Introduction
1. The Together for Children and Young People (T4CYP) Programme was launched in February 2015 following Welsh Government designating children and young people’s emotional and mental health a priority. With cross cabinet commitment, this multiagency service improvement programme aims to work at pace to consider ways to reshape, remodel and refocus the emotional and mental health services provided for children and young people in Wales.
2. Professor Dame Sue Bailey, OBE, DBE, then Chair of the Academy of Medical Royal Colleges, member of the Children and Young People’s Mental Health taskforce in England and Consultant Child Psychiatrist was appointed by Welsh Government to provide external advice and scrutiny to the programme, supported by the Expert Reference Group with a broad membership. Carol Shillabeer, Chief Executive of Powys Teaching Health Board and Chair of the specialist CAMHS and Eating Disorder network in Wales is the Chair the programme. The key focus of the Programme is
a. Resilience, well-being and early years: to consider issues of building early years resilience in children and young people
b. Early intervention and enhanced support: to consider the concept of early intervention for a broad audience and explore its application in supporting young people’s mental health
c. Addressing the needs of those with neurodevelopmental issues: to consider how best to meet the needs of those with neurodevelopmental issues in a timely and effective manner, with appropriate input from specialist CAMHS.
d. Specialist CAMHS: starting with a baseline audit of provision, this work stream will develop a delivery and quality framework based on achieving consistent and improved outcomes across Wales.
In addition there are 3 cross cutting themes:
e. Workforce, education and training
f. Care Transitions
g. Health Needs Assessment and evidence review
3. Importantly, during the life of the T4CYP Programme a number of other strategic policy opportunities have developed, including the Cymru Well Wales Programme with a focus on ACEs (Adverse Childhood Experiences), the Curriculum Development led by WG Education Department and the establishment of Regional Partnership Boards with a focus on integrated care for children with complex needs. The T4CYP Programme has engaged with these and shares some membership of working groups in order to provide strong connection.
4. The T4CYP programme welcomes the Committee’s further inquiry into this important area and in recognising the Committee’s request for a 5 page limit for submissions seeks to address specifically the terms of reference. The T4CYP Programme would, however, be pleased to provide additional written or oral evidence at the Committee’s request.
Specialist CAMHS
5. The T4CYP Programme has worked closely with the Specialist CAMHS Network on this area of service improvement. At the start of the Programme, information on service provision was poor within and across health boards. Performance information was of questionable quality meaning that the emphasis was often on challenging the data validity rather than on using this as a driver for service improvement. Key progress has been made in the following areas:
a. Undertaking a Baseline Variations and Opportunities audit (BVO). This was the first comprehensive assessment of sCAMHS across Wales drawing out variations and opportunities for improvement.
b. Securing the commitment from all health boards in the annual National CAMHS Benchmarking exercise. This means that we are comparing practice not only across Wales but across the UK.
c. Requiring health boards to produce an Annual Progress Statement
6. The single biggest change in this area is felt to be the transformation in approach by leaders in the service to one of collaboration and collective leadership. At the start of the programme, approaches across Wales were diverse and there was tension across health boards. The cultural change that has occurred over the last 2 years or so, more than any other factor, has driven the improvements to date. The progress made has been achieved through:
a. Facilitating a network of CAMHS lead professionals across Wales. This has included problem solving, sharing good practice and learning together. This particular approach has led to tangible benefits in relationships with the inpatient facility in South Wales with improved admission, discharge and follow up for young people. Furthermore, there has been a key focus on improving the equity of provision between North and South Wales through the adoption of good practice.
b. Developing a formal community of practice to underpin our work on neurodevelopmental services.
c. Bringing together the CAMHS and Adult mental health clinicians in the national Mental Health leaders Group. This has resulted in greater understanding of each others perspectives and approaches.
7. It is important to draw attention to an early decision of the Programme to specifically focus on the care of young people and families with neurodevelopmental issues. It was clear at the start of the programme that access and support for young people and families was particularly difficult, with some areas offering little or no service at all. In some instances families were waiting years to access assessment and support. The neurodevelopmental work has been led by a highly credible and motivated clinician and significant progress has been made. There is however some way to go in embedding new ways of working and fully realising the benefits. Key progress has been made in the following areas:
a. There has been considerable success in ‘getting people around the table’ through the development of a Community of Practice. Every part of Wales is involved and although led by the NHS this is a multiagency community. The Community of Practice model has been successful in other areas and is proving to be a good model to promote change in neurodevelopmental services.
b. The use of evidence produced for example by NICE (National Institute for Health and Care Excellence) has led to a nationally agreed Pathway for Wales.
c. The visibility of the work has enabled progress to be made, however more work is needed to fully interface with the Integrated Autism Service.
d. The neurodevelopment teams that have been established with the investment made by Welsh Government have proved to be the nucleus for the improvement. Whilst there is more work to do to fully embed the new service, the teams are providing a real focus for service improvement.
8. In addressing the specific questions posed by the Committee:
a. Waiting Times: There has been a significant reduction in waiting times for young people accessing specialist CAMHS. Furthermore the change of the waiting times standard by Welsh Government to 28 days has largely been met, although there remains some challenge in maintaining full compliance. This significant improvement has been delivered through new practices, increased investment and a more collaborative and innovate approach to service provision.
b. Variations in Practice (equity of access): The Baseline Variations and Opportunities audit has provided lead clinicians and managers with feedback for improvement. Increasingly single points of access and alternative ways of accessing consultation and advice are being developed. Specifically, reviewing the role of contribution of primary mental health workers/teams will be a further opportunity to enhance access. Largely all health boards are able to offer assessment within 28 days of referral or where clinically urgent within 48 hours.
c. Over-referral: Specialist CAMHS service recognise that referrals, even where they do not meet the criteria for specialist CAMHS, require a response and where appropriate consultation, advice and signposting. Increasingly services are implementing a more significant offer to referrers of advice and proactive consultation. The recently announced pilot project offering in-reach of CAMHS professionals into schools is one such example. Another example is a ‘pre-referral conversation’ service seeking to offer immediate advice and potentially reducing referral rates.
d. Out of hours/crisis services: A major step forward was the development across Wales of Community Intensive Teams (also known by other names). Each team offers out of hours assessment and intensive support leading to improvement in access and reducing the need for A & E attendances or avoidable inpatient admissions.
e. In-patient capacity: There is largely sufficient capacity. There are some young people whose presentation means they will require particularly specialist care that cannot at this stage be provided in Wales, although these numbers are low. Specific work was undertaken to develop and implement a Commissioning Framework for services secured outside of Wales to ensure a high quality and effective services for young people with particular needs. The Programme is aware however that (social care) residential placements for children without a specific mental health diagnosis is an area of concern for social services in Wales and it is expected that further focus will take place on this issue with Welsh Government.
Funding
9. Welsh Government has made a significant investment of over £7.6M into young people’s emotional and mental health in Wales. This investment has significantly supported the progress that has been made. It is important to stress that the exact amount of expenditure on services for children and young people is difficult to calculate dependent on scope. For example, presentations in primary care may not be easy to extract to be included in the health boards calculations. Individual health boards will provide the detail of current expenditure.
10. There has been an increase in the availability of psychological therapies in Wales; however there is more work to do in this area. Although fully embedding the new models of care will take some time, important steps have already been taken in introducing new therapies. All health boards have a Psychological Therapies Committee driving this work forward. The impact on medication prescribing is yet to be determined, with potential for a further commissioned study to understand this in due course.
11. There is further work underway currently to review the role and capacity of the Primary Mental Health Support service for children given the changing models of care and the introduction of service elements such as Crisis Intervention Teams, Consultation and Liaison services and the new pilot of in-reach into schools for example.
12. The additional funding put into the service has provided an opportunity to strengthen the core services that can respond to all children including those who are in care or are in the youth justice system for example. The Programme itself looks to enhance multiagency working and although good progress has been made, there is further work to support local mental health and regional partnerships in this regard. Good progress has been made in relation to the Crisis Care Concordat with the aim of never having children with a mental health issues being held in custody.
13. There has been a specific focus on the pathways for young people with early onset psychosis. Under the Framework for Improvement approach the pathway for psychosis has been developed. This should enable a consistent approach to early intervention and support. A review of progress of implementation and impact is planned.
Transition to Adult Services
14. There are policies in place across Wales to support successful transition between children and adults services. The consistent application of these policies will be subject to ongoing audit and review. The programme looks to focus on care transitions not only between children’s and adults services but between different components of children’s services.
Links with Education
15. There is a unique partnership developing between education and health in regard to the emotional and mental health of children and young people. The recent announcement of the joint commitment of the Cabinet Secretaries for Education and Health, Wellbeing and Sport indicates the way in which the sectors are working together to enable a greater focus on emotional and mental health in schools. An in-reach CAMHS service should provide teachers with a greater level of support and advice, and enable children and young people to access support at an earlier stage. This pilot project will compliment the school counselling service in place.
16. The Programme supports the development of the new education curriculum and particularly welcomes the focus on health and wellbeing. There have been calls for a greater alignment and potential integration between the resilience and early intervention work stream of the programme and the Education Curriculum. Further discussion with Welsh Government officials will need to take place in this regard. Any further development already builds on the positive steps taken in regard to School Nursing.
17. School counselling services appear to be well regarded. There is however in some areas a growing demand for such services and capacity is becoming a key issue. Innovative approaches such as internet counselling blended with face to face approaches are in use in some areas of Wales. This could provide opportunity for further roll out.
Summary
From the starting point in 2014/15, it is felt that considerable progress can be evidenced. Embedding these improvements through local arrangements such as Regional Partnership Boards and Mental Health partnerships is critical. Furthermore, maximising the growing relationship with education is key in developing emotionally healthy community schools.