Cynulliad Cenedlaethol Cymru Y Pwyllgor Plant, Pobl Ifanc ac Addysg Gwaith dilynol ar yr adroddiad Cadernid Meddwl MOM: 21 Ymateb gan: Seicolegwyr Clinigol a Therapyddion Systemig sy’n gweithio yn Adran  Gwasanaeth Seicoleg a Therapïau Plant a Theuluoedd, Bwrdd Iechyd Prifysgol Aneurin Bevan ___________________________________

National Assembly for Wales Children, Young People and Education Committee Follow-up on the Mind over Matter report MOM 21 Response from: Clinical Psychologists and Systemic Therapists working in the Department of Child and Family Psychology and Therapies Service, Aneurin Bevan University Health Board ______________________________________

Overarching issues
Key recommendation (2018). That the Welsh Government make the emotional and mental well-being and resilience of our children and young people a stated national priority. This status should bring with it a commitment to: ● provide adequate and ring-fenced resource for our schools to become community hubs of cross-sector and cross-professional support for emotional resilience and mental well-being. Schools cannot shoulder this responsibility alone - the support of other statutory and third sector agencies, most notably health, is essential; ● ensure that emotional and mental health is fully embedded in the new curriculum; ● ensure that everyone who cares, volunteers or works with children and young people is trained in emotional and mental health awareness, to tackle issues of stigma, promote good mental health, and enable signposting to support services where necessary. This should include working with professional bodies to embed training in initial qualifications and continuous professional development; and ● publish every two years an independent review of progress in this area. This process should involve children and young people throughout. Recommendation A (2019): The key recommendation in our Mind over Matter report called for the emotional well-being and mental health of our children and young people should to be a national priority. Further to this, we recommend that the Together for Children and Young People Programme is extended to help ensure sustainable improvements in access to support services within both primary and secondary care through Child and Adolescent Mental Health Services (CAMHS), as well as supporting the whole-system approach. It is our view that the Together for Children and Young People Programme should be extended to coincide with the end of Together for Mental Health 2012-22, the Welsh Government’s 10 year strategy to improve mental health and well-being.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	To our knowledge WG has not committed to making EMW&R for CYP a stated national priority. The proposals for the T4CYP fragmentation do not indicate in essence a commitment to a whole systems/joint up approach. There is still much work to be done on delineating between ‘curing’ mental health problems (refer on or signpost to CAMHS e.g.) and building ‘good’ mental health. To commit to the latter needs investment in staff too - at a training level so people feel equipped to manage some of these needs if they arise, but also at a staff level - cover and release for training, time for planning, thinking, value placed on outcomes not linked only to achievement etc.	That will depend on what WG commit to and how well education and others are supported to embrace and embed this cultural shift. It should be noted that austerity and continued chronic underfunding of public services will impact how the workforce are equipped emotionally to implement these changes in addition to resource barriers.	If WG would like to improve the wellbeing of future generations and reduce the perpetuation of adversity (ie ACES) it will need to commit to EMWR for CYP as a national priority. Only in addressing the root causes of poor mental health for CYP will the cycle of intergenerational and community disadvantage, distress and trauma be broken.
The new curriculum
Recommendation 1 (2018). That the Welsh Government publish, within three months of this report’s publication, a route map of how health (led by the Together for Children and Young People Programme) and education (led by the Health and Well-being Area of Learning Experience) will work together to inform the new curriculum. This route map should contain clear milestones and specify the agencies or individuals responsible for delivery.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
	Unsure if a publication of a report has been made. It is not in the public domain if it has but we are aware of joint working that is taking place – ie. Whole schools approach. There is much work to be done ensuring the approaches to mental health and wellbeing in schools are recommended approaches, which come with a sound evidence base and are in line with the WG agenda. Is there regulation/a criteria for who can offer input into schools and what is offered to schools? Some programmes, such as the mental health first aid programme offer a limited diagnostic view of mental health that is out of touch with the MOM recommendations. This could be viewed as a potential low level safeguarding issue and potentially falls under a breach of the rights of a child if children are not supported to understand their needs/why they are behaving particular ways properly and being given access to the most up to date evidence and information available.
Measurement of well-being in schools
Recommendation 2 (2018). That the Welsh Government prioritise the work of improving measurement of well-being in schools within the inspection framework in order to drive activity and performance. The development of these measures should involve all relevant stakeholders to ensure that they are fit for purpose and do not lead to unintended consequences. Most importantly, children and young people should be involved in the process of preparing these measurements to ensure that they capture correctly the factors that influence their well-being. These measures should be available within six months of this report’s publication, or form part of the report of the independent review of the implications of the educational reform programme in Wales for the future role of Estyn, whichever is the earliest.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A
Emotional and mental well-being initiatives in schools
Recommendation 3(2018). That the Welsh Government undertake a review of the numerous emotional and mental well-being initiatives underway in Wales’s schools, with a view to recommending a national approach for schools to adopt, based on best practice. The Welsh Government should work with exemplar schools such as Ysgol Pen y Bryn in Colwyn Bay to develop elements of this national approach, including but not limited to mindfulness Recommendation C (2019): Further to Recommendation 3 in our Mind over Matter report, the Welsh Government must ensure the implementation framework for schools is published without delay, by December 2019. This is to ensure that all schools are working to a fundamental set of principles in relation to children and young people’s emotional well-being and mental health and are supported to do this. We want the Welsh Government to be working with schools to implement the guidance and to begin the self-evaluation process. Recommendation 4 (2018). That the Welsh Government, while undertaking the review we call for in recommendation 3, work in the meantime with the Samaritans to develop its Delivering Emotional Awareness and Listening (DEAL) Programme for wider use in schools in Wales. Subject to the results of the DEAL evaluation that is underway, the Welsh Government should fund the extension of the programme to the primary school sector. Recommendation 7 (2018). That the Welsh Government issue interim guidance to health and education services (and other relevant statutory bodies) about the support they should deliver for emotional and mental health in schools. This should specify the support that they should expect from each other as statutory services. This guidance should remain in place, and should be resourced adequately, until the findings of the in-reach pilots are reported to us and others. The guidance should be issued within three months of our report’s publication and reviewed after the in-reach pilots conclude.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A
School counselling
Recommendation 6 (2018). That the Welsh Government assess the quality of the statutory school counselling available, not least how the service copes with increasing demand, tackles stigma and meets the needs of children and young people. This should include consideration of providing counselling support online and outside lessons/school, and for those younger than 11 years old.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Has WG considered how all the therapies and psychological provision operationalise across the different professions with shared goals? Does WG have a delivery strategy for the different applied psychology and therapies provisions? Given the WG wellbeing agenda how collaborative and joint up are the Education, clinical and counselling psychology training pathways? How relevant are the current commissioned training pathways to Wales’ specific legislative commitments and priories? What additional training will be needed to ensure all therapies and applied psychological professions have appropriate training in a whole systems/schools approach?	To have considered the issues and begun planning to resolve the silo working, gaps and overlap in therapies and applied psychology training.	Scotland have made some amendments to streamline their delivery and to better utilise the applied psychology workforce across its different career paths. https://www.nes.scot.nhs.uk/education-and-training/by-discipline/psychology/training-psychologists/training-programmes.aspx
School staff
Recommendation 5 (2018).That the Welsh Government commission a mapping exercise of the availability of non-teaching staff in schools to support emotional and mental health and well-being, and the anticipated level of future need. This exercise should provide an outline of how any shortcomings will be addressed. Recommendation 8 (2018). That the Welsh Government pilot the role of “guidance teacher” in Wales, or adopt another model that allocates responsibility for the emotional and mental health of pupils to a lead member of teaching or nonteaching staff. Recommendation B (2019). To ensure that all school staff have a sufficient understanding of children and young people’s emotional and mental health and well-being, the Welsh Government should develop―as a matter of priority―a programme of compulsory training for new and existing school staff.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A
Primary health care
Recommendation 9 (2018). That the Welsh Government make available the management data tracking progress in relation to local primary mental health support services (LPMHSS) waiting times for assessment and interventions for children and young people since the commencement of the provisions of the Mental Health (Wales) Measure 2010. Recommendation 10 (2018). That the Welsh Government set out an improvement plan for local primary mental health support services (LPMHSS) for children and young people in Wales. This should provide an assessment of current levels of provision, the anticipated demand for services over the next 5-10 years, and the estimated level of resource needed to join the two. It should also outline how LPMHSS will engage with other statutory and third sector services, and provide the most accessible, appropriate and timely “intermediate” support services to bridge the gap between emotional resilience support on the one hand, and specialist CAMHS on the other. The improvement plan should outline clearly the pathways available for children and young people so that signposting to and between each level of services is clearer and simpler. It should make explicit reference to how LPMHSS should liaise with schools in particular. Recommendation F (2019). Further to Recommendations 9 and 10 in our Mind over Matter report, we expect to receive a copy of the NHS Delivery Unit’s review of Local Primary Mental Health Support Services, as well as the Health Board improvement plans, this summer (2019). Publication of this information will help to provide a better understanding of whether there is enough capacity in the primary care CAMHS
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	There is good data tracking of PMHSS waiting times and intervention. There has been an improvement plan for PMHSS for children and young people. Although it maybe isn’t as ambitious as it could be as the opportunities for development are somewhat constrained by sitting with an adult mental health framework and the requirements of reporting individual contacts meaning that preventative work, open access support, support in to existing systems and consultation/training etc aren’t prioritised. The improvement plan does not specifically link in with other statutory providers and voluntary organisations. Although opportunities to support in to other organisations is acknowledged.  Wider transformation agenda very much does. Has the NHS Delivery Unit’s review of Local Primary Mental Health Support Services and the Health Board improvement plan been delivered? Not yet fully, it’s a work in progress.
Care pathway
Recommendation 11 (2018): That the Welsh Government ensure: ● consistent pathways for all specialist CAMHS services, based on the national referral criteria once agreed, are implemented by all health boards (and related agencies where relevant) in Wales within six months of this report’s publication; ● each pathway is accompanied by defined standards against which all health boards can be measured and benchmarked consistently; and ● information is made publicly available so that health boards and the Welsh Government can be held to account for performance in a transparent and well-informed way.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	It was not possible to find this information in the public domain.   T4CYP planned to collect data through NHS Benchmarking CAMHS data collection exercise – it was not possible to find a breakdown of this data for Wales specifically. It is confusing to the public that there are two streams WG communicate stats – 1) https://statswales.gov.wales 2) https://gov.wales/statistics-and-research Different information is held on each. The June/July 2019 scheduled care states – The Child and Adolescent Mental Health Services (CAMHS) performance declined. (pdf link inactive) Nov – dec 2018 - Child and Adolescent Mental Health Services (CAMHS) performance continued to improve in November. – (pdf link inactive) Additional notes: Stats Wales uses the term ‘mental illness’ – The BPS 2015 Guidelines on Language in Relation to Functional Psychiatric Diagnosis which is intended to support clinical psychologists in the development of documents using language consistent with the Division of Clinical Psychology (DCP) position on functional psychiatric diagnoses makes recommendation of the following alternatives - Emotional distress, mental distress, severe mental distress, extreme state, psychological distress. https://www.bps.org.uk/system/files/Member%20Networks/Divisions/DCP/Members/Guidelines%20on%20Language%20in%20Relation%20to%20Functional%20Psychiatric%20Diagnosis.pdf This statement was made in view of; The DCP’s position statement on Classification of Behaviour and Experience in Relation to the Use of Functional Psychiatric Diagnoses highlights the lack of validity of current systems (DSM and ICD), as acknowledged by both critics and those who support the idea of diagnosis in principle. The full statement is available on the Society’s website  www.bps.org.uk/system/files/Public files/cat-1325.pdf
The ‘missing middle’
Recommendation 12 (2018). That the Welsh Government outline as a matter of urgency, and within three months of this report’s publication, how it intends to address the challenges faced by the group of children and young people who do not meet the threshold for specialist CAMHS but for whom alternative services are not available – the so-called “missing middle”. This should include: ● the detailed steps it will take over the next six months to ensure that their needs are met and that relevant agencies are held to account for delivery; and ● an account of the consideration given to focusing referral criteria on levels of distress experienced by children and young people (the source of which can be behavioural, social (including attachment-related disorders) and/or medical in nature), rather than on a medically defined, diagnosis basis alone. This should include consideration of replacing the current “pyramid” model of care with the “iceberg” model presented to us in evidence. Recommendation E (2019). We want to see the Welsh Government implement Recommendation 12 in our Mind over Matter report as a matter of urgency, including publishing details of it how it intends to take forward the early help and enhanced support workstream to reduce the ‘missing middle’. We request an update from the Welsh Government on progress by the end of October 2019.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	It was not possible to find this information in the public domain.  The missing middle refers in the main to young people who fall below the criteria for S-CAMHS support? This may refer to ‘sub-threshold’ needs where there is nevertheless an opportunity for preventative support and (linked with my previous answer above) - this needs ongoing work at all levels to create a well-being culture. Many YP whose needs are chronic, long-standing, have cycled through lots of services, who have diagnostic uncertainty, or cannot attend clinic appts however, may also frequently miss thresholds. There needs to be some ongoing thinking and culture shifts including in CAMHS to respond to and work with these needs where there are high levels of distress but where preventative work is also not the most appropriate model.
Neurodevelopmental services
Recommendation 13 (2018). That the Welsh Government develop an immediate recovery plan for neurodevelopmental services in Betsi Cadwaladr University Health Board to address the unacceptably long waiting times faced by over 1000 children and young people. Recommendation I (2019). We recommend the Welsh Government fully implement Recommendation 13 in our Mind over Matter report in relation to neurodevelopmental services. Alongside this, the Welsh Government should: ● set out a clear plan of how it will support Health Boards, local authorities and third sector partners to meet the needs of the estimated 40-50 per cent of children and young people who do not the meet the threshold for diagnosis but need some help, to ensure that families are not left feeling unsupported; ● routinely publish data  on neurodevelopmental performance so that there is greater transparency and understanding of whether Health Boards are achieving the 26 weeks waiting time standard for assessment; ● provide further details of how the Welsh Government intends to monitor the performance of neurodevelopmental services, so that frontloading support into assessment to meet the 26 week waiting time standard for assessment is not  done at the expense of providing interventions following assessment; ● publish the findings of the demand and capacity modelling work it is undertaking to ensure effective neurodevelopmental service models are in place across all areas of Wales.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Whilst developments are occurring we could not find the data in the public domain.
Qualitative measures of performance
Recommendation 14. That the Welsh Government prioritise work to ensure qualitative measures of performance are developed to sit alongside existing referral to assessment waiting time data within six months of this report’s publication. This information should be made publicly available so that those responsible can be held to account for service delivery and performance.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	Unable to find this information in the public domain.
Crisis and out-of-hours
Recommendation 15 (2018). That the Welsh Government, within six months of this report’s publication, in relation to crisis and out-of-hours care: ● work with Welsh police forces to scope an all-Wales triage model which would see mental health practitioners situated in police control rooms to provide advice when children and young people (and other age groups, if appropriate) present in crisis; ● outline how resources could be directed towards enabling crisis teams in all health boards to provide training and cascade expertise to other frontline services, particularly colleagues in A&E, in border areas (to improve cross-border relations with those centres most often accessed by Welsh domiciled patients), and in schools (to normalise conversations about suicide and self-harm in particular); ● ensure that follow-up support is being provided by health boards after discharge, provide information on how health boards monitor this provision, and commit to making this information publicly available to ensure transparency and accountability; ● ensure that all health boards are adhering to the requirement to hold designated beds that could be staffed adequately for unders-18s in crises, indicating how this will be monitored and reported in future, and what steps will be taken if such beds are not available; ● implement with pace and in a uniform way across health boards the single point of access approach to specialist services, to ensure timely and appropriate access to support, urgent or otherwise; and  reflecting on the results of the review of crisis care, outline what more needs to be done to deliver a safe and cost-effective 24/7 crisis care service in all areas of Wales, how that will be done, and by when. Recommendation G (2019). Further to Recommendation 15 in our Mind over Matter report, we recommend that the Welsh Government undertake an urgent piece of work to better understand how and why children and young people access crisis/out of hours support. Further improvements to crisis and out of hours care for children are needed to help ensure children and young people can access immediate support when they are in distress, at any time. Access to mental health crisis support must be consistent across Wales, which may require Welsh Government investment to support those Health Boards currently unable to extend their services.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	There has been an expansion in the health board of emergency liaison and COT services recently - EL is operational, not sure about extended COT
Suicide
Recommendation 16 (2018). That the Welsh Government, in relation to suicide specifically, work with expert organisations to: ● provide, within three months of this report’s publication, guidance to schools on talking about suicide and self-harm, to dispel the myth that any discussion will lead to “contagion”; ● work with expert organisations to prioritise the issuing of guidance to schools where there has been a suicide or suspected suicide; and The Emotional and Mental Health of Children and Young People in Wales ● ensure that basic mental health training, including how to talk about suicide, becomes part of initial teacher training and continuous professional development, so that all teachers are equipped to talk about it. Recommendation D (2019). Further to Recommendation 16 in our Mind over Matter report, the Welsh Government must ensure that all schools and local education authorities implement fully the guidance on suicide and self-harm to be introduced in September 2019.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A
In-patient services
Recommendation 17 (2018). That the Welsh Government: ● engage as a matter of urgency in addressing the reduced capacity in the north Wales in-patient unit; and ● provide in its response to this report an action plan detailing the practical support it is going to give to Betsi Cadwaladr University Health Board to return the unit to its commissioned capacity of 12 beds by summer 2018. Recommendation H (2019). Further to Recommendations 17 and 18 in our Mind over Matter report, we want to see urgent action taken to address the demand pressures for in-patient care throughout Wales. We recommend the Welsh Government : ● ensure the capital works at Ty Llidiard are completed by the end of Summer 2019 and that the unit is in a position to accept children and young people at risk of suicide and self-harm; ● ensure the staffing issues at Abergele are resolved urgently so that the unit is in a position to accept children and young people at risk of suicide or self harm. ● explore with greater urgency options for creating extra in-patient capacity, specifically to cater for children and young people with complex needs who are currently placed outside of Wales; ● put in place more effective arrangements for ‘stepping up’ or ‘stepping down’ between different levels of intervention; ● provide capital investment to help progress at greater pace some of the opportunities for more integrated commissioning in relation to mental health, welfare and youth justice. ● Recommendation 18 (2018). That the Welsh Government use the results of the review of in-patient capacity in Wales as a basis to: ● provide as many services as close to home as possible for Welsh domiciled children and young people; ● engage in dialogue with NHS England about options for the creation of very specialist in-patient beds that could serve populations both sides of the border; and ● explore the viability of using spare in-patient capacity on the NHS estate to provide step-down services for those leaving placements.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A
Transitions
Recommendation 19 (2018). That the Welsh Government, in light of the importance of the transition period in retaining engagement with support services and the heightened vulnerabilities of young people as they enter adulthood, require health boards and local authorities to report to them on a six monthly basis: ● the steps they have taken to ensure implementation of the transition guidance; ● their assessment of their level of adherence to the guidance; and ● details of the challenges they encounter when seeking to deliver smooth transitions and how they are mitigating those risks Recommendation J (2019). Further to Recommendation 19 in our Mind over Matter report, and given the heightened vulnerabilities of young people as they enter adulthood, we recommend that the Welsh Government consider all options for improving transitions, including exploring the extension of CAMHS up to the age of 25, to provide an extended period for young people to move into adult services, rather than immediately transferring to adult mental health services when they turn 18.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber:	Our experience of this is limited but the transition process I have been involved in recently is not clear. An idea which came out of a CAMHs away day last year from a group we worked with was for the introduction of a SPACE well being type panel at exit from CAMHS as well as entry into. This would enable multi-agency needs to be thought about and a clear discussion about direction of care. Our experience has also been transition at 18, though given many YP are developmentally younger than their chronological age there is a rationale for provision of a more intensive, collective care as per the CaMHS model to go beyond age 18
Psychological therapies
Recommendation 20 (2018). That the Welsh Government, in light of the current variation in provision and the crucial role therapeutic interventions have to play, set out a national action plan for the delivery of psychological therapies for children and young people. As a minimum this should include: ● an outline of how primary, secondary and specialist services will work together to ensure a range of therapeutic services across the spectrum of need are delivered effectively; ● specific plans for developing and maintaining a stream of sufficiently trained (and regulated/registered) therapeutic practitioners; ● details of the proposed review of prescribing trends for children and young people with emotional, behavioural and mental health problems, building on previous work undertaken by Professor Ann John and including an assessment of whether other interventions have impacted on these trends, to begin in the next 12-18 months; and ● an assessment of the plan’s financial implications and affordability, and how its outcomes will be measured. Recommendation K (2019). The Welsh Government should work proactively with the Health Education and Improvement Wales (HEIW) to ensure the CAMHS workforce is prioritised in the 10 year workforce strategy. We would welcome further information about plans for developing and maintaining a stream of sufficiently trained therapeutic practitioners to deliver interventions to children and young people. Recommendation L (2019): Further to Recommendation 20 in our Mind over Matter report, we recommend the Welsh Government publish the children and young people’s version of Matrics Cymru by December 2019, alongside details of how this will help to ensure a range of therapeutic services across the spectrum of need are delivered effectively to children and young people across Wales.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	It was not possible to find a plan for developing and maintaining sufficiently trained TP’s. This information is not available in the public domain.  Working Together Whilst P, S and Sp services are able to work largely together within a speciality (ie. Child) the ability to work across speciality is compromised by systems, definitions and approaches to mental health that conflict with one another. This issue is a large barrier to good transition – It’s like moving from speaking Welsh (ie. child service) to speaking English (ie. Adult) without a good translator neither group is able to proficiently understand each other. It’s the person in need of the service that suffers. Therapeutic Practitioners There are considerable inaccuracies in the central statistical information collected on numbers of qualified clinical psychologists with misattribution of other non-clinical psychology staff allocated to clinical psychology grades. This has resulted in an overall 10-15% over-estimate of the clinical psychology workforce (across UK). However, a BPS workforce report from 2015 indicated that there are significantly fewer clinical psychologists per 100,000 head of population in Wales. National Statistics in Scotland produces quarterly reports on their psychology workforce. The workforce planning document of 2015 references "national policy" and "the government" with reference to the UK government and UK policy not Wales. Although the Scottish system is different there are 3 times as many clinical psychology training places compared to Wales. Wales has 16 South Wales and 16 North Wales CP training places per year. There is a separate bursary training course for Educational Psychologists (Cardiff University) and Forensic Psychologists (Cardiff Met). The counselling course is held elsewhere (Cardiff uni?). There is not a unified approach to applied psychology in Wales. There is no overall planning for joint up course content and conflicting messages are taught across the different groups. Question Does WG know what its projected psychology workforce needs are? Question Does WG have a sufficient psychology workforce to meet the demands of its policy commitments? Question How many Clinical Psychology/Psychology Practitioner posts in Wales are vacant or have been ‘lost to vacancy’? Question Is the WG satisfied the British Psychological Society (BPS) has an understanding of devotion and therefore able to make informed decisions about psychology provision in Wales? Question Would Wales benefit from a devolved approach to psychology provision specifically for Wales given its unique legislative commitments? Equality and Diversity  The majority of UK clinical psychologists work in secondary and tertiary care services with only around 13% in primary care and 10% in higher education.  Around 15% of clinical psychologists undertake additional employment outside of the NHS. About 80% of clinical psychologists are female and the number of clinical psychologists in practice from black and minority ethnic groups falls short of BME representation in the general population of the UK. Question How does WG plan to address the lack of diversity and inclusivity in the clinical psychology profession? Workforce Model The report made several recommendations for improvement including a call for an urgent need to develop more robust supply and demand modelling for clinical psychology on a National (UK) basis. It also questioned whether a new model of applied psychology was required. This would include a unified applied psychology approach incorporating clinical, counselling, forensic, health and occupational psychologists offering flexible, tailored services to a variety of provider and commissioning organisations. Question Given the WG policy commitment to implementing a whole systems approach and a whole school approach and its commitment to delivering on a wellbeing agenda, does the current psychology workforce specialities model support this integrative implementation?     Clinical Psychology Training The Cardiff University Clinical Psychology Training programme focuses on CBT and Systemic therapy skills. It introduced for the first-time training in leadership in 2017. CBT is a behavioural based model and is not a relational/trauma/attachment approach.  CBT does not yield good efficacy when working with those living with deprivation and disadvantage nor does its positive effects sustain over time (3yrs onwards). The Cardiff training programme claims to be “founded upon the increasingly devolved Welsh Government frameworks for policy and practice to equip graduates for employment in health and social care services in Wales.” Whilst WG funds all 32 training places in Wales there is no commit on trainees to work in Wales beyond their qualification. Question How many clinical psychologists trained in Wales stay in Wales? How many train outside but return to Wales? Does WG know if those trainees are equipped to work in a devolved context? Question Do the core training elements in CBT and systemic therapy equip the workforce for WG’s policy commitments to, for example, whole systems approach, preventative, mindfulness and trauma/ACEs informed agenda? Question Are trainees adequately trained to work in trauma and adversity informed ways to meet the demands of the WFG/SSWA and WG wider wellbeing agenda? Question Does the course adequately provide training on working with complex systems, social determinants of MH and understanding systems change? Question Does the course provide trainees with adequate competence development beyond direct therapy work? What makes its practice unique from, for example, counselling psychology?   Question Does clinical psychology training adequately equip them to be leaders in the Welsh Government’s wellbeing agenda? The Alternative Handbook Guide to Clinical Courses published by the BPS 2020 found that 13% of respondents were ‘highly unlikely’ to recommend the Cardiff course. At Bangor 88% would highly recommend the Bangor course compared to 44% at Cardiff. It would appear there is an issue with the quality of the provision at Cardiff University that requires some consideration to ensure WG is able to meet its training aspirations.  https://shop.bps.org.uk/the-alternative-handbook-2020-postgraduate-training-courses-in-clinical-psychology.html The children and young people’s version of Matrics Cymru (Matrics Plant) is out for consultation due Feb 14^th. The document is not as ambitious as one would have hoped and does not at present encompass all of the MoM recommendations and principles in it.	Acknowledgement of the issues Commitment to addressing them in a timely manner with adequate resourcing Have a specific plan for TP training and delivery.	A review of therapies and applied psychology in Wales training and delivery needs to inform the development of an appro unified approach. Wider consultation with those professional bodies concerned.
Prescribing and medication
Recommendation M (2019). Our view as expressed in Recommendation 20 of our Mind over Matter report, that a national review of prescribing trends for children and young people with emotional, behavioural and mental health problems is needed, remains unchanged. In the absence of such a review, we recommend the Welsh Government provide us with further assurances on this issue by December 2019.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	This remains unaddressed. Prescribing as first treatment option is a breach of NICE guidance. A lack of alternative to prescribing traps prescribers in a cycle of failure to meet professional guidance, CYP’s needs and ultimately their rights.
Advocacy
Recommendation 21 (2018). That the Welsh Government, within six months of this report’s publication, commission a review of the current provision of – and need for – advocacy services for children and young people accessing all mental health services, not just those in in-patient settings. This review should be undertaken in consultation with key stakeholders such as the Children’s Commissioner, the National Youth Advocacy Service, commissioned providers of services, and children and young people. Based on the review the Welsh Government should assess the viability of providing an active offer of advocacy to all children and young people accessing mental health services and should publish a full account of its conclusions.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber:	We are aware of efforts to address this but unsure where the review is up to. There are internal efforts to approach this.
Vulnerable children (including children who are care-experienced, adopted or have experience of the youth justice system)
Recommendation 22 (2018). That the Welsh Government work across agencies to ensure that the emotional and mental health needs of children and young people are assessed on entry to care and on receipt of a referral order within the youth justice system, and routinely thereafter. This will help inform planning of adequate provision of multi-disciplinary support to meet their often-complex needs in a timely and appropriate way. Recommendation 23 (2018). That the Welsh Government, within six months of this report’s publication, undertake a piece of work on the provision of emotional, behavioural and mental health support for looked after and adopted children. This should: ● be informed by the activity of the Ministerial Advisory Group on looked after children and the T4CYP Programme’s work; and ● consider, in the case of looked after children, the extent to which public bodies are adhering to their responsibilities as corporate parents to provide both the physical and emotional support they need. Recommendation N (2019). The Welsh Government should provide more detail about―and evidence that―the workstreams of the Joint Ministerial Advisory Group on outcomes for children, the whole-school approach programme, and the Together for Children and Young People Programme are linked and working in tandem to ensure that the most vulnerable children and young people are having their emotional and mental health needs assessed and can access support promptly. The Welsh Government should provide a further detailed update to the committee on this, together with timescales for progressing this work. In the meantime, we remain deeply concerned about the provision of emotional well-being and mental health support for care-experienced children.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	I find it difficult to rate the level of progress towards the aims as requested in the consultation, as I don’t feel that there is adequate communication between all parties involved for me to know how far things have progressed towards the aims. I think we need better communication between all parties. For instance, I have no idea what the Ministerial advisory group on looked after children are doing, nor how to find out about this. In terms of the ‘missing middle’ I think this term is used to refer to two distinct groups – which I think become conflated. There is one group of young people who do not present with needs which are not yet severe enough to warrant involvement from SCAMHS. A second group are those young people whose needs are very high and complex but SCAMHS do not recognise these as mental health needs due to using a narrow definition of mental health equating only to diagnosable disorders. These two groups need to be clearly and consistently pulled apart as their presentations are different and the services they need are different. With regard to the second group, I wholeheartedly agree with the proposal that the level of distress regardless of cause is privileged rather than using disorder as the principle around which SCAMHS is organised. In terms of looked after children – it has been very well known for decades now that the level of mental health need is extremely high in this group, and yet they are some of the most poorly served children by mental health services. I believe that mental health professionals need to be embedded into looked after children’s services, and that partnership working between health, social care and education is clearly the most suitable model, as these children’s complex needs and life circumstances require a co-ordinated response by all agencies. There are some good examples of this – for instance the Gwent Children’s Partnership Board has used ICF funds to develop multiagency partnership mental health services for looked after children such as MyST. However, alongside this progress, and examples of what is possible with vision and determination, there continue to be battles between social care and health about whether highly distressed children have a mental health problem, and whether health services have any role in their care. This needs to be addressed as a matter of urgency. In terms of assessing and meeting the mental health needs of all looked after children upon their entry into care and with regular reviews, my experience is that this is no way being done systematically, largely because the resources to be able to do this in terms of practitioners are just not there. We need to be clear whose role is this, how will it be undertaken, with what frequency, and, on the basis of the LAC figures, how many people it would require to achieve this. The existing workload demands of social workers is so vast, that simply adding another demand to the pile without supporting this requirement with resources and expertise is doomed to failure. Over the last few years there has been increased acknowledgement of the complex needs of children who are care experienced and move into adoption, and with this some commitment with regards to the re-configuration of services in Wales to create Adoption Consortiums. Whilst this is a great start, there is much work to be done (with regards to the training and on-going support of these social care teams to be trauma-informed and trauma-sensitive, but also the embedding of this along the whole adoption journey for a family). Whilst there is work underway to support adoption from the start (early intervention), or even to prevent further trauma through the adoption process which could have been avoided,  I am concerned that there continues to be limited support for those families who adopted years ago, who’s needs are particularly high. WG have recently demonstrated a commitment to increasing adoption provision by matching the funding for the new TESSA project, which was established through the national lottery, however, this still only goes a small way to meeting the needs for adopted children and young people. With regards to the above distinction about the different types of children that fall under the missing middle, adopted children sadly fall under both. Adopted children who are particularly challenging and complex get lost in the battle of what is a ‘health’ issue and what is a ‘social’ issue. And the adopted children who are struggling, but not yet severe enough have the added myth to fight through that, now they are adopted any presenting difficulty will somehow work its way out, as ‘love is enough’. This is particularly challenging in schools, where adopted children continue to struggle hugely. Similarly to the above and other parts of this response a whole service response to adoption from initial inquiry through to placement and beyond needs to be considered. The same applies to social care services – adoption should not be viewed as a success it is the lost opportunity to support a family to stay together. Whilst sometimes necessary there needs to be a stronger and more committed holistic response to supporting parents to be in positions to keep their children. For example, there is no mother and baby unit in Wales where parents can be safely assessed. There is a shortage of placements for mother and babies which would offer opportunity to allow parents to develop skills to parent in a safe and supported way. It is difficult to match the increased number of LAC placements and the decrease in resources for services and the UK welfare reforms. Monitoring of the impacts of environmental stressors on parents ability to parent well should be central to WG’s approach in reducing the number of LAC and adoption placements. The approach should meet both stressors that come from unmet physical needs and unmet emotional/relational needs. A shortage in the availability/ lack of available options for parents to be supported to meet these needs crucially needs to be addressed.     The voices of the adoptees are not heard/listened strongly enough and independent advocacy for these people needs improvement.
Working with the third sector
Recommendation 24 (2018). That the Welsh Government, within three months of this report, act on the evidence received from the Royal College of Paediatrics and Child Health that it needs to establish an overarching group “with teeth” to manage the joint working that is needed between statutory and third sector organisations in order to deliver effective and timely emotional and mental health support services.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A
Workforce
Recommendation 25 (2018). That the Welsh Government ensure that all health boards respond promptly and comprehensively to surveys on workforce numbers conducted by the Royal Colleges in Wales. This will help enable the design of services that take into account staffing capacity and respond in an effective and innovative way to any shortages.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	It is not known that the British Psychological Society Division for Clinical Psychology Wales or the Association of Clinical Psychology have carried this out. The ACP Wales Director post is currently vacant. There are considerable wellbeing issues and burn out issues for staff. We note that ABUHB has a staff wellbeing service but it internalises problems and provides 1:1 clinic based solutions to system and environmental issues. This issue should be embedded in a whole service approach and not just an oversubscribed bolt on counselling provision. The same issues the report exposes about CYP accessing direct therapy apply here too.   Wellbeing and mental health is not a DIY project.	That the ACP is filled. That a whole service approach to wellbeing is committed to in the NHS and that a plan and a model for this are developed.	A whole service approach to wellbeing needs to be developed akin to the whole schools approach. The same issues and underlying principles apply to the workplace like they do schools.
Welsh language services
Recommendation 26 (2018). That the Welsh Government ensure the T4CYP Programme undertake a comprehensive piece of work on the current and future availability of Welsh language emotional and mental health support services.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	Clinical Psychology do not have capacity to meet this met. ABHUB do not provide a budget for welsh language translation of materials to support this provision and expect department budget holder to allocate resource to this from existing clinical budgets. Effectively cutting frontline staff to cover the cost.
Reporting and data
Recommendation 27 (2018). That the Welsh Government require health boards to report expenditure on emotional and mental health services for children and young people in a uniform way to increase accountability and transparency. This data should include information on all services, not specialist secondary CAMHS services only, and should be broken down by area (e.g. primary, secondary, crisis, therapeutic, third sector etc.) This information should be made publicly available so that those responsible can be held to account in relation to the affordability, relative prioritisation and value for money of the services provided.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	This is not available to our knowledge
Youth work
Recommendation O (2019). The Welsh Government must ensure that within its Draft Budget for 2020-21, and in future financial years, sufficient funding is allocated to youth work in recognition of the vital role it has to play in supporting the emotional well-being and mental health of children and young people.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
N/A	N/A	N/A	N/A