1 Introduction

1.1.1 Public Health Wales welcomes the opportunity to respond to the Consultation on the emotional and mental health of children and young people.

1.1.2 Public Health Wales has stated as one of seven Strategic priorities that we will ‘Work across sectors to improve the future health and well-being of our children. In our current Strategic Plan 2017-2020, Public Health Wales has sought to place equal emphasis on both mental and physical health in the delivery of our priorities, as it is understood that health, well-being and a reduction in health inequalities can only be achieved by focusing on both physical and mental well-being. Our work to develop our new 10 Year Strategy has already highlighted that greater prominence must be given to mental health and wellbeing across the life course. The Mental Health/Learning Disability improvement team in Public Health Wales 1000Lives has prioritised and supported the improvement of Specialist CAMHS at both national and locality levels.

1.1.3 Public Health Wales contributes to the ten year mental health strategy, ‘Together for Mental Health’ through actions under a number of our priorities. Public Health Wales actively supports the Together for Children and Young People Programme, with representation at the Programme Board and the Project Group and specialist input to two of the workstreams (the Resilience and Early Intervention Workstream and the Neurodevelopmental Workstream).

1.1.4 In support of the Together for Children and Young People Programme, Public Health Wales has undertaken a Child and Adolescent Mental Health Needs Assessment (available at http://www.goodpractice.wales/SharedFiles/Download.aspx?pageid=185&mid=326&fileid=329 ).

1.1.5 Public Health Wales seeks to improve population mental health through the promotion of mental wellbeing and prevention of mental health problems at the population level, focussing on the universal approaches that reach children and young people through the home and educational settings.

2 Specialist CAMHS

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

2.1.1 Whilst CAMHS has participated in national benchmarking of service utilisation and capacity, there remains an absence of nationally agreed standards for quality and performance measurement and monitoring, with the exception of ‘waiting times’. Various measures and data metrics are used, but there remains a lack of nationally agreed data definitions to ensure robust comparison between services across health boards and localities in order to better interpret and understand differences between them on the ‘timely’ provision of assessment, diagnostic and treatment services. Public Health Wales is working with Welsh Government on a standardised set of data metrics/measures for national monitoring, including performance and quality standards. It is planned that these be integrated within the forthcoming Wales Community Care Informatics Solution (WCCIS, the joint HB and Local Authority Information Technology system being developed by NWIS). When this IT system is in place in all local services they will be able to demonstrate systematically whether new (and/or reconfigured) CAMHS services are delivering improvements in waiting times on other quality and performance measures.

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

2.2.1 In light of the challenges presented by current data metrics assessment of variation across Wales is difficult. More robust and reliable data is available from the two improvement programmes that the team currently support, (i) for Neurodevelopmental Services and (ii) early intervention psychosis services. Both demonstrate the variation in practice (and therefore inequity of access) across Wales that is generally more widely reflective of CAMHS provision across Wales.  

2.2.2 The Together for Children and Young People programme national work stream for Neurodevelopment (ND) Services for children and young people covers all ND conditions (including Autism Spectrum Disorder (ASD), attention deficit hyperactivity disorder (ADHD) andTic Disorders) and links to the All Wales Group for Learning (Intellectual) Disability service improvement.

2.2.3 Provisional audits of new ND services in 2016 and 2017 reveal variations in practice (and equity of access) across Wales. The new ND service teams funded since 2015 have inherited historic waiting lists for specialist assessment and diagnosis from pre-existing services, with some having inherited waiting times well over three years - from receipt of a referral to first face to face consultation (diagnostic assessment) meeting.

2.2.4 Referrals in 2017 range from 200 to almost 900 people per annum and waiting lists from 100 to 600 people – adjusted rates per 100,000 local Heath Board population. This significant variance in the demand for, and provision of ND services across Wales, reflects the different historic patterns of service development in many localities and a level of ‘unmet’ need which is more readily identified now that the new ND services are establishing a single point of local access under an all-Wales ND pathway.  

2.2.5 The establishment of a new service, and publicising its availability, focuses previously ‘unmet’ need to present at the front door/access point of the service.  The ND National Steering Group (NSG) is working to reduce such variance. The focus has been on access for assessment and diagnosis. The NSG is now working on access to evidence based service interventions.

2.2.6 The 2010 ‘intelligent target’ for First Episode Psychosis (FEP) services aimed to implement evidence based services for young adults with an emerging psychosis and to reduce the Duration of Untreated Psychosis (DUP). At that time only two Health Boards provided bespoke FEP or Early Intervention Psychosis services (ABUHB and HDUHB).  Only more recently have all health boards begun to develop bespoke FEP services, largely in response to the 2015 allocation of new funding for Early Intervention in Psychosis by the Welsh Government. There is currently a significant variation in service capacity and provision across the health boards. 

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

2.3.1 The concept of ‘over-referral’ to CAMHS is a function of the availability of alternative early intervention services; population need and effective referral management systems.  These take time to develop and implement.  In addition making comparisons requires robust and consistent data which enables comparisons to be made between different service models.

2.4 Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS

2.4.1 Public Health Wales does not have an evidenced based view on this due to the absence of reliable nationally standardised data. Anecdotal data and national service improvement work indicates that families, education, social services and GP’s etc, all routinely report experience of boundaries and restrictions in timely access to CAMHS, and also the newly developing Neurodevelopmental services. The establishment of routine Patient Reported Experience Measures (PREMS) and their equivalent for families and professional referrals will be able to evidence change. The use of a range of outcome measures, including Patient Reported Outcome Measures (PROMS) must be part of routine practice and data collection. A set of routine outcome measures/tools was agreed by CAMHS in 2015-16 and will be implemented as integral to the roll out of the WCCIS.    

2.5 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.

2.5.1 Public Health Wales does not have an evidenced based view on this due to the absence of reliable nationally standardised data.  Anecdotal data and national service improvement work indicates that the expansion of Community Intensive treatment teams has improved the out of hours service and decreased the use of out of area beds. It is anticipated the Welsh Governments 2015 funding to expand Liaison Psychiatry services will improve assessment and response at Accident and Emergency departments. The Public Health Wales 1000Lives Improvement team is establishing a national Community of Practice for the new Liaison Psychiatry services in November 2017.

2.6 Whether there is sufficient in-patient capacity in Wales.

2.6.1 Public Health Wales inputs to and supports the delivery of the review of Tier 4 CAMHS services, perinatal mental health services and eating disorder services led by WHISC.  Further work will be required to enable this question to be fully addressed.

3 Funding

3.1.1 Health Boards will be best placed to advise and comment on how funding has been utilised to support the goals and objectives of the Together for Children and Young People Programme.

3.1.2 Public Health Wales is aware that considerable developmental work has been undertaken by Health Boards across Wales to improve their understanding of the issues in their individual health board localities and to begin to utilise the available information to inform improvement action.

3.1.3 There is general recognition that mental health services have not always received sufficient recognition when funding decisions are being made.  We would also reflect that to date the emphasis on funding allocation has been in improving specialist CAMHS when the greatest gains are likely to be made by strengthening universal prevention and early intervention services and improving the capacity of the whole system to respond to the needs and concerns identified by children, young people and their families.

4 Transition to Adult Services

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

4.1.1 Public Health Wales supports and endorses the recent national guidance and standards for improving Transitions from CAMHS which has been developed under the T4CYP programme. Evidence of its impact has yet to be developed.

5 Links with Education (emotional intelligence and healthy coping mechanisms):The work being done to ensure children and young people are more resilient and better able to tackle poor mental well-being when it occurs including:

5.1 The development of the Health and Wellbeing Area of Learning and Experience as part of the new curriculum.

5.1.1 Universal approaches such as the introduction of a new curriculum in all schools are essential if improvements in population outcomes are required. Building the foundations for good mental health and wellbeing for all children and young people should be the starting point for any strategic programme to improve mental health outcomes. It is never too early to promote positive mental wellbeing. A focus on improving infant mental health and supporting the development of secure parent – child attachment provides an opportunity to improve mental health across the lifecourse.  In addition to a focus on parenting and infant mental health and wellbeing; schools are well placed to support the development of mental health and wellbeing in school aged children and young people.

5.1.2 Public Health Wales has been working to support the Welsh Government’s curriculum reform programme.  The approach being taken by the Health and Wellbeing Area of Learning and Experience is encouraging.  The work by the pioneer schools to date has demonstrated an excellent understanding of the role that schools can play in developing healthy and confident individuals.  There is much work still to do in shaping the detail of the curriculum but the work to date is in our view consistent with the evidence base and priorities in this area.  Public Health Wales will continue to support the AoLE as it continues its work.

5.1.3 In addition Public Health Wales has been reviewing and strengthening the criteria of the Wales Network of Healthy Schools Scheme (WNHSS) in respect of emotional and mental health. The WNHSS provides a platform for progressing action at school level in respect of health and wellbeing, including building resilience and emotional wellbeing and developing healthy personal relationships. A school which achieves the National Quality Award will be providing an environment; curriculum and support services which will support young people’s health and emotional development.  This whole school approach is consistent with the international evidence base and best practice.  The involvement of almost 100% of schools in Wales in the scheme means that we have an excellent platform on which to build; complementing the work of the curriculum reform programme.

5.1.4 A selection of those delivering the WNHSS have been involved in the WISE study a Randomised Controlled Trial with DECIPHER at Cardiff and Bristol Universities to examine the mental health of staff and pupils in secondary schools.

5.1.5 Public Health Wales hosts the ACEs Hub and has collaboratively developed and is supporting a feasibility study to consider what taking an ACE-informed whole school approach in schools in Wales would involve.  Public Health Wales is of the opinion that an ACE-informed approach must be strongly underpinned by existing initiatives within schools.

5.1.6 One of the challenges currently is to bring together at a strategic level programmes of work relating to young people and mental health and wellbeing across policy areas.  There has been a commitment to joint working to date; however strengthening the cross government and cross programme working in this area would be beneficial.

5.2 Children’s access to school nurses and the role schools nurses can play in building resilience and supporting emotional wellbeing.

5.2.1 There are a number of professionals who can contribute to this important agenda and support schools in meeting the mental health and wellbeing needs of their pupils.

5.2.2 The availability of school nurses in Wales has been subject to review and development in recent years but we believe there is much still to do.  School nurses should be the first point of contact for schools in assessing the needs of individual pupils and signposting to the most appropriate support and help.  Currently, there is variable practice across Wales in this area largely determined by the demands on school nursing from immunisation and safeguarding activities.  While these areas are of course important priorities in themselves there would be value in reflecting on the role of the school nurse in the future. 

5.2.3 When we talked with children and young people few were aware of the school nurse and had any contact with them.  It was clear that there was a lack of knowledge and understanding in many schools of the school nurse as a source of advice and support to pupils.

5.2.4 It is essential that the School Nursing workforce is skilled and confident to address the issues of greatest concern to children and young people and this would include mental health.

5.2.5 We would not expect to see school nurses contributing directly to curriculum activity in this area as this would not represent best use of their skills and expertise.

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

5.3.1 It is noted that there are considerable challenges presented in co-ordinating the activity of health professionals/ bodies working to improve the mental wellbeing of children and young people, those working on educational reform and action on pupil well-being and the ACE’s agenda. Public Health Wales recognises these challenges and is playing a key role in strengthening the integration of these issues and the closer working of professionals across the system.

5.3.2 Public Health Wales will be supporting the new CAMHS in School Liaison Services recently announced by the Cabinet Secretary; this will be a further vehicle through which more effective joint working can be established.

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

5.4.1 Public Health Wales considered the role of school counselling services as part of the Needs Assessment undertaken for the T4CYP Programme.  It was clear that school counselling services have the potential to support pupils in relation to their emotional and mental health but that inconsistency in data collection and reporting meant that it was difficult to assess the true impact of these services across Wales as a whole.

5.4.2 It would also be beneficial if General Practitioners were more aware of the availability of these services and could support young people to access them where they identify that less specialist support is required.