Introduction

1.   The Welsh NHS Confederation welcomes this opportunity to respond to the Children, Young People and Education Committee’s inquiry into the emotional and mental health of children and young people. Our response provides an all-Wales view, with individual Health Boards providing their own specific responses to the Committee.

              

2.   The Welsh NHS Confederation represents the seven Local Health Boards and three NHS Trusts in Wales. We support our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.

 

3.   Our response will address the Terms of Reference of the inquiry in turn.

1.  Specialist CAMHS

a.  The extent to which new (and/or reconfigured) services are helping to reduce waiting times in specialist CAMHS. Whether the improvements in waiting times that Welsh Government expected from CAMHS have been met;

 

4.   Children and Adolescent Mental Health Services (CAMHS) across Wales have improved as a result of new investment and funding in primary mental health, psychological therapies and reconfiguring neurodevelopment services. Innovative working practices have been rolled out across Health Boards and CAMHS generally have undergone a period of expansion and service development. However, it is acknowledged that improvements need to be maintained and delivered consistently across Health Board areas. Also, additional funding to boost Tier 3 Teams (second-line specialist services provided by teams of staff from within specialist CAMHS) within CAMHS has led to increased quality of service provision across Wales.

 

5.   Timely intervention is key to avoiding the development of complex and enduring mental disorder and illness. Since the introduction of the Mental Health (Wales) Measure, referrals to Local Primary Mental Health Support Services (LPMHSS) have been high and most Health Boards are meeting the 28-day Part 1 target.  There has also been Welsh Government investment in talking therapies over the last 3 years in CAMHS in secondary care resulting in many more practitioners trained in a broader range of treatment options, such as Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT).

b.  What the data tells us about the variations in practice (equity of access) across Wales;

 

6.   In preparing for the introduction of the Mental Health (Wales) Measure 2010, Health Boards have largely redesigned the entry services for children and young people through integrated primary and secondary care approaches. In some areas, specialist CAMHS teams have introduced a standard procedure for access, the specialist CAMHS single points of access (SPoA), which operate on a Local Authority area basis and have been developed considerably over time. SPoA have reduced variation in thresholds for acceptance into the service and increased consistency of responses through the implementation of standard access criteria. Children and young people no longer wait on a waiting list without first discussing the level of need with the professional who has requested CAMHS involvement.

 

7.   There has also been a move towards delivering specialist CAMHS SPoA in communities via links into GP practice, schools, and the introduction of standardised care pathways. There is the potential for roll out to partner agencies for jointly managing initial risk in self harm and suicidal behaviour. CAMHS are also utilising the positive feedback of the National Benchmarking Report (2016)[i] and recommendations from the Quality Network for Community CAMHS (QNCC)[ii] to improve services on an all-Wales basis.

c.   The extent to which changes have addressed the over-referral of children and young people to CAMHS;

 

8.   Generally, there is a growing demand on CAMHS with increased referrals across Wales. Health Boards have adopted unique approaches better to understand this trend and are identifying specific target areas. For example, in Powys Teaching Health Board, CAMHS are undertaking a three-month audit of referrals to improve understanding of where the referral came from; what the referrer was looking for; how the service met the need; and patterns of referral and demand. By developing this level of understanding, the Health Board will be in a better position to address the over-referral of children and young people to CAMHS.

 

9.   Other Health Boards have introduced a referral guidance document and have invested time in supporting professionals and GP practices on general referrals. The result has been an improvement in the quality of referrals and greater clarity around the inclusion and exclusion criteria (especially for GPs).

 

10.                In Aneurin Bevan UHB, a senior clinician carries a ‘consultation phone’. The phone is accessible for all potential referrers from 9am - 5pm, Monday to Friday, for one to one pre-referral conversation and consultations, acting as a filter.

 

11.                Specialist CAMHS in Wales have also been working on SPoA initiatives which has allowed services to introduce standard responses based on need at the point of entry. This has brought about an overall reduction of inappropriate referrals with signposting, and faster responses for those who need the service the most.

 

d.  Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS;

 

12.                Specialist CAMHS SPoA are available for children and young people aged 0 – 18 years where there is a concern about their emotional or mental health. If a child or young person is resident in a relevant Local Authority area, there are no restrictions imposed on them requesting help.

 

13.                Children and young people who need the help of a specialist service are booked in for primary mental health assessment and where required, primary or secondary mental health services will be offered post-assessment. Primary and secondary care services are delivered by teams who deliver both in a seamless manner, allowing assessment and intervention to be tailored to the needs of the individual. Those who do not need the direct help of specialist services, but who have some needs, can access support from a professional working in frontline services, who themselves can access support and consultation from a specialist mental health professional.

 

14.                As for the timeliness of assessments, the picture is largely positive across Health Boards, with most CAMHS consistently achieving the 80% target of delivering an assessment within 28 days of referral – some Health Boards have achieved a percentage of more than 93%. One of the most significant ways that has allowed Health Boards to succeed in this area is by utilising all staff members who are able to carry out assessments instead of referring patients immediately to a designated professional e.g. crisis and Community Intensive Therapy Teams who would not normally undertake this task as an ordinary part of their role.

 

15.                It is acknowledged however that while these percentages are positive, they are not a reliable indicator of how many children and young people are accessing the appropriate services. It is often the case that professionals refer a child or young person to a specific service according to his/her needs – it is often the case that the child or young person will be required to wait for an additional length of time before receiving the most appropriate service.

e.  Whether the changes have helped to improve specialist CAMHS’ ability to respond out of hours and at times of crisis; whether out of hours care is working effectively, and specifically looking at the needs of those children and young people who present and are assessed at hospital A&E departments;

 

16.                Health Boards have established designated teams to address crisis situations and out of hours services. In Hywel Dda UHB, a Crisis Assessment and Treatment team provides mental health/psychosocial assessments for young people admitted following self-harm. The benefits of this are earlier discharge with community support and a reduction in bed days, as the patient can be discharged in a timely manner following assessment. The service has been further expanded to increase accessibility, and since September 2017, the crisis service for children and young people has become operational on a 24-hour basis with the Adult Mental Health Crisis Team, which provides a crisis response during the hours of 21:00 hours and 09:00 hours.

 

17.                In Aneurin Bevan UHB, a Crisis Outreach Team has been developed which has led to a decrease in total admissions to Tier 4 inpatient care (very specialised interventions and care, including inpatient psychiatric services for children and adolescents) and a significant reduction in in-patient stay for those who need time in hospital. The team works flexibly to suit the requirements of families in crisis and is closely connected with other teams within specialist CAMHS. This supports seamless movement between teams for patients as determined by clinical needs. Also, a dedicated 5-practitioner emergency liaison team at the Health Board has led to significant improvements in responding to emergency and crisis presentations.

 

18.                Health Boards on the English border face unique geographical challenges – where vulnerable young people are accessing hospital services across the border. This often means that these patients experience lengthy delays in assessment and treatment when they are eventually referred to Health Boards in Wales due to the significant differences between the English and Welsh systems. The situation is made more challenging in instances where a patient seeking support for a mental health condition presents themselves at an English A&E unit because their place of residence is a considerable distance from the nearest centre in Wales that delivers CAMHS. Such environments are not conducive to a patient’s emotional health at such a vulnerable time.

f.   Whether there is sufficient in-patient capacity in Wales;

 

19.                Generally, there is sufficient in-capacity in Wales. A useful measure of whether there are sufficient beds is how often Health Boards use out of area placements. Health Boards have found some units to be more flexible and accessible since the Care and Social Services Inspectorate Wales’ review[iii] of such placements was carried out. However, due to capacity issues and (very occasionally) the specialist needs of patients, Health Boards have, on some occasions been required to seek out of area placements with the support of the Welsh Health Specialised Services Committee (WHSCC).

 

20.                It has not been possible for some Health Boards to designate age appropriate beds within adult mental health services for older adolescents due to pressures within the adult mental health service. In some cases, this has contributed to reduced access to beds for older adolescents and a requirement to further utilise out of area referrals.

 

21.                The requirement for inpatient capacity is directly linked to the timeliness, quality and effectiveness of intensive community interventions and the capacity of community services to take positive risks. Several Health Boards have found that this has been significantly enhanced with the new investment from Welsh Government.

 

 

22.                However, there is a need to undertake an ongoing review of the requirement for access to beds and overall inpatient capacity in Wales to address this challenge more specifically. Sufficient capacity may potentially be achieved with full recruitment to inpatient staff teams and ongoing developments in community services. Moreover, there is still considerable work to be done for all agencies and services to understand their role in meeting the emotional well-being needs of their population, and managing their own expectations and service gaps. There remains an expectation within society that one small service within the Health Board should meet all the emotional and mental health needs of its local population, which is largely unrealistic, and with increased support in primary and community care, more preventative support is being provided by the whole NHS workforce.

2.  Funding

a.  Annual expenditure on CAMHS in cash terms and as a percentage of the overall spending on mental health, by local Health Board;

 

23.                Individual members will provide specific figures relating to their own Health Board areas on this question. Expenditure on CAMHS nationally in recent years is provided below:

 

 

 

 

 

Expenditure on mental health services by category in £ over recent years[iv]

 

2009/10

2010/11

2011/12

2012/13

2013/2014

2014/2015

2015/2016

General mental illness

306,627

327,713

316,356

254,377

271,147

305,874

310,624

CAMHS

43,814

41,928

42,819

42,846

40,248

41,320

45,818

 

24.                Transition from CAMHS to adult mental health services usually takes place on a person’s 18th birthday and this can present a number of challenges. Problems can emerge through the transition of young people into adult mental health services as this marks a change in clinical staff, a change in environment, and a different approach to treatment. Age-appropriate services are important for safeguarding and therapeutic reasons. The threshold for adult mental health services is high, which often results in a gap in service for young people, particularly for those with neurodevelopmental problems, personality disorders and moderate/severe anxiety and affective disorders.

 

25.                Together for Children and Young People is chaired by Carol Shillabeer, Chief Executive of Powys Teaching Health Board and lead Chief Executive for mental health, and supported by an independent external expert and an expert reference group. The Programme is working at pace to reshape, remodel and refocus emotional and mental health services for children and young people. The Programme is now entering its third year and has work streams that cover health services, education and social care services.

b.  The extent to which access to psychological therapies for young people has improved. Whether there has been a subsequent reduction in the use of medication for young people;

 

26.                Access to psychological therapies in Wales has largely improved following the provision of additional recurrent funding. Health Boards have recruited new members of staff across a range of professional disciplines including Clinical Psychologists, Dietitians, Occupational Therapists, Registered Mental Health Nurses and Health Care Support Workers.  There has also been a number of innovative service developments across Wales with organisations such as MIND, which provide additional support for young people to engage in training, attend college courses, and take part in voluntary work or employment.

 

27.                Investment in a number of treatment options means more children and young people across Wales can now be offered the appropriate evidence-based approaches for their conditions. Examples include Dialectical Behaviour Therapy, Eye-Movement Desensitisation and Reprocessing (EMDR) therapy, Cognitive Behavioural Therapy, Child Psychodynamic Psychotherapy and Video Interaction Guidance (VIG).

 

28.                Health Boards across Wales are looking to develop formulation-driven approaches to deliver psychological therapies in the context of children’s development within families. A formulation-driven approach in this context refers to a hypothesis about the mechanisms causing and maintaining the child or young person’s condition before consideration is given to the most appropriate treatment options. This work will link to regular reviews of NICE guidelines and the national work on the development of psychological therapies for children and young people.

c.   How the additional funding has been used to improve provision for children and young people in local primary mental health support services;

 

29.                Welsh Government investment has been utilised by Health Boards to make significant progress in a variety of areas, including the implementation of Crisis Intervention Treatment teams (CITT), Crisis Intervention Practitioner roles, High Intensity posts and Psychological well-being practitioners.

 

30.                An increase in the number of primary mental health workers has also facilitated closer working with GPs, schools and partner agencies. The additional funding has enabled Health Boards to ensure that the recruitment of additional staff members are not restricted to Part 1 of the Mental Health (Wales) Measure, thereby allowing for a greater number of referrals from all agencies being accepted and the provision of training to education services and fostering agencies.

 

31.                Further key developments in this area include new developmental roles working within enhanced governance structures; the development of a robust community of practice of LPMHSS staff working with children and young people; the standardisation of assessment processes; the initial implementation of a multi-agency, SPoA model in Local Authority areas; implementation of new managerial supervision structures; and work with specialist CAMHS to streamline referral processes to name a few.

d.  The extent to which the funding has been used to meet the needs of vulnerable children and young people, for example, children who are in care, children and young people with ADHD and autistic spectrum disorders, and those who are already in or at risk of entering the youth justice system, including those who are detained under section 136 of the Mental Health Act (1983);

 

32.                Health Boards have supported a range of initiatives to enhance services for vulnerable children in recent years, with different projects currently operational across Wales. Examples include the Multi-Disciplinary Intervention Service Torfaen (MIST) project, the Family Intervention Team (FIT) and professional Psychologists working closely with foster and adoptive teams.

 

33.                Expansions within Child and Adolescent Learning Difficulties services (CALDS) have improved access to evidence-based assessments and interventions for young people with moderate to severe learning difficulties.

 

34.                In relation to those detained under section 136 of the Mental Health Act (1983), the Welsh Government, police forces, the NHS, councils and other agencies signed the Mental Health Crisis Care Concordat in December 2015. The Concordat sets out how partners can work together to deliver a quality response when people with acute mental health crisis need help, have contact with the Police and who are likely to be detained under section 135 or section 136 of the Mental Health Act 1983. Partners who have signed up to the Concordat are committed to work to reduce the use of powers of detention under section 135 or 136 of the Act, to cease to use police custody suites as a place of safety and to ensure there is access to mental health professional advice 24 hours a day at the point of crisis. Through working with a range of partners, the Concordat has developed pathways of care which has led to significantly fewer numbers of people in a mental health crisis taken into custody.

 

35.                These instances are generally uncommon in Wales. There is evidence that some Health Boards’ CAMHS are actively involved in local task and finish groups established to roll out the recommendations from the National Concordat regarding crisis presentations. Furthermore, specialist CAMHS have in place robust Service Level Agreements with Youth Offending Teams within their localities which provide a Mental Health Link Nurse and access to a Mental Health Advisor for complex cases and Forensic assessments when required. The exception to this lies in the North East of Wales, where the Local Health Board has undertaken work to review the situation, and has agreed to work with partner agencies and colleagues from Adult Mental Health services to address concerns and identify ways to address these challenges. Commissioning a service to support the development of participation is already underway, which will directly involve young people and their families who have been admitted via Section 136 (including retrospective cases).

 

e.  The effectiveness of current planning and commissioning arrangements to address the needs of young people who have early onset of a severe mental illness, such as psychosis.

 

36.                Health Boards across Wales have made significant progress in establishing specific teams to address the needs of children and young people presenting early signs of a severe mental illness. Examples in South Wales include the Early Intervention Psychosis service (EIS) in Gwent, which works closely with the Health Board’s CAMHS when psychosis is suspected or identified in young people. £156,000 of new funding was recently diverted into the EIS to boost evidenced based interventions for young people with psychosis.

 

37.                In north Wales, a steering group has been established, which meets once a month, and is chaired by a Consultant Clinical Psychologist in first-episode psychosis. In the Western area of the Health Board, another dedicated team has been established, building on an existing arrangement within adult mental health clinical psychology. This has resulted in new jointly-funded clinical psychology and nursing posts working entirely within the first-episode psychosis speciality. The intention is to replicate this model across the Health Board area, and commissioning additional capacity to support this challenge is the goal - the steering group is leading the development of a business case to move towards a consistent model.

 

3)  Transition to Adult Services

a.  How well planned and managed transitions to adult mental health services are;

 

38.                While transitions to adult mental health services in general are well planned across Health Boards, there remains a lack of awareness of the transitional arrangements in place between specialist CAMHS and adult mental health services.  All young people who require transition, due to their ongoing mental health needs, would be under the remit of specialist CAMHS Secondary Mental Health Services and therefore subject to a Care and Treatment Plan (Mental Health (Wales) Measure 2010).  As part of this process, all professionals involved in the young person’s care and treatment, including GPs and School Nurses, are involved in the transition process.

 

39.                Health Boards have introduced their own policies to address these challenges however, with an emphasis on ensuring that ongoing patient needs are met. The introduction of a ‘transition passport’ is a positive step in this direction, which helps to facilitate a smoother transition from CAMHS to adult mental health services. There is evidence also of Health Boards having undertaken audits and feedback exercises on the policies in place – observations to date have indicated that despite recent developments, further work needs to be done around facilitating conversations between services at a much earlier stage than is the case, to ensure continuity of care.

 

4)  Links with education (emotional intelligence and healthy coping mechanisms)

a.  The development of the Health and Well-being Area of Learning and Experience as part of the new curriculum;

40.                In September 2017, the Welsh Government announced that children with emotional and mental health problems will receive early help at school from teams of experts as part of a unique initiative. Pupils at 28 secondary schools, six middle schools and 190 primary schools in north-east, south-east and west Waleswill take part in pilot studies. Results conclude in the summer of 2020 and a process of evaluation will then take place before a decision is made on whether to extend the initiative across Wales.

 

41.                Schools are becoming more proactive in the emotional resilience of young people, and Health Boards have reported a number of positive outcomes following previous pilot studies. There is clear agreement that these initiatives could be rolled out across NHS Wales and that the use of Education Learning Support Assistants (ELSAs) in schools is having a range of positive effects.

 

42.                More specifically, the North Wales Transformation Group has been established and has representation from the Local Authorities. The group has been discussing the development of the Health and Well-being Area of Learning and Experience within the new curriculum and are keen to contribute to developing the vision and key deliverables for this. Further discussions with the Association of Directors of Education Wales are planned. Health Boards are working to improve links between schools, health and social services using a multi-disciplinary model and formal “face to face” liaison combined with a telephone model, with regular, named link professionals working across schools and health teams. The strategic objective is to reduce emotional distress and prevent mental illness by offering early support, and appropriate referrals and interventions.

 

43.                There is a clear need to provide support for teachers to better understand emotional and mental health conditions in children, and have the skills to support their pupils. This is to be achieved through education and up-skilling teachers to recognise and deal with low level mental and emotional distress within their competence. Health Boards are taking positive steps to ensure that when teachers identify issues which they consider to fall beyond their professional remit, then consultancy and advice is available in a timely fashion from the Health Boards’ CAMHS to enable the young persons’ needs to be met either by CAMHS or to advise where the appropriate service can be accessed quickly (e.g. via LPMHSS).

 

 

b.  Children’s access to school nurses and the role Schools Nurses can play in building resilience and supporting emotional well-being;

 

44.                There is evidence that, following the Cabinet Secretary’s announcement in May 2017 that every secondary school and their cluster primaries will have an identified School Nurse and associated health team who will be accessible for support and advice both during and outside of term time, a baseline assessment of the ‘All Wales Standards for School Nurses for the promotion of Emotional Well-being of School Age Children’ has been undertaken in some areas. Some Health Boards have used a traffic light rating system to score each of the 22 standards within the competency framework, and are looking to produce an ‘Action Plan’ type document in due course.

 

45.                There is evidence that some Health Boards have taken steps to ensure that School Nurses across the Health Board area are trained in mental health first aid and deliver the Added Power and Understanding in Sex Education (APAUSE) programme. The Programme aims to develop positive changes in young people’s knowledge, attitudes and behaviour around sex and relationships, including myth-busting, resisting unwanted peer pressure and raising confidence and self-esteem. Health Boards have also adopted other approaches to building resilience and supporting emotional well-being among children, such as through ‘drop-in’ sessions and sustained efforts more generally to raise awareness of these challenges with education partners.

 

c.   The extent to which health, education and social care services are working together;

 

46.                Health Boards across Wales are taking positive steps towards piloting CAMHS ‘schools in-reach’ projects to increase collaborative working between health, education and social care services. Current pilot studies are focusing largely on raising awareness of mental health services in the community and promoting early intervention. Some Health Boards have supported these developments by hosting a series of workshop sessions in local schools on a variety of topic areas including eating disorders following the Welsh Government statement in August 2017 that an additional £500,000 per year will be invested in improving the care young people with eating disorders receive when they turn 18. Currently, CAMHS deliver a family-based treatment approach up to age of 18, whereas adults’ services deliver an individualised model of treatment from the 18th birthday, which may or may not include the involvement of family members in the treatment. Funding will enable the recruitment of new specialist staff and for existing specialist staff to increase the time available to support young people with eating disorders.  Other workshops under the ‘schools in-reach’ project are focusing on topics including coping with strong emotions, mindfulness strategies and early intervention in psychosis.

 

47.                There is strong evidence also of School Nurses reporting good links between individual teams within CAMHS, and the use of a bilingual DVD, which acts as an emotional well-being resource, has also showed signs of being effective in raising awareness of the relationships between health, education and social care services. There is however a need to increase capacity within schools further to reduce the number children and young people presenting low level needs, and subsequently, reduce demand on CAMHS when effective treatment options can be provided in other settings. There are also examples of excellent practice where Local Authorities have commissioned additional services to address low level emotional health and well-being concerns for vulnerable children and young people.

 

d.  The take up and current provision of lower level support and early intervention services, for example, school counselling services;

 

48.                While there is considerable evidence of early intervention services being provided by Health Boards in partnership with schools, data on the number of children and young people who have benefitted from these services, and to what extent, is not held by all Health Boards. The data that is available however shows that a similar number of children and young people are participating in individual and group-based activities in settings where given the opportunity to do so. Group sessions often take place in school settings and take the form of sports games that require teamwork, communication, resilience and promote healthy lifestyles. The available data also reveals a significant number of children and young people accessing online materials when seeking advice – consideration should be given to whether a more substantial bank of online materials could be produced to increase uptake further, particularly if new materials were to involve the third sector.

5)  Conclusion

 

49.                Health Boards across Wales have adopted unique approaches to deliver the step-change in CAMHS that is needed. Whilst challenges around capacity and population engagement persist, there is strong evidence that mental health services for children and young people are becoming more accessible, are being delivered in more community settings outside traditional GP surgeries, and are better placed to address the challenges faced by children and young people in a more streamlined manner.

50.                Health Boards are continuing the drive towards collaborative working across CAMHS and are realising the potential of staff members’ individual skill sets in delivering the well-being outcomes that matter to children and young people. By ensuring that positive action is taken towards addressing challenges around capacity and cross-border issues in some areas, there is strong evidence that recent developments in CAMHS are well-placed to deliver the step-change that is needed.



[i] https://www.nhsbenchmarking.nhs.uk/news/2016-benchmarking-of-adult-and-older-peoples-mental-health-services-findings-published

[ii] http://www.rcpsych.ac.uk/pdf/Quality%20Network%20for%20Community%20CAMHS%20Brochure.pdf

[iii] http://cssiw.org.uk/docs/cssiw/report/150130lacen.pdf.

[iv] Source: StatsWales https://statswales.gov.wales/Catalogue/Health-and-Social-Care/Health-Finance/NHS-Programme-Budget/nhsexpenditure-by-budgetcategory-year