National Assembly for Wales

Good morning, everyone. Can I welcome you to the Children, Young People and Education Committee? We've received no apologies for absence. Darren Millar will be arriving slightly late. Are there any declarations of interest, please? No, okay, thank you.

Item 2 this morning is a further scrutiny session on the Welsh Government draft budget, this time on the communities and children main expenditure group. I'm very pleased to welcome back Vaughan Gething, Cabinet Secretary for Health and Social Services, and Huw Irranca-Davies, Minister for Children and Social Care. Also attending is Jo-Anne Daniels, director of communities and tackling poverty, and Alistair Davey, deputy director of enabling people at Welsh Government. Thank you all for your attendance today; it's much appreciated. If you're happy, we'll go straight into questions. The first questions are from Llyr.

Thank you, Chair. Bore da. I just wanted to ask, to start, about the new Children First approach. I was wondering whether you could give us an update on the work that's happening with the pioneer areas.

I'd be glad to. Thank you for the question. It's interesting in terms of this, looking back to when the announcement was first made by Carl Sargeant in his role in this, and the philosophy underpinning this was quite interesting in terms of that integration, that collaborative integrative approach of bringing things together. I was looking back, over the last couple of days, at when he launched this, his statement. He said that he hoped,

'in time, the benefits of Children First areas will be clear and that there will be an increase in delivery of this multi-agency, collaborative approach.'

So, that's where we're heading. Where have we got to on it? Well, as you know, there were 19 expressions of interest in this, which was heartwarming to see. There was clearly a demand here from local authorities and partners on the ground to take this more multi-agency approach.

The first five, what we're calling the pioneers for Children First, are Carmarthen, Newport, Cwm Taf, Caerphilly and Gwynedd. They are developing at the moment for us their baseline information now, based on their initial expressions of interest. We're hoping that they're going to submit this information to us, on the baseline information, by the end of the year. So, things are moving ahead very well on that.

We're also looking, by the way, at a number of other areas that are interested in developing their own Children First areas. So, this isn't simply those five. Those others, the 19 expressions we had and others, clearly, there's a will from them to move in that same way. I think it's partly to do with this flexibility of approach, of combining and looking at the needs within an area, looking at their particular needs, and having a more flexible, less bureaucratic approach to targeting the outcomes, so they also then—. We've got quite a number of those who are looking at developing their own Children First proposals. In terms of those, although they're outside of the five pioneer areas, we're also looking to see what help and support we can give to them so they can take it forward. 

So, you're not waiting for the pioneers to complete their work. There's work that could well be starting in other areas in the meantime as well.

Yes, there's a real appetite here to take this forward. I think it probably reflects the broader approach we're taking across Government, across the portfolio areas that we have, which is that there is clearly an appetite out there that says we've traditionally had—and I understand why—this approach that says, 'Let's put within silos the way we deliver grants', and in order to do that, there's an element of bureaucracy, there's an element of the fixed nature of it. Whereas what we've learnt over the years is, if we can give some flexibility whilst focusing on the outcomes that we want—the well-being outcomes, the educational outcomes, the housing outcomes, the dealing with aspects of poverty, the tackling the adverse childhood experiences—allowing the local partners to have some flexibility on this, not only is there demand from them, but also from third sector providers on the ground as well, who say, 'We know better than you, frankly, how to pigeonhole something and say it must be delivered in this way.' There's a subtlety to this. With that, of course, comes, I have to say, a proper approach to partnership and trust within that, because it's not a top-down one; it's much more a, 'Let's collaborate to get the outcomes we want.' But yes, we're not waiting. The five first ones are developing the baseline information, hopefully this side of Christmas, and others, meanwhile, outside of that, are progressing, and we'll give what support we can.

You mentioned the baseline information, which probably answers my next question, but just to be clear, then, because I saw there's an allocation of £100,000 for evaluating the pioneers: that will be based on the baseline information that they're now gathering. Is that going to be—?

Yes, indeed.

Yes. There we are. And is that going to be publicly available as well?

Yes. Once the analysis has been done, I think we're minded to put as much as we can as possible in the public domain so people can look at this, because we need to evaluate how is the baseline information being used, and is it delivering the outcomes we want. And that's good for front-line professionals as well as for us in terms of scrutiny.

Okay, thank you for that. Just to move on to children's rights impact assessments, I note that there's no stand-alone CRIA for the draft budget, and you tell us about the integrated impact assessment that you've undertaken. Are you confident that that approach is sufficient? Because, clearly, allocation of resources is probably the single biggest driver in terms of children's rights, isn't it?

I think this is a really important point about how the whole Government works—we've got a whole-Government allocation. And we had some of this the last time we were in front of this committee, again about integrated compared to sectional impact assessments. We've taken the view that having an integrated approach is the right one to undertake, because there is always a balance in what we do, in the priorities that we have and how we want to allocate our resources—but then not just the resource allocation but the policy drivers as well. The first conversation is really a policy one about how are we using money and what do we expect from it. This, really, is trying to underscore the integrated approach to services across the whole Government, and I think it's consistent with that approach. I appreciate that others have a different view and would want to see children's rights impact assessments and other assessments done, but the view of the Government is that this is the right way to approach this, and that fits in with our broader approach.

But it could be argued that you need a CRIA in order to then incorporate that into the integrated approach.

It could always be argued that you need more assessments than one. I know there is an honest disagreement here about those people who would like to see a CRIA undertaken on the budget as opposed to the integrated approach that we have taken. And obviously, the Government's view is that we think this is the right way to approach a whole-Government exercise in allocating resource, and then how individual expenditure groups and portfolios actually buy into that. So, 'Prosperity for All' was a deliberate approach to the whole policy approach, and the budget has to be aligned in a properly integrated, whole-Government way. I expect we'll continue to get asked this sort of question, but this is the approach the Government is taking.

I've only been in the role now for barely two weeks, but it was one of the questions that I asked officials: how do we come to the decisions? And actually, there is a mapping process internally, which is quite an interesting one, as to whether—. It isn't an absolute, definitive one, but there is a sort of analysis of when is it right to do a CRIA, when is it right to take a more integrated approach. But one of the things we are doing with this as well—. One of the themes of this Government and one of the things we've learnt is: rather than doing things to people, it's actually using, particularly, children and young people as a feedback loop as well. So, part of the thing that we're doing with Young Wales, on the budget, is actually running workshops—one, I think, is in Llandudno, and there's one in south or west Wales—in order to bounce off them and get their feedback on what they think these decisions, in the budget, will mean for them, and whether they think they're right or wrong. Now, that's less a question to do with CRIAs, but it is an interesting one to do with the underpinning approach of this Government of participation in decision making and formulating decisions; we've got to involve children and young people with it. So, there are feedback loops, even if we take this integrated approach to budget decision making and analysis.

It would be interesting, if you are able to share that with us, in terms of the way that you decide whether a CRIA or integrated approach is required. If that could be shared, it might help some of us to understand, maybe, a bit better. Because clearly there are merits to both; it's just that I'm not quite over that line yet in terms of the need or otherwise for CRIAs.

Looking at the draft budget there, can you give us any examples of where proposals were amended or changed as a result of the Government's obligations now under the Well-being of Future Generations (Wales) Act 2015? 

Yes, I think there are some specific examples. There are many, but let me give you one specific one, which I think is sometimes helpful with committees. If we look, for example, at the additional £500,000 that was allocated for 2018-19 in terms of the violence against women, domestic abuse and sexual violence services grant—that's one specific example, but also, if you look at employability programmes, investment decisions—. If you look at the investment that we're putting into advice services, particularly for those families in disadvantage that need that advice—all of these have been guided by the underpinning logic and the five principles of the well-being of future generations Act, which are to do with those issues of employability, early intervention, prevention, early years provision, and all of those things. So, they have affected that cut-through throughout all the budget decisions, not simply in one department. That has meant that that has ended up in things like those investment decisions. That has to be the way: this reach across Government of trying to get all Ministers thinking in terms of, 'How do we deliver those well-being of future generations outcomes?' That means a constant—with officials and Ministers—discussion on, 'Right, where are you going to contribute, where are you going to contribute?'—and not in silos, but how does that join up? How do we tackle the multiple issues we know about in terms of helping families? 

And how do you balance that sort of preventative investment with the firefighting that, obviously, is the here and now?

Well that's the constant challenge of being in the Government. We want to take a more preventative, long-term approach. That's one of the five ways of working: thinking about the way that we want to work with people. You always have to balance delivering a service in the here and now with wanting to change and reform services. And, you know, there's no easy way of doing that, which is again part of our challenge. Even when times are good financially—and times are definitely not good financially now—but even when there's lots of money around, there's always a challenge about investing in longer-term services rather than the here and now, and you'll see that in every single portfolio. You know from the overall budget strategy that the two big winning areas in terms of extra resource are NHS spend and money going into the childcare offer. So, we've been clear about those as priorities, and the challenge is what we can't do—because we don't have money to do everything we might want to do—and, as I say, that balance between longer-term investment and the here and now. 

Julie's got a supplementary. 

I just wanted to ask you, Huw, in relation to the advice services that you mentioned. Obviously, in terms of prevention, all areas could be important, but were you referring to any particular advice services that you saw as being very crucial for prevention? 

We're supporting a number of advice services, including ones that are designed to enable families to maximise their incomes—so, around employability, but also not simply employability, but helping people into work that also pays well and where they can upskill as well. So, we have specific investment into that, including around things such as not only the advice, but also things like the Communities for Work and the Lift schemes. So, they very much embed together. So, it's the advice that goes not only through our front-line delivery of things like Flying Start and Communities First, but then working with those parents again to say, at the appropriate time, 'When you're able to go back into work, we will give you the wraparound advice to help you do that, and, by the way, when you're in a position to actually step into work, we have schemes that will help you make that transition into work as well.' So, it goes from the early years through the advice of employability through to the practical help into work as well. 

Thank you. I just wanted to know the scope of the advice you were talking about.

We're going to move on to talk about childcare now. We've got a lot of questions to get through, so can I just make an appeal to Members and to our guests to be as brief as possible in the answers? Mark.

You gave a very fluent rundown of how Ministers and officials have worked together to integrate the goals of the future generations Act in producing this budget. Were you in Government at that time?

Well, you know he was in Government two weeks ago. 

Two weeks ago.

And when was the budget published? 

Well, you were there, weren't you? I don't quite understand the point of the questions. 

I was just surprised that Huw was able to give quite such a good account of how that happened given his limited—

Well, thank you for that compliment—[Inaudible.]—[Laughter.]

I will take that in a complimentary way. My answer would be that I'm new to this ministerial brief, but I'm not new to being a Minister. I have some familiarity with this, as you do, from being an Assembly Member as well, but it has been interesting, even in these two weeks, to get into the detail of this and to understand how the processes work. You don't, when you come in as a Minister, simply pick up a package and say, 'Right, now I accept everything.' You explore it, you examine it, you say, 'Why did we come to these decisions?' So I guess my knowledge—and I will take it genuinely in a complimentary way—is based on the fact that I've sat down and interrogated officials: 'Why have we come to the point that we have?' I wasn't there while it was being done, but probably my colleague here, the Cabinet Secretary, can better express his discussions during the actual negotiations around the budget lines.

Thank you. Moving on to the childcare issue specifically, is £100 million still the best guesstimate of what the cost of that's going to be?

It's still our working figure, but that's the point about having pilots and understanding in more detail. It's a point about the resource level that we've indicated. We'll learn more from those pilots and we'll have greater certainty about that, but this is demand led, let's not forget. We know that, in England, not every single parent takes up the offer. Some people have their own arrangements, whether they are paid for or family and informal childcare, that they will want to stick to. So, this is about understanding in practice where we'll get to, but it's still our best working estimate of what is broadly the right sort of figure, and you'd have heard that from the previous Cabinet Secretary.

And we have the revenue spending at around about £10 million this year, £20 million next year, then £45 million in 2019-20. The following year, it's about midway through the year that we'll see the programme generally available, and then the next year will be the first full year. Do you have any idea of 2021-22 likely revenue spending in this area?

Well, we've deliberately not forecast that because we'll learn more and have more certainty, and I think there's a challenge about giving that information about the years to come that we can give some certainty to. After that, as I say, we'll learn more, and I expect that, when we come back before this committee during the year and then in next year's cycle, we'll have more information about the pilots to give you greater certainty. So I don't want to give either any hostages to fortune or any convenient answers for today that aren't based on the evidence that we will be gaining over this next year.

I think the Cabinet Secretary's absolutely right. We're only two months in, but we're starting to learn lessons already. It may be of interest to the committee to know that we do also have—we have also committed some independent evaluation of the pilots in order that that, along with what we're learning from the pilots directly themselves on the front line, can help inform our future decisions on budget allocations. But the Cabinet Secretary's right: what we're learning is that there are some interesting variables here on how the demand will rise, depending on the area, depending on the type of take-up, depending on some of the interesting things around traditional routes of parenting and grandparenting provision as well. So, we will learn and we've got an independent evaluation as well carrying on to help inform our decisions.

The capital spend kicks in from next year at £20 million a year. One of the things that's differentiating the Welsh childcare offer from that in England, at least previously, is that, in Wales, it's largely been within the maintained sector and with nurseries attached to current primary schools. Is there a variety of approaches on that amongst the seven pilots? What are the implications of the balance between the expansion of private nursery provision and maintained sector provision in terms of the capital implications?

The pilot areas were chosen deliberately because of the variety on the ground, not only in terms of Valleys and urban and rural, but also in terms of the mix of provision that exists on the ground already in order that we can learn exactly those lessons—how does it streamline, dovetail? What are the challenges, actually, with dovetailing with existing provision? What has to change? I would say at this point again that it is too early to make any clear assumptions on the way forward, but that's part of the learning process with it about how we're dovetailing with existing provision. But, yes, it's been deliberately done because there is a variety on the ground and we'll learn the lessons about how it's properly integrated with existing provision.

And finally from me—

But that capital money, by the way, is important as well because, depending on how this rolls out—and it's being done in a phased way deliberately—that is part of the solution of dealing with the demand issues.

It is an important goal of the offer to increase employment rates, particularly female employment rates. What are your expectations of how that could flow back into Government finances through the 10p rate of Welsh income tax that you should benefit from if employment rates do rise?

Well, look, the general point there is that there's a strong evidence base that improving childcare, in particular, helps women who are already in the labour market to become more active and to undertake more hours, whereas people who are on the point of entry, but where childcare is a factor, are not able to be actually economically active. There's then about how we then forecast the exact amount, but we'll learn more about that as we go through—about the exact rate, and how it will affect revenues coming in and out of Wales. But to be able to identify one single stream from childcare, and what that means in tax revenue, I think it would be a brave person who could tell you now, if they could give you an exact figure. And, of course, that's about forecasting our future tax income anyway. There's more than one factor that affects that. Everyone around this room will know there's a clear evidence base about the impact of childcare and economic activity in particular for women.

Okay. I've got Llyr and John on this.

Just very briefly, the children's commissioner made some comments about the childcare offer recently, and I was just wondering whether you shared her concerns that the exclusion of children from non-working households might actually widen the school readiness gap between that group and children of working parents.

I appreciate what the children's commissioner is saying, but we have to appreciate that this is a very, very targeted approach to childcare, and it's based very much on the previous question of focusing on those parents' route back into work—the provision of childcare in order to do it. It's based on very good evidence, including from examples elsewhere, in England, but also Organisation for Economic Co-operation and Development reports that have looked at this on a much wider global context. So, we know that there is a good foundation for taking this particular approach forward, focusing on that—getting into work. But what we also know—and it's interesting sitting here on the day that we're listening to see what comes out in the budget—from the evidence of what's happened before, is that it's not only a question of enabling parents to get back into work through providing childcare, this good childcare offer, it's the fact of what it frees up in terms of household income as well. Now, that is fascinating because some of the studies point in the direction that this puts money back into the household. Now, that becomes quite interesting in terms of some of the communities you and I represent, because it has the double hit. Now, I do understand what the children's commissioner was saying, and there is an argument to be put that if money was no object, should we offer a much wider, Scandinavian-style provision, but that isn't what this is.

No, although it's called a childcare offer and not a 'household income and parents back to work' offer, so—

But we were pretty clear that this was about working parents.

I'm not saying you weren't—

And there's the challenge then about remembering that the majority of children growing up in poverty in this country are in a household where at least one of the parents works. So, it's the working poor that is the biggest group represented, and children in poverty. So, there is some understanding of how we need to do something about people in work, and there are different levers that, I think, are more likely to be more helpful about school readiness for those people who are not in work. Actually, the understanding of where people are and their readiness for the labour market, and actually how you help them in terms of parenting—with respect, I think there are different policy answers in trying to resolve some of the understood and acknowledged challenges that exist.

But would your ultimate ambition be to have it provided to all children?

Well, look, you're asking me about a world that doesn't exist, Llyr. That would be—

 [Inaudible.]—because we are working towards something, aren't we?

Well, that would be a world where austerity doesn't exist, where the choices we have are entirely different.

It's all possible.

It is all possible, but I don't think it would be helpful for me to forecast where I'd like to be, if I could have a magic wand and redraw how things are. We're talking about the choices we're making in the here and now, and our ability to set a two-year budget and what we think we'll deliver. If I told you, in an answer in the Chamber, 'Well, that's all well and good, Llyr, but this is what I'd really like to see, if only I had a whole load of things available to me', you'd say that I was refusing to answer the question and deal with reality, wouldn't you? [Laughter.]

Oh, don't be so cynical. [Laughter.]

I just wanted to ask you about—[Inaudible.]—budget provision and the £4.50 as the single national funding rate. We know that certain extra charges will be allowed. The experience in England, I think, has been far from unproblematic in terms of the roll-out of their childcare offer generally, but particularly perhaps in some of the issues around the adequacy of the single national funding rate and additional charges. I'm just wondering if you think that £4.50 is adequate and whether there would be tight control in terms of what additional charges and the rate of those additional charges might be.

John, it's the right question, and as you're probably aware—as the committee is probably aware—the feedback that we've had on the figure that we've come to for the pilots has been good. The feedback has been that, subject to additional charges being made for things like transport and food, or whatever, this is not only workable, it's slightly more generous than the median point of the English offer as well. But the feedback we've had has been overwhelmingly good that this is the right level.

You rightly point out, however, the issue of the approach in England—this is why we've chosen to go for a phased approach. We recognise that this is going to be a rapid learning process. What will it look like 12 months down the line? What will it look like when we come to the full roll-out? Where will we have assessed the demand? Where will we have assessed that there are capacity needs? How do we work to fill those capacity needs? That's why the phased approach is right. But I think this starting point, the figure that we've identified, is the right one, but it's not fixed forever and a day. If part of the feedback that we have is that it's likely—I won't say this to put the fear of God into people—to be too generous, or it needs to go up slightly, or there needs to be some subtle calibration, we're open to reviewing that—that's part of it. But that's why we're doing the phased approach. But, certainly, at this moment in time, we're not having negative feedback saying we've got this wrong; it's quite the opposite.

I think part of the problem in England as well is that they've got variation in their rates. So, the minimum rate here gets passed to the provider and there isn't an administration fee. In England, they can have variation in the rate, and there can be an administration fee as well. That's part of the unhappiness within the childcare sector in England. It does vary in different parts of the country. And equally, they've got greater costs and economic variation within England as well—if you compare the south-east, say, to Cornwall, there are radically different rates, just in two parts of the country. So, we've set an even rate and it's been broadly welcomed, but, of course, there's more learning to be taken in those pilot areas about our ability to deliver what we want.

And the level of additional cost—that would be closely monitored and limited.

We'll need to review the levels of additional cost, and to understand whether that's actually being a real barrier to the take-up of the offer or not, but that's part of what we have to be able to do—to talk to providers about what's being done and how. People need to be open with each other about the cost, the cost for the parent and how the offer is being delivered in practice, as opposed to the headline measures that we want to announce as well.

Thanks. We've got lots to get through. Hefin on Flying Start and Families First .

Minister, in response to the compliment from Mark Reckless earlier, you said one of the first things that you did was challenge civil servants on decisions that had been taken previously. Were you happy with the decision to merge, under one budget expenditure limit, Families First, Flying Start and Communities First? 

Well, that's my fault, really, Hefin. [Laughter.]

Right, okay. I was hoping to pin the Minister down, but there we are.

Disagree with him—[Laughter.]

Well, I was wondering if he agreed with it.

Well, it was a decision taken by the previous Cabinet Secretary, but there is a broader point within Government, and you've seen it within the health main expenditure group as well, about realigning some of the budget expenditure lines to try and be clear about what they are. So, changing the budget line and the description of it doesn't change the money, it's just how we bring those budgets together, so it's, 'This is what we're talking about in this particular area.' It's supposed to help clarity.

But it made it harder for us to see where those were allocated, then, or were going to be allocated.

You make a valid point. On a budget line, it's then more difficult to say, 'Well, precisely what amount there is going for this?' So, the challenge of this is turning that on its head and saying, 'What are the outcomes we're looking to deliver? Does that integrated fund deliver it on the ground?' Now, that is a real point of critical evaluation, to say, 'Well, is this now delivering, with the flexibilities that have been demanded, the outcomes that we want to see, and in a better way than they were before?'—in a better way.

Okay. So, let's take Flying Start, then, and the delivery of outcomes. The measurement with Flying Start is the number of children benefiting from health visitors. That's how the outcomes are measured, but there are three other outcomes that are considered—speech and language, parenting support and quality childcare. So, how can you be sure that children are benefiting in the way that they should be in all four areas?

Well, participation with the health visitor isn't an outcome.

Sorry?

It is not an outcome. It shows the different levels of participation with the offer, and that's the universal consistent part of it, and so we had to choose a measure, otherwise there was a whole range of varying figures, and you and others would understandably say, 'How on earth can we understand who's benefiting from it?' The point is it's voluntary, so we want to persuade people to take up the offer, and, actually, the outcomes and the evaluation will tell us more and more about that, and that’s what I think is really exciting, actually.

How, then, do you know you’re getting value for money for speech and language, for example?

Well, that’s the point about the evaluation. There’s something about the intelligence you gather through the whole system. If you go to headteachers and talk about school readiness, for example, they’ll tell you they can tell who the Flying Start children are, and speech and language development and a whole range of social skills development, the things that they pick up themselves—. The work that the Minister is going to be overseeing with the data-linking exercise with SAIL will tell us even more about that, and give us more detail about the real impact and value of the programme.

There’s something about understanding the logic and the rationale when you’re trying to spend money and create programmes, and how you acquire evidence at the start. To be fair, we just talked earlier on about the childcare offer, and having an evaluation at the outset. We started the Flying Start programme and then had to backtrack on evaluation, because we didn’t understand at the outset of the programme, being perfectly honest—I’ve answered these questions before—we didn’t have the evaluation at the start to see where differing areas were. So, we’ve had to look back to understand where we think people had moved. That means you can’t get the level of quality in the evaluation for the first part of the programme that we would have wanted. But I absolutely think the data-linking exercise will tell us much more about what you’re asking about, which is: what outcomes have we delivered? And then how long have those outcomes been sustained for the programme, and what does that tell us about our general approach?

Before we move on, I must have a forecast of what is going to be spent on Flying Start, Families First and Communities First. We were given those figures in budget scrutiny last year. Are you able to share those figures with us today?

Yes, if I can find—. I’m looking to my colleagues here—

I'm sorry, I haven’t got them in front of me, but we will write and confirm the amount of money that will be spent on those areas, because, yes, there is a forecast, but there’s also then the policy part of how those programmes are supposed to work together. But we’ll confirm the actual programme expenditure that’s been forecast for both those areas.

Okay, thank you. Hefin—

The Cabinet Secretary mentioned the SAIL project. Is the committee familiar with what we’re doing with that, with the evaluation of Flying Start? The essence is we’re working with five local authorities, but also with Swansea University’s SAIL unit. The SAIL unit is the—hold on—secure anonymised information linkage. They are pulling together the way in which we analyse Flying Start. This has long been an issue of how you best evaluate the outcomes, so we have a project working with them to try and develop a new set of standardised, individual-level data on Flying Start children—what the interventions are, what the outcomes are, what the success is. So, as that is taken forward, that should give us a more robust understanding of the impacts of Flying Start, and as that is taken forward, we’re more than happy to share that with the committee, then, as well.

And when is that reporting?

It’s being taken forward as we speak. I don’t know what the actual date of the outcome of it is.

I would have to check. It’s not long. In the next couple of months, I believe.

Yes, so it won’t be long before we can share something with you.

Okay. And that will give you an indication of value for money.

Yes. Value for money and in terms of the outcomes that it’s actually delivering—yes. That will be helpful in various Flying Start proposals, to actually share the best way of delivering Flying Start.

Okay. And finally, outreach—we’ve received evidence that outreach is actually fairly limited. Two thirds of people who are income deprived are living outside Flying Start areas. How are you going to ensure value for money with regard to outreach? Is there any scope for expansion in the allocation?

Yes. Well, two questions there. That will be part of our evaluation as well. We wouldn’t exclude outreach from the evaluation that we’re doing on Flying Start.

In terms of the scope of the outreach—and I’ve seen this in areas that I’ve visited myself with Flying Start—that flexibility that has been there, there’s been a lot of discussion about whether it can be extended. It has been recently agreed—and this was a decision that preceded me—to increase the outreach element to 5 per cent of the whole Flying Start budget. This will be taking place with immediate effect. In fact, we’ll be writing out this week to confirm that, because we recognise that the advantage of some flexibility that the outreach gives to reach beyond the geographic boundaries of Flying Start enables us to identify the right families who are outside of those geographic areas.

Now, I know that the committee is looking to come back to a wider inquiry on Flying Start, which we’re looking forward to coming in front of, and seeing the outcomes of that, but, yes, outreach we believe is effective. We need to evaluate it as part of the wider evaluation of Flying Start, but the measure of the fact that we think it is effective is that we're actually extending some of the flexibility to 5 per cent, and we'll keep it under review. 

Okay. No doubt we'll come back to that. 

Seventy six million pounds for Flying Start and over £38 million for Families First. 

Seventy six million pounds and £38 million. 

Yes. 

Okay, thank you. And if it would be possible for us to have a note on the Swansea University evaluation project on data linkages—just a short one—maybe before you come in to committee next week for the session on that, it would be really useful. Okay, thank you. John. 

I was just wondering about the merging of the 13 grants for 2019-20 and whether it's the intention to eventually move all of that funding into the revenue support grant. 

It's not our intention, John, to actually put these grants into the revenue support grant, but the underpinning logic of merging grants where we think it can deliver efficiencies—. Partly with that, by the way, is the demand that we've had from local authorities and others to strip out some of the bureaucratic necessity and the administration costs with administering different numbers of grants, and replicating. So, it will drive efficiency, but, more importantly, with the flexibility, that it actually, within an integrated grant, can hopefully deliver better outcomes as well. But, no, it's not our intention to move the grants into the revenue support grant, so there will be some clarity within the new integrated grant. 

In terms of those better outcomes and being able to assess whether they are being delivered and whether they have been delivered, going back to some of the issues we discussed earlier, is there a danger that this decision is going to make it more difficult to assess whether value for money is being achieved and to track spend and outcomes from that spend?  

Because this is a different approach of amalgamating grants and because the outcomes are so critical to us in terms of future generations and well-being, as well as for every individual touched by these programmes, we will be carrying out a full impact assessment of these with the Pathfinder areas. It is a different approach to getting those outcomes. So, yes, we'll conduct a full impact assessment.  

Okay. So, in terms of those pilots and the greater funding flexibilities for some areas for the next financial year, could you say a little bit about how in practice they are going to operate to help you make a decision as to the success or otherwise of that approach, and how that then feeds into whether or not to merge the greater number of grants? 

A lot of the focus of this Government has been to move much more, very much along the principles of the Well-being of Future Generations (Wales) Act 2015, into early intervention, preventative measures rather than always dealing with the rescue costs, and so on. So, that will be the measurement of the success of these, in an integrated fund, as to what extent it helps us to do that. Our full impact assessments will indeed help it. 

But it's worth pointing out as well that, beyond the seven local authorities in the Pathfinder areas, there is—. You know, this is not being driven by us entirely. There is also a demand out there to get this flexibility, so the areas outside those pilot areas are also going to have an additional amount of flexibility in the way that they use those same grants. So, we're looking at around 15 per cent flexibility in the way that they can also use their grants as well, because they have a demand to do it. But, yes, that full impact assessment of how this new approach to integrated funding does is key. We need to make sure that this works.

Okay. Just finally, coming back to what you mentioned about savings in administration costs, could you tell the committee how that figure of £13 million plus was arrived at and whether it's local authority bureaucracy or Welsh Government bureaucracy, or both? 

It is an element of bureaucracy, and it is an element of when the grants are devised in those single areas, they all require an element of administration in order to process them, to monitor them and to evaluate them, and that adds to costs. So, working with partners on the ground, including those within the pilot areas, and with independent advice as well, that's the figure that we've arrived at. We think that it's a realistic figure as well. It's undoubtedly the case—I mean, common sense would say—that if you can strip out some of that back channel administration, you're going to end up with freeing money that you can actually put then onto the front line and the delivery of the outcomes. So, we are hopeful with this approach, and we're confident in the figure that we've arrived at there. But the evaluation will tell us whether that figure is accurate or needs revising upwards or downwards. 

And you'll be aware, Chair, that it's underpinned by work done by the Wales Audit Office as well. 

Thank you. Julie.

Thanks very much. I wanted to ask about looked-after children and the Children and Family Court Advisory and Support Service Cymru. So, I'll start with CAFCASS, because I think we all know there's been a huge increase in the number of cases dealt with by CAFCASS, both in public and private law. But I think the—[Inaudible.]—of CAFCASS that you have to spend within your existing budget with no allowance for inflationary increases. Could you confirm that that is the situation, and how do you think this is going to be possible when you're dealing with such crucially important cases and the future of individual children and families?

Yes, it's a stand-alone budget. There are no cuts being made, but that provides real challenges in every part of our service. And, again, this goes into the unfortunate balance we have to take, when we simply don't have the money that we would otherwise want to have. So, that's the context in which we're having to make all of these choices, and areas where we've reduced expenditure in other parts to allow us to balance those areas. The Minister has responsibility for CAFCASS and there's been a review of their work, and we're actually very impressed with the work that they've been doing and their ability to manage the case load as it continues to expand. 

So, you have reviewed their—. What are the results of the review?

The performance is good. CAFCASS Cymru, and its outcomes in terms of its response to the issues that it's dealing with, are better—they're the best within the UK, despite the constraints that they have had on them. We can't escape from them. 

When you say that it's the best, in what way? That they're best in—.

In terms of response times and in terms of the cases that they've taken forward. And they've done this against—you are correct—a very difficult backdrop, but it is the reality of the constraints that we currently face. But the way they have done it—and having spoken with the leadership of CAFCASS only in the last few days—is working within their organisations to see where efficiencies can be made whilst focusing, quite rightly, on the outcomes we have determined for them, and they are doing it. Now, it isn't without challenge, Julie, it really isn't, but they are doing it, they are delivering. The year ahead will be a challenge again, but short of a sudden huge bundle of money coming through the budget announcements today, I don't think the Cabinet Secretary is going to be suddenly waving a cheque book around unfortunately. 

That is the reality of austerity, and we can't contract out of that. I hope for better news today, but I don't live in expectation. 

Yes, let's hope. The organisation itself, what are their views on this budget? Did you discuss that with them?

Yes. And they are not either publicly or privately complaining. They realise the reality, and I have to say they also realise that, with good efficient management and delivery of their services, they can do this. They can do it. It is challenging internally within any organisation, with any agency, to deliver at the same time efficiencies whilst, also, the demand for their services is inexorably rising. And we will keep this under review. We will. 

Well, I think that's what we have to ask, is to keep it under review. 

We will keep this under review. 

Because it is a 25 per cent rise, isn't it, in the last two years. 

It is. And the crying need for their services, and for the services to be delivered well and in a timely way, is absolutely clear, so we will keep it under review. But, at the moment, we are confident that the staff, the workforce and the management are committed to delivering this, are delivering it, are performing well. But we will keep it under review, because this is a double-edged challenge for them: being asked to maintain within a standstill budget going forward, and, at the same time, having a rise in demand for their services. But their performance is the acid test, and their performance at the moment is good. 

Yes.

So, how will you keep it under review? Can you be a bit more specific about that?  It's sort of on an in-year basis now.

Well, certainly from a policy perspective, we will be discussing with them and keeping very close tabs on their continuing performance measures as CAFCASS. From a budgetary point of view, we are constrained with the reality of exactly where we are, but things do change occasionally with budgets. We don't know what's going to come out of the budget today. We have to keep an eye on that as well as what our constraints across the wider portfolio are. But, Chair, as you know, the reality is, within the constrained budget that we have, that what we give with one hand, we take away from somewhere else. But we will keep this under review because we don't want the performance suffering.

And then the money for the funding for children and social services has been transferred from health to children.

Yes, indeed.

So, could you say exactly what's happened there and whether the changes in portfolios have made any difference to any of these arrangements, and whether there's going to be any—

It hasn't affected the sums of money; it's just about how they've been presented and having them managed internally within the Government. So, a transfer took place because of the previous Cabinet organisation. We'll probably move that back and around when it comes to supplementary budgets. Again, it relates to the clarity about where the budgets are and where the departments are. It doesn't affect the amount of money, but simply how it's presented.

So, the funding for children and social services is now within the looked-after children transition grant budget in the budget expenditure line 410. So, it's just what line they now appear in, but it hasn't affected, as the Cabinet Secretary says, the allocation.

Thank you. And then, in the paper, you referred to £8 million allocations for various workstreams—looking after children and preventing children going into care. It says that this funding will be included in the revenue support grant from April 2018. So, does all that £8 million move to the RSG?

Yes.

All of it.

Yes, Julie, in its entirety.

Right, thank you very much. You are creating a new national £1 million St David's Day fund bursary grant. Can you tell us a bit more about what that would be used for?

Yes. This is very much focused on those young adults who are looking to move towards independent lives and successful adulthood, having moved out of a care setting. We know the challenges with this and it's often a forgotten area. So, the St David's Day grant of £1 million is focused at that area. Again, it's within our approach around early intervention and prevention. So, this will hopefully give those young adults the right tools so that they can transition into independent living, going forward.

In terms of the grant itself, as a Welsh Government grant to local authorities, it falls within—or it will fall within—the amalgamated grant going forward. So, we're looking at a pilot approach being undertaken to the grant in 2018-19, and then a view going forward to look at creating a single grant encompassing those amalgamated grants from the years afterwards.

As a grant to the local authorities—

Indeed.

—covering all early intervention and support for young adults—it'll be all in one grant.

Yes, eventually, but, at this moment, because we very much need to focus on this issue, the St David's Day grant is there as is for now, and we'll be expecting local authorities to report to us on how they've actually utilised that grant.

Right, thank you.

Thank you. Hefin.

What longer term assessment are you making with regard to the discontinuation of Communities First and particularly its impact on child poverty?

The decision, preceding my time here, to actually move from Communities First has been well articulated—the reasons around that. Before that decision was taken, there were a number of assessments done: equality impact assessments and children's rights assessments. It's worth reflecting on the fact that, at the time, even though there was great discussion on the merits of taking this approach, the children's commissioner herself remarked that the consideration of this had been done in quite a thorough and thoughtful way.

Going forward with the Children First approach, within the zones that this is taking place, we need to again make sure that the outcomes are now being delivered—so, taking the very best of what was there in the schemes before and going forward. We will, of course, evaluate now whether that is being delivered on the ground in these areas. But I think it's been taken up with enthusiasm by those areas where the Children First approach is being piloted.

And the alternative point to make, of course, Hefin, is that, in terms of child poverty, the biggest factors are outside the control of this Government. The reality of tax and benefit changes, and the rising tide of child poverty we expect to see—there's a direct correlation with the economic position and the changes to tax and benefits.

Yes, I accept that, but the Trussell Trust has been critical of the Government's decision to, for example, not have a poverty Minister, and critical of the decision to remove a separate budget line for child poverty. Are there impacts? There must be impacts there that you must be thinking about.

The move around having a budget line doesn't change the reality of how money is spent and what it is spent on. There's a constant battle and people are always asking us to reorganise the way in which we should present the budget to make it clearer, and we are trying to do that, to provide greater clarity in the groups, but then, also, in the programme areas as well. And this is still a cross-Government activity, because having one Minister responsible for child poverty may provide some clarity on individual leadership in people to ask questions to, but actually getting people not just into work, but into well-paid work, and that's not just an issue for this department, it's an issue for the economy and others as well—the impact of housing, the impact of a range of other areas. And so, actually, this has to be a cross-Government approach as to what we want to do.

Again, we come back to why we have integrated assessments on the budget, why we have 'Prosperity for All'. We're talking about a whole-Government approach and the impact of it. But, in 'Prosperity for All', early years is a key area, because we recognise that, if we want to intervene or to act in a preventative manner, if we want to do something about child poverty, we have to act in those earlier years and we have to have decent quality work for people to go into as well. So, there is something around seeing the different way that Government behaves and the impact on this. Even if we accept that we don't have all the levers, this is about this Government doing what it could and should do to make a real and defining impact in this particular area. Although, sadly, I think, that'll be about how many people don't go into poverty, rather than our ability to fundamentally shift those numbers, unless the UK Government changes course on not just austerity, but the—. The way in which the benefits system is being run now I think is going to create a much worse impact. Don't just take my word for it; look at the IFS and a range of others too.

So, within that UK context, on which I agree with you, would you say that you are now, more than before, allocating maximum resources to tackling child poverty?

I think we've put all of the resources we could and should do into tackling child poverty, but I think there's an awful lot about how money works, and this is why I know you don't just ask about the money questions, you ask about the policies, about what we're actually delivering with the money as well. And that is at least as important in so many ways as the amount of money that we put in. Because, if we don't persuade all parts of our Government to act as a Government that works with each other, as opposed to single areas that compete for resources and attention, well, actually, we'll lessen our input. But it's also about our partners as well. So, that's about the conversation with health, with local government, with the third sector, with businesses as well. That all really matters too. The new economic contract, the expectation we have for businesses about how they'll behave, how they'll treat their workforce: all of those things matter if we're going to have a real impact on child poverty, because, as I said earlier, the majority of children growing up in poverty are in working households. So, this is about the quality of work, about the nature of work, and so many other things.

And the poverty strategy is there, driving that with us. So, it isn't as if the drive to tackle poverty has disappeared from the agenda. It's packaged now right across Government. But issues to tackle household income, debt, financial advice, addressing the poverty premium, action to mitigate the impacts of welfare reform, all form part of our poverty strategy, and in evaluating this—. And you can point to things such as the Better Advice, Better Lives project, which is being funded out of the budget, the discretionary assistance fund, where the take-up has been massive, and even things like the council tax reduction scheme. But to come back to that constant theme of, 'Well, then, how do we actually evaluate that it's working well?', well, part of this, some of the indicators for poverty, are within the 'Well-being of Wales' report, which was published back in September, and that'll be an annual publication. So, things like what are we doing in terms of tackling the issue of NEETs, what are we doing with the levels of achievement at key stage 2—all of those things. But we're also working at the moment—our officials are working—to try and explore the possibility of interim outcomes, interim milestones, in relation to indicators that measure the progress in tackling child poverty within that child poverty strategy. So, we are working at this. We're both focused on evaluating what we are doing on poverty, but also that poverty strategy is driving all of these interventions right across Government, rather than in one small area—right across the piece, from housing, education and everything.

Julie.

Yes. I wanted to ask about the funding for taking forward the reasonable punishment legislation. I really welcome the Minister's statement earlier this week, on international children's day, I think it was, wasn't it? But, obviously, it's very important that the work that the Welsh Government has done on positive parenting is able to continue. I wondered what evaluation you've made of how effective that work has been and how you'd be planning to take it forward.

It doesn't stop. The positive parenting campaign doesn't stop, because we recognise that it's had validity right up to now in terms of changing the awareness around different approaches to positive parenting. That isn't going to stop at the point when legislation arrives or even when legislation is in place, subject to the will of this place, when it is put in place. We're going to need to continue working, and it's the same with other major progressive pieces of legislation, where the persuasion and the awareness and the information and the advice—there'll be a continuing need.

So, for example, the 'Parenting. Give it time.' campaign—it still remains as a commitment for the Welsh Government. It's resourced appropriately every year. That campaign, as you know, gives very practical tips in different ways, including on social media and websites, to parents of positive parenting. The positive parenting budget—we use it flexibly each year. It does respond to emerging needs of where it should be shifted and where it should be focused. But, for example, in 2017-18, a large part of the budget was allocated to local authorities to train staff in priority areas, such as what you and I will see on the ground: working with families, working with incarcerated parents—the sort of work that I see in Parc prison, where I've been in regularly—understanding parental conflict.

So, there'll be a continuing need for that intervention, because we know it's not a question of simply passing a piece of legislation and moving on, it's the wider cultural change that comes with it and the advice and support we can give to parents to help them.

And I think some of the money that is being used for positive parenting will be used to help the communication and promote the legislation. 

Yes indeed.

So, that—. How are you going—you know, will that mean there will be some gaps in what's happening at the moment, or—?

No, we've got a number of ways. The front-line companies involved in helping us promote this, the social media companies, we have a feedback group from them on the level of engagement with the campaign. So, we monitor the traffic and engagement on social media sites and websites and so on. We regularly have feedback groups with front-line parenting and also health professionals on the levels of engagement that they are finding with parents on positive parenting materials and the various materials that we have.

We've also commissioned independent research as well to gauge the attitudes of parents, both at a baseline level, before this even started, and then subsequently, to see what change there has been in parental attitudes, parental knowledge, parental capacity, to actually use positive parenting approaches.

So, it's quite intense, the amount of evaluation we are doing on this, because we know the importance of this. It's not simply to do with the legislation. In some ways, that's an incidental part of the way of moving towards a different style of parenting. Some of the budgeting within this to help do this evaluation and to promote this is key.

Thank you.

Thank you very much. We have come to the end of our time, so can I thank the Cabinet Secretary and the Minister for attending, and also the officials for your attendance today? We appreciate your time. As usual, you will be sent a transcript to check for accuracy, and if you could provide the notes that you agreed that would be very helpful. Thank you very much.

Thank you very much.

Thank you, Chair.

The committee will now break until 10.10 a.m. but can Members please not rush off? Thank you.

Can I welcome everybody back? Item 3 this morning is our first evidence session on our inquiry into the emotional and mental health of children and young people, and I'm delighted to welcome Carol Shillabeer, who is chief executive of Powys Teaching Local Health Board and chair of the Together for Children and Young People programme, and Dame Professor Sue Bailey, who is the external adviser for the review of child and adolescent mental health services in Wales. So, thank you very much, both, for attending, this morning. If you're happy, we'll go straight into questions, and the first questions are from Darren Millar.

Thank you, Chair. Good morning to you. Thank you for your paper. One of the things, Carol, that we've been looking at, in terms of your paper, is obviously that the evidence that you've presented suggests that there's been quite a significant shift in the mindset, really, within the national health service, in terms of engagement at all levels. I've been drawn to this windscreen model that you've adopted, which talks about prevention, protection and remedy, rather than just the 'remedy' section, which, I think, has been everybody's focus in the past. I just wonder to what extent you are happy that all three of those elements, now, are being fully pursued by the people that are working through the Together for Children and Young People programme.

Thanks very much. I think—. There are two parts to that, if I may, the first part being the commitment of people to get around the table and really work together. I felt it was important in the evidence to try to demonstrate that shift over the last two and a half years, so thank you for picking that up and seeing that in the evidence. If we look at the whole windscreen model—and we have used that consistently through—there's no doubt that we've had to focus very much on the specialist CAMHS end. There were real and significant issues in that regard, and a lot of work has taken place in relation to that, and a lot of improvement, although we're not there yet—sustainability is an issue for us. There is certainly a much greater awareness and much greater appreciation of the need for agencies to work together on what I would call the left-hand side of the windscreen, which is about general resilience and well-being, often in school settings and preschool settings, from the very early stages of life right the way through to some of that early help and support. And if I just stand back a moment and look at the programme, it is probably those areas that we will need to continue to drive forward and further expand, and possibly some of the more challenging areas. Because education has a role, social care has a role, even preschool has a role, as well as the health service. So, I think there's much more to do in that area.

So, can you give us some concrete examples of that sort of engagement, particularly with education?

Yes. So, there are a couple of streams, if you like, that have developed since we started the Together for Children and Young People programme, that focus on that part of the windscreen wiper. There's the Cymru Well Wales partnership, which I think you'll be aware of, which is multi-agency and includes police, education, et cetera. There's the work on ACEs—so, adverse childhood experiences—and then there's clearly the work on the education curriculum and the whole-schools approach, which we do want to try and touch on later on. There has been considerable work, and some of our conference themes have been held, on how do we ensure that all of those elements are working together. I've started to see—not that I spend a lot of my time in the education world, but I've started to see a real change in the education sector around being more emotionally and mentally aware and being healthy schools. I had the pleasure of going to Crickhowell High School recently where there was the launch of the in-reach CAMHS pilot, and, whilst I was there for that, actually I was very impressed by how that school, and I'm sure it's not unique in Wales, is taking a much broader look at wellness and well-being and is not focusing—what I'm told—just on academic achievement, but on having children that are well-equipped for life more broadly. We've done some work with the, I think, University of Sussex. This work's been led by Dr Dave Williams and Jenny Williams, who's a director of social services. Dave Williams is a CAMHS clinician on early intervention, and I know that the children's commissioner is pushing us to try to bring that work and the curriculum development work together. Welsh Government officials are having discussions about how that might come together a bit more. 

So, where are things at, then, in the curriculum development work? Obviously, we've got pioneer schools, haven't we, that are looking at this particular stream, but what about progress in the non-pioneer schools in the meantime? Because it's going to be some time before the curriculum's fully implemented, isn't it? We know that the curriculum's been moved forward in terms of the timetable of implementation, so we need to act now, don't we? 

Yes, and I think it's important for me to stress that I don't believe education, in any way, are putting all the eggs in the curriculum reform basket. I'm not sighted enough on the detail of timescales on pioneer and non-pioneer, but I am sighted on schools across the board having a greater focus on well-being of pupils, and, actually, of staff as well, because that was one of the themes that came up in our initial fact-finding conference, the support for teachers, and that has been a really important factor that, actually, the children themselves raised. So, I'm sure I can get hold of more information on pioneer and non-pioneer timescales, but I don't believe for one moment that education is just waiting for that to happen; it is moving forward. But, as with most areas, I think there is a degree of variability amongst schools in terms of what they feel able to progress with.

Can I ask—? I mean, one of the things that some committee members have witnessed is mindfulness operating in schools, and there's an excellent example of a school in my constituency that is applying mindfulness in the classroom, from the tiny tots right through that primary school, and it seems to be having a significance difference. It's not a pioneer school, so how do you make sure that the good practice from there is being applied in other schools across Wales, particularly given the impact of mindfulness on resilience—that other end of the wide perspective?

I've heard exactly those examples. I've heard of the talk time, the talk circles, that schools have as well, where they talk about the things that are troubling them. They seem to be fairly successful as well. I think I should probably be clear about the scope of the work that we've been doing and where this links in or—you know, the challenge from the commissioner is that she wants to see it much more linked in, and we've had some level of separation in there. Given, you know, that we're at the phase of the programme now—we're two and a half years in, we've been having discussions with Government officials about an extension to the programme; we're at the stage where we are now needing to be very clear about the additional year of how, what, the areas we would focus on in our programme of work and how we interface or even join up these parcels of work, if you like, these parts of the windscreen wiper. So, that's what I would really say to that: what is it that we would do? What is it that the education service—? Or is there merit in bringing it together at this stage?

Obviously, the attempts to build the resilience side of the business, as it were, were attempts to reduce the pressure when it came to the referrals into the secondary care system. So, do you see any impact of that having been the result of this work to date?

Well, you can talk about cause and effect, and there may be some scientists amongst you, but there has been a growth in referrals. We undertake a benchmarking exercise every year, which we instigated as part of the programme. So, referrals from 2015-16 to 2016-17 have increased by just over 200 per 1,000 of the population. So, there's been an increase. My understanding is that it's not as steep an increase as previously, but, importantly, the referrals that are coming through—more referrals are being accepted as the appropriate referral for CAHMS. So, I don't want to overly make a connection here, but that feels positive.

But doesn't it suggest that the resilience side of things isn't working, if we're getting increased numbers of referrals and they're more appropriate referrals?

Is there anything that Dame Sue Bailey would like to add, particularly on this point of whether there's been enough focus on delivering universal resilience and the preventative side of things in the programme?

[Interruption.] It works automatically.

Right, okay. So, if I can sit slightly outside of the discussion and talk about what we know, I think you make a very important point that you can't wait while pilot schools are doing things; other people aren't going to sit still and do nothing. So, I think there is enough knowledge across systems both within Wales and outwith Wales that you can align what schools are doing across eight principles, and key to that is the leadership and the heads wanting to drive this, having a clear understanding of what emotional well-being is—and I think there still tends to be confusion about that. And I think what you could align it against across the system is the curriculum that you're using to promote resilience and well-being—so, it may be mindfulness, it may be other approaches, but that it's being done, that it's aligned against the local needs and the unique knowledge that a headteacher has of his pupils and their demographics and their families and their teachers, and it enables the student voice to influence decisions. 

I think one of the key things for me, as I went to each of the big meetings that we held was that the traditional, 'Well it's your problem', 'It's your problem'—the thing that drove through that, because we took our time to do that, was the voice of young people at our conferences. And they said, 'Hang on, this is about me and this has been my experience, so what are you all going to do?' Getting the student voice in, I think it's very important. The teachers have felt, 'This is yet something else that you're asking me to sort out and do and I've got enough on my plate.' So, I think supporting the staff, identifying the need, working with the parents and carers, which I think will come up in the work that's been done in specialist CAMHS on consultation, and then, as well as emotional well-being, how do we make sure that those young people who have more problems and difficulties get targeted support. And that will bring effectiveness, efficiency and will make sure that the right children get through the waiting lists for the service they need.   

So, I think there are models out there that, across what we're doing and what the schools are doing and the sectors are doing, we could align it against and measure.

I think the problem is, though, if you're getting more referrals and more of those referrals are referrals that really do need a secondary care intervention, which is what you suggested earlier on, Carol, then these elements of good practice that you've identified, Dame Sue, clearly aren't being applied on the ground, are they? They're not working. The resilience side of things isn't really working, is it?

If I can just come back on that, I think we need to think that this is no quick fix. Emotional and mental health issues, I believe, have a higher profile now than ever before in our society, not just in Wales but across the UK. We're encouraging people to talk about issues, we've got high-profile campaigns, et cetera. And that's something that I think we should be really pleased with. People are now starting to talk about these things. My own sense of that is that demand will continue then to come through. I don't believe for one moment that we will be able to do a quick fix on resilience. This is, I think, years of work. When we start to think about how we work differently in terms of future generations and the integration and partnership working, that's exactly how we need to work in order to make that change. So, we're starting—if we think about our First 1000 Days programme, we're starting at that preconception, and it is going to take some time. I'm hoping that you'll hear some different voices around how it is in different parts of the system, how education are feeling about trying to become more mentally healthy, if you like, but the clear sense is that this isn't a quick fix. I appreciate the question and the driving, because that's what we're thinking—'How can we turn a corner?' I don't think we yet know when a corner would be turned.

It's just that, the last time you came before the committee, you were very confident that those numbers would come down. Now, you're telling us they're going to go up.

Then the growth level—. What I don't have in front of me is the—

You didn't tell us that the growth level would come down. You told us that these numbers would come down.

So, if we look at the windscreen model—. And this is something about how we completely change our way of thinking. So, if I was just to say that service provision in the old days was out-patient appointment or in-patient, we're now talking about group work. We're talking about telephone advice and liaison. We're talking about multi-professional meetings with parents. We're talking about many different means of offering a service. All of those are contacts, because our contacts have also gone up. But I'm hoping it's not in the more traditional 'you wait in a queue and have an  appointment', but you might have had a phone call with a consultant psychiatrist or community psychiatric nurse. So, part of trying to deal with that end of the windscreen was not about using the same models, but really about saying, 'Can the guys in this end also support—?' So, headteachers— I was talking with headteachers. Their biggest worry is that they have, on a Friday afternoon, a child they're really, really worried about. They want to be able to pick up the phone to someone who will risk-assess with them and then feel assured. That's the service we're getting into now. That's still a contact. We still write it down. So, I think we probably need to get a bit more sophisticated about how we are supporting people across that whole windscreen model. There's definitely more to do. I wouldn't want to give the impression that there isn't.

I think there are two lessons here, and it is about listening to the experts, who are the young people. From what the young people in Wales have said—and the young people outside Wales have said—they actually want to have more knowledge and feel more in control of their own mental health and well-being. They live in an age of artificial intelligence, and they want to be able to do self-guided help with support. So, going forward, I think it's looking at the changing role of CAMHS teams and how they work in that way. They are also very clear that they want teachers to have more mental health awareness, without it frightening them and becoming a burden to them. So, I think it's very much about the way in which, in future, not only specialist CAMHS but whole systems—whole school systems and whole systems across localities—will need to learn how to work together. Critical to that, if we learn together, is how we train together. So, I think that will—. Over time, but not a short time, that will—. It's not going to happen quickly.

Carol, when is the work that Dave Williams is undertaking going to be completed, please?

So, the work stream has published a directory of best practice in conjunction with the Early Intervention Foundation. So, that's already available now, and—

Is that something that can be shared with the committee?

Yes, absolutely. We can certainly do that.

There are discussions taking place. As you probably are aware, we put the well-being and early resilience and the early intervention streams together. There is some discussion going on at this stage about how does that link with the schools agenda and should that move across there, how will that work. This continues to be one of the key areas—well, we'll say it's for the next 12 months—in order to have a much clearer route-map with education about what is the expectation of schools, whether they're pioneer or not, and where do other services help and support.

Okay. Thank you. Julie.

Yes. Thank you. I wanted to ask about advocacy. We do understand that not all of the health boards are currently commissioning advocacy provision for children and young people. Is that the case?

So, advocacy commissioning and provision is a requirement of the mental health Measure for those children who are in an in-patient service, but that's a very small number, recognising that. Most health boards do joint commissioning with the local authority, with the local authority being the lead agency, under what was, and some still exist, the children and young people partnerships. So, general advocacy. Just from Powys's perspective, we've used a well-known advocacy service for a number of years. As we move forward and the services change, change shape, as I was just alluding to, I think there is a need for us to reflect on advocacy for children not just in the general sense of things, but as they enter into mental health services, not necessarily in-patient, but whether that be an out-patient consultation liaison, and particularly those children who we are supporting in the community. So, we've got community-intensive teams right the way across Wales now, which has been a real step forward. But they're not classed as in-patients, so we want to be able to look to see whether we should be stretching the advocacy for those. My view is that every child should have access to advocacy. If it's not a provision as part of the partnership arrangements, there will need to be specific provision made. 

It sounds as though you're going to reflect on it. Are you thinking of a different model, or what are your plans?

Well, one of the things that we've got under way at the moment, particularly around what are called the tier 3, the community-intensive teams, is we're doing some evaluation work. We should get that report in March of this coming year now. One of the areas will be, as we've talked about, the child and family voice and advocacy, to make sure that the review covers that off, because if that's a gap, particularly for those children and families who are in a crisis situation, it's really important that we look to fill that gap. That would be the priority area, and I would need to just double-check the coverage of what I would call 'general advocacy'. My understanding was that general advocacy was available right the way across Wales, commissioned through local authorities, but largely in partnership. So, if there are health boards that haven't participated in that, then I can also find that out. But I'm particularly keen to look at those who are just sitting below the in-patients, who are in a sort of crisis situation, being supported. 

Yes, of course, they need advoacy as much as in-patients.

Being an in-patient, yes. Completely right, yes.

Dame Sue, did you have anything to add to this?

I'd totally agree with that, that that's the way forward, and that we need to look at giving advocacy to children who, in some ways, their need for advocacy—. I know that once you're in an in-patient unit, there are regulations and conditions, but it's even more important for children because, I think, good use of advocacy may well prevent them having to step up into an in-patient bed and, maybe, with wraparound care, enable them to stay in the community, which is what we want. We want children's lives to be as normalised as possible, even when they're experiencing an episode of mental illness. 

Thank you. Llyr.

I just wanted to ask a few questions about referrals to specialist child and adolescent mental health services. You touched briefly on it at the beginning, and I just want to ask really to what extent you've been monitoring the referral acceptance rate for specialist CAMHS?

We do monitor it. It's one of the key questions as part of the NHS benchmarking. And the referral acceptance rate has increased in the last round from 72 per cent to 74 per cent. That tells us that that's going in the right direction, but it also tells us that there is more work to do, just to ensure that there's the right level of even pre-referral advice. And some health boards have been testing out like a phone-first—'Just give us a call. There's somebody who will take calls every day. If you're not sure if it's a referral or not, then pick up the phone, we'll talk about it. We may be able to help resolve or find a pathway there and then. Other than that, send the referral in.' The referrals are generally discussed in a multidisciplinary team. Some of those teams are multi-agency, and we want to move more to that level and that teams bring referrals in with them from their networks, be it in schools or whatever. So, it is something that we've been looking at carefully, mainly because, at the beginning of the programme, it was felt that it was very hard to get through the gate into CAMHS, and we've still got to test that out. One of our important stakeholder groups is GPs, and I think there's still a bit more testing out for us to do: 'How does it feel for you as a GP now? Do you have enough contact yet? Do you feel your referrals are being accepted or can you get the telephone advice?'

Sorry, did you say that some are utilising the phone-first approach?

Yes.

So, how do you share that good practice when it does work?

Absolutely. So, Aneurin Bevan have been using this and have been testing it out. We've got the CAMHS clinical leaders group. So, where different health boards are testing out new developments and initiatives, if something works in one area and it's evaluated well, we would be looking to say, 'We need to spread this.' So, that is something that Aneurin Bevan feel is helping. I'm not sure we've quite got to the full evaluation stage yet, but it's also part of the suite of working differently. So, the in-reach into schools is another means by which, if we know the population in the school and we know which children teachers may be a bit concerned about or where there are particular issues that have happened, it's a bit less of a formal referral into the service but more watch and wait, offer advice and support in that arena. So, I think there are a number of different ways. So, those small tests of service development, once they're evaluated, we should be looking to push them and roll them out.

How confident are you that the referral guidance being used by health boards is right? Or is that a constantly evolving thing?

I think so. My own view is that there should be no wrong door to go through. So, if somebody is making a referral, they're obviously worried about something. The child or young person may not have a mental illness, but they're obviously in need of some support, so there is a responsibility, I think, to then try to make sure that that support is provided. Albeit, that's why we're trying to push much more on the multi-agency approach here—that there is a place where support can be given, even if it's not the more specialist CAMHS service itself.

Okay, thank you for that. I just want to ask as well about the current capacity for providing specialist services through the medium of Welsh. What is the current capacity and what's being done to address any shortfalls in that respect?

I think it's very variable across Wales. I know that, for colleagues in north Wales, this is an absolutely core component of the service. One of the issues that we've had, when we did have very high numbers of children going outside of Wales, was that that choice was often actually not a realistic choice, if they wished to speak in the language of Welsh. As we're keeping more children in Wales—there's more to go at there, I think—that offer is better. It is definitely better in north Wales than it is in south Wales. We're doing a lot of work across the NHS to be sure of where our Welsh speakers are and where our deficits are in certain services so that we can either encourage staff to learn or, if we can recruit—and workforce is a challenge, as you know—we are trying to recruit people who are able to speak Welsh.

So, the essence of my question was whether you know what the situation is, broadly.

On the whole, each health board keeps a register, a log, of where the Welsh speakers are, at different levels of fluency. There is probably some specific work that we need to pull out in terms of the profile on CAMHS at a national level—the health boards will know—just to see whether there is anything more that we can do to push that along.

Are you confident that enough is being done proactively then to try and address where those deficiencies exist?

Yes, so this is in the broader sort of Welsh language—. I do have a role and support the Welsh language in health and social care partnership, which is a Welsh Government partnership. There's so much more for us to do, both in terms of undergraduate training but also in enabling people to learn Welsh or to make the start. If recruitment and workforce challenges weren't where they are now, I'm pretty sure that we would be really pushing hard on having a Welsh language—. Most job descriptions have got 'Welsh language desirable',  so, recognising that. But we're not where we need to be.

 But is there a programme in place to target those deficiencies? That's what I'm asking.

Yes. From an NHS point of view, all health boards have a Welsh language improvement plan as part of their core objectives. We haven't got a specific stream in this programme. We haven't got that. There's nothing precluding us having a little look. We should be able to get hold of the data and just give ourselves a picture of where that is, but we haven't done specific work on the Welsh language here.

Okay.

Thank you. Hefin.

Are you satisfied that the waiting times for routine referrals to specialist CAMHS are meeting the 28-day target?

A lot of progress has been made—a lot. You'll probably recall that, when we started the programme, it wasn't even 28 days; the time frame was much longer. So, absolutely right, in my view, that the Welsh Government realigned that, in line with the adult target. So, there's nothing wrong with the target.

Huge strides have been made, but it's not consistently being met at this stage. A pretty substantial investment was made into CAMHS in the life of this programme—£7.6 million—and we've been very pleased with that. I should never—and this is not a complaint—. Having an influx of money then to recruit people, when the recruitees aren't necessarily there, has been a bit of a challenge, but health boards have responded by being really flexible, putting on additional sessions in order to see children and families. Our challenge, as we move forward, and our task, is to support health boards to maintain that on a sustainable level. So, it did really well, but there are some areas. I know from my own experience of being around the chief executive table with the Welsh Government, and in performance meetings, that Welsh Government officials are very focused on ensuring that health boards meet that requirement of 28 days.

Is that geographically patchy?

Geographically patchy. You'll know from the evidence, obviously, about the 28 days for specialist CAMHS. We separated out the neurodevelopmental work. I'm sure we'll come on to that. That's got a longer timescale on it. I think the progress on the specialist CAMHS has been really very good. There are some areas in south Wales, particularly around workforce-related matters, where it's not being met consistently. I know—well, I'm aware—that health boards have plans to rectify that, and the expectation of the Welsh Government is really clear.

Okay. Thank you.

Thank you. Mark, on neurodevelopmental conditions.

Can you tell us how many of the health boards are meeting the 26-week waiting time for neurodevelopment conditions?

Not all are meeting it. I think probably about half are meeting it, at this stage, consistently. If I can give you a little of a background to this: this was really, largely, a new service that has been developed as part of this programme. There was a situation where some health boards had specific teams that looked at neurodevelopmental issues and families with those needs, but some health boards had none. So, they were starting from a zero position. There was quite a lot of concern, considerable concern, that some people had been waiting a very long time—and I do mean years—for assessment. We developed a neurodevelopmental pathway for Wales. This piece of work is led by a highly credible and motivated consultant paediatrician—a community paediatrician with a specific interest in this. She has managed to galvanise people in a community of practice. Teams have been established and all health boards have made significant progress. There are some people waiting beyond 26 weeks.

Do we know how many people are waiting beyond 26 weeks in all, across Wales?

I don't know if I've got exactly—. But I can get it.

Perhaps you could write to the committee with more detail on that.

We can certainly get that.

We're very clear in our programme board and we spent some considerable time talking about the neurodevelopmental progress. The lead clinician will say, 'Good start; a lot more to do.' We asked that group for a plan and a proposal for the coming year. We will be considering that in our meeting in December, because we know, again, we've got to embed this process, this new team, this new pathway. We've also got to do some work on referrals and, again, variation. Some areas have much higher referrals than others; is that unmet need or is there something else going on? Because what we've talked about is putting a service in for today's capacity needs, but if the referrals will keep coming through we need to be forward planning. We don't want to see this work slip back.

In that context, you've had, I think, an extra £2 million grant from Welsh Government for the development of services in this area in 2016-17. I wonder if you can just give us an update on how that £2 million has been spent. 

Yes, I can do. I've largely covered it, really—so, new teams, each health board has a neurodevelopmental co-ordinator, additional resources to develop the team itself. So, you'll have nurses and therapists in there as well. Also, some of the health boards have been using the money looking at broader third sector support and provision. We've got a strong and active third sector in children's services who are very, very keen to support. So, that money has been spent largely on developing that new service. 

And are you expecting that money to be recurring? 

Yes. 

Just moving on, then, to workforce issues, are you able to tell us how much of the £7.6 million extra has been spent on recruiting specialist staff for CAMHS? 

Yes. We've had about an 8 per cent—or just more than an 8 per cent—increase in the total CAMHS workforce per 100,000 of our population. Why we describe it in that way is because we make comparisons between ourselves and others in the benchmarking world. When we looked at the benchmarking, what we saw was we had more consultants and fewer nursing staff than others, so we've been redistributing. So, I would give a cautionary note about just looking at numbers. It's really about the shape of the workforce and whether we have sufficient workforce in each of the areas that is required. 

The funds that we were given—I alluded to this earlier—are a significant investment. It was in part a challenge to recruit into those posts, and one of the downsides of doing quite a big recruitment piece was that people moved across and left gaps. So, we're very interested—and Sue might want to speak on this—to ensure that we're working very actively with Health Education and Improvement Wales and Social Care Wales now on what I would call the pipeline of staff coming through. We've asked a lot of this workforce and we know the demographic profile of our workforce and we know we're going to have to put significant efforts into increasing that pipeline.  

Did you want to add anything on that?

Yes. I think it will be very much about developing all health workers, especially mental health workers, in working to the absolute highest level of their competency, and looking at how across a team you can cover all the things that need to be done to meet the needs of those children on that patch. I think it's a different way of looking at how we train people up and, obviously, one of the challenges is that that takes time, but I think for some workers, that can be done quite quickly. And I think working across both health and social care will be one of the solutions to that, and having common content to the curriculum but obviously delivered in a way that fits the professional group that's in there. And I think that's something, particularly looking at neurodevelopmental conditions, that has helped to bring the waiting list down, although they're not there yet. I think that's been a significant shift in the way that professionals in different groups across health and beyond health are actually thinking first and foremost what will be best for the child. I think it's this mindset shift that will move the workforce. 

Okay, thank you. You may not have these figures to hand, Carol, but I think the committee would be interested in knowing the current staffing establishment and vacancy rate for specialist CAMHS in each health board, and how that figure has changed since the start of the programme. So, maybe we could have a note—I'm conscious I'm giving you lots of notes to write. 

That's okay. I'll take my homework. So long as you didn't expect me to be able to recite it. Perhaps I should have been able to. But, yes, the change over time, and in the different groups—I'm going to offer something above that, if this is helpful, but we could share the benchmarking information and how that compares to others. You always have to think that there are slightly different models, but with that assumption underlying that, we can forward that as well. 

Okay. Thank you very much. John.

Thank you, Chair. I'm interested in access to psychological therapies and the additional Welsh Government funding for CAMHS, and to what extent that's been taken forward by health boards. So, what additional provision have health boards made in making sure that access to psychological therapies is improved?

Thank you very much. You're absolutely right; £1.1 million was earmarked by Welsh Government for the further development of psychological therapy provision. So, just by way of background on this, all health boards have a psychological therapies committee. That is a requirement. That should cover all ages, and, actually, be much broader than what we might traditionally think of as emotional and mental health services, but right the way across service provision. I think we've got some areas that are leading and pushing forward. So, Hywel Dda, for example, have got some extensive psychological therapy provision, and we're utilising their work—a bit like I said earlier about how do you take something that works well and then spread that—as our sort of menu, or standard, really, that should be expected from all health boards. All health boards have psychological therapy services in place, but they may not be fully up to the full menu that we would expect. 

There is something called 'Matrics Cymru', which is a definitive list of the psychological therapies for children. That's been developed by the psychologists group in Wales, so that and the Hywel Dda work will give us the clear standard that we will need to work to. Clear prioritisation—but what I would say at the moment is that there are some very good patches, but it's not yet fully comprehensive right the way across Wales. 

So, in terms of that additional Welsh Government funding, do you know the level of investment by the individual health boards in improving access?

Yes, we do. Again, I can give you some additional—. We tried very hard to stick to your five-page challenge, but we can certainly provide the additional information. 

If that could include the number of specialist posts created, and the beneficial effect of those posts, that would be useful. 

Could I make a comment on specialist posts? I think we're in the realms of really adopting a psychological therapy approach. Therefore, we would expect to see not just psychologists delivering psychological therapies, but a broad range of staff. So if, in that return, we're able to indicate where nurses or occupational therapists or others—social workers—offer psychological therapy, where there may not be a specialist in it, we'll do that. But there are certainly specialist roles in Wales—cognitive behavioural therapy practitioners et cetera. We can provide that. 

Okay. In terms of the Together for Children and Young People programme, has that included monitoring of the number of referrals made across Wales for the different types of psychological therapy, and, hopefully, including the number of referrals that are actually accepted?

We haven't gone into that level of detail. Activity is monitored and reported in to Welsh Government. In terms of the same level of data capture that has happened with specialist CAMHS, we haven't got that level of information. As I say, the expert group that is helping us across Wales to lead this work—I would be expecting them to be able to advise us on what are some of the data sets that we will need to be able to indicate that. What we've talked about for our final year of our programme—it is the final year—is a much greater focus on outcome measures rather than activity. I know that you'll be interested in activity—how much and by when—but actually is this making a difference to people and is it reported from the individual?

We do have some ways of working in Wales that we've been testing in other areas called PROMs and PREMs—they are patient-reported outcome measures and patient-reported experience measures. We really want to get into that territory about, 'So, did the help we offer you make a difference to you?', rather than just the numbers. But I think this is an area where we have more to do on numbers and access to psychological therapy.

Do you think there's enough transparency, Carol? Because obviously the figures for assessment are published, but you could have a young person who was seen within 28 days who then waits for two years to see a psychologist. Do you think there's enough transparency in the system?

I think there is a bit more for us to do. I know, just from my own health board, we've got the assessment and the intervention, but we need to be clear about whether that intervention was the definitive intervention or whether it was a very helpful intervention, but leading to something more substantial, i.e. family therapy or whatever. I think it is a perfectly reasonable requirement for us to be able to track through access times to psychological therapies, given that it is such a big service offer.

Okay, thank you. John.

You mentioned family therapy, Carol. In terms of that, we see an increasing number of children and young people experiencing difficulties with attachment and coming to CAMHS with those issues. So, is that family therapy going to become more of a priority for CAMHS as we move forward?

Aneurin Bevan are doing some work on this. I don't know if you're aware of that. It's a four-week intensive programme. The psychologist who is leading that has been in touch once to make sure that that evaluation is able to feed through. This is where all of those developments that we talked about earlier—the Cymru Well Wales partnership, First 1,000 Days, the perinatal review that's been going on—all of these parts of the system start to come together on prevention and resilience and early intervention. Then when we do have a situation, we've got to be able to offer the right therapy at the right time.

So, family therapy is one where we particularly want to make sure that we've got a good level of provision right the way across Wales. So, we're very interested in the Aneurin Bevan programme. It's achieving good outcomes and it's reporting good outcomes. And that's where investment can come in. So, if that's the impact, and if the group of experts feel that those are the top three priorities for us, how do we put the resource behind that and make sure that that gets implemented everywhere? It's a bit like our neurodevelopmental pathway and our crisis service that we've put in place.

Darren.

I just want to, if I can, refer to out-of-hours and crisis support. So, obviously, some money was made available by the Welsh Government to put crisis teams in place. I just wonder if you could describe what that crisis intervention and support looks like now, if somebody presents in a crisis situation to the NHS.

A couple of years ago, there was a model, largely in south Wales in the Cwm Taf provided network, but there were gaps right the way across Wales. The CAMHS network, just as this programme was getting established, got a business case supported to get that right the way across Wales, and I think that was a very important step for us. That meant that there was an evening service and a weekend service right the way through Wales. Opening times vary a little throughout Wales—but into the evening and at weekends. Some areas, like Hywel Dda, for example, have joined up with the adult mental health service as well, to make sure there's provision after the CAMHS service has closed, so that it's becoming more of a 24-hours service. We want to make sure that that is something that we can take forward.

So, the service will offer immediate support, usually in the person's own home, and a period of intensive support over a couple of days, or even a couple of weeks, largely to help people to stay at home and to reduce the need to go into an in-patient setting. They also offer a service in which, if somebody's been into an in-patient setting that they come out of, they can come out with that intensive support. What we heard before is that they were being discharged and it felt like there was not quite enough there. So, that's the service there.

That service links with the police, with paediatric services, with accident and emergency, and has got those connections and has built those relationships. We are currently testing out—we'll have the report early in 2018—the effect of all of that and whether we've got sufficient coverage of all of those areas right the way across Wales. I'm able to say, and I think it came through in a couple of pieces of evidence, that there are some issues for us to resolve on cross-border into England, so we will be picking that up. But this was one of the big tests of the programme, because we were hearing at the start that families weren't being supported in the out-of-hours period, the risk that the police were getting involved, and I have a case in which I had personal experience of that a few years ago, and that's something that we want to be in the past now, because that service is there.

So, all of these have been established in all parts of Wales now.

Yes.

And what's the impact been on reducing in-patient numbers?

Yes, there is some data in one of my sheets here that I've been given, and if I can't find it, I shall definitely let you have it afterwards. So, if we were to just talk about in-patients—

Because that's what these were designed to prevent, isn't it? Unnecessary in-patient admissions.

Absolutely, as well as admissions into A&E. I know that, in the Gwent area, there has been a specific focus on young people who've taken an overdose and whether they end up in an in-patient setting and how quickly they're seen and supported. We can provide that information to you, because that's been quite impactful.

In terms of admissions to in-patient care, you will recall that we had 15 plus—even into the early 20s at one point—admissions to in-patient care outside of Wales. That's much lower now. We've had 11 out-of-country placements as at just last week. Eight are in secure placements, so wouldn't have been reasonable for us to have. Most practitioners are reporting to us that they are able to offer a crisis service to people in their own homes and that the length of stay when children do go in as an in-patient is shortened. 

Is shortened. Okay.

So, again, you know, you've been asking for quite a lot of data. We can provide all of that; that's not a problem at all.

I think, if we could have that, and also the numbers of young people, because I know that, in Gwent, children also get taken into paediatric wards to keep them safe, and some young people are being put on adult wards. So, I think it would be useful if we could have that data.

Indeed.

And, in fact, of course, those concerns are still coming through in the evidence to the committee in terms of inappropriate admissions to inappropriate wards, and we're still getting issues presented to us about people not having sufficient support post discharge. So, clearly, while some progress has been made, there is still some evidence of problems. They may be more localised than they were previously, which means that they can then be targeted and addressed. 

Yes.

And I assume you measure the presentations to each of the individual emergency departments in Wales when a crisis might occur and a presentation might be made, so that you can target those areas immediately that are served by those hospitals.

Yes, completely. So, one of the biggest categories of presentation is young people who are self-harming. Therefore, how do we enable—which is in the thrust of the work, really—that partnership relationship between A&Es and the crisis service? Because we really don't want young people to be on a paediatric ward. And we definitely do not want young people to be on an adult ward; that is just not where we need to be.

My sense is that the timing of your work and the timing of our review work comes together really nicely in that we've made progress, but we know there are still issues in the system. You will continue to hear, as we do, of particular cases and concerns. If we are very clear about that, what we want to try to do in the early part of next year—I'm not quite sure when the publication date of your report is—but, to be very clear about the issues we need to deal with in what is likely to be the final year of the programme, or maybe the final year of the programme.

Thank you. Julie.

Yes, just some last questions on local primary mental health support services. Do you feel that they still are geared towards adult services, as we've had some evidence to indicate?

I think there's been a reflection in the service on the primary care mental health workers generally who've been in, if you like—sorry I'm using this language—tier 1 or 1.5, so in primary care. The introduction of the mental health Measure was not intended to do this, I think, but it gave us some specific focus about secondary care and the sense of whether we do enough work on ensuring the right capacity and capability in primary care. And it goes back to the early question about the windscreen wiper and have we got enough at that very early stage.

So, we've committed, and the CAMHS network is doing this work, to take another look at CAMHS, for children, and whether the capacity is sufficient. And we have had some additional funding, which helps us on this. I was just looking for the amount of money that it is and I don't have it in front of me, but we have had some additional funding. But, before the Measure, we used to track very carefully the numbers of primary mental health workers per 100,000 of the population, so we will bring that back to bear, with the new lens of how we ensure that that CAMHS expertise is supporting those other agencies. My gut is telling me that this is a real area for us to focus on. We might need a little bit more capacity in there.

Right, and are you able to track referrals, whether they're accepted or not and what the reasons are? Can you tell us something about that?

Yes, we do track referrals into primary mental health and, a bit like the conversation we had earlier about the different modes of working, we're going to have to reflect that as to whether this was telephone advice and support or whether it was an appointment or a therapy intervention, because all of those are very valid ways of working. So, the currency of activity, if you like, we will need to modify, but we have got that.

So, primary mental health workers will spend a lot of their time linking into primary care to schools, to school nursing services and others, but they will also spend quite a bit of their time on face-to-face interventions. We need to ensure that they've got sufficient time to do both of those things, which we all hope will mean that children don't progress into specialist CAMHS. 

What was really clear from our work with children and young people is they don't really want to go to a specialist CAMHS service, they want to have their help and support from different places, which is why the focus is on schools in particular, but also the focus is on the local primary mental health support service, because that's probably the edge of CAMHS, you know, and children were really clear with us that they didn't really want to enter that system unless they really had to.

Did you have anything to add on this, Dame Sue?

There is evidence, for instance, outside Wales, that you can actually radically reduce the presentations to paediatric A&E by having a very active responsive consultation telephone service. So, there is evidence available. I think it might be worth pushing at that and pushing how far we can get that in. That's better for everybody in the system.

Thank you.

Okay, thank you. Llyr.

Thank you, Chair. Some people have been expressing concerns to us about inappropriate prescribing, particularly of antidepressants for young children. I was just wondering whether you share those concerns and, if you do, what's happening to maybe try and address that.

I know that Sue will want to make a comment on this one. So, Welsh Government commissioned some research activity from Swansea University back in 2015 on this very issue. The report, I think, was from Dr Ann John, who also is in Public Health Wales, and that gave us a view that, actually, our prescribing rate was probably no different to other parts of the western world. That's not to say—. It might not be where we want it to be, but it was largely no different. What we did—. The steps we did take—the steps I took as the chair of the programme—following that report, was to write to medical directors in health boards to draw their attention to the report and to highlight that they may wish to look at those prescribing areas, particularly for very young children. I think there was a concern raised about that.

We have discussed whether we should encourage, or even commission ourselves, a follow-up on that, which was in 2015. The time frame would probably be in the next couple of years, just to see, well, has anything changed. What we would want to be sure of is that the offer for children and families is not purely a medication route, but a much broader route, hence why we're trying to work right the way across the system, really. I know that Sue has views; I don't know if you want to add in.

Yes. I mean, I think the fact that we're no worse than anywhere else, it's not a place to sit, is it? We want to be better than anywhere else, and I think we'd certainly—. I would strongly advise that they ask for this to be repeated in 2019. That will give you clear space to see if there's been change. And then I think it will be seeing how, in fact, what many of these, particularly younger children, need is either family intervention or low-intensity psychological intervention, and see if we're getting that to the right place at the right time. So, I think this is an opportunity, and I would certainly be pushing this as something we need to look at over the next 12 months, in a way that we could measure, if there's improvement, why there's been improvement, because then we can learn.

Okay, thank you.

We know that there are concerns that have been expressed by young people about the transition to adult services and also the transitions to other parts of the care system. To what extent will the guidance that you're developing actually address those concerns?

Thank you. So, transition has been part of the programme, and you referred to the guidance that has been developed. Our view—we've talked about this quite a bit—is this still feels like it's a really important element that is unfinished, and we still need to make more progress. We have meetings on the age range, scheduled I think on 6 December, between CAMHS and adults, communities, to ensure that guidance is absolutely right and how we're going to test and monitor how well it goes, including, importantly—. Well, the most important is how does it feel for the child and the family; that's No. 1 on the outcome measure. 

But, you're also right in identifying it's not just an age transition. It's a transition between the different parts of the system and there is more work for us to do on that. Thankfully, the royal colleges are already working on this as well, so there is a real benefit in us making sure that we're joined up on that too. And the sense that we've got to make sure the transitions aren't just between different parts of the health service, but between health and social care. So, young people and families are not seeing the join-up between the agencies. So, this is actually quite a complex piece of work and quite challenging, I think, to get 100 per cent right all of the time. But it is an absolute focus, and I've got to say that this is the one thing—this and workforce—that Sue is pushing us quite hard on. So, I don't know, Sue, if you wanted to add a comment.

I think this is absolutely critical, and the different parts of the colleges in the college in Wales are working on this with the child psychiatrists and eating disorder and adult psychiatrists, but I think it will follow through into the workforce because the adult mental health workforce needs to feel comfortable and competent in dealing with what's been handed over to them in a good transition. So, I think this is absolutely critical, and I also think, in terms of—you mentioned young people coming out of in-patient units. I think this is why there needs to be more confidence in working with the third sector on some of the step-down care that may not be about the actual mental illness intervention, but helping children to get on with the rest of their life: getting back into school, getting back into leisure, back into avocation. So, I think if there's anything I'm going to be a nag about, this will be it. 

Thank you. Hefin.

Are there any specific things you want to highlight for the year ahead? 

Yes. [Laughter.] I know time is short, so I will—

Key things.

Key things—this is the list. This programme formerly was due to end at the end of March, so I can't, first of all, believe we're two and a half years—[Inaudible.]—next few months. We have this programme we've all been considering—we're doing stock take, which is why all this is very helpful, and there are some key areas that we think are important. Just to be very clear: the Welsh Government and I have been in conversation about an additional twelve months, so it'll be three years plus a year, and some of that will focus our minds on what we need to get done. So, we absolutely need to get the embedding of the work that's happened collectively into local mental health partnerships. The danger of having a programme running at a national level is it's at this level—we really need to make sure it's sustainable and systematic through. Now, we do have mental health partnerships and we have regional partnership boards, so the mechanisms are there, and so our aim would be to support transition and hand over—embed local arrangements for planning and commissioning of service delivery for all partners, taking a public accountability-type approach to that. We really need to get into place the outcomes framework and the more effective monitoring of that outcome so we can see it across the board. There is a new computer system being implemented; it won't be everywhere by the end of this programme, but we will have made good progress on that. 

The focus on healthcare value, so the 'what matters to you'—and the PROMs and PREMs we talked about. We'll finish the local primary mental health capacity piece of work and make sure that we're very clear about the status of that— where the gaps are, where there are areas that need to be worked on. The psychological therapies: we'll build on the work undertaken so far, but have a very clear menu of what needs to be done and where, even if that gets implemented over a period. 

We do need to do some double-checking on—which is actually work in training now, as I say—the crisis: out of hours, the access to beds, that end of the spectrum. We think we've made significant progress, but let's double-check that, and that's where the advocacy issue comes in of those children being able to get their voices heard sufficiently.

Workforce: we still have got quite a way. Workforce is going to be a life's work, I think, but with Health Education and Improvement Wales and Social Care Wales—it's how we work with them to embed that as part of their psyche as well, moving forward. And there are some specific areas in neurodevelopmental and transition that we have discussed.

What we have to try to do is try not to spread ourselves too thinly in the last year, but really be focused, which is why I want to test that out with our stakeholders and children and families who have been helping us anyway, but also your considerations from the committee—whatever you feel is important. It'll be important for us to try and dovetail some of that. So, we would be looking to ensure that Government are supportive of our final-year programme by March, really. So, I'm not quite sure about the timescales for the publication here. If there is any possibility of getting some early indications to help influence that, that would be fantastic.

Okay, thank you. Just in closing, then, can I just ask you both: there's a lot of work still to be done, isn't there? And I think we all recognise that there's been progress, but is another year going to be enough to get that step change that we want to see for children and young people? 

So, we've been in a real dilemma: clearly, Welsh Government are funding this programme, and we've been very pleased with that support. I think we've got to balance having a programme that would be three, then four years, moving very much beyond that and, if you like, a reliance on the programme versus how we make this business as usual and make sure it is sustainable. There are a number of mechanisms, which is where we were sort of talking about public accountability models of what the business-as-usual model would look like. How could we be assured that, when the programme came to an end, we wouldn't be sliding back? So, I think there's a balance to be struck in terms of having a programme for a very long period but making sure we're mainstreaming and embedding this in business as usual.

That's the dilemma. We welcome your view on that and obviously Welsh Government's as the sponsors for the work as well.

Okay, thank you. Have you got anything to add, Dame Sue—no?

The key thing I've seen is a mindset change, one that I thought at times I wouldn't see, and that has happened—the move in neurodevelopmental. I think in terms of moving forward, whenever the programme is coming to an end, the handover period needs to be sensible so that things are handed over to the right people who should be accountable and so there's almost a template for going forward because I think that's perhaps—here and elsewhere—what has not happened in the past. So, those would be the key things for me.

Okay, thank you. At the moment, the committee is looking to report around Easter next year— sort of the end of March. But, obviously, we've heard what you've said about the importance of getting a Government decision on that, and that is something that we will discuss. It's always open to us to follow up certain issues earlier. So, thank you for highlighting that. Thank you both for your attendance today and for answering so many questions and also for the fact that you're going to have to go away and do lots more work for the committee. [Laughter.]

I'm sorry I didn't have all of the detail to hand, but we certainly can get that across to you.

Okay. Lovely, thank you. As usual, you'll be sent a transcript to check for accuracy. Thank you very much to you both.

Can I welcome Dr Sally Holland, Children's Commissioner for Wales, and Nia Evans, policy adviser on health and mental health, for our second evidence session on this inquiry? We're delighted that you've been able to come. If you're happy, we'll go straight into questions. The first questions are from Mark.

Thanks, Chair. The chair of the Together for Children and Young People programme told us that good progress was being made in delivering a whole-systems approach to emotional health and well-being rather than just a focus on child and adolescent mental health services. Do you agree with that sort of upbeat assessment?

I would say that that aspect of the programme is an area where there's still a lot of work to be done. I think that the programme has first of all concentrated on some of the most urgent NHS delivery issues, and I understand why they've done that for a number of reasons. You as a committee and I and many others pressed them hard on waiting lists et cetera. There has been some welcome progress, as you know, in some of those areas, although I think we'd all still like to see that uniformly throughout Wales and even more progress. But I have to say that, in terms of—I just caught a tiny bit of the evidence earlier when you were talking about the windscreen, weren't you, and the left-hand side of the windscreen?

I think really, across all the agencies who are responsible for this, we haven't really properly touched the surface of reforming prevention and early intervention aspects of children's emotional and mental health. I think there's an awful long way to go. I think there's an urgent need for the NHS to do its bit, and it's got a very important role to play in the early intervention and prevention aspect of things, but for us to not just see it as an NHS issue, and for all of our services to join up together, to really plan a really strong service that would help prevent mental ill health and help children when they start to display problems, or experience problems, with mental health—what that would look like that would be really excellent.

We've got a number of good potential new structures in place: some of them since you did your last inquiry, as a committee; some of them are already in place. We could do this a lot better if we can get those new systems and structures and legislation to work well. As you all know, we've got the public service boards, we've got regional partnerships, bringing together health and social services planning—I think that really misses out education for children and young people. We've had already, since 2012, the mental health partnership boards as well, locally.

One of the problems could be, in fact, that we have now quite a plethora of structures to plan and deliver what should be, I hope, joined-up holistic services for children and young people, but we have an issue, I think, of still working out exactly how best to use those new structures, making sure that they have a focus on children for enough of their business, because they're all-age mechanisms. I think that children's issues tend to drop off the end of agendas with them. And also to attack some of the governance issues there—so which of those structures report into the others and what is best tackled at a very local level, what’s best tackled at regional level, what’s best tackled at a national level.

That’s the big picture stuff, but I think it’s really important, in those contexts, that, as I say—we need to see children’s emotional and mental health as being supported and provided for by our education system, our social care system, our voluntary services or youth services and, of course, the NHS. I think, at the moment, we’re missing some opportunities to move that forward. As you know, I’ve got real concerns about the join-up between education reforms and the mental health reforms. You may give me an opportunity to talk about that in a minute.

If I could follow up on that, because I though that was a long and comprehensive and very illuminating reply. Thank you. I’ve learned, from what you said, of a particular concern about how education is sort of knitting into these structures, and whether the partnership working includes schools and education sufficiently. I know that you’ve also expressed concerns about the development of the new curriculum and how to link that into what we want to achieve on the emotional and mental well-being. Are you aware of the work that’s being done with the Together for Children and Young People programme and the Donaldson pioneer schools? Is that something that you’d want to see developed more broadly? And how are you going to use your role to help drive partnership working in this area, incorporating the new curriculum and schools properly?

I sit as an independent member on the independent advisory groups for both the Donaldson reforms and the Together for Children and Young People reforms, which has enabled me, really, to see the scope of ambition and good ambitions, I think, in both programmes, but it’s also given me the opportunity to see where I think we’re certainly having some missed opportunities to make those programmes work together to drive really holistic change for children, particularly in the early intervention and prevention aspects of children’s well-being and emotional and mental health. I have been doing my utmost to use my role to press that point. So, I raised it with the independent advisory group chaired by Professor Sue Bailey for the Together for Children and Young People programme a year ago. On her invitation, I wrote a paper to present the case for how those two programmes should be planning and delivering this aspect of their work together.

I presented that also to the Donaldson independent advisory group. I wrote to both the Secretary of States for education and health about it in March. I've continued to press the case for it with the Cabinet Secretary for Communities and Children and with the First Minister—indeed, in my last meeting with him. The response I've had on all of that from all of these individual Government Ministers, and from the two independent advisory groups, is that they agree that this is something that they should be doing. 

We had the response about the inreach programme—that was the response from the Cabinet Secretary for health to my letter in March. I had a response at the beginning of May saying that this programme was in development and would be announced before long. It was announced in September, and I was pleased to see it. I think it is a positive step forward and I really look forward to seeing it being available more broadly around Wales, but I do think that that is just still addressing one aspect of what needs to be done. It is a very welcome development in providing some mental health expertise to support teachers and children in schools, and to help develop the right structures within schools.

However, we have a whole strand of the education reforms—they're called areas of learning and experience, as you know—for the health and well-being of children, which has, as one of its fundamental aims, to not just teach children about health and well-being, but actually to provide a school environment where that is nurtured and developed for children. We also have a whole strand of the Together for Children and Young People programme, which has as its key aims to develop local structures within schools and community services where children's well-being is nurtured and developed.

I find it quite baffling, really, why those two groups aren't sitting together and planning together, bringing in the best of that health expertise and the best of that education expertise, working much better with children and young people as well, to hear from them what works for them, to really—. I think we've got the opportunity with those two very well-meaning and ambitious programmes in Wales to do something really quite special in Wales, actually. I really do think we've got the potential to do that, and this is what I've been saying for the last year, with both of these programmes. I really think we could do this; we could draw on what we know works best in schools—a whole-school approach—and draw on the expertise and the bits of finance there are in those two programmes and design a fantastic support structure for children in Wales. But I'm quite frustrated, I have to say, at how those programmes still seem, to me, to continue to work individually. I haven't even listed all the people I've written to and met about this.

Can I just ask very quickly, commissioner—? You've said that, and it's on the record, and we'll consider that for our report, I'm sure, but are Ministers engaging with you when you push that issue to them?

I've now been offered a joint meeting with the Cabinet Secretaries for health and education in January, where I hope we'll be able to make some progress on these issues, because I do think it needs some real direction, now, for the people who are running these programmes to—. I think, quite understandably, they're thinking, 'We've got these targets. We need to push our programme on' and it can be quite hard, I think, when you feel under pressure to take what is actually quite a difficult step, sometimes, to step up and think, 'How could we do this differently?', which is what the future generations Act is about, of course.

Just before I bring in Darren, would you mind sharing that correspondence between yourself and the Cabinet Secretaries with the committee? I think it would be very useful.

Absolutely. I think with some of them, we have done so, as we've gone along—we've copied you into some of them. But we can resend them to make sure you've got them all in one bundle.

Thank you. Darren, you had a supplementary on this.

Yes. I just wanted to ask, commissioner, about the role of school nurses in potentially supporting mental health resilience in schools. I mean, obviously, each school has a nominated school nurse, and there are school counselling services as well, of course, but as I understand it, at present, school nurses don't have a specific role around mental health resilience. Is that something you'd like to see develop?

Certainly, and I have seen some individual examples of school nurses who see that as their role and promote it very well in schools. I think I've said to this committee before that what I've heard from school nurses themselves is that sometimes their expertise and training is probably underutilised when they're mainly being used for things like vaccinations and other aspects that they do routinely. They, of course, tend to be spread very thinly, and that can be an issue, but I think they can be an enormous resource.

What I'd really like to see us thinking is what are the different roles people could take in a school. We won't have identikit schools all around Wales, because it will be different for different types of communities, but there are certainly different roles that can be taken within a school to provide that whole-school approach—whether that's health staff, school counsellors. Youth services are increasingly working within schools, as well. We have some very good family liaison workers in some schools. I think school nurses, certainly, could have a good role there. There is a new school nursing framework. Nia, do you want to add in anything about—is there anything particularly there about mental health? 

Only that the framework was out this year, as you know, and I think, as Sally has already said, really, it's about utilising the roles within the school to look collectively at what their contribution to identifying signs and symptoms is, and then understanding the pathways that are available to them then for more specialist mental health support.

Can I just ask another question? One of the things that you're aware of is, obviously, some of the research that's been going on in building mental health resilience in the university sector, but in education. So, for example, in Colwyn Bay, in Ysgol Pen y Bryn, which you visited with me, you saw some of the work that's gone on there with mindfulness in particular. Do you think our universities have a role in trying to develop resilience in our Welsh schools?

Absolutely. With developing any of these services, we should be building on the best evidence that we have, and, of course, whilst international evidence is often relevant and important, research that has been done specifically in the Welsh context is usually invaluable. There is, as you know, a trial going on of mindfulness by Bangor University at the moment, which is important.

Just related to that is the fact that universities, I think, have begun to develop some good structures for supporting students, who are, obviously, just at the next stage after schools in terms of their mental health. It's a big issue for universities to support students, and there are some good models within the universities of things like group support, as well as individual support et cetera. I visited St David's sixth form college in Cardiff about a year ago, and they had actually brought in, in their head of well-being, someone who had come from the university sector, and she'd brought in a lot of—. It was for sixth formers, who are obviously not very far from university, but there are a lot of really useful, I think, approaches from the universities. So, I think there's some learning as well from there.

Julie. 

Thank you, Chair. I wanted to ask you about advocacy, which is obviously something that we have discussed a lot. We understand that not all the health boards are currently commissioning advocacy for children and young people and their families. Obviously, we know that advocacy is provided by other bodies as well, and local authorities. But what are your views about the availability of advocacy for children and young people in this position?

As you probably know, I have raised that as an issue over the last year with the Cabinet Secretary for health, because it's come to my attention that we have an inconsistent provision of advocacy right across the health service for children. The community health councils are only required to provide for those aged 18-plus, and the provision for those under 18 is patchy and inconsistent, in my view. It is commissioned by some health boards from external providers, but that's not consistently done. Children, obviously, have a statutory entitlement to advocacy if they're receiving in-patient mental health treatment. That's correct, isn't it?

Yes, under the Measure.

Under the Measure. However, obviously, the vast majority of children who receive mental health services wouldn't fall into that statutory requirement. As with advocacy in other services, which this committee is very well versed on, there will be a number of scenarios where children will need to be able to express their independent view, independent of advocacy services, for example, available to their parents and carers. It is something that I feel is essential to be available for children as and when they need it. As you know, again, we have a new national approach to advocacy provision in children’s social care services. I think it will be relatively straightforward for commissioning to go on that would extend that provision to health as well. I have had a fairly constructive response, I would say, from Government on this. They’ve met with some of my team to discuss the need and my understanding is that they are looking at it seriously, and recognise the gap. Do you think that’s fair to say, Nia? Because you represented me in that meeting.

Yes, absolutely. I think as a result of Sally’s meeting with the Cabinet Secretary for children we subsequently met with Welsh Government officials who had at that point actually requested information from local health boards as to their provision, so that information should be available. I think that was as a result of Sally’s intervention. So, we’ve been invited to what they hold as listening and learning meetings. So, that’s coming up in December, and also, this issue formed part of our response to the recent health White Paper as well, which we can forward a copy of, if that would be helpful. But it’s certainly moved. The agenda’s certainly more on the Welsh Government’s radar since Sally has spoken up.

I also raised it in the parliamentary review of health and social care. I think it’s a fairly straightforward thing that we could get right in Wales, but it is a current gap, and it’s completely inconsistent around Wales, which is obviously unacceptable.

When you say it’s patchy, would you be able to say that more than half the children who should be having an advocate haven’t got one, or are you not able to make comments like that?

I think we absolutely don’t know, because it’s not being offered to children at the moment in most areas. We don’t really know how much unmet need there is for these services, but my understanding is that in one or two of the areas, when they’ve commissioned advocacy for other services, they've also said, ‘We also will commission you to do health provision as well’. But there’s no publicity about it that I’m aware of. If you look on health board websites, for example, the latest Government leaflet about advocacy directed children to the Meic helpline, which of course has an important role in Wales, but it’s not a direct face-to-face advocacy service. So, we’ve pointed all this out to Government and asked them to sort it out.

And you think that there may be a way forward.

I hope that next time we discuss it at this committee I’ll be able to report progress. But I think it’s a really important issue for us to keep raising until it happens, because we find that, obviously, different things get different priority according to how often we raise them.

Thank you.

We’ve got a lot of questions to get through, so can I appeal for brief questions, and as concise as we can be in terms of answers? Darren.

I just wanted to ask, if I can, about the investment that’s going into CAMHS services in terms of the budgets. Obviously, there’s been additional cash that has been awarded to local health boards in order to improve access to all aspects of the windscreen model of services. To what extent are you satisfied that that’s sufficient resource going in and that it’s being put into the right places? Obviously, there’s significant variation in levels of spending from one health board to the next, and we have this ring fence for mental health more widely, but there’s no ring fence within the ring fence for CAMHS services. So, do you think that they’ve got the balance right, or is there more work to do on investment in services—and if so, where?

I think it’s always a difficult issue for me to get a clear view on—let alone for children to get a clear view on seeing any accountability about where public spending goes in terms of children’s services. I really welcome, by the way, this committee’s current scrutiny of the budget in terms of children’s services. I think that’s a really important step forward.

When we look at the amount of expenditure allocated to children’s mental health services, they do seem to me, as part of an overall budget, very low when you consider what an enormous issue children's emotional and mental health presents to everyone who's concerned about it—to families, to schools, to health services. We know this is an enormous and growing issue, and yet I think it's 0.7 per cent of the overall NHS budget that's on children's mental health, and only 7 per cent of the mental health spend. 

Now, I do understand that children have less in-patient care than adults—obviously, in-patient care is an enormous expense—but it still seems to me, when we think that children are nearly 20 per cent of the population, that 7 per cent does feel to me to be on the low end. Whilst we've seen that additional and welcome funding of £7.5 million—and it is recurrent; I've had reassurance because I've asked if it is recurrent funding—it's certainly made some changes to the clinical end of NHS care. It's quite clear to me that that's not going to do the job that's needed for some of the preventative and primary mental health services. I would really welcome more of the spend to go on children's mental health than is currently going on it. 

So, do you have a percentage in mind? Are there percentages in comparable NHS systems around the UK that you think are more appropriate? How does Wales compare to England, Scotland and Northern Ireland, for example? 

I know that the English commissioner was talking about this in committee yesterday but I didn't catch the actual percentage, but I know she was complaining that, in England, it's far too low compared to the percentage of children in England as well. So, I think this is a UK problem. In fact, I know she's raised it a number of times recently with the NHS in England, that it's chronically underfunded there too. So, I would—

Is that a phrase you'd associate with the situation in Wales—chronic underfunding? 

I would say that 7 per cent of the mental health spend to me feels like underfunding of children's services. You know, we know that a lot of mental health conditions start to become apparent in adolescence. Some will continue into people's adulthood, but some will be helped to recover in adolescence, and surely it makes sense to invest at that stage in people's lives to help them either learn to live with a mental health condition, or to recover from it and, obviously, prevention of conditions developing is a key role in childhood. So, yes, I would say 7 per cent is underfunding. 

But you don't have a percentage in mind—10 per cent, 20 per cent, or—

I would want to see it nearer to the percentage of population of children, which is, I think, 18 per cent, while accepting the fact that there is more need for in-patient care for adults which does take up—

Which may be more costly, so that has a reducing factor. Okay. 

I just want to ask a few questions about referrals to specialist CAMHS, and your paper raises concerns about acceptance rates for specialist CAMHS. So, do you think that the eligibility criteria for CAMHS is presenting a barrier to those who are needing assessments? 

Yes. On the whole, yes. The mental health audit suggests that a lot of referrals are accepted at least for first assessment. There are two aspects to this. One is to consider whether people are actually put off referring because they feel there'd be no hope of receiving a service, and the second issue is what happens once people have had their first assessment, and we don't know and we don't have enough information about whether children receive services after that point, and whether they feel better as a result of having those services. 

There's certainly an issue around the type of problems, I suppose—the mental health problems—that specialist CAMHS feel able to tackle, feel that they have specialisms to tackle. There are issues around dual diagnoses—so, young people perhaps with autism or Asperger's and mental health conditions, and how they are helped and by whom. I'm very aware from my engagement with looked-after children and children who were formerly looked after and who are now adopted that there can be a real issue for young people who face enormous problems with their everyday behaviours and emotions and functioning across a wide range of aspects of their lives, but they don't quite hit the threshold for specialist CAMHS on any individual behaviour. They're nearly there on all of them, but, as a whole, as a young person, they really struggle, and their families really struggle to care for them as well. So, I think the key issue for me is how we respond to children and individuals in a holistic way, both medical needs and their social and emotional needs, rather than expecting them to fit into systems. And, of course, that's an issue right across a lot of our public services. 

You've gone to where I was hoping we'd go really, because I was going to ask you about the lack of alternatives to referrals to CAMHS for those needing emotional health support or early intervention. So, what kind of service provision would you like to see developed or expanded for those who don't meet that threshold?

I would like to see a more holistic service, where we're not funnelling children either into, 'You need to see a psychiatrist'. I would like to see us having more multidisciplinary teams, both at community level and at a specialist level, who can help meet children's wide range of needs in one place. That would be really good to see. And, as I said at the beginning, I think, whilst there have been some real improvements in access to specialist CAMHS, there clearly is a still long way to go in the level just below that. 

So, there's not enough happening there then, because I think Carol Shillabeer told us, or suggested earlier, that maybe over a quarter of referrals aren't accepted. So, that's a huge group of children and young people not getting the support that they need. 

Absolutely. And I don't think people make referrals lightly. They make referrals because a child needs some help. And they may not need to see a psychiatrist, for example. They may not need specialist medical intervention, but they probably need something, and we need to be able, as a whole system, to offer them some support. And you will all have this in your constituencies, but I have this as well, obviously, coming to my office quite often: people being told, 'No, you can't be helped by CAMHS' but not being offered any sort of reasonable alternative. And I just feel that's a really unhelpful way for our public services to respond to children and families in distress. 

Okay. Thank you.