Cynulliad Cenedlaethol Cymru Y Pwyllgor Plant, Pobl Ifanc ac Addysg Gwaith dilynol ar yr adroddiad Cadernid Meddwl MOM: 27 Ymateb gan: Dr Liz Gregory – Ymgynghorydd Seicoleg Glinigol Bwrdd Iechyd Prifysgol Aneurin Bevan ___________________________________

National Assembly for Wales Children, Young People and Education Committee Follow-up on the Mind over Matter report MOM 27 Response from: Dr Liz Gregory – Consultant Clinical Psychology 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?
Amber	I am delighted that T4CYP has been extended for this purpose but proportionate funding is required across all agencies	Clarity regarding the gaps and the picture across Wales and key actions required to progress	Clear guidance to T4CYP ( I am confident this is in progress)
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?
	Not able to comment specifically
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?
Amber	Estyn have demonstrated clear commitment to well-being	Collaboration across Estyn and whole school approach re outcomes	Commitment to this in WSA framework
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?
Amber	This ties in the Whole School Approach framework which is under development	That this WSA framework has been agreed	Clarity re outcome of Ministerial task and finish group
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?
Red	Not clear who is undertaking this piece of work	Sits within the WSA agenda	Clearly identified this as a piece of work
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?
Amber	This core training is on the agenda but commitment and timescales are not clear	A plan to embed this training in teacher training across Wales, and access for teachers in employment in Welsh schools
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	My understanding is that the DSU has undertaken their review	The findings implemented into PCMHSS work plans	Clarity on whose role this is and where accountability lies.
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	Our local CAMHS (ABUHB) is evolving in response to what is available locally	A broad enough remit developed that can ensure services dovetail with local needs	Clarity on whose role this is and where accountability lies
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?
Amber	Very pleased that this is a priority area for phase two of T4CYP	Clarity regarding the definition of the missing middle, and responsibility assigned regarding addressing gaps	Strong multi-agency participation in the development of understanding of this area
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	Please that this has been identified in phase 2 of T4CYP	A continuation of important work started in T4CYP and	Commitment to this area, and how it dove tails with other areas of work
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?
Amber	A more sophisticated programme of work re outcomes is required	Families and young people feedback on their experience of the service, and the much broader offer of services to address mental health and well-being	A whole systems approach that includes co-production and a philosophy of no wrong door.
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?
	Not able to comment on where this is currently being held
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?
Amber	A priority area that needs to be led and held, but is clearly on everyone’s agenda	A clear commitment to implement recommendations from the research	Identified tasks clearly allocated, with a recognition that this is multi-layered and involves all agencies.
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?
Red	We are making good progress in ABUHB to improve services for children at the sharp end of mental health services BUT it is slow and in the mean time demand is growing. I am less optimistic about other regions as partnership and trusting relationships is central to this	For it to be prioritised through Partnership boards	Strengthened systems to improve partnership working and creative cross agency solutions
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?
Red	The nature of adult and child services are radically different, and the multiagency holding of some of our most distressed young people does not easily transfer to adult services	A more flexible arrangement that is based on need not age	Commitment from Welsh Government with funding that ensures it doesn’t become a battle ground.
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	There is still a long way to go to view all these systems as a whole, complicated by the fact that interventions are provided by a range of agencies and services outside of health, all of which impact on CAMHS	A better understanding of a whole systems approach and how services interact.	An acknowledgement that often children are referred to camhs and receive medication because there are no other community embedded options available.
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?
	Unable to comment
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?
	Unable to comment
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?
Amber	The work of the Whole School Approach Task and Finish Group is showing promise	A clear definition along with guidance about the external services that schools need to be able to access in order to feel well supported with more vulnerable children and those with specific needs.	Commitment to a Whole School Approach model with associated service development plans
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?
Amber	Hopeful that the extended t4cyp will achieve this	Clear actions emerging from T4CYP
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?
	Not able to comment
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?
Amber	This is vital, and fits with an inclusive agenda that should permeate t4cyp
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?
Amber	Hopeful this way of thinking about wider CAMHS will evolve as part of a whole systems approach as it develops
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?
	Fully agree but not able to comment