National Assembly for Wales

Good morning, everyone. Can I welcome you all to the Children, Young People and Education Committee? We've received apologies from Hefin David and there's no substitute. Julie Morgan will be arriving a little bit late. Can I ask Members—? Oh, and also apologies from Darren Millar as well. Can I ask whether there are any declarations of interest, please? No. Okay, thank you.

Item 2, then, is our sixth evidence session on our inquiry into the emotional and mental health of children and young people, and we are taking evidence this morning from the Royal College of Psychiatrists. I'd like to welcome Professor Alka Ahuja, Dr Warren Lloyd, Dr Peter Gore Rees and Dr Amani Hassan—all from the royal college. Thank you all very much for attending, and thank you for the paper that you provided in advance. If you're happy, we'll go straight into questions.

If I can just start by asking you: do you think that Together for Children and Young People has got the right balance of emphasis across the four tiers of child and adolescent mental health services, in particular between prevention and early intervention in specialist CAMHS?

Firstly, I would like to say, as a college, we welcome the Together for Children and Young People programme, because unlike the previous programmes and reviews we've had—it was quite critical and undermining for the CAMHS workforce. In the past, most of them were about what was not going right, whereas this was a programme that was very much focusing on improving services and was tied in with funding. It was looking at a windscreen model, so, obviously, it was quite an ambitious programme, but we had all the agencies on board.

We've done a lot of work at the high end, which was looking at the crisis and the emergency care. As regards the prevention work stream, which is looking at the early intervention and resilience, progress has been made, but we've got a long way to go. There's a lot of good work that has been done along with young people as well, and linking in with education, the school mental health programme, and the pilot that was launched by the Welsh Government—we are very pleased that that's been addressed. There's work that's been done by Dave Williams and Jenny Williams, and that, itself, reflects that the leadership of the early intervention team has been very much in support with social services and education colleagues. So, we're aware that the focus, at the moment, has been at the top end, but the lower end is something that has been taken on board. So, it's probably going to be a couple of years before we see the results and outcomes.

Okay, thank you. Anybody else? Or is everybody happy with that? Okay, thank you. John.

I wonder if we could move on to referrals to CAMHS and your statement in your paper that the number of referrals hasn't reduced and that restrictions and thresholds are necessary to ensure that specialist services are available to those most in need of them. Are you concerned that too many unnecessary patient referrals continue to be made to specialist CAMHS?

I think it's important to note that there's some variability still as primary mental health services are developing across the health boards. There is still some variability. Overall, I think if we can move to well-developed primary mental health services fully integrated with the specialist mental health services, that demand issue should not be such a problem. If there can be sensible discussions at single points of access, appropriate decisions can be made so that no-one is left falling between services and good decisions happen at a really early stage.

But we're not in that happy position yet, unfortunately.

That's why I talk about variability. I think it will take time and we are moving towards that position steadily. As I say, some health boards are further along that road than others because there have been different emphases on the pace of development. We've moved faster on crisis and emergency services in some health boards because that's been necessary. We've moved faster on primary mental health services in other health boards. But I think there's a real consensus amongst college members that if we can have an integrated approach to primary mental health services and specialist CAMHS, the issue you're describing will be manageable.

Would you accept, then, that, in some areas, at least, of Wales, where primary care services aren't sufficiently developed at the moment, it is necessary to refer cases to specialist CAMHS that wouldn't be referred if the primary services were sufficiently developed?

Yes, I would. We agree.

I think that's inevitable.

Yes, because we've heard a lot of evidence that there should be a lower threshold rather than a higher threshold, in the evidence that we've taken up to this point. So, do you recognise the need for that approach, perhaps, at least in some areas of Wales?

I think it might be a necessity right now, and that's absolutely right, because you have to preserve the very specialist services for the people who need them the most. But the key is to integrate services so that good decision making happens at a very early stage, with a really broad knowledge of the range of services that are available. I do think that's going to take time, and it needs our overall workforce developing, and I think the investment has been extraordinarily successful in moving us along this route, but we've got a way to go yet. I do agree that it will take one to two years to fully develop the range of services and to get the very best out of the investment.

Okay, thanks for that. We've also heard, in taking evidence, that those making referrals often find it difficult to access CAMHS and that little attempt is made to measure which referrals are rejected and what happens to those children and young people once they are rejected. We've also been told that it's even harder to get an accurate idea of the number of potential referrals where the referrer has decided not to make a referral. Is that a picture that you recognise across Wales?

I think I recognise the picture, but, from a college perspective, there's such variability. But, absolutely, I recognise the picture. We can't possibly collect data on referrals that aren't being made. Again, I think the key to improving that situation is the development of integrated primary and specialist mental health services.

In the past, it used to be easier, when we came across, for example, a referral that was not really suitable for specialist CAMHS, to signpost that to the primary mental health team. But there are certain areas or certain health boards where primary mental health teams are not working as they used to work before. So, these other types of referral maybe were rejected, but when there is no clear signposting at all, the referral is just faced with the rejection of the referral with no idea where to go because the health board is unable even to signpost because there are certain areas where the primary mental health team is not there, actually.

So, again, it's that variability from one health board area to another that you think is a very significant problem.

If I might add to that, in addition to what she's already raised, I think, in terms of the infrastructure—and what I'm talking about is the IT infrastructure—to enable us as clinicians to collect that information, that's key. And that's not always in place to enable us to collect that data and to contribute to the NHS benchmarking. So, for us, again, it's key in terms of the investment in infrastructure to enable us to have that data that's reliable data and that we can use in terms of our operational and strategic decision making moving forward.

I see. 

I'd just like to add that the other thing is that, historically, we've always undermined the role of consultation, and that itself can be an intervention for many of these cases where they may not need face-to-face contact. But it would be helpful to highlight the role that primary care and specialist CAMHS can do as regards consultation.

Consultation here also is not just for primary care; consultation with the psychology department, education and consultation with social services can sort a lot of problems, but this is an area where we also need to work.

Okay. I was going to ask: where there is a low level of need that wouldn't be a diagnosable mental health problem for children and young people, what sort of services and interventions do you think would be appropriate for young people in that situation?

There's a really significant range of interventions already in place. Again, there is variability across health boards, but you start with simple, good-quality advice and information that's readily available, bilingually across the board for a range of common conditions and problems.

Secondly, we can develop in schools targeted groups for improving mental health—groups that are specifically designed to prevent anxiety or the development of anxiety and increase resilience. They can be targeted or they can be more general. There can be consultation provided from specialist services to enable other teams, such as pastoral support teams in schools or school nurses or Families First projects to carry out their own brief interventions. Self-help—there's an increasing interest in developing accessible self-help. There are various independent companies that are already providing those services. So, there is a range of things that can be effectively developed, and I think the focus over the next few years on developing primary mental health services with this aspect is right.

But you said that information and advice is readily available everywhere. Is that really the case, and can you give us an example of what kind of services are actually delivering that, because—?

One example would be—it's being called bibliotherapy, but there's also what's called the Better with Books scheme, which has been scrutinised across Wales with a series of books available in public libraries that can be prescribed by a range of people to inform families. That's just one example.

The college again has done a lot of work with the MindEd programme, which is the online programme for professionals. Recently, there was a pilot programme launched for families and young people, and this is freely available online and has been put together by professionals, not just from the college but even the Royal College of Paediatrics and Child Health, GPs and education. So, that's very well received.

I do think there's more work to be done in making everybody much more aware and putting those things much more into everyday practice, but they are there and they're there to be built on.

Can I just ask if you recognise the picture, then, that perhaps one of the reasons why specialist CAMHS is so clogged up is because those earlier interventions aren't readily available? Llyr.

Just picking up on the variability, to what extent is that, or should that be, reflected in the way in which Welsh Government funds some of the services? Should they be targeting areas where services aren't sufficient, or should they be spreading investment more equitably across all of Wales?

I don't know, from a college perspective.

Neither do we, that's why we're asking. So, don't worry.

I don't know what's the best way to resolve the variability, but I think having very clear expectations is as effective as spreading the resources, because when more resources flow, it doesn't necessarily mean they're directed to exactly the right area. I think if there are very clear expectations of the models—the primary mental healthcare pathway, for example—if there are really clear expectations that we deliver on that within health boards, we'd be more likely to do that and there's more likely to be a reduction in variability.

I think it's a hard ask, informed by all the stakeholders, in terms of the services and that service provision. I guess, in terms of Wales and our population in Wales, it's how we meet both urban and rural communities, because, in some areas in Wales, you can be half an hour between appointments, in terms of meeting needs in local communities, and, in other parts, it could be a two-hour journey. So, there will be variability in terms of accessibility and how we respond, just in terms of the transport links and accessibility in terms of roads. So, that's something we all have to consider when delivering our services within the resource envelopes.

Okay. I was going to ask you about how effective you thought local primary mental health support services were in terms of picking up mild to moderate mental health issues, but I think we've covered a lot of that, and I suppose the variability aspect of it would make characterising a national picture very difficult. But you say in your paper that GPs rely on—well, clearly, they rely on local primary care mental health services and other health professionals to assess and treat common mental health disorders. So, what more can we do, then, to give GPs the confidence and the information to be able to treat or refer properly? You mentioned prescribing books. Is that sort of widely known amongst GPs? Is that something that they would ordinarily do?

This, again, used to be the role of the primary mental health team because they used to do this psychoeducation bit.

I couldn't speak for the GPs. It's hard to know how well they, as a professional group, know, but I do think there is more that could be done. So, just as an example, I know one of the clusters in our health boards has commissioned a post from CAMHS to work solely in GP practices with a training role, specifically to train GPs and to work alongside GPs with the aim of developing their skills and doing some very strightforward assessments in primary care. There are multiple gains from that.

Again, from the college point of view, we did a survey recently that involved 140 GPs, and we've now set up a primary mental health working group along with GPs, and they identified that they needed support, especially in terms of common presentations like anxiety, depression, self-harm. We've linked this work with the central college as well and, also, we've been involved in a focus group that we did with CAMHS professionals and GPs, looking at bridging the gap. So, there are lots of recurring themes that are being addressed. There is GP training that the college has been actively involved with, especially this year, and we've tried to spread ourselves across Wales, even using online resources. So, I think we're working quite closely with GPs. It's something that has a variable picture when you look at different health boards.

It varies from one health board to the other, but certain GP training in certain health boards will invite, say, a consultant from CAMHS, or professionals from CAMHS, in their training programme. I'm not quite sure about the other health boards.

We mention integration as well, so, what do we need to do to better integrate, then? You say the process is ongoing effectively and it'll take a few years maybe to get to where we want to be, but are you confident that enough is being done to gee us along on that journey?

I think there is enough being done to gee us along. If I were making a play for anything, it would be patience and sticking with what we're trying to achieve. The greatest risks are if we expect too much too soon. I think we have to stick with what we're doing. There are some very substantial workforce challenges. The resources have been invested really wisely, but now, to develop a workforce, we're in competition with England, sometimes, for recruitment, we're having to be more flexible than we've ever been in the type of staff we appoint. So, I think, allowing ourselves the time to train and develop those staff is key. I think we are going in the right direction.

Absolutely.

Thank you. Mark.

How would you describe the current availability and capacity for psychological therapies for children and young people across Wales?

Firstly, the college welcomes the investment to improve access to psychological interventions, both in terms of group and individual work. The college understands that all health boards have established a psychological therapies management committee, and, within that committee, there is currently a requirement to do a demand capacity analysis in terms of the provision and to produce an action plan in terms of this financial year, and over the next two financial years, in terms of how that provision is going to be delivered.

In addition to that, nationally, the specialist CAMHS clinical leads and nominated health board representatives have met on a number of occasions and the consensus view is that there needs to be a clear link to Matrics Cymru, which is an adult matrix in terms of psychological provision. However, further work is needed within specialist CAMHS to inform the matrix, and we understand that the all-Wales CAMHS psychological therapies interest group will take that work further forward over the next six to 12 months to inform the Matrics Cymru, which will then apply to all health psychological therapies and commissioned services from health boards.

Thank you. Is there anyone else who'd like to comment on the current level of availability and capacity?

I think, as with the responses to previous questions, there will be variability in terms of the provision and in terms of some of the legacy position that's been described, and also in terms of workforce recruitment and in terms of skill sets.

Matrics Cymru referred to low-intensity and high-intensity work, and it's about how we develop the workforce to deliver that low-intensity and high-intensity work, and that's ongoing. Again, as Peter said, it's allowing health boards to embed those processes and skill up the workforce, and having patience with that process, because it's not a process that we can implement overnight because of the nature of training staff and the skill sets required.

How important is the work of the all-Wales CAMHS psychological therapies special interest group?

Our understanding is that they're going to have a leading role in taking forward the work of the specialist CAMHS provision in terms of psychological therapies and how they will link into the Matrics Cymru, which is currently the adult matrix.

So, it's that interest group rather than the local health boards who will be the lead on this.

And the local health boards will have representation on that interest group. So, it's making sure there's an all-Wales approach to it, and that's why it's so important that all the key stakeholders are represented and contribute to the discussions to form a consensus view, and significant progress has been made. It's about how we take that work further forward and how that's fed into the Matrics Cymru.

Peter?

I think you're right to pick up the role of the health boards as well. We're clearly trying to achieve something through the college, and the psychological interest group keeps things consistent, but the drive to improve the availability of psychological therapies as quickly as we can has to come through the health boards. That's where we're grappling with our workforce issues and the range of skills that are available.

And the workforce issues are—[Inaudbile.] Who is delivering these psychological therapies—the therapeutic interventions? Are they at the appropriate level of experience and qualification and competence to be doing that?

The actual people delivering them will vary by profession. They will range from clinical psychologists, occupational therapists, social workers who've previously been social workers who now work within CAMHS teams, and clinicians who don't have a core profession but who've undergone higher training in things like cognitive behavioural therapy or family and systemic therapy. So, there's a vast range.

But not psychiatrists.

Psychiatrists will be involved in delivering psychological therapies, but to a lesser extent, personally, than the broader range of professions.

And that, again, may vary from health board to health board, because there will be some health boards where there is a psychiatrist that has done additional training in terms of delivering some very intensive psychotherapeutic intervention. But it's having the menu available in terms of accessibility and delivering the low and high intensity, and that's what we're working towards on a health board and national footprint.

Within each of the different psychological therapies, there are different levels of training that people can achieve and different levels of skill, and I think we're all working within health boards on that all of the time.

I would like to draw to your attention that the Mental Health (Wales) Measure 2010, although it's helped us make huge gains, also imposes some restrictions on us in terms of eligibility to take on certain tasks, and I think if the regulations were reviewed and they were more enabling, we could have a little bit more flexibility with our workforce. So, for example, very sophisticated CBT therapists would be very capable care and treatment co-ordinators, but they wouldn't technically be eligible under the Measure at the moment because they may not have a core profession. Certainly, I'm hearing from colleagues that the rather long time it's taking to review the regulations is restricting our flexibility, and I think flexibility in developing our workforce is one of the things that really helps at the moment.

One of the things I would just like to add, as a training programme director for CAMHS trainees who develop to become consultants, is that, surely, one of the main competencies in their curriculum is to train in some form of psychological therapy, so all the trainee graduates have to show competencies with regard to various psychological therapies. We cannot sign them to become consultants unless we make sure that they've achieved these competencies, but, again, we are—when you become a CAMHS specialist in a service, for example as a consultant, you are very restricted with your time by the million other tasks that you have to do. So, sometimes, doing psychological therapy, knowing that it's time-consuming and that you would like to do other things—

But they have the capability—

They have the capability. They cannot be signed up without that.

I suppose we do use it in our clinical practice without knowing, because we all use a very systemic model when we meet with families, we use a lot of behavioural interventions when we're talking to families. So, knowingly or unknowingly, that is very much embedded in our day-to-day work.

Are psychiatrists at the top of co-ordinating and structuring this work? For instance, the design of psychological therapy and what the various interventions should be, is that something psychiatrists, in their research, take responsibility for designing, or is this done separately through psychologists, perhaps, without that full medical qualification?

I would say they have a key contribution to make, both in terms of the research and the knowledge and their training, and also in their leadership role, but it's got to be done in partnership with other, very well established professions.

Again, it varies from one health board to the other.

Can I just move on? I've got a question on waiting lists. The impact of the Together for Children and Young People programme—we were hearing from them that the shift to a 28-day target had broadly been a success and was being implemented across every health board. When we had the children's commissioner in, I think I'd probably fairly describe her evidence as, perhaps, questioning that, or somewhat sceptical as to whether that was wholly the case in all local health boards. Can I ask for your perspective as to the extent to which that 28-day target is generally being met?

Yes, and, again, the college welcomes the review of targets and when they were implemented in April 2016, not just in terms of the 28 days, but also in terms of urgent. Prior to April 2016, urgent cases were seen within four weeks, and routine cases within 16 weeks. That's been a significant step change in the changes in terms of 48 hours and 28 days. All health boards have worked and put plans in place to adhere to those targets. However, as we've said before, there have been significant recruitment challenges, and that's not unique within the NHS of Wales, and specifically within specialist CAMHS. So, the new funding was very much welcome. However, if there's a new resource available, unavoidably we all fish in the same pond in terms of recruiting staff, because, as new services are developing, you need staff and you need skilled staff. If you have a limited pool of staff, even in terms of recruiting external to Wales, that takes time in terms of establishing those services. In addition to recruitment challenges, there's also been a continuous increase in the demand upon specialist CAMHS and the referral rates. However, health boards are working, and have plans in place, to comply with the 48 hours and 28 days. There's been recent NHS benchmarking data and there's clear evidence that there's a significant improvement. We understand as a college, for those health boards that are not currently meeting the 28 days, they have clear plans in place to meet the 28 days in terms of the routine referrals, but also in terms of the 48 hours.

And in terms of the waiting times targets, are you satisfied that they're effective in giving us the information we want? Because they just measure access to the initial assessment. There's no measurement of what happens in terms of young people getting access to the therapeutic intervention, or the quality of the intervention. Are you satisfied these targets are telling us what we need to know?

It's a good starting point in terms of accessibility, providing urgent and emergency care, and in terms of routine referrals. Coming back to the point we raised earlier in terms of infrastructure, in terms of capturing that information, that's key in how we strengthen that infrastructure to enable us to capture that information. Also, in terms of access to psychological therapies, in terms of having a framework to capture that, to make sure that it's reasonable in terms of meeting expectations of what can be delivered, and in terms of the service model and capturing some of the data post referral, NHS Wales has adopted the CAPA model, which is a service model for specialist CAMHS and refers to the choice and partnership approach. Within that model, one of the strengths of the model is capturing capacity and demand in terms of referrals to partnership to specific work. So, we'll be more able to capture that demand now on services post initial referral and access to further services.

Okay. Thank you. Michelle.

Thank you, Chair. Good morning. The chair of the Together for Children and Young People programme has told us that each health board has put in a new crisis intervention team, or enhanced the ones they already have. What's your view of the impact this has had on improving access to services for children and young people in crisis with serious mental health issues?

The college welcomes the investment in improving the crisis response, and I think what we've seen is improved and timely 24/7 access at the point of crisis. That's very important, especially in terms of the 48-hours time period. It also allows us, when clinically appropriate, to deliver brief, intensive interventions and/or support for the child or the young person and their immediate social network. In addition to that, if a child or young person requires admission to a designated CAMHS bed within the local health board footprint and/or one of our tier 4 provisions, our crisis teams can manage that transition in a much more co-ordinated way, therefore, in terms of managing the admission but also being proactive in managing the discharge. So there's a robust discharge plan and a wraparound service for the young person when they get discharged from either the designated bed or the tier 4 provision. That should lead to shorter admissions and more targeted interventions whilst admitted.

In addition to those benefits, there's also the benefit in terms of actually improving some of our touchpoint interfaces with stakeholders, our relationship with emergency departments, and our relationships with other referrers that use our services. That improves some of the training and education opportunities. And also a very key point in terms of being there and intervening at the point of crisis is challenging some of the stigma and discrimination that's associated with mental health and somebody who's in a mental health crisis. So, there are significant improvements made in terms of crisis response.

However, workforce is an issue in terms of recruiting and sustaining those services, and some of those services are very small services and they cover a huge area. If you have one vacant post or you have somebody having a long period of absence, that has an impact in terms of our responsiveness. So, it is how we use that resource in the most efficient way for those critical cases that need that urgent response. But overall the college is welcoming that investment and attempts by all the health boards to provide that response.

Can I add something about the crisis teams that have been developed? Yes, they have impacted positively on services delivered, but at the same time we are facing a crisis with regard to recruiting higher trainees so that they help, I would say, the whole management of the crisis process, because we're not talking about a nine to five service; we are talking about a nine to nine-the-next-day service. For example, the training programme schemes that we run for CAMHS, we've been short by three trainees, and we failed to recruit, but this is a national problem; not only Wales is affected by it. So, as we rectify one area we're struggling in another area as well.

If I may add to that, there will also be a national review that will be launched in January/February of next year in terms of the crisis provision across Wales. Again, it'll be to look at good practice in terms of looking at how that's delivered on a 24-hour footprint across Wales and the consistency in practice, but also appreciating that there will be some variability in terms of how those services are delivered. 

Is that a Welsh Government review? 

Yes. 

Thank you. 

Do you have any evidence that the developments in crisis care have led to a reduction in use of overnight stays in paediatric beds and attendance at emergency departments?

I don't think we do have any evidence that it's reducing attendance, and I think there's some evidence, for whatever reason, that attendances on paediatric wards are going up rather than down. Whether that reflects a wider cultural demand, we just don't know for sure, but I don't think there's any evidence that we've reduced the demand on paediatric wards.

Okay, and the impacting about—. There are fewer children and young people being detained in police cells. Are you confident that the children aren't being shunted elsewhere? 

It's one of the never events in terms of a young person being picked up on a section 136 and conveyed to police custody. All health boards have provision for a place of safety for that young person to be assessed in terms of their presentation and then in terms of the most appropriate intervention, and everyone is signed up to that, but at times things do happen and, as I say, we've tried—that's a never event, but we can't give a guarantee that that will never, never happen in terms of a young person taken to custody, but there are provisions in place to make sure it's a never event.

So, do you feel that the majority of children and young people are being assessed in the most appropriate and safe place?

Yes. 

Yes. 

Yes. 

Yes. 

Okay, that's good. 

Thank you. Llyr. 

We heard evidence from teachers recently that they felt there was a wider cultural demand for services. Is that something that you'd concur with, just out of interest? 

I do. I think there's something—. I think there are higher levels of self-harm and higher levels of distress, and we don't really understand that probably. 

Okay. Just given that you mentioned it, I just thought that I'd confirm with you. I'd just like to look at in-patient care for children and young people, and we've heard quite often, actually, that access to in-patient services for children and young people is very, very difficult and, of course, many then end up being accommodated in paediatric wards or on adult psychiatric in-patient units. Do you recognise that access is an issue and why is that the case? 

Access is an issue. I think both the north Wales unit and the south units strive to improve access, but there are a number of reasons. There are specific groups for whom we will never appropriately have proper services in Wales; we'll always need to go to a UK solution. So, for very young children and forensic beds and most secure beds, we will never have the capacity. And to a certain extent, it also depends on the resilience and capacity of community services. So, if you've got very well-established community services with good step-down facilities, you can improve access. And then, finally, there are the workforce issues that I know have significant vacancy rates. 

Yes, okay. You say there's no capacity for some of the more specialised aspects—no capacity, or not enough—

Not in Wales. There's UK capacity, but we never sought to develop it in Wales. 

No. Okay. So, how far would children and young people end up going? It depends what they needed I suppose. 

It depends on their need, and also availability. So, I don't think we have very good relationships between NHS Wales and NHS England. 

But should we just accept that as a necessity, or is there anything we can do to try to—

This is a personal view, but I think if we could have a more sophisticated relationship between NHS Wales and NHS England to look at the locality of the more specialist services that would be helpful, because we know children are going all around the UK in extreme circumstances. 

Is there not a possibility that, actually, we could locate some of those in Wales and have those being accessed by people in England as well?

That's more difficult because you have to have a critical mass in order to deliver the service as well, and they're very rarely needed, some of them. 

But would you not design that service with both sides of the border in mind?

If I may, the CAMHS and eating disorders network has recently requested a review of the national framework in terms of providers, and a task and finish group has been set up specifically looking at the issues you've raised, because they are very important issues in terms of what resources we have working in Wales and what provision we commission, and how we commission, review and monitor that provision to make sure that the quality is there, but also in terms of making sure that services are as close to home as possible for that young person because of their social network, and in terms of how we ensure that we can transition that young person back to their local community as soon as possible, acknowledging some of the complexities in their presentation. 

The task and finish group has a number of stakeholders, including in-patient leads, community, learning disability, forensic and so forth. I'm the chair of that task and finish group, and what we're doing at the moment is just scoping in terms of what is the current provision in Wales, what is the demand in terms of specialist requirement, and then in terms of what is the cohort of young people that do require those specialist services that are currently not available within NHS Wales. And once we've done that, we will then undertake an option appraisal in terms of what would potentially be the provision in Wales if we need to think about a bespoke service. And, in addition to that, is in terms of the critical mass, in terms of the workforce requirements, and also, the acknowledgement for some very specialist conditions or criteria. We still have to commission that external to Wales, because of the specialist nature of the assessment and interventions required. So, there is work under way and we will hopefully report on that. 

I was going to ask: when do you expect to conclude that work?

There's a very tight time frame around that, and one of the reasons is that there is currently a funding arrangement in terms of who's overseeing the framework in terms of those commissioned placements. There's now been an agreement to extend that for another year. That gives us some capacity to actually do a proper piece of work, and what I'm hopeful is that that workstream will be extended into next year. So, when we provide an option appraisal, it's an informed option appraisal, in terms of what's the capacity for us in Wales, but also in terms of the smarter commissioning with other providers. And, in terms of some very specialist populations, and in terms of Amani with learning disabilities, that's key as well, and that feeds into our conversation, and she's a member of the task and finish group as well.

Okay. Thank you. Well, we look forward to seeing that. Just finally from me, for now: how sufficient are the step-down services that we have, in terms of avoiding readmission and making sure that people don't spend too long in hospitals?

I believe this varies again according to what sort of admission, whether it is a forensic admission, whether it's just serious mental illness, or whether it's an LD. It all depends really on the type of mental illness, the type of admission, and type of service, and it varies from one health board to the other. 

So does that, again, reflect workforce capacity issues more than anything else?

Exactly, yes.

Yes, and the college is aware that step-down provision varies from area to area, in terms of placements available for children and young people and the skill mix of the receiving teams. And, again, work needs to be done to map out that provision, and how, as an NHS, we commission some of that provision to deliver what we need it to deliver rather than setting up a facility and then—. So, hopefully, all of that will feed in to the work, but there's variability, as I've said.

Thank you. John.

I wanted to ask about some of the inequalities in access to CAMHS services. You state that there are the regional variations that we touched upon earlier and that deprived communities tend to have poorer service, and also looked-after children. I just wonder, with regard to looked-after children, whether you could tell the committee what you think a good level of service for looked-after children would look like.

With regard to looked-after children, it's a broad terminology, but we don't have criteria where looked-after children are excluded. If a looked-after child presented with a mental illness, that looked-after child would get the same chance of accessing specialist CAMHS. So, we don't have criteria of excluding looked-after children, but we know that looked-after children are more prone to mental illness than others. They've got different needs. They move all the time, and there is a—how can I say it—huge percentage of learning-disabled children who are actually looked after. So, really, 'looked after' is a broad terminology, but when you dissect it narrowly there are different needs. When we talk about a group of looked-after children, for example, who do not have a mental illness, do not fit in a diagnostic criteria, who do not have a learning disability, they just present because of instability, moving from one place to the other—we acknowledge that there is a sub-group of the looked-after children who are maybe lost. But, again, I don't think the answer is with specialist CAMHS; it's a multiprofessional approach, a multi-agency approach to sort that.

I think the principle of treating children as children first is fundamental to this. All children should have equal access to our services. We may need to slightly adjust our services to facilitate access for vulnerable groups. So, for instance, the youth justice population traditionally find it quite hard to access services, as do looked-after children, but the key to meeting the needs of looked-after children is to have no waits and to have timely access for all children, and then to put in whatever steps are necessary locally just to make sure that those young people who have added layers of adversity and complexity can still access the same services.

Okay. Are you able to flesh that out a little bit just in terms of what it would look like across Wales to have the sort of service that made sure that looked-after children weren't relatively poorly served? Is there anything in particular that should be put in place to achieve what you've just described?

I think it's going to depend—. Again, it's very difficult to speak for all the health boards as a college, because there will be variability and it will depend on local working relationships between local authorities at all levels—you know, at a senior strategic level, at county level and at a local team level. I think that, by expecting and requiring that those relationships are well developed, problems can be tackled. If there are difficulties in access, it becomes the quality of the relationships between the various services that can then address solving that. So, if there were an issue in any particular county or area where it appeared that looked-after children were having difficulty, it would be critical that that was quickly looked at and that whatever local steps were required to solve that were put in place. I can just give you an example of one local solution. One health board in one area has always set aside two appointments for a first appointment, just because it's necessary to meet with the social worker and the extended network as well as doing what's usually done with a young person and their immediate carers. That's just a choice that's been made locally. I think the key is that they're viewed as children and that appropriate arrangements are in place. 

In terms of the emergency response, all health boards will have that crisis response to respond to somebody in need. Some of the challenges in terms of looked-after children are where places are commissioned outside of their local area footprint, and they then appear on the doorstep of the service without any dialogue in terms of needs, complexity and what's required. It's about how we try to agree some key principles in terms of managing those transitions, because they can be very complex, they can be very time-consuming and have a significant resource implication. So, if those conversations are taking place in advance, then that enables resources to be mobilised in adequate time, rather than a knee-jerk reaction with a lot of challenges in terms of getting everyone around the table.

I do think we still need to deal, to a certain extent, with the legacy from very long waits in the past and our whole systems of trying to find ways around our system for looked-after children, because they were seen as so vulnerable in the face of very long waits, which had disadvantages as well as advantages. I think now we're moving to a world where waits are short, and it's key that we see them as children first.

Okay. Might you be able to suggest a way that we could better assess whether looked-after children are receiving adequate services—services that they really need? Is there anything in particular that might be put in place to better test whether they are being fairly treated?

I'd come back to the point Warren was making about having really good data systems, so we can really collect systematically the data. I don't think we have adequate data collection yet to really answer that.

Okay, thank you. In terms of the neurodevelopmental pathway, we've had a separation between the assessment for the neurodevelopmental pathway and specialist CAMHS generally. Have you seen any evidence that that is leading to delays for young people because they're being bounced between the various systems?

I think we need to be mindful that, pre Together for Children and Young People, the neurodevelopmental teams were very variable across Wales. There were some that were embedded within CAMHS, there were some that were being offered by paediatrics teams, and there were some health boards that weren't able to offer these assessments at all. But in the last two years, a lot of work has gone in. Although the service is variable, we've got a lot of standardisation and equity in terms of what is being offered. Every health board is now having an ND team, and the neurodevelopmental work stream has put together an all-Wales neurodevelopmental assessment pathway with a single point of entry, which all of us are working to.

The referral-to-treatment time of 26 weeks is something, again, that everybody's aspiring to. But be mindful that every team is evolving. There's a clinical peer group that's been set up as part of the neurodevelopmental work stream, and I chair that, and the purpose of that is sharing good practice, because we are aware practice varies. There's a lot of support needed because a lot of members of these teams are not as skilled as other members. There is newer representation that's coming in from education and social services, so we've had the community of practice events with a view of training the workforce that is then supporting them.

We've also produced guidance in terms of what happens when a child or a family requests a second opinion, what happens when there's a concern about pathological demand avoidance, or there's a private diagnosis. There's a lot of work that is being done, but it's not a finished product. I think there's a long way to go, but we're on the right path, because the representation in the group reflects what is happening in our clinical practice. We've got all the agencies there. We've also got representation from the parent group. So, we're working very closely. We've also developed links with the integrated autism service, which is up and running in certain health boards, and we've now developed a clinician ADHD toolkit to replicate the ASD toolkit that was developed for ASD. So, there's a lot of work that is being done, but obviously there's still more work that needs to be done in the years to come.

Thank you. Llyr.

We touched briefly on schools earlier, and, Peter, you mentioned the possibility of groups in schools and those with pastoral roles in schools being key. I'm just wondering: how can we best support teachers to spot the signs of mental health issues in children and young people, do you think?

Again, from the college point of view, there's a lot of research that's been done specifically looking at upskilling teachers and empowering them. We know, from the young people's point of view—the report that was put together, 'Making Sense', suggested they don't want to come to specialist CAMHS unless they need to, and they would rather talk to a teacher, a peer or family member. The Green Paper put forward by the college and the National Association of Head Teachers reflects that schools that are more focused on mental well-being and have teachers who are more capable of working with these young people tend to do better, even with academic performance. As a college, we've been working very closely with education. Only this week, on Monday, we had our 'Working Together' event, which was open to colleagues in education and primary care, along with the people in the well-being team in the Welsh Government. This involved sharing good practice that's happening across Wales.

We know of a pilot project that's currently running in a school in Newport, which has worked with teachers and school pupils from year 8 and year 12, looking at issues around mental health and stigma. We heard some of the young people from the school, who came and did a presentation there as well. We've got the DEAL project, which is run by the Samaritans, again looking at upskilling teachers and working with young people. The college in Wales—I think we should be proud, because we are the only college that has been running primary school debates, because we think we need to work with children even at a younger age, and we've been doing it for two years. This year, we actually had two debates because we had such an overwhelming response. We also have been running the Christmas debate that we had on Monday with sixth-form pupils, inviting teachers, because they find it very difficult to get time out of their school schedule. So, I think there is good work being done. We've got a joint event in January next year, with the National Association of Head Teachers, which is a UK-wide event, and I think the college does realise that that is an investment that needs to be made.

You've pointed to a lot of what I'm sure are very excellent projects, but they are—not isolated projects necessarily, but there are pockets of good practice, aren't there, everywhere? How can we better embed all of this into daily routines in school, and the curriculum, of course, which is being reformed?

I was going to make reference to that, and again, the £1.4 million that has been invested to pilot in the three health boards, working for schoolteachers and having a dedicated CAMHS practitioner, looking at common presentations of anxiety, self-harm and conduct disorder, and upskilling them, because that is something that needs to be embedded in every school. Sharing good practice is good. Again, we've been working with the additional learning needs reforms that are taking place and, when we think about young people going up to 25 years of age, what support can be given not only in schools, but even thinking of further education.

We've seen a wonderful example mindfulness being used in a primary school as well. Is that something that you'd positively encourage in terms of activities in schools?

There is some emerging evidence to show that it works, but again, that is something that depends very much on resources—on what is available locally.

But you recognise that it has a contribution to make or a role to play.

Yes, if they can provide it.

Okay, thank you.

In terms of the next 12 months for the Together for Children and Young People programme, what do you think should be the priorities?

I'll start with myself. I think there's a lot of work that has gone in in the last two years, and all that needs to be consolidated. We've still got a lot of work to do with neurodevelopmental and psychological therapies. Transition, we know, is a big thing that needs to be dealt with. You referred to outcomes and quality of assessment—I think outcome measures and having satisfaction measures, and to be mindful that it's not just about waiting times, but the quality of assessments and the quality of service that we are offering. So, I think that is something that we're hoping to work on in the next year.

Can I just bring Llyr in?

Workforce is the other theme that comes through quite clearly. Is there enough happening in terms of ensuring that we have a robust pipeline of practitioners coming through over the next few years?

There is, but there is a shortage of candidates. So, we are doing our best, but there is a shortage across all professions. I'm talking about nursing staff and consultants or even doctors. So, there is a clear shortage, but I believe that the shortage is not affecting Wales only.

Because there's a short-term issue, but then there's a longer-term strategic approach as well. So, are you confident, taking the longer view, that work is being done to make sure that, in six, seven or eight years, this issue is something of the past and not still something that we're grappling with?

I think from a college perspective, there's been a good campaign launched in terms of Choose Psychiatry, because we know, in terms of per head of population, that there aren't enough psychiatrists in the UK and especially working in Wales as well. That's recently been launched by the college in terms of bringing forward the profession in terms of psychiatry. As we've said, it's not just in terms of the medical workforce; it's much broader than that and it's about how creative we are in terms of utilising the resources, not just in terms of the NHS, but also in terms of our partners and the third sector and working collaboratively in terms of developing those roles and resources.  I think it's very broad because it's in terms of our educational institutions in terms of the training programmes and what we are training for the future in terms of our workforce, delivering workforce in urban and rural parts of Wales, and also in terms of some very specialist areas in terms of learning disability and so forth. It's making sure that we build in the capacity to meet the future demand. So, yes, there are real challenges and I think the college is contributing to looking at solutions, but it's broader than the college. It's in terms of how we all work together to address the challenges that are here now and very clearly evident, in the next five to 10 years, will have a significant impact on how we deliver our services.

Okay, thank you.

Is there anything else to add in terms of priorities for the programme other than workforce? No?

I think just what we said in terms of just patience in terms of embedding the processes, but absolutely understanding the requirement for accountability for local health boards in terms of delivering on the investment. 

I do think the neurodevelopmental work stream is absolutely critical as well, because we're not as far advanced. The work is excellent and there's steady progress being made, as Alka has described, but the waits are significantly longer. There's more of a logistical challenge there. I think making good progress on the neurodevelopmental work stream has a knock-on, helpful effect all around for all children's services.

Okay, thank you. Well, we have come to the end of our time, so can I thank you all for attending this morning and answering all our questions? It's been very useful for the committee. You will receive a transcript to check for accuracy in due course. Thank you again for attending.

The committee will now break until 10.45 a.m., but if Members could not rush off, please.

Can I welcome everybody back for our next evidence session with the British Psychological Society? I'm very pleased to welcome Dr Bethan Phillips, Dr Rose Stewart, Dr Abigail Wright, and Dr Liz Gregory, who is also representing the Applied Psychologists in Health National Specialist Advisory Group. Thank you all for attending. If you're happy, we'll go straight into questions.

If I can just start by asking you generally whether you think that the Together for Children and Young People programme has struck the right balance in terms of emphasis on the four different tiers and in particular on early intervention.

It's something that we really wanted to open up with, I guess. We feel that there needs to be a culture shift in how we understand children's mental health and that the pyramid, if you like—the tiered approach—misses a huge underbelly. We've tried to represent it diagrammatically, really, but, actually, in order to represent the services shown on this paper, you need to be able to turn up to clinic, sign up to psychological intervention, commit to regular appointments and, actually, many of the children that lots of people are very, very concerned about in terms of their behaviour don't meet the criteria for a diagnostic disorder but are displaying very, very severe signals of distress, and the children at the bottom of this iceberg, if you like, rather than pyramid, are the ones who are costing society a huge amount. They're being placed out of county at huge cost, they're in our penal reform services, they're really troubled children.

Unfortunately, I think our concern is that mental health has been located up here, as though this approach will provide the answer, but, actually, it needs to be considered much more widely from our perspective, and I think the adverse childhood experiences research really brings that into sharp relief. The children down here are in distress, they're in trauma, they can't access services in traditionally delivered ways. But, as psychologists, we feel that we've got a huge amount to offer these children in terms of attachment-related interventions, relationship-delivered interventions, but they're not traditional therapy in the traditional therapy approaches.

So, we just wanted to open with that. Obviously, it's not an 'either/or'; we need 'both and'. But I think the focus from our perspective has been very much up here, rather than down here, and, as psychologists, we try and formulate and understand the whole context of a child's life and where the intervention needs to be. When the Holy Grail is a diagnosis that very much locates the problem within the child it's really hard then to work with the system. So, we just wanted to open with that and then have direct specific questions beyond that, but we didn't want to not make that point at the start.

Thank you, and that point is very well made. Do you think, then, that the Together for Children and Young People programme has had sufficient focus on psychology and psychological therapies?

I think the focus has been very much on the within-child model at the top. So, for example, there has definitely been an increase in awareness of psychological therapies and in what we would call single-modal approaches like cognitive behavioural therapy or particular specific approaches for specific disorders. But that is again very much focusing within the child, and the child is the focus of the intervention, and we would be keen to broaden that out so that, for example, if a child is very anxious, and you work with them in clinic, but actually their anxiety is because there are gangs outside their home taking drugs, or their parents are in a domestic violent relationship, then it's kind of missing the point of where that anxiety is coming from. So, it's about a whole contextual understanding of distress as something that we're keen as psychologists to broaden out. So, we welcome it. We absolutely welcome that this is more psychological at the top, but it's not the whole story, and we don't want the impression to be that it's the whole story. 

What's really important as well is that, as Liz was saying, at the bottom, not much research is carried out with those populations, because it's very difficult to, and it's difficult to include that holistic picture that the formulation involves with these young people as well. So, we're getting a lot of research in therapies such as CBT and those things that are much easier to research, but the things at the bottom are a lot more difficult, so we're getting a bit of an under-representation as well of the things that are of value and worth while in mental health. We need a much broader focus on that as well.

A lot of clinicians would say the work they do on a day-to-day basis, the bread and butter, the patients and families that are coming to them in distress—what they do in the room with those doesn't quite fit, sometimes, what the evidence says, or National Institute for Health and Clinical Excellence guidance, because it's often too narrow when you're thinking about that child in that family in that community in that system. So, there's a bit of a mismatch there sometimes.

Okay, thank you. Llyr.

I agree wholeheartedly with the point that you make about that different cultural take on the whole situation. I don't want to say 'but' because that's too negative—

I think it's 'and'—

Yes—and there's a challenge, there's a huge challenge there, which is probably as big, if not bigger, than the whole cultural change thing itself, in that you're then bringing in so many additional layers of services, practitioners, professionals, organisations, which would be the panacea, but how realistic is that?

It's tricky. I think as clinical psychologists, part of our training is about thinking about the formulation around a child and young people, thinking about the context. So, the years that we've had in our training sort of bring us up to be able to do that. So, the British Psychological Society and the division of clinical psychology, we'd be saying as a profession that we're best placed to be able to do that. So, for example, there are posts in Liz's service in things like Flying Start—Liz can explain more.

Because there's a whole community approach, and community resilience and everything comes into this.

I think the point is that down here it's not about therapy, it's about facilitating change through the relationships. So, when a psychologist is available to a team down here, whether it's Flying Start, social services, whatever it happens to be, we can help formulate and inform what the front-line workers do so we can actually channel their energy in a therapeutic way, as opposed to delivering therapy in a formal way. So, actually, we've got the resource here, but because this is the panacea and everybody wants to get up here, it's very hard to maintain that as being actually the most helpful thing for that child at that point in time.

But there's that vicious circle as well in that you'll always need the top bit—

Absolutely.

—but you need that preventative approach as well, and then there's a squeeze, isn't there, when you're trying to provide both without realising the benefits of having exercised the preventative approach in the early years and then seeing the gains later on?

Yes, but I would say the preventative bit is here. These children are incredibly distressed. This is very severe and it's very complex, and it is mental health, but the model doesn't allow it to be considered in that way, if you like.

The first step, really, is just the awareness of that, and the awareness of the spectrum of mental health, and all the different things that we can do to help so that we're not just thinking of it as the top approach in terms of labels, but everything that comes with mental health. It's really promoting that understanding.

So, for example, I'm an educational psychologist, so I'll work in education settings. At the moment it's very difficult because there's such a focus on attainment, which arguably also influences the mental health of children and young people. So, a lot of the work we can do is on a much simpler level of just promoting that awareness of mental health, and the importance of putting emotional well-being before those academic levels, because that's what's going to produce the better outcomes in the long run. Because, really, that emotional health is the roots to the development of the leaves, as such—what you see as the attainment levels. So, I think that's important.

Our inquiry's just gone like that, hasn't it, really? But it's a key, key message, I think, that we need to reflect in our report and in our deliberations.

I want to reassure you that, from our perspective, any intervention happens through a relationship. It's the people who have a relationship with the child who are in the best place to be able to facilitate change. It's much harder when you're a remote service, seeing a child once a fortnight, to effect change, as opposed to when you're seeing that child every day and you're alongside them. So, I actually don't think—. I think it's about redirecting resources and reframing how we think about mental health, rather than a huge unmet need that we don't stand a chance of actually managing.

Right, because I was going to say that the obvious question then is: how many of you do we need to meet that demand? But you say that you could actually reconfigure the service somewhat and cover most of the bases.

I think there is definitely potential, because a lot of time goes into turning away referrals from the top end—there's a lot of energy put into that process—and trying to make children fit into a clinic-based model, when, actually, a community-based model is actually much, much more appropriate for them. So, there's a lot of energy that I think could be redirected. But, mostly, I think, it's about a different message about what mental health is. So, rather than chasing a disorder, if you like, actually, we all kind of accept that change for children is going to happen through whoever's closest to them. 

Okay, that's really interesting, but we are in the here and now, so I'm just wondering whether you could tell us how effective you think local primary health support services across Wales are in picking up children and young people with mild to moderate mental health issues, such as anxiety, low mood and behavioural difficulties—which is a lot of what we're talking about, really, but how effective are we at the moment in picking those people up and identifying those issues?

Some of the experience and the feedback we've had from members and colleagues is that the primary mental health teams, now they've been established, are able to sometimes do the assessment, but, often, because of the targets and the waiting lists and the pressures on them, on the ground it doesn't always feel like they're able to do that. So, for example, they're able to see a child or a family within four to six weeks. This will be a child and family who have maybe gone to see their general practitioner and told their story, then they've gone again, met someone and told their story, then they're being told, 'You're being put on an intervention waiting list', but that's six months. So, it's helping, and it's getting more people through, but, in terms of some of the children and families that I meet, or that my colleagues are aware of, it's not always helping those children who are often very distressed.

Yes, okay. That's all right. I just want to ask as well: what's been the level of investment in applied psychology posts based within local primary mental health support services? How important is it that those working in these services have access to specialist supervision, training and support? 

It's been very, very limited. I think, certainly in Gwent, there was no investment in psychology originally. We have argued and argued and made the point that, actually, that holistic kind of formulation-based understanding is really a priority. We've now recently appointed a psychologist to lead the child aspect of that service.

I think, ironically, the move to making primary mental health all-age—and I appreciate it was fully done through an inclusive and accessible perspective—has meant that an adult mental health model has been transposed on children. So, again, it's the within-child model. Prior to that, our primary mental health teams, their role was to offer consultation, training, facilitate access to other services, be completely aware of what else was out there, and it was hard, because of the culture shift for people, but they had made some real progress. When it became all-age, it suddenly became something that people referred to and their waiting list built up.

So, again, it's so hard for us, as psychologists, not to come back to that wider formulation and actually empowering people who are closest to children to believe that they have some value in providing, through their relationship, the interventions that children need.

We heard earlier about variability in services across Wales and the UK. You mentioned Gwent—well, presumably it's different elsewhere.

It's different, yes.

Yes, that's another message that we wanted to bring to you. I work in the Noah's Ark Children's Hospital, to come from a health perspective, and one of the main issues for me is the parity, the equity, of services across south Wales. So, I'm funded in a specialist post for children and families with cystic fibrosis, which has a massive psychological impact on them, but it's just me, for two and a half days, for all the children and families. So, that's about 200 families across south Wales. Those who live around Cardiff and Gwent, within half an hour or an hour's distance, can get to me and we can meet with them, but, for example, I've got a young boy who's six, who lives in Kidwelly, who I'm really struggling to be able to be helpful to because it takes him and the family twice as long as the appointment will last to come, and that means he misses a day of school. We need more in the local areas, and that's just coming from the hospital perspective. I know a lot is concentrated in Cardiff because there's Noah's Ark and that's where the specialisms are, but it just doesn't seem fair for these children who've got a health condition that they've got to travel all this way, and, again, not all families have the resource to do that, have got the access to it. And then it takes them out of school for a day when they've got to come up to see me in the clinic, so that's something that we're quite passionate about as well. Recruitment for our profession rurally is quite difficult, but equally there are no posts. So, it's difficult.

I think that sort of mismatch of services—I also work in health psychology and I'm in north Wales, and we've been piloting an integrated service for young people with type 1 diabetes where I've been sitting in clinic, and so our young people have been able to access psychology as a routine part of their clinic, which has had incredible effects on reducing stigma. But we're also finding it's having a huge effect on unscheduled care admissions into our hospital in Wrexham; it's saving a lot of money. But, although our service is being used as a national benchmark now and is in all-Wales guidelines, this service—which is offering psychology up to the age of 30, so we're fully covering transition—there's no money for it, so it's being withdrawn at the end of this year. And, although there are now national guidelines that now stipulate there must be integrated psychology for people with diabetes up to the age of 25, the guidelines have no money attached. And this has so many knock-on effects—the ill health of young people with health problems. I think something that I'm particularly passionate about is trying to push those resources to people who are clearly going to be vulnerable. So, for example, with type 1 diabetes, the suicide rate is three and a half times that of the normal population. A young person with diabetes is three times more likely to develop an eating disorder, and there are no specialist eating disorder services for people with diabetes in Wales.

And you'd assert that investing in those services would save money for the—

Huge amounts of money. There's a young person I'm working with at the moment who, in the last four years alone, has cost the NHS in north Wales £14,000 through unscheduled care usage, and through seeing me for 10 sessions has completely turned his diabetes care around. It's a money-saving service, but trying to get that initial funding in place is almost impossible at the moment.

And there are children like that who are being sent to costly out-of-county placements, so for specialist eating disorder care for instance. And it's just (a) costly, but (b) who wants a teenager to be hundred of miles away when there's no local provision for them? So, that's another concern of ours.

Okay, thank you.

John, did you want to come in on this?

Yes, very quickly, Chair. Just going back, really, to what you said earlier about the need for a much wider approach to dealing with what seems to be a rising tide of mental health and anxiety problems amongst children and young people and others, I just wonder to what extent you think psychologists in Wales have the opportunity to work with Welsh Government and others at a strategic level, where you might get the level of change that you've described as necessary. Do you have that opportunity at the moment—you know, when it comes to curriculum reform in schools, Flying Start, as you mentioned, and other major programmes?

I think it's very difficult. I think it's because we are such a small profession that we struggle to do our clinical role, which is obviously huge and valued, and our passion, and be strategically represented as well. I also think that, as a profession, we're trained by health to think very differently to health. So, we're always about broadening it out and we're always about challenging within the individual way of thinking. And somebody likened us to chilli really: a little bit of us and we go unnoticed, just right and we can make a difference, too much and we're too challenging. So, it's a hard balance to get both in terms of how palatable what it is that we're saying when the direction of travel and the model that we work within is so organised. The fact that we operate in health, in clinics, with individuals already, before we even start challenging the system—you know, it's quite a difficult message.

Would you welcome the opportunity though to have a more strategic role in Wales?

Absolutely.

Yes. We welcome being invited here today, because as the BPS, the British Psychological Society, we're only becoming getting involved in these types of things, so we really, really welcome you inviting us here today. But, definitely, as a profession, we've got lots to say and would be keen to be involved more at that level as well. It's just balancing it and your day-to-day job as well, when you've got patients waiting.

Yes, absolutely, but interestingly—. I was very fortunate; I worked in Gwent for 20 years, but I had a career break and I spent three years in Canada. I've come back and there is a definite shift in culture, and I think the adverse childhood experiences research has really opened the door for thinking about context and children's distress. So, we are finding ourselves much more in a position where we're not so much the lone voice, which historically has been very much the case. So, I think times are changing; I can feel change. I suppose my concern is focusing up here too much, but also my worry about this model is that it implies that it becomes less complex as you move down the tiers and, actually, in reality, that's not our experience at all. It's the people who can't get to clinic, for whatever reason it happens to be, that professionals are most worried about. So, in a way—. It's been a terribly helpful model and 20 years ago, 15 years ago, it was fantastic and it really helped us, but I think it's got its limitations too, and this idea of severity only being located at the top is one of the ones that I would challenge about it.

From an education perspective, I think educational psychologists would be extremely excited about becoming involved in things at a more strategic level. At the moment, there's a huge burden on educational psychologists to complete statutory work, which is taking up a huge amount of time. Obviously, there's limited funding for the creative and wonderful things that educational psychologists can do. In Newport at the moment, they've just been piloting a really exciting piece of work on mental health and raising mental health awareness in year 8 and year 12 pupils, which has had some really positive effects. They've been able to recruit two new members—one education based and one clinical based—to take this project further, which is a really nice example of the type of work that we can do. I work, as well, in Flying Start, which has a really novel approach, because I don't do any statutory work, and that's really opened my eyes to how much can be achieved if we are able to be given these more preventative and more time to be more creative with work and make a difference to not just children, but their family as well. So, I think it's just more.

Thank you. The next question's from Michelle. I think we've covered a couple of them, but maybe go on to the medical model one, if that's okay.

Sorry, which one are you talking about, Chair?

Early intervention and prevention.

Yes, I know. Yes.

But I think we've covered—. We've done—

I was actually going to ask how much actually—. In your experience, how much early intervention is there? Because you talked about the benefits of the—

Specifically, or across—?

Sorry—early intervention into mental health. You have children and young people with very, very low emotional issues that could potentially develop into something more serious. I think the whole message you're trying to get across is that if we intervene earlier then you head the trouble off at the pass. How much is that happening at the moment, in your experience?

Very little and in pockets. It's fantastic to hear about educational psychology within Flying Start. We've got a couple of examples in Gwent where psychology is within Flying Start. Because, really, if you can get that relationship right at the start then it helps the trajectory move in a positive direction. So, absolutely, and that's where we would put our investment into really changing things for children.

I think the experience in our health board, particularly in health psychology, is that when services are sufficiently staffed—. So, we've recently had an increase in our paediatric psychology team, which has meant that the psychologists can now come into clinic, they can start seeing people from the moment they're diagnosed with a condition, and they can do really valuable work—both in helping young people and their families at that initial, very, very distressing point of diagnosis, but also reducing stigma, so that families and young people, when distress may become an issue in future, are much more willing to access that help quickly, so that the work can be done with minimal resources used to the NHS, and whatever is used has a very, very profound impact.

I think things can go even before that, as well. I think that there needs to be more of an emphasis on things even antenatally and before the early years even, because some of these problems often stem from context and families that also have mental health conditions and need support themselves. So, at the moment, within Flying Start, we are very focused on attachment and bonding and how that has a huge impact on later life. Those things are often missed, I think. I think, also, that there is a growing increase in mental health conditions becoming apparent in very, very young children and sometimes those can go amiss as well because they are more low level, and psychologists are really well placed, especially within schools, to start discussing and raising awareness of those things as well.

What sort of engagement is there with families? Because if the family's engaged and in full support of the child getting help and is sensitive to the emotional state of the child, they're going to be on board and they'll get it sorted. Do you think there's any impediment in children accessing help that comes from maybe feeling that it might be disloyal to their family? How can that be addressed?

I think, again, that's where formulation comes in for us. But I think the really important point I think we want to make is that we're not suggesting psychologists are the ones who have the relationships with these families. It's about facilitating other people to think about the whole context, to think about attachment, a relationship, the importance of getting to know and being alongside families in a very supportive way, and almost re-parenting parents in order that they can parent their children, because that's where the gaps are. And, you know, we've got lots and lots of people on the ground who are in a position to do that, but because they're concerned and alarmed it's mental health and it needs a specialist, they're frozen from being able to take that. So, it's very much a facilitative, relationship-based intervention, based on a formulation, and all of those things like children being incredibly loyal and absolutely feeling that home is home, regardless of what home is, is something that we work with all of the time. 

But then, for example, to have teachers feeling more confident to have conversations with children rather than thinking, 'This is mental health, who can I ring?', because, for lots of children, school is a sanctuary and having those relationships—. We've also been in discussion about school-based counselling and things like that, which is helpful for some children, but a lot of teachers I will speak to just are afraid of saying the wrong thing, doing the wrong thing. But, actually, with support and with training, they're much better placed to be able to do it than we are because they're with the children for so much longer than coming to see someone like us once a fortnight. So, it's about that culture. People are now happy to talk about it, but there's still afraid of what to say next.

Llyr, on this. 

Well, you've touched on it, really. I was just going to ask how do you help teachers to be better placed to spot the signs and initially deal with the situation. You mentioned training, and we know that the curriculum has been reformed as well.

Yes. From our profession, it's establishing links and this is where we'd look at our colleagues in educational psychology. I mean, for me, in my clinical role, I can pick up the phone and ring a teacher and they really often value a conversation on the phone with me about a young person that we're concerned about, and you can almost feel their shoulders dropping when they know you're involved and you can provide them with some advice. Because it's often like rabbits in the headlights, but educational psychology is key there to bridge those two links.

Yes. We work with a range of different educational professionals to empower them because we're quite uniquely placed in that we offer a very person-centred approach to things and we offer a strengths-based model. So, it's often quite an enjoyable learning process for everyone involved. So, we'll use formulation to, obviously, identify the things that are working well and build on those to improve everyone's mental health, but also to raise awareness of the things that a child can do rather than can't do, so it empowers them forward. We'd work a lot in consultation with individual teachers. We work at more systemic levels, or whole-school levels, providing different training, support, offering different programmes as well. There's a lot of emotional literacy support assistant training going on by educational psychologists at the moment. But I think what is perhaps one of the most important points, as educational psychologists, is that we work really hard to understand the constructions of everyone involved in the process, and that can be a huge barrier even to getting someone involved in support and how effective support is, because often our understanding of what we think mental health is is very different to a young person's, or even a teacher's, and I think that's a really important role we have—bringing everyone together and having that clear understanding and also having other people to work with to develop that as well.

I think that's absolutely right, about dispelling myths about what mental health is and what children need, actually, and what's most important to help them through their troubles. I guess your question struck me—you know, how do we help teachers spot the signs? I suppose it's 'Spot the signs of what?' and moving away from spotting the signs as disorder towards spotting the signs as distress and what the children need is nurture, someone who's there regularly, reliably, who spots if they're having a bad day, whose very proximal to the child. That's the difference that I think we're all talking about.

Of course, we do have school counselling services. So, how effective do think those services are currently?

I think school counselling services can be effective in certain situations, but I feel that, at the moment, they might be becoming sort of the default so that, if someone is presenting with a mental health need, as such, they're just referred to the student counsellor, without any real assessment or formulation of what is going on in a lot of circumstances.

So there needs to be something before that.

There needs to be something before and, perhaps, in addition and, perhaps, afterwards. I think it's just one very small programme of a much wider context. At the bottom line, I think it's raising awareness, again, about mental health and the different aspects and also offering schools lower level things to be able to assess children's strengths and areas for development as well as providing interventions at a much lower level.

There's quite a lot of stigma from the young people that I see in terms of doing that. So, I think, in some cases, school counsellors, for things like exam stress, quite typical difficulties, day-to-day difficulties, are really well placed. But often, as a school counsellor, they may only be trained in one modality, so in CBT or even a lower level of counselling training, and to have then children who are presenting with things like self-harm or suicidal thoughts or more complex things like hearing voices and things like that, it can sometimes be almost a bit beyond them.

Then also, often, how it's arranged in schools—. I had a young girl who came to see me. We'd been talking about trying to get her some help in school so she didn't have to travel to come to see me. The head of year came up and gave her a purple slip so she could go to the counsellor, in front of everyone, so that went in the bin. So, some of it's stigma, which doesn't help, and sometimes it's thinking about the skill level of those counsellors. So, I think, for some children, yes, they're well placed, they're in school, they do what they need to do, but for other children who need a bit more than that, often, the school-based counsellors are quite isolated and then there's not much link between them and CAMHS or them and other services to try and think, 'Actually, am I the right person to help this child or is there something else?'

And, again, it's based on a within-child model, so the child goes and has therapy and the context of the child and all the issues that might be contributing aren't part of it. And that's not to say that having someone who is safe and who you can talk to isn't hugely valuable—of course it is, but it's not fixing the bigger problem, I think.

And you've touched as well on how we need to think differently about the service, because the default position for a politician would be, 'We need more counsellors'—

Absolutely right.

—but, of course, what you're saying is, 'No, we need to look at the whole service around the counsellor and make sure that there is the pre-counselling bit, the post-counselling bit, and we might not actually need more counsellors if we do it properly.'

And I think psychologists can do a lot to advise what can be done even within a school context and at a school level, so as far as even changing the ethos of the school and what they can do. Could they implement mentoring projects? Can they buddy up people? Can they have that caring, attachment model embedded through the school?

So, what you're saying is that we don't need more counsellors; we need more psychologists. [Laughter.] But you would say that, wouldn't you, anyway? No, but—[Laughter.]

And we don't need many to make a difference. I think that's a really important point.

It's just that awareness that we are out there and there are things we can do to promote and help as well.

And we certainly don't see ourselves as the ones seeing individual children. That's not the model that we're—

No, but you sit in the middle somewhere and you're the key—

It's just to advise and provide consultation—just thinking about how the school sets it up. Where's the room and how does a child access it? Because if you've got to have a badge on to say, 'I'm going to the counsellor' it's not going to work, and that seems natural to us as psychologists in terms of how we think about things, but it isn't a natural thought process in the schools because that's the system that they use.

Yes, and going back to your default position as politicians, I absolutely understand that, and a lot of what we're saying isn't palatable to society, actually. If I can give an example—it's from 15 years ago, but it sticks in my head and I still hear about many, many similar examples all of the time. I was working with a boy. He was referred to me for very severe challenging behaviour. His mum and dad were in a very domestically violent relationship, both were drinking heavily. His mum left, they went to a hostel together and, eventually, the mum found a house and they were living together and they came to me for support around the challenging behaviour. My job was really to help the mum understand that his behaviour was trauma as a result of the experiences he'd had, but that's very, very hard for the mum, because, obviously, she's been part of that system that's facilitated that. So, we did it gently, we got to know each other over time, we reframed things, we talked, we built a relationship. In the meantime, in the way that happens in services, a referral was made for a diagnosis, and the boy went off to see a specialist who sees things through a different lens, if you like. The boy came back and the mum phoned up and she said, 'Oh, he's had a diagnosis of conduct disorder, so we don't need to see you anymore.' Now, conduct disorder is just a description of behaviour. It doesn't say where the behaviour's come from, what's needed around it. So, it's just an example of how that shuts down a more contextual relationship and understanding of the difficulty. A couple of years later, I met that boy again in care. He came with his foster carers, and I recognised him and he recognised me, and I said, 'How come you've come to be in care?' and he said, 'It's because I've got a behaviour disorder.'

That's what I feel we're constantly trying to unpick and work within and change, and that's why we're passionate about it being a much bigger issue and children's distress being recognised as signals of distress rather than signs of disorder.

The problem as well is that, when children are given a label, it's kind of like it's out of their control what they can do about that situation—and not just children, but young people and adults as well. Even though they think it's going to access more support services, it doesn't always act that way. We can work with them to understand the reasons why things might have become that way—so, trauma, for example—and we can start building ideas of how we can move forward, whereas a label implies, sometimes, to people that, 'I can't do anything about it; I'm just how I am.' That can have a huge negative effect on mental health even further, so it's like a cycle, isn't it?

Okay, thank you. Mark, on the role of educational psychologists—if you want to explore that more.

Yes. In some ways, I've found this inquiry a little frustrating, because there seems to be quite a substantial gap between what we hear from health professionals such as you, and what we hear from teachers and headteachers at the schools. Unless there is a high level of deprivation and a lot of specific grants associated with that, there just don't seem to be the resources or availability in schools of this type of psychological input. I just wonder what you'd say to that.

I do think that there is a lack of funding, which does have a knock-on effect on the types of services that people can offer and the support. But, again, as I was mentioning earlier, a lot can be done from consultation—from one session with one psychologist for one pupil. You can learn about reframing different ideas about a person's behaviour. Sometimes we do group sessions where we try and unpick what might be going on with that child, and embedding that type of thinking can have a huge positive effect in itself. So, it doesn't necessarily mean loads of cost and loads of resources all the time. I think the huge issue is that big cultural shift, which is what we were saying, and we are really well placed to be able to help people understand that as well, I think.

And I think the timing is right. I think lots of people are recognising that—trauma-informed services, ACEs; it's very much the language that is being spoken, and I feel we've got the skills and the intervention skills, but also something that we're passionate about as psychologists is that you provide the lightest touch possible. If we can stop a child coming to see us, that's the best possible outcome. If they see us once, that's the second best possible outcome, and it's only with children where everything else—all the context—is absolutely where it needs to be and supported that we will do individual work and prolonged interventions with an individual. So, we don't want to see lots of children. We want to help society to think psychologically about children.

I also think that schools need support to understand how their funding can be used as well because, obviously, with that huge pressure on achieving outcomes and attainment, there is a focus on their funding to be spent on that, and maybe they're not understanding how that emotional and well-being aspect is part of that as well. So, it's reframing those constructions around things and their understanding of our role and everyone's role as well.

Is it appropriate that this funding is only available for more deprived areas? You were talking about your work with Flying Start. Are the problems much more prevalent there or are they in society as a whole?

Within the Flying Start areas, it's very appropriate funding being allocated to that. There are lots of issues within the Flying Start areas I work with and, like I said, they are generational as well, but I don't think that it means that the funding should just be given to those areas, because this is a problem that's entrenched. Even in children who are high achieving with the best backgrounds, sometimes, the mental health needs come across just as much. You can't differentiate as such. I think it's important to have that understanding and to break that stigma, again, about mental health as well. A lot of things don't come out in research because some of the most complex children never access or aren't able to access the support so they don't come up in the research.

I've found in some of the more affluent areas, in the schools that are high achieving, they're often higher achieving because they're perhaps starting the GCSE curriculums a bit earlier, so I'm seeing children who may be in year 9 who are now starting GCSEs and the pressure from that—. Okay, with me, they've got health conditions as well, but it's targets, targets, targets. And, actually, a good school in Cardiff, where people would move to to get in there—but, actually, because of that, the pressure that's being put on them and some of those children aren't developmentally ready to be doing that kind of educational, academic work—. Yes, the children I see have got an extra burden with their health conditions, but it's not just all about the deprived areas that need that support as well.

Llyr on this. 

Sorry, can I just have one more on this? Does that mean, therefore, that we need a different model of funding with the education authority or the health board having responsibility for providing at least a basic service so a head or a teacher can ring up and perhaps get that advice, the reassurance from an educational psychologist on the phone? I mean, isn't that something that needs to be provided at the authority or health board level, rather than expecting schools with very bare-bones budgets to be able to pay for that out of that budget?

Yes, I think more funding does need to be provided to schools to be able to do that, absolutely.

Yes. From the schools I speak to where perhaps it isn't me and it might be that the educational psychologist is best placed to do it, they've got this amount of money that they can spend on the educational psychology pot and this many children and they've got to allocate it and they've got to make some really difficult decisions. So, I'm lucky in my post that, if a child's got cystic fibrosis, I can see them and then I'm flexible in terms of what I can provide that child with. So, some of us will be able to go a little bit above and beyond to help that child in that school, but that's because they've got the health condition and they're on my caseload so I'm able to do that. But, for lots of other teachers, there are lots of other children I know they're worried about but they're not going to hit the radar for that threshold to see the educational psychologist often because they're tied up doing the statutory assessments.

Yes, that's what I mentioned earlier. There's a huge amount of pressure, obviously, on doing statutory assessments, which leaves little time for doing this mental health focus on things in an educational setting as well.

Are the statutory assessments worth while, in your opinion?

I think that, for particular children, again, they are going to be. For some other children, they're not going to be. Again, it's based on the individual. It's not something that I could just answer across the board, I don't think. I think that we do need to encourage a different way of thinking because, sometimes, statutory assessments are kind of a reach out for the help that isn't there. I think that we just need to get more creative generally across the board about how we think about assessing and meeting needs within a school.

And I think it's about the building blocks of emotional well-being that need to be rooted right at the start. I'm a very passionate advocate for something called Roots of Empathy, which is a programme that was developed in Canada and is now worldwide and has reached nearly 1 million children. What happens is that a parent and baby come into a classroom for a period of a year, and the children learn about their own emotional well-being through the baby. So, they have to guess how the baby's feeling, what the baby's temperament is, how the baby feels when certain different things happen. It's a very, very powerful learning tool for helping children get in touch with their own emotional world. The research evaluations are really powerful. They reduce bullying and increase pro-social play. And it's a universal programme, so you don't target it at the children most in need.

Empathy is important throughout our society, and having that as part of how educators see their role, I feel, is fundamental. It's been amazing to watch. I worked in a couple of schools in Canada where the programme had been embedded for 10 years, and teachers were holding lotteries to have the programme in their classroom. It really helps them because they learn to see their children through a different lens. But the power of the baby, and that unconditional positive regard, is also really helpful for the children who are most distressed, because the baby doesn't judge them at all. They lock eyes and they fall in love with each other and they learn through that relationship.

But you're not aware of any of that happening in Wales.

I'm trying very hard to get it over here. England has taken it on board—the early intervention foundation in England is very signed up to Roots of Empathy, and I know that Scotland also are developing it there. I think Action for Children did bring it over here temporarily through lottery funding, but unfortunately that funding was lost.

I just want to pick up on this conflict, if you like—although maybe that's overly dramatic—in terms of academic achievement and emotional well-being and the pressure being put on individuals. We know that the curriculum is being reformed, and I'm wondering whether you have any involvement or any knowledge of what's happening in that respect. Well-being and emotional resilience are going to feature more prominently in that, so what would your message be to Government around that reform?

I don't have direct experience, but what I hear is what young people tell me or what I see as a parent myself as well.

I'm really excited about the changes to the curriculum. I think it's a real opportunity. I would say: get Roots of Empathy in every classroom. It helps the teachers, it helps the children, it helps the parents with new babies who are frightened about understanding their baby. So, that's one example. But the most important thing is: make it universal, make it embedded, make it part of how teachers see their role, rather than a bolt-on, and certainly not, 'This is mental disorder, and this is how you recognise it.' I have real alarm bells about that sort of approach.

And 'Here's the school counsellor'.

Absolutely.

Okay, thank you. Mark, did you want to ask about the psychological therapies?

Yes and I wonder if I could follow up on the specialist advisory group. Our predecessor committee had concerns raised about the competence of some of the clinicians and others involved in delivering therapeutic interventions in this area. I just wonder: is that something that has improved since that evidence was given to us? What would be your assessment of the current state of play?

I think the timing of my career break was really opportune, in a way, because Together for Young People happened while I was away and I came back to a service, and services, that felt quite different in that they were much more focused on psychological interventions. Obviously, I'm really delighted about that, but what I would say is that the training is for existing professionals who are very steeped in a particular model and way of understanding—it's not about psychological formulation, which is what we've been talking about. It's more single modality therapeutic approaches, and also it's very hard to embed that and have ongoing consultation and support.

So, I think there's definitely been a shift. It was recognisable, the difference, when I came back. But, again, it's very much belonging up here in terms of its approach, which is what we're keen to broaden.

Do we have your diagram in written evidence?

We don't. I was going to ask if you could supply it to us.

Yes, because you've referred to that several times.

I've got a presentation about how we've come to this conclusion, so I can forward that, maybe.

Thank you.

I think the other point that was made—and, again, I'm not sure whether this is as much of an issue now—was that referrals were being made to particular programmes, perhaps your single modality sort of programmes, because they were available rather than because there was an evidence base that they worked for the type of patient being referred. Is that as big an issue as it was, or has there been some improvement in that area?

Within our own service, I think it ebbs and flows. I think when everybody's in post and everybody's up and running then there is a good range of services, but we're such small services that changes such as maternity leave or sickness or a spike in need elsewhere mean that people are redirected, and means that it's very hard to keep that breadth available. But I think, in theory, that's the aim, and the choice and partnership approach—I'm not sure if you're familiar with that, but that's an approach to delivering CAMHS, again at the very top of the triangle—is an approach that really aims to have a consultation with the family and facilitate a choice of which approach is going to fit best. So, I think the intention is definitely there. I think resources mean it's a real struggle at times, and often we're recycling the same staff into different jobs.

And that sort of meeting with the family to decide what sort of approach is appropriate: is that the initial assessment, for which I think we have the 28-day wait?

Yes.

And what then happens in terms of referrals to other interventions? What are the waiting times like there?

Again, it varies hugely, and it varies according to the team at a particular point in time. So, again, I manage a number of psychologists who work into CAMHS into different teams, and they get very excited when their team feels well resourced, and that they can respond in a timely way, but it doesn't take much to slip. It's a precarious resource issue, I would say.

Thank you.

Thank you. John.

In terms of referrals to specialist CAMHS, we've heard from the psychiatrists that it's necessary to have thresholds and restrictions in place to make sure that there aren't unnecessary referrals and that those specialist services are available for those who most need them. But perhaps primary care isn't sufficiently in place at the moment to make that work in an optimum way. I take it from what you said earlier that you probably support the view that specialist referrals should be more limited in terms of the model that you prefer. Would that be right?

Can I answer this one? I think the question, and the committee asking the question—whether the number of appropriate referrals to CAMHS has been reduced—is, really, something that triggered a lot of our discussion within psychology to come up with this model. We undertook a gaps analysis funded by Welsh Government into referrals to CAMHS and what the gaps that that left were, and the research is really consistently saying people only refer children that they're most worried about. So, the idea of considering them to be inappropriate is quite challenging for us. That a clinic-based intervention or a diagnostic intervention is the intervention of choice I would challenge. That they're worried about these children—that these are mental health issues—is something that I feel quite passionately about, and we in psychology feel passionately about: that they need support and they need specialist support, but it's not necessarily a within child CAMHS model.

So, in terms of restrictions, as the psychiatrist believe should be in place, would you support their view on that—that you do need to ensure that those referrals to specialist CAMHS really are there for those who most need them, and others that perhaps are not at that level shouldn't be referred? Would you support that view?

I would take a different view. I think having open access to support and consultation is much more important than building a barrier. I think it has the opposite effect, ironically. It's a bit like advertising for luxury goods. If it feels like you can't get it, you want it more, and that's how that culture's been perpetuated. So, I would challenge that and say that open access to consultation, and I suppose what I would be saying is instead of asking whether 'Does a child have a mental disorder?' is the question that dictates whether you get a referral to CAMHS, or 'Are you worried about this child's mental health?', I would prefer a situation where you asked, 'Do you think this family's resourced to make use of a clinic-based intervention, or do you think a community-based intervention would be more appropriate? I think if referrers were given that choice then there are very few families that would actually pursue the clinic-based intervention, because they know that their families would struggle to take that up. But what they need is an equal and equivalent access to specialist support so that they can be reassured, because they're genuinely worried about these families.

If I can give you a very, very extreme example, we know from the Romanian research into autism that children who are brought up in very, very traumatic and neglectful environments, they present in exactly the same way as children with severe autism. So, it's really difficult to unpick. That's obviously an extreme example, but we've got lots of overlap running, if you like, all the way through. For some children, their signals of distress look exactly like a mental disorder, so spending time trying to unpick that doesn't feel helpful. I think the adverse childhood experiences research really, really demonstrates that—that what happens in a child's life impacts on them physiologically and physically, so having services that are organised around separating what those are, as opposed to 'What does this child need at this point of time, and what can they access?' feels really important to challenge.

And in terms of the boundaries in specialist CAMHS, thinking about the staff that work there, some of our colleagues and other members have said that by having those boundaries that mean that only certain children can get in, there are staff that are very skilled in working with children who are very distressed, but then they're not able to share or cascade those skills down, whereas a one-off consultation with someone who's very skilled in one area might benefit a child, but because they've not got the diagnosis, they can't get in to see them. So for us, from psychology, we'd be looking more to loosen those boundaries and have a bit more flow between the tiers so that, if there's someone there who could help this child here, why not match them up rather than mean they've got to jump through lots of hoops to get there? More often than not, over time, that child and that family will be struggling more and become more and more distressed and their circumstances deteriorate. So, yes, you need specialist skills to deal and help with families who are very distressed, who have a significant level of health difficulties and those kinds of things, but equally, one-off consultations, or just being a little bit more flexible in that system, would be more beneficial to some of those children perhaps who are waiting for primary mental health or whatever. So we probably take a different view from the psychiatrists on that one.

We mentioned earlier about some of these children who are proposed to need more specialist help and have great difficulty even in engaging with services, and their families engaging with services. So, if we shut one level off, they might never be able to even access the real, intense support that they need. It has to start at the level at the beginning, and build on those relationships in a lot of cases as well.

Okay, thanks for that. Moving on then, Chair, in terms of those with co-morbid mental health difficulties, are you confident—I think this is probably a question for you, Liz—that developments such as the CAMHS pathway have done enough to address the variations in the way health boards were previously implementing those access criteria to specialist CAMHS for those with co-morbid problems?

It's a difficult question to answer as a psychologist, because I wouldn't use the language of 'co-morbid', because that is disorder with disorder. So, I would challenge that anyway. But what I would say is that I do think—and again, I think having been out of the country and come back, there is definitely a shift in trying to be more consistent, and services trying to develop along lines that are more consistent, I guess, as opposed to the very patchy and idiosyncratic service delivery models that we've seen historically. So, I think there are attempts, but again, that's very much at the top. So, it's hard to comment without making my usual point.

Okay.

Just a final question, then, from me. Liz, you said that you would prefer to ask whether a community-based approach is more appropriate, or a clinic-based approach. But isn't the nub of the problem with all these referrals to CAMHS the fact that the community support just isn't there, certainly in a consistent way across Wales?

I think that there has been a huge loss in front-line staff, absolutely. Also, I think that funding streams mean that a lot of the support that's available is short-term and has to fight for survival for the next round. So, I think that is a significant and big issue. Having said that, there are some people there, and let's help them to do the best job that they can. So, I don't want to be defeated by it, but I would absolutely say you're right.

Going back to the question about early intervention, those front-line relationships with families are absolutely at the root of change, because it is through a relationship that you have change, and even in all the evidence-based therapies at the top of the triangle, the key core factor that comes out is the relationship and the alliance that you have with the person, regardless of the technique and the approach. So, it's not to be underestimated, and the current system underestimates it by making it remote and specialist. So, that's what I would say.

And if you got to choose what the priorities were for the Together for Children and Young People programme for the next 12 months, what would you say they should be?

Early intervention and prevention, absolutely, but recognising that that needs to be down here as opposed to here. And also a recognition that this is mental health too, and that these are some of our most troubled children.

And that it's equitable across all of the areas.

Okay. Well, we've come to the end of our time. Can I thank you all very much for attending? It’s been a really useful and interesting session indeed. We’re very grateful for your time. You will be sent a transcript to check for accuracy in due course, but thank you on behalf of the committee for your time.

Who would I send the presentation to?

If you do it through Deryn, we can—. 

Yes. Thank you. 

We’ll move on, then, to our next evidence session, which is with the Time to Change campaign. I’m very pleased to welcome Lowri Wyn Jones, who is programme manager for Time to Change Wales, Ian Johnson, who is a senior research and evaluation officer with Time to Change Wales, Sara Payne, who is a fostering practice manager at Barnardo’s, and Sandra White, who is central services manager at Action for Children. Can I thank you all for attending today? If you’re happy, we’ll go straight into questions. If I can just start by asking you if you think that the Together for Children and Young People has struck the right balance in terms of the emphasis across the four tiers of CAMHS, but particularly in terms of their emphasis on early intervention and prevention. Who would like to start?

Action for Children feel that there’s a gap between CAMHS and counselling. So, at the moment, it’s CAMHS or counselling. There’s a large gap that sits below the specialist CAMHS tier, which then impacts on early intervention services. So, we’ve got a lot of young children and young people who don’t meet the CAMHS criteria who then fall just short of that, and there are very little services out there to refer on to. We’ve worked with, in Wales, 22,500 children this year, and 41 per cent of those are displaying emotional needs and mental health issues. It’s a big issue. It’s a big issue.

I think from our perspective, balance is an interesting thing, isn’t it? You strive to create a balance and yet when you fund different resources and put more work in, the balance automatically changes and shifts because you’re identifying perhaps more issues than you would have if you hadn’t been focused on that particular area of work. So, for instance, with primary mental health, I think Together for Children and Young People has allowed more resources to be put into identifying and assessing children’s mental health needs, and because all of the energy has been targeted in that, the opportunities then for accessing psychological therapies has decreased, because although that’s what people want, that element of the services is less accessible to children, young people and families.

The third sector has a wealth of expertise and skills that can provide these services for these children and young people, but we need the funding to be able to deliver what’s needed. It is a big gap. Another gap is raising awareness with children and young people and professionals about what’s available out there.

Just to pick up on that and to highlight the role of the third sector within this model, anti-stigma work, which is the work that Time to Change focuses on, is almost the tier zero of the windscreen model, and we would always welcome anti-stigma to be part of that whole process, really, and strengthened across Wales.

Okay, thank you. That takes us on to Llyr’s questions.

Can you tell us a little bit about the work that you’ve been doing around the stigma stuff?

Certainly. Time to Change Wales was established in Wales in 2012, and we continue to work with adults, tackling stigma and discrimination in relation to mental health. That’s funded by Welsh Government and Comic Relief. More recently, we have embarked on a children and young people strand, which started in September last year, in 2016, not funded by Government, because of the sheer demand for anti-stigma interventions that are needed in schools. It’s a pilot, so the parameters are quite tight in terms of what we’re able to achieve within a three-year programme, and the interventions are broadly along the lines of inter-group contact and social contact with young people with personal experience and lived experience, sharing their experience within a school-based setting. The other delivery model is around mass population, young population social media campaigns. So, that’s the way that we approach it.

We work with nine pilot schools across Wales. It’s an all-Wales campaign; we’ve got cluster schools in the south, mid Wales and north Wales, and we provide support to teachers for that pastoral role. It’s a whole-school approach and that’s really important; it’s not just about providing education and awareness raising to the pupils, but looking at the parents, the wider school community and the teachers, which is very, very important. More broadly, we’re looking at the sustainability of the programme after the three years. We’ll have a lot of valuable learning, which we think might be valuable for this particular discussion, and we hope that there’ll be a legacy that’s left. A lot of resources and materials have been developed for every school in Wales to access, but the focus is very much on those nine schools to do very intense interventions and test that it works. That's really important: ‘Does this work? If it does, then let’s look at rolling this out further.' 

So what can you tell us about the preliminary findings of the work around helping teachers to spot the signs of mental health issues amongst children and young people, but also the best ways of working with children and young people to tackle some of these?

It’s not so much geared towards teachers spotting the signs. The aim is a reduction in stigma, and that stigma is something that is held at all levels. Reducing stigma towards people with mental health problems is the key goal. And we recognise that there are two different audiences within that in a school setting. One of those is about informing and improving the emotional response of people who may be stigmatisers in future, and the other is providing a level of support and normality for those who are currently experiencing difficulties of whatever sort.

We’ve started the project in the south Wales area with schools in Rhondda Cynon Taf, in Caerphilly and in Bridgend. Our initial findings are concerning in terms of the scale of the challenge that we’re facing. So, as part of the work, the starting point is a questionnaire and the self-report data on there shows that between one in four and one in five of the young people we’re dealing with who are aged 14 to 16 years—so mostly years 9, 10 and 11—one in four, one in five of those young people are self-reporting that they have personal lived experience of a mental health problem. We have a further 15 to 20 per cent who are saying that they’re not sure whether or not they’ve had this experience. So, we’re talking around 40 per cent of children in the schools we’ve worked with so far self-reporting that they have personal lived experience. That seems a very high number. But also, it’s quite in line with many of the experiences and other information that are being collected around this.

One of the issues that we’ve found is that that shows a need for mental health literacy amongst young people in Wales. A lot of people are familiar with labels that they might hear or see emblazoned in all sorts of red tops and literature, but are not always sure exactly what that means. So, part of what we’re doing is raising awareness and raising knowledge, but still one in four of the young people were saying that they think a mental health problem is when you find it difficult to learn new skills or information. Forty per cent are unsure if people are born with mental health problems, rather than developing them through society. We have some broadly positive impacts and outcomes so far, but there are still large numbers of people and it's also come out within the questionnaire that's been organised as part of this investigation that there are large numbers of young people who don't know where to turn and don't know how to access some of the services that might be helpful to them. As you know, as I've explained, we started off in south Wales, so we've been working with schools here. We've started moving westwards and moving northwards as the next 12 months take place, but we're hoping to have a fuller mid-point report at the 18-month mark, which is in a couple of months' time. 

What ages are we talking about here, when you say 'schools'?

We're focusing, as a broad campaign, on the 14-25-year-olds—

Yes. I was going to ask why.

—but within schools, specifically, we're targeting adolescent populations, starting around 14 and going up hopefully to sixth form. So, years 9, 10, 11 and sixth form. The reason for this is there are a number of potential benefits relating to that. Stigmatising attitudes begin to form in childhood and adolescence, so this is preventative work against future stigma being developed. Also, previous research from YoungMinds, for example, shows that around half of mental health problems are established—75 per cent of them are established in that 14-18 age gap, so this is an age where both lived experience and supporting friends is a hugely important area. What the international research has suggested is that stigma and lack of mental health literacy leads to delays in seeking help, and that compounds problems amongst these young people.  

Although, a lot of people have been telling us, clearly, that some of these issues are emerging much earlier in life, you know, when you look at the ACEs agenda and everything. I'm sure you recognise that, but I was just interested as to why the 14-25—.

We recognise it. I think the nature of the interventions that we do in schools—working with young champions, people with lived experience who come and share their story as well as help deliver the training—some of that content, we feel, perhaps wouldn't be suitable for under 14s; it could be triggering, occasionally there may be talk about suicide or those kinds of things. We've also taken very strong guidance and leadership from the programme in England—the Time to Change England programme—who've been running much longer and have a wealth of research. They start at 14 and upwards.

Can I also add to that that there are pockets of good practice across Wales, where, in primary schools, they are delivering emotional literacy programmes and part of that would hopefully be to develop a sense of empathy with each other?

I wasn't questioning the legitimacy of 14-25, but I was just intrigued as to why. 

Some of the international literature suggests—the contact model that we use, which involves people talking about their emotional experiences, that's slightly different to a pure educational model. So, some of the international evidence suggests that emotional resilience and empathy are not always fully developed at the age of 14, and so ensuring that there are positive outcomes to the intervention is also quite key. That's something we're monitoring on an age-by-age basis as we go forward with the project. 

Thank you. Mark. Oh, sorry—.

We believe that conservations need to start with primary school aged children because if they are to develop good emotional literacy and emotional health, they're going to have to learn these words very early on in life. As Sara said, there's some really, really good work going on across Wales in all the schools but it's very, very sporadic. We believe that every child should have the same opportunity of the same services at each point at which they need it. 

When we talk about stigma—just very quickly to add—of course, the most important people in a child's life, in a school, are the teachers. There's a missed opportunity perhaps looking at the way their training is delivered in order to make sure that it's underpinned, that they understand about attachment trauma, loss, and how that impacts—. Children display their behaviour; they can't tell you how they feel so they do it by showing you how they feel and sometimes that can be misinterpreted and, you know, things develop. 

Sandra, in your evidence for Action for Children, you called for a ring fence on funding for school counselling services. The directors of education, in the evidence they gave us, said there was some ring fencing currently, albeit that the headteachers, I'm not sure [Inaudible.] evidence either. Are you able to clarify what the situation's been with ring fencing and how policy's developed in that area?

School-based counselling was developed in 2008 as a result of the 'Clywch' report, which recommended that children get their voice heard and that they're able to have a safe space in which to discuss their feelings and emotions. So, it was developed by a panel of professionals, including Action for Children. They developed a bespoke toolbox and model, which was underpinned by a framework. In those days, it was grant funded by Welsh Government, so it was ring-fenced. So, every quarter they would report to the Welsh Government about outcomes, how it fed into the framework, good practice, numbers and distance travelled of the children involved, and the service. However, a couple of years ago it was put to the local authorities that they had a legal obligation to provide a reasonable amount of school-based counselling. So, in every local authority, that differs, and so there is school-based counselling going on of some sort, but it's not the same. So, for instance, in west Wales, there's a private consortium of counsellors who provide the school-based counselling across west Wales, which is very sporadic again. So, I think the focus here is on the word 'reasonable' amount. So, it should be benchmarked as to what that reasonable amount is, so that every child across Wales gets an average amount of school-based counselling, because it varies a lot at the moment.

Okay. And, defining 'reasonable'—that would lead to every child getting an average amount. Surely some children take this up more than others.

Pardon?

Surely some children will take this up more than others. It's not compulsory to see the school counsellor, is it?

No, no, it's not compulsory, because at the moment, in our Cardiff school-based counselling service, they get six sessions but the waiting list can be up to two terms before they can see the counsellor. 

The demand for school counselling—what's been the trajectory of that? We've had, I think, some references to stigma, and other evidence suggested it's fashionable in some quarters to see the school counsellor. What's been your experience of the level of demand?

Well, school-based counselling shouldn't be seen as the golden ticket to resolve every issue for every young child or young person. It's based around year 7 and up, so we're seeing a constant increase in counselling requirements for younger children, hence the discussion before about it starting in primary schools. And also, for us as Action for Children, we are providing the service at the moment and have been since the ring-fenced money was taken away. We're running at a deficit, but the need is still growing.

Okay. Just picking up on some of your phrasing earlier, could you describe to me what the difference is between a framework, a toolbox and a model in the case of school counselling?

A toolbox is the tools that they use to engage with the young person—

For example—what type of tool?

A resource, so within the session they could use an activity that's sort of been evaluated.

And the model and the framework—what are they?

The model and the framework will work within those structures. The school-based counselling is a very formalised thing that the counsellors work within, so it's a professional model. 

So, that's the model, and then what's the framework in this context?

It's the rules and regulations that they work within.

Okay, thank you. Could I ask the panel more generally how much collaboration there is between specialist CAMHS and professionals from the third sector?

What I'd like to do is to continue on from the school-based counselling question, actually, because I think it's a really good opportunity to highlight that you've got a counsellor in every high school in Wales at the moment, which is fantastic—it's been a great resource, it's become the go-to resource—so counsellors aren't trained in specialist CAMHS kind of issues. They're not trained to manage risk either, and they're having to manage waiting lists, and within waiting lists there are often risks. And if they're not part of a pastoral care system in a school, there are some fundamental ethical issues that are tucked up in there that I don't think people realise if they're not involved in it, in terms of managing risk and managing expectation. So, everyone says, 'Isn't it great we've got a counsellor?,' and, of course, it's great that there's one counsellor, but often, what you need when you see distressed children is to link in with a system that's around the children, and counselling doesn't do that. That's not what they're trained to do; it's an individual person-centred relationship mode.

So, when it comes then to recognising that the counsellor might be there to deal with issue-based work over a six-week period, and suddenly they've got a child in front of them with an enormity of different challenges, the counsellor isn't trained, either, to work with the multidisciplinary team. They haven't got the authority, if you like. Sometimes it works really well in schools because they're part of a pastoral care system, but there are other counselling models that would see them working more in isolation. So, it's very much pot luck what happens. With specialist CAMHS, you can't refer directly into them if you're a school counsellor, and I think that's another issue. They are professionally qualified, registered people, and yet their value is not always recognised. 

And the work they're doing with an individual student is confidential.

Absolutely.

How, then, do they then relate into the overall pattern of pastoral care at the school?

Well, that's part of the challenge, isn't it?

How would you like them to do that?

There are protocols. There's a toolkit that is essentially a way of making sure that everybody understands the expectation around confidentiality. Obviously, if there are safeguarding issues, then you have to be able to break confidentiality—well, I say 'break'; you would talk to the child about reasons for having to work in a wider safeguarding context. Other than that, it's tricky, and I think that's what the challenge is.

So, how widespread is the situation you've described, then, where you're saying that some school counsellors are effectively unsupported, really, in a role that does involve managing a high level of risk with children and young people?

Again, I think it's about the quality of the leadership in the school and whether or not they recognise that that's a dynamic that's playing out underneath their auspice. And, actually, they're not working in isolation; they would always get clinical supervision and they would have a clinical supervisor who they would be able to talk to about those things. But I do think that, again, the training is so different as a counsellor. I am a qualified counsellor, so I'm kind of able to talk about this. They're trained to be a counsellor; they're not trained to work in a school setting.

You have to be valued and respected and understood in that role to make the most of it. And you have to be able to work systemically, and that's not something that is generically done. It should be. I think the school counsellor should be much better built into that.

On the third sector issues, then, that Mark raised generally—.

Yes, I've got a particular question in terms of the Barnardo's work. You describe the commissioning process for local health boards from the third sector as 'complicated and difficult to achieve'. What reforms would you like in that area?

I think we've had a limited amount of opportunities, so, to date, our experience would be that, and it's because, I suppose, we're used to commissioning under a different framework. So, local authority commissioning we're well versed in, and there's a framework there—a partnership framework—that feels easier to negotiate. From a local health board perspective, perhaps we've had to spend a lot more time than we would've envisaged dealing with with the bureaucracy of managing the process and the system. It would be great if there was something a bit more joined up and integrated with commissioning that we could approach on an equal level.

So, Barnardo's, for example, do you have contracts with the all the health boards in Wales?

Hardly any. I can think of one, possibly two, and, having been involved in one of those commissioning arrangements, it was more complex than other arrangements I'm aware of, and that's to do with working in partnership. It can be done, but it's a challenge.

Why do other health boards not commission you? Are you not able to use where you have been commissioned to promote your services to other health boards? Is that what you see as part of your role or—

I'm not sure. They've tendered for services and either we decided not to engage in that tender, because it's not our bag, or we're not going to be able to actually deliver on what they need or want, and we have to back out and say, 'Actually, we can't do that', much as we'd like to. Maybe there's not enough money there for us to deliver either. Have you got—?

It's the same from an Action for Children perspective. We've got to look at what our specialism is, whether that contract that's up for tender is right for us and the young people that we're involved with, or whether it's cost-effective. Is it sustainable, because budgets are reducing year on year? It's very difficult to make that decision, because we know, as senior managers, that that service is very, very much needed, but yet we've got our own systems and procedures to follow, and it has to be sustainable.

And we have to be able to meet the outcomes. There's a massive integrity issue for us as third sector organisations. We're committed and motivated to doing the work that we do to the highest possible standard, and, sometimes, when we look at tenders, we know that that would be compromised, potentially. Therefore, unfortunately, we don't go for opportunities.

Thank you. Llyr.

Funding is always an issue when we talk about the third sector, and, as someone who has spent most of my working life in the third sector, I can testify to that. But I'm just wondering whether you have evidence of projects on the ground that are working with children and young people around mental health issues that have very insecure futures or have questions around them because of the short-term nature of the funding in the sector.