partnership agenda. So, that's where the oversight happens in terms of the plans.

Rhiannon, in the Powys written evidence, it said that increased referrals to specialist CAMHS had adversely affected the targets both in respect of assessments and interventions. Could you update us on where you are in terms of demand and that trajectory in referrals?

11:25

We've had an increasing improved performance from April. We're currently undertaking a three-month review of all referrals that have come in so that we can understand where the referrals are coming from and what people are being referred for, so that's going to be quite a helpful exercise as part of a formal review of CAMHS that we're undertaking across Powys. Additionally, in terms of the assessment and the mental health Measure and our performance, we're just about meeting the target now, although we're trying to steer away from numbers and actually look at the experience of individuals, because you can have an assessment within 28 days, but it's actually about the outcomes and impact that’s clearly important.

So, improvement's being secured. A lot of the issues have been around the investment, so it hasn't been about the resource in terms of money, but it's been about the resource in terms of capacity and appointments where we've had significant gaps in the establishment.

Thank you. And for Hywel Dda and Betsi Cadwaladr, can I ask just for an assessment of the level of demand for specialist CAMHS and what the recent trend in that has been?

We've certainly seen an increase in our referrals year on year. In terms of compliance with the Measure, we did have a dip in compliance with Part 1, the local primary mental health support services, over September last year, but we were realigning some of our teams at that point and we had some significant vacancies, so we've put measures in place now to track the vacancies and the capacity of the teams to deliver those interventions.

Yes, and I think in terms of our acceptance rate for 2016, it was 58 per cent of all referrals; for 2017 it was 64 per cent of all referrals. But we have seen an increase in demand and also an increase in the complexity of the cases referred to our services.

The national referral criteria—how involved are you across the panel in the development of those?

As senior clinicians we've been party to those discussions. Both Peter and I sit on the clinical directors for specialist CAMHS, and as partners of the programme we've been contributing to the discussions and the drafting of those criteria.

I think they're helpful because they introduce a degree of consistency and shared thinking. I think the interpretation of them is still absolutely critical, because whatever criteria you have, services and teams still have to respond to them. So, I think the flexibility and the availability of single points of access are critical so that we don't end up with just a set of criteria that lead to exclusions or acceptance. I think it's the quality of the dialogue at the point-of-referral discussion that matters more than the actual criteria.

We've seen that in Hywel Dda in terms of our setting out the single point of access since January 2016, in terms of removing some of the variation in terms of how information is considered, having a much more proactive and assertive dialogue with the referrer, and also using that opportunity to seek consent from the young person and/or family to speak to other professionals involved, so that when we make a decision in terms of the outcome of that referral it's a more informed decision. Therefore, if somebody doesn't require services we can be more supportive in signposting to the most appropriate services. That's also allowed us to take some duplication out of the system and create more clinical availability to respond to emergency and our 28-day targets. So, there are significant gains in terms of having that single point of access and how we utilise the criteria to enable us to deliver on that.

It is key, because we don't actually have exclusion criteria in Betsi. As long as you're a child aged between 0 and 18 and you have a professional who's concerned about your mental health, you can have a dialogue with our service, and there will be a range of outcomes from advice, discussion, the offer of consultation, the offer of information, signposting to an alternative service, or the offer of a mental health assessment. So, the referral criteria sit behind all of that, and it's a map of the sorts of things we provide. But, essentially, the service is accessible.

So, you're saying that you're providing something irrespective of whether someone meets the referral criteria. For people who don't meet the referral criteria, you're nonetheless providing, for example, signposting to the appropriate other services. Are you confident that children and young people who are—I was going to say 'denied a referral'; I don't know if you'd accept that language—not accepted following a referral by specialist CAMHS—? Are you confident that they're then dealt with appropriately in all cases?

11:30

I'm confident that's steadily improving. There's going to be a clinical leaders' collaborative early this year looking at exactly that—the Part 1 schemes, bringing together clinicians from across Wales to look at the nature of those schemes. I've seen a growing sophistication of each of our single points of access, the range of knowledge they have and just the skill level with our teams now to do that constructively.

If I could make a comment, although I cover adult and older people's services. The very meaning of a single point of access is to avoid people slipping through the net. So, there is one point where everybody can refer into and they take the responsibility to make sure that some sort of action is taken, and even the decision of not taking action is actually an action. So, we have exactly the same system in adult services, and it seems that at least we have avoided people getting lost in a very complex system. We had, of course—this is also the result of SUIs, serious untoward incidents, analysis where people were referred and rejected because of the criteria. One of the limitations of the criteria is excluding people. So, if you embrace people and you are responsible for the outcome, that should help everybody, really. 

And can school counsellors refer into that single point of contact as well as GPs?

Absolutely, yes.

The only thing I'd add, just because I think it's relevant, is that, because we've disaggregated all the neurodevelopmental work, there are longer waits for neurodevelopmental assessments, for autism spectrum disorder assessments and ADHD assessments, so finding a way through that is more of a challenge. So, I'm talking about a very upbeat analysis of where we are with CAMHS and the core mental health issues, but it is more difficult to as rapidly respond to the needs of young people who have an autism spectrum disorder and ADHD. I think that's work in progress too, but there are greater challenges there.

It gives me a little bit less confidence in our overall data about where we are with referrals, because we've taken out the neurodevelopmental group from that. So, it's much harder to accurately analyse what's happening with referrals year on year.

If I might just take a little step back, I think in terms of the availability and the provision within the third sector, it's something that's been called out in evidence. I think that, within our health board footprint, we will see that as well, and it's about how we as partners are smart in identifying where the opportunities are in terms of how we commission services but also how we support the provision of those services to make sure that the services we do provide within the third sector, which are very good services, meet the local population needs. So, there's a real challenge in terms of moving that forward across the board.

Okay. In terms of the single point of access, at the moment, that doesn't exist for everyone across Wales, does it—the single point of access? So, I'm understanding it correctly when I say that, when this new referral procedure is in place nationally, there will be a single point of access for everyone, yes?

Within each health board footprint, yes.

Thank you. Yes, I wanted to ask you about waiting lists—waiting times, basically. The change to the 28 days for routine assessments: how have you managed to cope with that? What challenges has that produced?

I think we've met those targets, but I think that, given the increasing number of referrals, they do become more difficult. We monitor that through the use of CAPA, which is a monthly meeting that looks at demand and capacity. So, if the service has assessed that the capacity is going to struggle to meet that demand then there's a way of escalating that through the directorates, and we can put some actions in place to support those targets being met.

From the Powys perspective, the feedback from the teams on the issues around the 28 days is that it doesn't take into account if there are some further questions that are required. So, sometimes it's about the quality of the information that is within the referral. The clock is ticking, if you like, irrespective of whether we've got to go back and get more information. That's something that the teams have fed back as being an issue. Additionally—

Once the referral is received, if more information is required, you're still within the 28 days, and that can sometimes take time. So, there have been some issues there. Additionally, it's about weekends and out-of-hours. Powys is rural. We haven't got acute services. And based on that as well, there were some issues in terms of the out-of-hours and the weekend working. So, they are the challenges, but from a Powys perspective, there's been increasing positive performance in terms of meeting the 28 days.

11:35

And from Betsi, I think, on the whole, we're fairly confident about meeting the 28-day target. There have been periods of time when it's slipped by a few weeks and I think we've been able to take action to bring that back. I think the challenges in meeting that are when there are some surges in demand that are unexpected. Because it's a tight target, and to respond quickly when you've got unexpected demand is difficult. But I think we're confident overall that we will be there or thereabouts with the 28 days. I think the choice and partnership approach that other people have referred to has been really helpful with that, and we've introduced that across the board.

Similarly, with the treatment times, we were less confident in our data because we've got three different information systems across Betsi. But again, we think we're more or less on target for the further 28-day wait for treatment, but it's a little bit harder to be as confident, but we don't think we've got any great gaps there.

You mentioned the lack of confidence about data—. Because I know there have been queries generally about how accurate the CAMHS waiting time figures are—. Do any of you have any comments about that, generally?

I think one of the advantages of the programme, to date, was the baseline variation and opportunities for assessing that came in 2015, and that very quickly brought to the fore that, actually, our infrastructure isn't able to give us that information, and it required a huge amount of manual hours to find the information that we needed. I think, although there's been some improvement, that is a real challenge for us in terms of collating that information, having that at our fingertips to be more informed in terms of where some of the demand and capacity issues are, and in terms of the waiting lists. So, our corporate infrastructure on using different systems is still a challenge for us in Hywel Dda.

I think a further challenge as well is in terms of measuring the targets, because you can see somebody within 28 days. It's about the input. It's about what action is required and the treatment that's with that. I just think I'd just be urging a focus on outcome measures as opposed to numbers, if I may.

Thank you. Additional funding is being provided so that the capacity of specialist CAMHS can be increased. What's the current staffing level, and what's your current vacancy rate in each of your boards, please?

We're about 68 whole-time equivalents, excluding medical staff, within Hywel Dda. We've got a 1.24 vacancy at the moment, so it's quite low, but it might be different. The medical position is a more challenging one for us in terms of psychiatry.

In medical, we've got a number of vacant posts, and that's a national position, not just in Wales but in the UK as well. The royal college has acknowledged that and launched a campaign in the autumn of last year in terms of ‘Choose Psychiatry’, but there's a real challenge for us in terms of our medical recruitment and retention. But what we have done is use the new resources in a very creative way, so when there are opportunities, we look at how we complement the services that we deliver and how we can deliver those services with a broad skill set. That's enabled us to utilise the resources the best we can, and to deliver the services and the quality of the services. Because, ultimately, we're here to deliver a safe and quality service to our population. But it is about being creative in terms of how we deliver those services, and not always using a more traditional role or discipline in taking forward some of the new developments.

In Betsi, in 2016-17 we had 258 whole-time equivalents, and that was an increase of 21 whole-time equivalents from the year before. We've had significant vacancy issues with consultant psychiatrists and, to a certain degree, with our nursing staff and clinical psychologists. We rely quite a lot on agency staff, in the short term, to meet the targets. That's gradually going down now as we move to fuller recruitment, and I think we're having to adjust our workforce. I think it's unlikely that we will recruit to all the consultant psychiatry posts, for example, that we've got. So, we'll be looking for alternative solutions for tasks carried out by doctors that can be carried out by other non-medical staff in the future. Clear progress.

11:40

Yes, there is a national piece of work and a commission that I'm part of with regard to recruitment because in adults and older people, we are facing similar problems, and, UK wide, there is a 15 per cent vacancy rate at consultant psychiatrist level. We know from the start that we won't fill those posts. There are multiple reasons, it's multifactorial. So, the strategy. First of all, the study that we commissioned: the projection of the Welsh need for CAMHS consultant psychiatrists is not going to increase in the next 10 years, but there will be a steep increase in the need for older people mental health consultants because of the aging population. So, that is reassuring, and I agree with Peter, there are two strands to the strategy: one, making roles attractive and offering something extra to attract people, but also to review the role of the doctors within the mental health services and to delegate to other professionals some of the functions that, historically, are taken up by doctors.

From a Powys perspective, the investment has been very welcomed. Small is beautiful. We're talking about 23.9 whole-time equivalents in 2015-16, but that's increased by six with the investment. Again, the same as the rest of the panel, the issues in terms of recruitment to psychiatry are significant for us and even more significant when you're talking about small numbers.

We've got the national challenge in terms of psychiatry, but when you work in a rural health board such as Powys—although that's applicable to Hywel Dda as well—there's an even greater challenge. And then, because there are gaps in other areas, where we might look at some creative options about linking in and partnering with other health boards where they've got gaps, that isn't such an attractive option. In terms of specialist CAMHS nurses, there are some gaps there as well.

Yes. This is a discussion we could've had seven years ago, really, and we're still having it. So, are you confident that this is going to be addressed over the medium term, because it's déjà vu, isn't it?

I think that the challenges—and I absolutely wouldn't disagree with you that these have been ongoing for a number of years, but I think that the challenges create opportunities, and, as Peter indicated, it is about working differently; it is about role redesign. It is about looking at other partners in terms of who can do what. So, it does present opportunity, and we're seeing that. Think about it in terms of the neurodevelopmental service: we haven't been able to recruit, we've redesigned that role, and we've now got a nurse, and that is having a positive impact. So, we need to not think about traditional models, we need to look at new ways of working because of the challenges, and it's not because commissioning numbers haven't been put in; it's nationally very difficult.

But instances of mental health issues amongst young people is increasing, so, clearly, even if we reconfigure it, there's probably a need for more people at the coalface.

There are. I'm not confident. It's clearly not an environment where we can go out to adverts and expect to recruit appropriately trained people; that's not likely to be the case for the foreseeable future. So, we're all talking about being as creative as we possibly can be, bringing in people from different professions, doing a lot of training within our services, being quite innovative in some of the training we deliver to our own staff. It's a challenging environment.

So, what can be done to make it a more attractive proposition for potential practitioners?

One of the things we're doing—I think it helps—is to really be clear that we offer good-quality training, good-quality clinical supervision and good-quality opportunities for personal development; that we collaborate with the local universities and we share that. I think the other thing is collaborating with the educational programmes that are already there—the resident medical officer training, the clinical psychology training. It's long-term work.

And it's engaging with the deanery, it's engaging with Welsh Government, engaging with the UK Government in terms of university placements and our training schemes across the board to make sure we train the professionals for the future in terms of meeting our population needs, whether it's in urban or rural parts of Wales.

And it's a multi-agency environment, so that it's not seen as sectors, as health, and that everybody's working together. I think it is also about the early intervention and the prevention element, which is what we were talking about more at the beginning. So, focus on that element might help.

We've had some very interesting experiences of recruiting occupational therapists and social workers. We've trained them to be CAMHS clinicians and they bring a set of skills that they already have. That's one example of just doing things differently.

11:45

I'm sorry; I've lost my place. Access to psychological therapies, isn't it?

Are you all meeting the 26-week target for neurological developmental conditions?

Within Hywel Dda, we do, in terms of the target that was introduced in April 2017.

Twenty six weeks for all new referrals for the neurodevelopmental pathway. We do, however, have a significant legacy position. When we started to develop the integrated pathway in 2015, there was a combined list of over 1,000 young people waiting for assessment, and some of those young people were waiting for a very long period of time—in excess of five years. 

What we've done to date is we've made a significant inroad into those numbers, and, to date, we've got 248 young people still waiting from the historical waiting list. We are—

Two hundred and forty eight young people still waiting.

From the previous list, yes. 

We had some significant challenges in terms of recruitment for that integrated pathway, both within mental health and our child health colleagues, and we've used a number of initiatives to try and address that. The team are working additional hours to get us to a position where we don't have a historical waiting list, but it's a real challenge and it's not a position that we want to be in. But, I can assure you that we're doing everything we can with the resources we have to address that position.

In Betsi Cadwaladr, it's a really significant challenge.

Well, there are some differences. We didn't have a legacy position, but our current waiting times are between 12 and 18 months. We've brought them down. We have over 1,000 young people on our waiting list at the moment in all of our areas. We've got a very clear plan in place and we're very clear about the model. We think we've made huge progress with our community paediatric and child health colleagues—

Against a target of 26 weeks. So, we're absolutely not hitting the 26 weeks, and all of our areas are indicating that there are real capacity issues. We think we've got the model right—the multi-agency and the multidisciplinary approach. We haven't got the data to prove this, but we're pretty confident that the demand for neurodevelopmental services has gone up. We weren't recording it as systematically in the past, but there's a clear message coming across that the demand has gone up.

The total numbers waiting are just over 1,000 in BCU. That's across the six counties.

So, have you got something in place to try and bring that waiting list down rapidly?

We are. We're bringing it down, but we're going to need—. We're also getting a clear indication that we're going to need to increase capacity, and those debates are going on within the health board at the moment. Again, it's another example where we've been using agency staff to help us.

You've had funding for that, as well. There was £2 million earmarked for—

Yes, but I think it was about £440k that came into Betsi Cadwaladr, and that was invested in speech and language and psychology and clinical time. That certainly hasn't been sufficient to address the capacity gaps that we're seeing across the six counties.

We don't have the comparative data with other health boards. I know that we're working on bringing it down and that the model is right.

We heard from the Aneurin Bevan board, for example, and they didn't have anywhere near that kind of problem.

I think, if I can—. In terms of where we are as a health board, when you identify that problem, you put all the resources you have in to address that. When you have a limited resource pool—I take on board the new funding—there are delays in recruiting. You have to have the right skill sets, because what we have agreed nationally and through the neurodevelopmental work stream is that there needs to be a good enough assessment, and it needs to be evidence based. Therefore, it does take time to undertake those assessments and to make sure that they're comprehensive and informed assessments, to make sure that there is a clear formulation for that individual, and then in terms of what their needs are.

So, it is, unfortunately, not that straightforward in terms of just initiating a waiting list initiative and bringing the numbers down. There are a number of factors that play into that in terms of recruiting, in terms of sickness in the team, in terms of being over capacity, overwhelmed by the numbers—

11:50

Okay, but I'm trying to understand why the pictures are different across different areas, different boards, and there doesn't seem to be any understanding of that.

I don't have a mechanism for comparing data, really, other than that we count it and look at it exactly from health board to health board. I've got a lot of confidence in our own data. We know what we're doing to address that. I think it's going to be a combination of developing the model as fast as we can and putting in more capacity.

The same position for Powys, really, but on a much smaller scale. As identified earlier, we've looked at alternative approaches in terms of neurodevelopment, so we've appointed nurses additionally, in terms of the money we've had, and it equates to 1.6 whole-time equivalents in terms of investment for this area, but we've now been successful, so that'll start having a positive impact.

I'm not sure of the numbers. I'll have to let you know.

Okay. Thank you. The Welsh Government provided an additional £1.1 million annually for health boards to improve access to psychological therapies. How many additional whole-time equivalent specialist posts have been created using that money, and what impact is this having on the provision and access to psychological therapies in your health boards?

The investment is obviously welcome, because we are, in terms of—having the reserves in terms of delivering psychological interventions for children and young people is absolutely key and core to our services. Prior to the new funding, we had provision within the health board in terms of psychotherapy, and we had a number of psychotherapists to deliver those services and systemic family therapies.

However, the additional funding has allowed us to recruit four cognitive behavioural therapy therapists. To date, we have no waiting list for our CBT provision and, during 2017, we had 89 referrals to that service. The way we develop that service is that they have a strata above the primary care provision and the secondary care provision, so they can support primary care in terms of providing brief interventions and supervision, and they can also take the more complex end in terms of the secondary care and support other clinicians that work within secondary care in terms of a psychological framework.

In addition to that, we also have a dedicated community dialectical behaviour therapy team that's been in existence since 2018 and we've invested heavily in that resource. We've got eight therapists delivering a DBT service, and, again, that's been significant in terms of impact and benefit to our population with emotional dysregulation or risky behaviours, and, again, we've seen some significant positive outcomes in terms of that resource. But I think the additionality has just enabled us to provide a broader scope of interventions, both for primary and secondary care.

It's a similar picture in Betsi Cadwaladr. We had a range of psychological therapies, but with some key gaps, so the new investment has enabled us to recruit three full-time family therapists, and we now have a really coherent plan to add family therapy to all of our areas. We've also developed a specialist child psychotherapy post, which we hope will bring some leadership to that area of work in north Wales. We've also developed a CBT training post, in partnership with Bangor University, so we've dedicated some clinical time to running the CBT training and then, in turn, we can put the majority of our CAMHS clinicians through CBT training that has different levels, and that runs on a recurring basis. So, it's been really welcome, and been very effective.

It's quite good going last every time, because I can say, 'The same as them.' [Laughter.] On the specifics we have been able to gain, the investment's been really useful in terms of psychological therapists, and there's a real focus on DBT, but, again, very small numbers. One of the things, again, we're looking at is hoping to be able to partner with neighbouring health boards, because to have a therapist using that approach, it's about maintaining skills when there are small numbers. So, that's a particular challenge for a small, rural health board.

Is there a national overview of the number of referrals that are made across Wales for the different types of psychological therapies, and is there a record of how many referrals are accepted? As well, just one more point, why do we still have such big waiting lists?

As far as I know, there isn't an overview of referrals nationally to all the different psychological therapies. There's some emerging work now to develop the range of psychotherapies that are available in Wales that Dave Williams is leading. In terms of waiting lists, we don't have particularly long waiting lists for therapies. On the whole, young people get their therapy in a timely way after their assessments. We try and flex our capacity, and the new investment has helped us increase the range of therapies. I think there's work to be done in getting ever more sophisticated about selecting the most appropriate therapy—when something doesn't work, to move to an alternative therapy. I think that's about the overall service developing its sophistication. 

11:55

And in terms of Wales, there's the Cymru matrix that's been developed for adults, and what we've done, working with specialist CAMHS, linked to that there's going to be a separate work stream to look specifically within specialist CAMHS in terms of what the core interventions are, and then in terms of how we collate that data. So, that's something that will progress through this year and then link in with the Cymru matrix in terms of that adult provision and the matrix in terms of low-intensity and high-intensity interventions.

I was going to say that an additional element there, in terms of somebody who's had intervention, is about what impact that's had, and the longer term impact, which is over many years, in terms of the impact on them in terms of their life course. That's another piece of work that's really important as an evidence base against this range of therapies that we've got.

There seems to have been an increase in the number of children and young people presenting to CAMHS with attachment difficulties. How much of a priority is the development and expansion of family therapies? Most of you have mentioned family therapies, but how much of a priority is it to you?

There are two clear strands to that. One is the need to increase the capacity of all of our staff, and all of our teams, to work helpfully with families, without calling it specialist family therapy, but to increase the capability and skill level of all of our staff not just to deliver individual therapies, but to be able to work with groups of two or three people, whether it's two parents and a child or a whole family. We've got a line of work to develop that, but, at the same time, developing family therapy is also important, so that when specialist family therapy is needed, it's available.

I'm a bit more cautious about linking it specifically to attachment problems. I think we've got some very clear guidelines from NICE now that say we should be really careful about diagnosing attachment problems, and we should do very thorough, broad-based assessments that are needs-led before we move in to delivering specific therapies more related to attachment.

And, actually, the choice and partnership approach service model that's now being implemented across NHS Wales, the core element of the CAPA model, in that choice and partnership, is having the generic skill sets for all our clinicians to be able to deliver that low-level intervention and support the young person, the child and the family through choice and partnership. All those cases would need to go into specific—where they need that high level of expertise. So, it's making sure we've got those broad-based skill sets and that we enhance those skill sets.

So, is there now a 24-hour, seven-days-a-week crisis CAMHS service in each of your respective health board areas?

Yes, it relies heavily on our colleagues, but there is 24-hour advice available. It's constructed from paediatrics, adult mental health and CAMHS, but it's there.

But we are hearing evidence that there are still concerns about inappropriate out-of-hours care and crisis cover. For example, we hear that there is lack of in-patient beds. We hear that some children and young people are being placed on paediatric or adult mental health wards. So, how do you respond to that?

I think that's accurate. I think although we're clear we've got a 24-hour response, we're using a range of services to manage that, and I think the key is the whole-systems response to it. To concentrate only on the crisis end doesn't solve the problem. I know I've talked about early intervention, but it is critical, and having sound, well-functioning, well-resourced community teams that can respond quickly to crisis is going to reduce demand on crisis beds.

I think we always will rely heavily on our paediatric colleagues to help us do crises. I think the key is that we can respond rapidly when they're in that situation. The sea change for us in the north is we can guarantee that you get a good CAMHS assessment within 24 hours, regardless of the day of the week or the time of the year. You may not get it at 2 a.m., but there'll be certainly someone there at 10 a.m. on a Sunday, if need be, and that's such a change.  

12:00

And then, I guess, in Hywel Dda, what we do have is 24/7 provision and, again, working between our specialist CAMHS and our unscheduled care provision and the training supervision and the joint working, and that transition management is very, very key. We also have two designated beds within our footprint that we will utilise in a crisis, and investment in terms of training staff to be able to support that individual when they are in the crisis bed, but also how we use our crisis provision in terms of gatekeeping but also facilitating quick discharge from hospital, whether that's within our designated beds or within the provision within south Wales, Tŷ Llidiard. So, the investment in those services has been key in enabling us to manage that pathway. 

However, what we have seen in terms of our data is that there has been an increase in the utilisation of beds, and that comes back to the increase in demand and an increase in the acuity of the cases we see. There are times where the only safe option we have is to use a designated bed for the shortest period of time whilst we ensure we've got a community provision to support that young person or child and their social network in terms of returning to the community. 

And, at least in north Wales, what we clearly understood a long time ago is that we need to respond as a system, because there was a huge variation. When it's unregulated, you've got a huge variation of response, because we all are aware that a child in an adult environment is inappropriate, but if you don't have a policy or a common understanding of how to respond, you can have a huge variation and hence increase the risks to the child. So, what Peter and I have done over the last three years, I would like to say, is to try to collaborate as much as possible to avoid the variation of response. Our intention in north Wales is to continue this strong collaboration and openness between the adult/older people and, of course, CAMHS services.

But also, there are still ongoing task and finish groups to address some specific issues. For example, the section 136 issue for children is clearly increasing, at least in north Wales, so how do we sort it out? There is just concluded an options appraisal and all the transition or admission for 16 to 17 to adult beds. So, the temporary solution is that we have an allocated bed in the Heddfan unit in Wrexham. There are some bureaucratic barriers in regard to the use of that bed, for example, with disclosure and barring service checks or the training in child protection—so, a safeguarding issue for some members of staff. It's actually, as we speak, being addressed by a couple of managers. So, there are some bureaucratic barriers but, generally speaking, we have an identified area at least, and we are training staff. And, of course, it very much depends on the availability of beds in adult care, because we don't have a surplus of beds, as you know very well. But, generally speaking, the philosophy is to collaborate, so we avoid variation of response and we decrease and contain the risks to children.  

Could I just mention—obviously, there's the Welsh picture, but from a Powys perspective, although I know this will impact on other health boards—that we commission services from over the border, and we've had some significant issues in terms of Shrewsbury and Telford, where we've had young people that have been held in emergency departments, let alone paediatric wards, for a significant time? Recognising that they're serious incidents and galvanising our response to ensure that there's a remedy to that is really important. The collaboration you've been describing—we've been doing that with our partners both in Hereford and in Shrewsbury and Telford, where they've got different measures, but, actually, it's about the experience of the young person.     

What have you done across the board to make sure that primary mental health support services are age- appropriate for children and young people?  

Within Hywel Dda, that provision has always been within specialist CAMHS for those under the age of 18. In 2017, we co-located our specialist CAMHS primary mental health workers with our adult lump services, to galvanise some networks and see where those opportunities were in terms of delivering some interventions. And they remain under the management of specialist CAMHS. So, they have never been separate from our services in terms of the provision of specialist CAMHS with expertise in primary mental health.

12:05

In Betsi Cadwaladr, they've always been at the heart of children's services, with children's staff running them, so they've always been—

So, the criticism we've heard from stakeholders that they aren't always child-orientated and child-appropriate, that's not the case in your boards.

All right. That's fine. And is there enough capacity in local primary mental health support services to ensure that young people are having rapid assessments, particularly in line with the Mental Health (Wales) Measure 2010?

I think, as you said earlier, it's about an assessment, it's about the outcome, and probably outcomes are more important for us to focus on for young people. But it's critical that we get to see those individuals really early on in that pathway, but, actually, it's what difference it makes for them that's really important. 

I'd echo that. I'm confident about the assessment times, but it's what you do after that—it's the building resilience in schools and working with partners to do effective things that are brief and time-limited, and we want to keep building that. 

Thank you very much. I was actually going to ask a specific question to Betsi Cadwaladr because we'd heard evidence about the reduced in-patient capacity at the north Wales adolescent service. So, we wondered what the problems were. It was told that it was workforce problems, and I wondered if you could explain to us what's happening. 

Absolutely. We've had some very significant workforce challenges. It's always been difficult to recruit RMNs and adequate numbers of nurses. And, in addition to that, we've had a crisis in recruiting consultant psychiatry time. So, we haven't been able to recruit a psychiatrist to lead the in-patient service. So, we've rapidly moved to a model where our in-patient service is led by a consultant clinical psychologist. We've had to do this apace over the last two months, so a lot of the arrangements are interim. We've sought approval through our health board and our own governance arrangements. We've discussed it with colleagues in Wales and with the royal college. So, we've now got a model where it's been led by a consultant clinical psychologist, with community psychiatrists inputting into that from the local areas. We're actively recruiting as fast as we can. 

We have to do a lot of training. Even when we recruit staff, it still takes a long time to bring their skills up to the level that we need. We're confident we've got the right things in place. We're open for business. We are admitting. How long it will take is difficult. I very much hope, over the next two, four, six months, that we get back up to full capacity. At the moment, we have no waits for admission and we're able to accept admissions. Our out of areas—we don't have any generic young people out of area; it's only very specialist placements that are out of area. So, the right things are in place. What I can't predict is what the workforce challenges will be over the next few months. 

I just want to make a comment with regard to the workforce, because I think the committee needs to be aware that there is actually significant progress at every level, and there is a huge effort in recruiting. But my experience—and I bet it's the same for children—is that the only way of recruiting is headhunting and offering good conditions. But, even when you do it, it may take several months from the moment that you find someone to the moment they are actually in post, partly because of contractual issues and partly because of negotiation, and partly because of a number of reasons. So, it is a significant national problem, not only for medics, but also for nurses, and that has a major impact on how you actually deliver front-line services.

Okay. That brings us to the end of our time, so can I thank you very much, all of you, for attending and for answering all our questions? As usual, you'll be sent a transcript to check for accuracy following the meeting. Thank you very much. 

12:10
5. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 20
5. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 20

Okay. We'll move on, then, to our final evidence session this morning, with the Welsh Health Specialised Services Committee. Can I welcome Carole Bell, director of nursing, Carl Shortland, who is a senior planner, and Robert Colgate, associate medical director? Welcome to the committee and thank you for attending. If you're happy, we'll go straight to questions. The first ones are from Michelle.

Thank you, and good afternoon everyone. A lack of data transparency has cropped up as an issue for us during this inquiry. There seems to be a lack of concrete, transparent data in relation to in-patient CAMHS services. So, can you provide us with a picture of the demand for in-patient CAMHS services across Wales?

Yes. There's, obviously, quite a complex range of data that's available, but, if we look at the actual number of admissions, it may be helpful. In 2015-16, we had 140 children from across Wales requesting tier 4 in-patient beds. That reduced to 130 in 2016-17. It's currently forecast to go back to 140 in the current financial year. We have managed to reduce our length of stay during that time, which has allowed us to deal with that increase back in the number of admissions. Obviously, the occupied bed day data that we put into the initial response adds to that, and gives a more detailed picture. But I think, if we concentrate on the total number of admissions, it's probably the best indicator to look at at a national level.

Yes. We wondered if you could tell us what the recommended bed occupancy rate for CAMHS in-patient care is, including home leave. This is one of the points we wanted to find out.

If I start, and then maybe Bob can join in, there are no actual recognised royal college guidelines or anything of the sort. What we have got in Wales is we've got contracts with our two providers and an expected occupancy rate of 70 per cent, which excludes home leave, and we've got a notional target of 95 per cent including home leave. What we have done is looked at UK benchmarking data across 39 units, and the average occupancy level across the UK, excluding home leave, is around 76 per cent, which is slightly higher than what we have in Wales.

I think there are issues there that our occupancy rate, again, does reflect demand at any given point in time. Certainly, we do have issues in the north that I'm sure we'll come on to in a bit, but, for the south Wales units, we don't have any people waiting, we don't have patients out of area who potentially could be in the south Wales units. Their throughput has increased as lengths of stay have come down, so their occupancy levels are quite low at the moment, but they are seeing more patients than they've ever seen before.

If I can add a little bit, if you reflect on acute units for adults, or perhaps old-age psychiatry, the usual accepted figure, the guideline, would be 85 per cent, to allow for flexing and peaks and troughs of admissions. I think for a specialist unit to say that the expected rate would be higher than that, including leave, is reasonable. They can still justify then that they're working hard, but they're also able to take in emergencies or—I know the tier 4 admissions are planned, but they can still take cases that are perhaps more urgent and need to be dealt with. So, the figures that you've heard, which are reflections of the national picture—England and Wales—I think, are reasonable.

Yes. I think the key figure to avoid is 100 per cent, because then you have no flexibility.

12:15

Chair, I think the only caveat to that is, clearly, we have got issues in our north Wales unit that are affecting occupancy levels. If that unit was operating to full efficiency, occupancy rates within that unit would be quite a lot higher, but I'm sure we'll come on to it in more detail later on.

Well, yes, it's exactly where we're going next, really, because a few of us visited the unit, the adolescent services unit in Abergele, and, from what I understand, they've 12 beds there but operated at a capacity of about six to eight for the last 12 months or so, and were actually not able to take anybody in between April and May last year, from what I understand, which is rather disturbing. We heard previously from a panel and representatives of Betsi Cadwaladr that there was a staffing issue, that they couldn't recruit a consultant psychiatrist so they had to move to a clinical-psychologist-led model. So, looking forward, how confident are you that that workforce issue is going to be addressed, and how long will it be until we're back to full operating capacity in Abergele?

We heard some of their evidence on the feed. There's a national shortage of consultants at that level, particularly within CAMHS, but also more widely in mental health—you know that. The discussions that we've had—I've spoken to Dr Gore Rees and exchanged correspondence. The reason that they've gone to a clinical-psychologist- and then a consultant-nurse-led service, supported in terms of mental health Act functions by the other senior consultants in the community teams, is because they have to. There is not another alternative. You can't find adequately trained and competent staff.

Several services are in that position, nationally. As a member of the Royal College of Psychiatrists, we need to start at the bottom and actually bring staff through. I heard you talking about workforce issues. It starts at the bottom. It starts in medical school and it starts in the foundation programmes. So, in terms of actually having a model that works, this is a perfectly reasonable solution, within the rules. The only issue, medicolegally, is to address the mental health Act functions. I'm confident that, with the input from the community consultants, that is being covered.

So, is there a recovery plan to get to a point where the 12 beds will be operational?

Yes. I think if we just step back to—. If we start back in April/May time when the unit actually closed to new admissions, the initial problems at that time were not with the medical workforce—they're more recent. The initial problems came with a severe shortage of qualified nursing staff, and one of the major reasons, unfortunately, was a side effect of the new investment—a lot of the posts that were created out of the new investment into CAMHS services in crisis and other areas were banded higher than what the in-patient service was banding their nurses, and they lost a significant number of qualified, experienced staff.

So, the health board, as the provider of that service, took the decision and notified WHSSC that they couldn't provide their full level of commission capacity. From that point forward, WHSSC have escalated that service to our internal escalation process and we have quarterly meetings with board members of BCU, and we have had some improvement.

As I say, the medical workforce then became an issue that sort of delayed that process, but at the moment they are working back towards the 12 beds. I would say they're probably able—it depends on the acuity of the patients—to take eight to 10 patients at the moment. I'm not sure we're going to get back to the 12 beds in the next couple of months, but I would hope that we were there by the summer.

They have taken other mitigating actions and are actually going to over-recruit qualified nurses. So, when they're going through a recruitment round, if they get sufficient candidates of the right calibre, the health board have taken the decision to over-recruit, given some of the issues about retention of this type of staff.

The medical workforce, as Bob's touched on and others have touched on, is a slightly different issue. We are confident that the interim model they've put in is safe and sustainable at the moment. Longer term, they need to develop a sustainable plan about what they're going to do about recruiting consultants into that service.

12:20

I would expect a commitment from a consultant CAMHS in-patient specialist to be the preferred solution. Until that can be achieved, this is acceptable.

Thank you for that, and I appreciate the pressures in terms of staffing, et cetera. But, in the meantime, then, whilst the unit has been operating at reduced capacity, could you tell us how many young people who required in-patient service at that unit, potentially, had to be located out of area as a result?

Just since April, when the real issue started, there have been 10 children and young people who've been placed out of area but would have gone into that unit if the unit was operating sufficiently.

Since April 2017, so, in nine, 10 months. That has improved recently, and there's only been one of those 10 in the last three months. So, the situation has stabilised and is improving. 

Okay. So, what's your assessment, then, going forward, of demand and capacity? You paint an improved picture there, in the last three months. Is that a trajectory that you expect to be reflected going forward?

I think the important thing is about working with—you know, with the health board. We've got plans in place where we do meet with them on a regular basis, and therefore it's about making sure that what is in place is sustainable. So, we're trying to provide them as much support as we can, and having those ongoing discussions, I think, is what will give us the confidence in terms of what the longer term plans and working towards those can achieve.

As the planner of the service, I've obviously gone into quite some depth on the demand and some of the figures. Over the last three years, the north unit has potentially got a cohort of between 40 and 45 patients a year. At the moment, roughly half of those patients are going into the unit. So, therefore, half are going out into out-of-area placements. From what evidence I've seen, in an ideal world, probably two thirds of the patients who are going out into out-of-area beds from the north at the moment could have gone into the NHS service, if it was fully operational. So, going forward, looking at 12 beds, I think that's a reasonable level of service to meet the demand of the general CAMHS patients that require a service in north Wales. Clearly, the more specialist and the secure beds, which will be the other third of the patients who are going out, we currently don't have those services in Wales, so they will continue, at the moment, to go out.

Because there is a second ward, of course, with, potentially, seven beds at that unit. So, there's no thought being given to utilising that as part of the solution.

Yes, prior to April 2017, so during 2016-17, we did have a working group between us and the health board, looking at alternatives and potentially use of that second ward. That work was really put on hold as they started to have this issue about keeping the single ward fully operational. In the long term, there's a piece of work that—. We've got a planning network across Wales that's chaired by Carol Shillabeer, who is also the chief exec for the Together for Children and Young People programme, and that network is currently looking at potential best use of NHS resources across the two sites. And so, obviously, we'll consider the potential of any beds that are currently not being used. That work is due to come to fruition to us at the end of late summer, and obviously WHSSC, as the commissioner, will take on board what those findings are and have discussions with the health board about that.

And I think we do know that that ward has been used on occasions where they need to manage challenging situations, so they have used the ward. But it's about using the work that's ongoing to influence what the commissioning will be in the future.

So, you expect, after the summer, for that piece of work to inform, maybe, a decision that you will need to make at that point.

Yes. From looking at the data, I don't see that there's a need to open any more beds for generic-type CAMHS, assuming the worst.

It would need to be for a cohort of patients that, currently, we can't meet the demand for in Wales. I do think that, where they are located and the staffing issues they've got, that will prove a real challenge if we're going into a more specialist area.

12:25

Have you thought about offering those services to other health boards, in England, for example? Because sometimes I get the feeling it's all one-way traffic and maybe we should be utilising our own services for others. 

I mean, obviously, that would come in to any business case or development that we did, but I do think we'd need to get some surety around clinical expertise and workforce issues before we considered that. I think that is the major issue stopping any development of any beds at the moment in Wales.

We're going to ask some questions now about south Wales and Tŷ Llidiard. Julie.

Thank you very much. Some of the committee did visit Tŷ Llidiard and we did hear some conflicting evidence about the fact that there appeared to be spare bed capacity while being aware that you still continue to commission out-of-area placements and use non-NHS providers to have CAMHS in-patient care in the south. So, I wondered if you could explain that.

I think Tŷ Llidiard—we changed the way we commissioned that service back in April 2015 as well, and I think we developed quite a novel arrangement. I'm not sure it was anywhere else in the UK. Obviously, they've got the two wards in Tŷ Llidiard, but what we recognised was that there wasn't the demand, potentially, to use all those beds. So, we agreed with them that we would allow them to access both wards as required, gave them additional support to meet more challenging patient need and also provided a second clinical area that you could de-escalate patients onto. So, some of the previous problems about running the service from a single ward—if you have one or two difficult patients that can quickly destabilise the whole service, the ability to move and take those patients out into a safe, clinical environment I thought made a real difference to the way Tŷ Llidiard were able to manage their patient cohorts. 

The people who are placed out of area from the south Wales area are virtually entirely due to the fact that there are no services in Wales. So, the majority will be secure patients, and there'll be a few specialist placements. So, I think we've got three in London; they will be in a very specialist eating disorder service or they will be younger patients who go to Great Ormond Street, et cetera. So, as far as south Wales goes, I think there's only been one placement of an out-of-area child in the last three years that could have gone into the service, but at the time, they were full. So, we see the evidence as being we've got the right number of beds in south Wales and it's working well. The only challenge—and, again, this will feed into the work we talked about earlier with the network—is to look at the types of services that we currently don't provide in Wales and whether there is anything that we could do to address that.

One patient has been in Tŷ Llidiard and has got severe and enduring eating disorder issues, so they're going to a specialist eating disorder service in London. That patient, I believe, was on liquids for two to three years and currently is now starting to eat some solid food and making progress. She will turn 18, I think, later in the year. So, she's unlikely to come back into CAMHS services in Wales.

The other two patients, again, will be accessing specialist services; they will have some comorbidities, maybe a particular learning disability or autistic spectrum disorder background as well as their generic mental health. So, any placements we make out of area from south Wales, as I say, apart from the one, have been for a specific reason. The majority will be into secure beds, either forensic medium-secure beds, which is a network that England have in place that all Wales patients requiring that service use—but we're only talking a handful of patients across Wales at any one time. The bigger cohort is going into low secure. So, it's the framework—we've got a national framework that we implemented in 2015 as well, and, at that point, we got a Welsh private sector provider that provides low-secure beds for patients and two thirds of our patients who require low-secure care, although they go into the private sector, are now getting treatment within Wales at Ebbw Vale hospital.

12:30

The framework is a mix of both independent private sector providers, such as Regis in Ebbw Vale, and also English NHS trusts that have agreed to come onto our framework. But the use of the framework has diminished over the last three years as the numbers of out-of-area patients have reduced as well.

Right. So, in terms of Tŷ Llidiard, Healthcare Inspectorate Wales say that they regularly provide for more than the 15-bed service, which is commissioned and staffed—. You're not saying that, or—?

Occasionally, they will get to a sixteenth, or possibly a seventeenth. Bearing in mind that they may have half a dozen patients on home leave at that given point in time, they physically may only have 10 or 11 patients in 15 beds, but they'll have 16 or 17—it's not a regular occurrence—on their books because they allow some scope where they've got a significant number of patients on home leave. And, of course, home leave in these services is used quite regularly. So, for example, in the Christmas period, where we try to get as many children and young people home as possible, I know that there were only two patients on the unit and there were 10 patients out on home leave. So, they would officially be saying that they've got 12 patients, but there'd only be two patients sleeping in the unit overnight.

That's really a clinical judgment, and it helps with discharge. I think, historically, the use of home leave in Wales has been quite high. We have tried to cut that back somewhat, but it's clearly a key element of virtually every patient's pathway back out into the community or alternative provision.

Yes, I see it's a good thing, absolutely. It's just that we were wondering about the effect on staff numbers and how the leave balanced with the required number of staff.

I think it's probably similar to any kind of health service in that you do have peaks and troughs, and we would expect them, as the service provider, to be able to bring in additional bank or agency staff in particularly busy periods. As I say, there are other periods in the year when they will be less busy, and they manage the leave of their permanent staff around those periods. That's really operational for the health board to consider. 

Right. And then a last question from me: South Wales Police suggested in their oral evidence that Tŷ Llidiard could be used as a regional facility, a sort of hub for the reception of children and young people detained under section 136. Do you have a view on this and do you think Tŷ Llidiard could be used as a triage centre?

I don't think that's either clinically or logistically appropriate. The general adult units where this work is currently being done, or occasionally the police stations—I know the preference is for a medical place of safety these days—I would suggest are much better geared up. So, the surroundings can be quite cold and clinical but neither Tŷ Llidiard nor the north Wales assessment centre are in a position to deal with acutely unwell children in crisis in terms of the fact that that's not their normal work. They're planned admissions and they're complex admissions. So, it would demand a completely different area of expertise from what they would normally do, with an expectation from the police of an immediate response.

I would suggest that the depth of staffing, the surroundings and also the usual expertise of staff within the regular 136 suites, wherever they may be or adjacent to the ward areas—in terms of patient safety, because that's really what we're talking about in a 136 setting, despite the fact that the patient is younger—really should occur where there's expertise and familiarity with those patients. That's expecting something different from Tŷ Llidiard, which I would struggle with. I have not heard the responses from the clinicians at Tŷ Llidiard, so I can't speak for them, but I would be surprised if they felt it was a reasonable exercise to do. Otherwise, it would have been done. That's the logical step.

12:35

Certainly, I'm not aware of it being done anywhere else. I'm not saying it isn't. But I would have concerns, particularly around triage, where you've got a specialist in-patient unit with very disturbed children, if you turn it into a triage centre with people being dropped off into a locked environment at any point of the day.

I think they were putting it forward as a suggestion—you know, the police. I know you said if it could have been done, it would have been done, but there's always a first point to do something, isn't there? I'm not saying it's the right thing to do, and I accept what you say, but there are changes in practice, aren't there?

I think that would be a fair question to ask of the health boards who potentially would have this responsibility, about what arrangements they've got in place, and would they put additional arrangements in place for children and young people over and above what they've got in place on their adult section 136 suites.

Yes, perhaps if I can link them. We've had front-line NHS practitioners telling us it's a very challenging and stressful process to get people through the referral and assessment process in order to go into tier 4 in-patient CAMHS services. I was just wondering, given the number of assessments of young people, often before they get to that stage, is there a case for reviewing the process of admission to make it more accessible? Although, of course, if it were reasonable, it may have already—perhaps it should already have been done. But in terms of looking at the evidence, do you think that is somewhere we can go?

I think that the outcome of a child being admitted to a tier 4 service as an in-patient—a child or a young person—should be unusual. So, the vast majority of children and young people who have mental health problems—. I know, from the clinicians involved in this work, that the usual idea is to maintain tier 1, tier 2 or tier 3 services. Tier 4 is unusual as an outcome, and I think that the number or the depth of the assessment that's taken to ensure that a child that is admitted to tier 4 really needs that should be rigorous. That's my view.

And therefore very challenging and stressful for the NHS practitioners involved with trying to put their charges through that.

So, NHS practitioners—I'm not clear whether you're talking about primary care practitioners or secondary care practitioners. Are you talking about GPs, or are you talking about other CAMHS staff?

Well, we had it in written evidence. I'm not sure—I don't have the particular quotes in front of me, but it has been a theme of the inquiry to date.

The actual process of going through tier 4 assessment is a well-established practice that we use in Wales across all specialist services, where it's about applying a consistent threshold. So, there are well-defined processes where referrals to tier 4 come in, and then there is a single gatekeeping assessment that's done, either on an urgent or a non-urgent basis, to apply consistency. As my colleague has said, the idea is to try to keep patients out of tier 4 in-patient beds, obviously unless they need that bed. So, it's to make sure that we're not moving thresholds and making inappropriate admissions, almost. But maybe sometimes—. All admissions to CAMHS tier 4 units ideally work on a planned basis. You will get exceptional crises, but generally admissions to a tier 4 CAMHS will come as a culmination of a number of assessments and referrals through the CAMHS system. So, it's just that point of contact to say, 'Yes, we can offer a service. This patient needs this type of service, and we're making that judgment that this is the most appropriate place for that.'

I wonder whether the difficulty of getting these admissions leads to more crisis incidences elsewhere, where they're being dealt with by the police or in the community, of people who properly should be in an in-patient tier 4 setting.

12:40

I think it's a balance. I think some of the additional money that came in has gone into crisis care and, obviously, we are quite fortunate in Wales, having that funding, that we've now got well-developed, enhanced community support provision. So, actually, patients can be supported in alternative environments, I would say, to a higher degree and a higher level than, essentially, they are elsewhere. 

Whilst those assessments are taking place.

But, ultimately, if they need a bed and the clinical decision is that they cannot be managed anywhere else, there is a clear process, and access to beds is done through a recognised process. If the service either cannot meet that patient's needs, or because of capacity issues, then immediate agreement is given for an out-of-area bed to be found for that patient once the clinical decision is made that that is what the patient requires—an in-patient stay.

We welcome the enhanced investment in community services, but isn't the incidence of admission to adult mental health beds or acute standard paediatric beds—and there is particular evidence, as you said, in north Wales on this—evidence, or symptomatic potentially, of not having the right level of provision at tier 4 in CAMHS?

I think it depends on what you expect from a tier 4 CAMHS service. They haven't historically been used for short-term crises. They're for particular longer term enduring mental health issues, and a child going in with, I'd say, an overdose or something, into A&E, potentially doesn't need to go into and also then have the stigma and everything of being in an in-patient CAMHS service. But, clearly, we need to ensure that we've got the right capacity to meet the demand for the number of children who need to go into and get proper assessments and treatment for long-term mental health issues.

So, you're saying that a child who goes to A&E having taken an overdose, you wouldn't want them to be in a tier 4 CAMHS bed because of stigma.

No, not necessarily because of stigma, but ideally, unless there were underlying issues, an automatic admission to a CAMHS tier 4 bed would not be the normal use of—

It wouldn't, actually, normally be necessary, going back to my previous comment that a tier 4 admission to a tier 4 in-patient bed is unusual. It's not the preferred option for the specialist CAMHS practitioners. It's not their preferred option because you'd lose all the connections with family and you, to a certain extent, disempower the child or the young person. So, I think the perspective is different in adult services. It's certainly different in old-age services. But the theme and the trend is always to support the child and the family within the surroundings that they have—the social network that they have.

So, acute crisis admissions up to a given age are done on paediatric wards with in-reach staff, and we've talked about crisis CAMHS staff going in there; some are actually based in those units. And then, there are difficulties with age-appropriate beds for the 16 and 17 age group, particularly. We've spent time ensuring that those beds are available within the health board. I don't know whether you've heard evidence on that, where there has been difficulty accessing age-appropriate beds in the past.

Finally, if I may, Chair, in a question earlier around Tŷ Llidiard, you said that the fact that it hadn't been used in the way that Julie suggested—for particular police-led admissions—meant that, almost by definition, it was reasonable. I've just been struck that there seems to be quite a lot of activity and movement in this area. We're looking at having these national referral standards and we've heard quite good stuff about the clinical directors and their involvement with that. I know it's been a priority area. So, generally, are you satisfied with the provision, with what WHSSC is doing and the interrelationship with the health board? Is everything okay in this area? Is that your message to us?

Is everything okay? I'm a relatively new appointment to the WHSSC panel; I started work in August. Since then, from visits that I've had both to Tŷ Llidiard and to the north Wales assessment service, plus the contact I've had with clinicians, we've seen improvements in the staffing on the nursing side. We've certainly heard about, and would acknowledge, a deterioration in the staffing on the medical side, so that is cause for concern. What I've also come to understand is that the in-patient units often act as a barometer, or they're an indication of the health and the effectiveness of the community teams. So, if we take that for services in the south, that's actually a very good picture, so, yes, I would be satisfied with that. In the north, we're certainly making improvements, but, again, the capacity issues, particularly around nursing staff and now around consultant staff, remains—I think the phrase used was 'work in progress'. So, there's work to do.

12:45

Thank you. Is it the case that you've achieved a reduction in out-of-area placements in the south due primarily to the increase in the use of the private sector, as opposed to reducing in-patient admissions because of the work of community intensive treatment teams?

No, I don't think that's a true assessment, because I think the number of out-of-area patients in the south is at a historic low, and, certainly, the number of admissions through the NHS unit has increased significantly. As at today, we've only had six out-of-area placements from south Wales since April. Going back three years, probably that was bordering on 25 per year. So, there have been dramatic improvements, I would say, in south Wales. Hopefully, that will be replicated in the north, once we can get the service stabilised and operating to its correct commissioned capacity.

You mentioned the issue of eating disorders, at Tŷ Llidiard, as one of the reasons for taking up beds. Is that a true reflection across Wales?

I'm not sure I understood the question—

I can't remember who answered the question. Eating disorders were having an impact on the proportion of beds used for patients was the answer you gave, wasn't it?

Over recent years, the proportion of patients with eating disorders versus patients admitted for other reasons, usually emotional concerns, is lower. So, the proportion of eating disorders—

[Inaudible.]—managed for eating disorders, that's reduced.

Yes, so that's picked up by the community teams, and not only are those children not always being admitted now, when they are, the length of stay is shorter.

So, both north and south, the case mix has changed from predominately eating disorders to a much more balanced picture, or even more of children with emotional concerns.

I think, certainly, to give the north some successes, they have made a real difference with their eating disorder outreach team. They're working in collaboration with paediatric staff and with other staff across the health board, and the number of patients going into their unit for eating disorders has dramatically reduced. That also impacts on length of stay, because patients with eating disorders tend to stay, on average, two to three times longer than other types of patients. I think, probably at some point in the past, up to 40 per cent of patients admitted to our CAMHS unit, certainly in the north, had either a primary or secondary diagnosis of eating disorder. I would say that's more in line with 15 per cent to 20 per cent today.

Just briefly on commissioning agreements, I was just wondering whether the national framework agreement for CAMHS is fit for purpose, because members of this committee who visited Tŷ Llidiard heard from the staff that they felt that current commissioning arrangements don't recognise the importance of home leave, for example—you touched on home leave earlier—as part of the clinical care package for young people. They also criticise the contract for not supporting transitional work in the community. Do you think that their assessment is a fair one?

I think there are two different questions there, if I've understood you. Firstly, if we look at the national framework agreement and whether it's fit for purpose, I'm not quite sure what people are getting at there. The national framework agreement is basically an overarching arrangement that was signed off by the Minister that brings some quality standards, quality pricing and performance managing quality improvements around all the providers that provide CAMHS tier 4 services in Wales.

12:50

It's certainly in a lot better position than before the national framework was introduced. We have a separate team in Wales that monitors those providers to make sure they're delivering the standards we signed up to. That framework is due to be reviewed in April next year, and I think part of the work, again as was touched on earlier with talk of best use of NHS capacity, will influence whether that framework continues in its current format or whether we change, depending on what we can do with our NHS estate.

On the second part of the question, around Tŷ Llidiard and the contract, as I think I mentioned, home leave we do recognise as an essential part of the care package for all patients. We have recognised that by having an occupancy level of 70 per cent. The way the contract works—I won't get too detailed—we will pay to the provider the full contracted amount if they deliver 70 per cent of activity if they exclude home leave. If it includes home leave, it will go up to 90 per cent. So, while they say they don't get paid for it, they do in a way, by getting additional money for treating patients on admission, getting the throughput through, reducing the amount of stay.

The other thing I'd say is that Cwm Taf as a provider of that service have an annual discussion with WHSSC about the contract, and they haven't formally raised any issues at all during the last two years regarding how the mechanisms of the contract work. Certainly, we don't recognise every bit of work. So, community contact wouldn't be specifically part of the contract, but, within the overall funding that is available, we'd expect all these different elements of service to be delivered by the health board.

Just briefly, then, to finish, what happens to children and young people who are under 12 years old who might require in-patient CAMHS services?

They're assessed on an individual basis.

Generally, the under-12s will not be admitted to the two CAMHS units. Generally, there will be an individual funding request that will be approved by WHSSC and they will go into child services in Great Ormond Street, Alder Hey, Central Manchester. Occasionally, there will be an 11-year-old who, as part of the assessment, may be considered to go into the CAMHS unit—either they've started secondary school or they are developed enough to go into a CAMHS environment. But that, generally, is the exception to the rule and the numbers are very small.

I was going to say, it's a really specialist area.

I can imagine it is. So, is there any thought being given to developing that kind of provision at all in Wales?

It's about maintaining that expertise as well in that very specialist area. That would be really difficult.

I think we've probably, though WHSSC, funded three patients in three years.

Thank you. That concludes our questions. Can I thank you all for attending and advise you that you will be sent a transcript to check for accuracy, as usual, following the meeting? Thank you very much, all of you.

6. Papurau i’w nodi
6. Papers to note

Okay, item 6, then, is papers to note. Can I just ask Members if they're happy to note all the papers, but just draw your attention to paper to note 6, which is an e-mail to the Cabinet Secretary for Education from Fair Deal for Supply Teachers? If Members are content, I suggest that we write to the Cabinet Secretary for an update on that and then consider her response when it comes.

7. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
7. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Item 7, then. Can I propose, in accordance with Standing Order 17.42, that the committee resolves to meet in private for the remainder of the meeting? Are Members content? Thank you.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 12:54.

Motion agreed.

The public part of the meeting ended at 12:54.