National Assembly for Wales

Good morning, everyone. Can I welcome you to the Children, Young People and Education Committee? We've received apologies for absence from John Griffiths and Mark Reckless.

Are there any declarations of interest? No. Okay.

Item 2 this morning, then, is our twelfth evidence session for our inquiry into the emotional mental health of children and young people. I'm very pleased to welcome Sally Jenkins, head of children's services, Newport City Council, and chair of All Wales Heads of Children's Services; Annabel Lloyd, head of children's services at Merthyr Tydfil County Borough Council; Suzanne Griffiths, director of operations, National Adoption Service; and Councillor Geraint Hopkins, Welsh Local Government Association, deputy spokesperson for health and social care and cabinet member for adult and children's community services at Rhondda Cynon Taf council. So, thank you all for attending.

If you're happy, we'll go straight into questions. If I could just start by asking about the general responsibility you have for the welfare of looked-after children and in what way children's services are working with child and adolescent mental health services to align services, ensuring that looked-after children do get the mental health support they need.

I'll start, but I've no doubt my colleagues will contribute. Obviously, the local authorities have the primary responsibility for looked-after children. We hold parental responsibility for the majority of looked-after children. Sometimes we share it—we may share it with parents—but very often we hold that responsibility. And, as the corporate parent, whilst other agencies also have a responsibility, that technical ownership in terms of responsibility for those children sits with us. I would say that looked-after children are all our responsibility. As a society, our looked-after children are our most vulnerable children and are inevitably children who experience significant emotional and physical disadvantage. I think, as a society, we all have a responsibility to those children.

In terms of our relationship with CAMHS as local authorities, clearly, what we have to do is try to work to ensure that the needs of our children across the piste for all of their well-being domains are met, and we struggle. I think it would be disingenuous for me not to say from the outset that, as local authorities, we really struggle in accessing sufficient emotional well-being support for looked-after children. And I think one of the things we almost really need to start to say is that, whilst we absolutely support prevention and early intervention as the driver in terms of emotional well-being for children, our children need services now, and they very often need services that are about children who've experienced acute trauma and distress. So, whilst we would support, for example, moves away from a specialist CAMHS towards a wider service delivery, for us, specialist CAMHS is still hugely important, and our current position for looked-after children, I suspect across all twenty-two local authorities, is that, despite valiant efforts, we struggle to access those services for looked-after children.

Okay, thank you.

I—. Go on, I'll come in after you.

I just wanted to add what we've been trying to do within the arrangements for the National Adoption Service to kind of promote the relationships with CAMHS. Obviously, the National Adoption Service isn't different to local authorities; it's just an organisation of those services in a particular way. What we've needed to do—. It's actually been quite difficult to break in to the Together for Children and Young People programme to actually begin the dialogue about what might need to change. We are nearly there now, but it has taken some considerable time, and I think we found ourselves needing to go back to scratch in terms of recreating relationships that we thought were there.

So, I found myself setting up a meeting between the Welsh Government CAMHS adviser, clinical directors and the managers for adoption services to actually get them talking to each other so that the types of services that are sometimes available in terms of consultation and access to referral to local authorities—sometimes, not always—can be available to adoption services as well. There does remain a misunderstanding about the entitlement of children who are placed for adoption prior to the adoption order being granted—their entitlement to assessment for services and access to them—and there's a lot of work that we need to do, and I hope CAMHS will work with us, to actually get that to a better place.

Julie.

Just on that point, you said 'prior to the adoption'—the need for the services. But what about post adoption? Isn't there—? What about access to services then?

Well, I think that the issue is, really, that actually the assessment for adoption support starts pre-adoption and actually needs to move through and continue to be available. So, regardless of a child perhaps changing location because they're moving with their adoptive placements, or their legal status changing at a latter point where the adoption order is granted, we're advocating that actually they should continue to be able to be entitled to access services and actually have some priority for services, but that doesn't happen.

It doesn't happen.

It doesn't happen, no. No, it doesn't happen, and that's one of the things that we hope, in future, we will be able to address.

Which would help with the stability of the placements.

Absolutely. In the same way as that kind of ongoing continuation of service, where it can be accessed, needs to continue for other looked-after children who may change location. There is a bigger issue about whether the service can be accessed, which I think is where Sally came in.

Yes. Thank you.

Annabel would like to speak.

If I might add that, in the way Sally's described, our transformational legislation means that the focus on early intervention and prevention is greatly welcome, but there's a great here-and-now need with our looked-after population. And there's something about prevention of escalation of need for that cohort of young people, and making sure that we get services right here and now. Prevention in that sense—prevention of escalation of risk and need—means that we'd be much better placed to address need for future generations as well.

And dependent, I suppose, on the client group that we're talking about, mental health services can be seen as both preventative and dealing with symptoms as well, can't they? They can be seen from both angles. So, from our angle, obviously, we see them, very importantly, as part of the early intervention and prevention strategy—prevention of escalation. It's very difficult to see, at the moment, how we can adequately deploy those resources for early intervention whilst almost all the resources in this area are being taken up by dealing with symptoms when they reach that escalated point. So, it's how we try to turn that around within that.

Okay. Thank you. How confident are you that the initial assessments on the emotional and mental health of those entering care are thoroughly and consistently carried out across Wales?

I think we're not. I think what we currently have is a position where the primacy of children's physical health is reasonably well met in terms of those assessments, but emotional and mental health is not assessed in the same way. I suppose our position would be that, ideally, we would like the support of colleagues to be able to fully and adequately assess those needs at the point where children become looked after, or even shortly before then. Because, ideally, what we're looking for is a solution for children prior to coming into care, and we don't have that. So, I think, in terms of that really thorough understanding and assessment of children's needs, it's not a given that all children are assessed in that way by a specialist in any shape or form. Whilst social workers, I think, have some real skill in understanding emotional well-being in the broader sense, in terms of specialist psychological and psychiatric support for those assessments, that's not currently an automatic given for the vast majority of our children.

When you say 'support of colleagues', you mean colleagues in CAHMS.

I would mean colleagues in CAMHS—specialist CAMHS and early—. But both, yes.

Okay. Thank you. Julie.

Right. Thank you very much. Just before I go on to what I was going to ask here, you said right at the beginning, Sally, that it was the responsibility of everybody, the emotional well-being of children. Do you want to just expand what you think can be done about that so that we're all generally more aware and supportive of the emotional stability of children?

I suppose, like many in this room, I remember 'Everybody's Business', and I remember absolutely the agenda, which was that children's emotional well-being—not just looked-after children, but all children—is our responsibility as a society, and I absolutely accept that. I think one of the difficulties that we've had is almost, if you look at where we are now, the responsibility of that has almost been—. Again, I don't want to be too critical of colleagues in this, and I recognise there is some really strong and excellent work taking place, but I think, very often, it almost becomes, 'Well, other people pick this up rather than colleagues in health', and I think that's become really challenging because other areas of the public sector and the third sector don't have the resource to do that either.

I think in terms of strengthening, the kind of models that I think we see where the relationships work really well are where we're able to access support and consultancy for other workers, for example from specialist CAMHS professionals. That can work really effectively, and we do have some models within our services linked to, for example, the south-east Wales adoption service, where that's worked really strongly. So, I think those sorts of models of offering that are really important. I think enabling and strengthening all professionals to recognise their roles in children's lives and consistency—but that is about confidence, and very often even professionals don't have that. We need that support from specialists in order to grow that confident workforce to take that forward for children.

Thank you. I just want to follow up, I was going back—

Shall I bring Llyr in now? Did anyone want to add to that? No. Llyr.

I just want to ask a few questions about referrals to CAMHS, because it'd be good to have clarity, really, on whether there are any restrictions on referrals in terms of social workers or looked-after children's nurses. Do they only take referrals from GPs, for example, in some areas?

There are some different approaches across Wales. I think what we particularly want to convey today is that in our legislation we have a shared understanding of the definition of 'well-being' and what that means, but what we're operating structurally in terms of governance are often two different systems with different measures of performance, and what is ostensibly—whilst there are features of holistic multi-use assessment—a medical model where diagnosis carries with it the weight of access to certain services. I think what we're advocating today is that where we'd like to be in the future is a 'team around the child', where that shared understanding is lifted out of legislation and into day-to-day operation, so that, right from the very early days, there are no barriers to accessing the correct professional at the correct time throughout the journey of that young person, which will put us in a much stronger position to achieve the stable and successful lives that these young people should have, and should be having consistently.

I don't think anybody disagrees with that. The question is how do we get to that point, isn't it, really? So, what do we as an Assembly or the Welsh Government need to do to facilitate that?

I think one of the interesting things is the very fact that the questions about referrals probably takes us down the wrong road, because that suggests we're referring a child to receive a service, and I think if you look at—. For the vast majority of children, unlike with adults, where they have some degree of control over their lives, children don't, and particularly looked-after children. Adult models of services in mental health are predicated on adults being able to take some control, hopefully, over elements of their lives. Children just don't have that, so to even think that a referral model is of itself—. So, when Annabel says about well-being, it is about all of us working around that child as a package as an automatic, rather than children having to meet a particular threshold to enter CAMHS services, which is how the current system works. That's where the shift would come, away from referring for specific individual service to almost an assumption that all looked-after children would be part of a system where the professional shared responsibility for them.

So, that's a big cultural shift, but also a big demand on resources—additional demand.

Well, if you look at what the current demand on resources is, we're not meeting the need in any shape or form, and the way that we currently distribute the resource means that, very often, children fall out of that system and, further down that line, are costing us enormously in terms of resource as a nation. For those individuals, that cost is beyond belief.

Could I just add that I think something else that would be very helpful in terms of those children and young people, sometimes, who leave care into other arrangements, is that, actually, we could have a better understanding and entitlement for formerly looked-after children who require services? As it stands at the moment, the Social Services and Well-being (Wales) Act 2014 did not change the entitlement arrangement in the Adoption and Children Act 2002, so we've got a dual system. And, actually, whilst I would not advocate—we don't want or need a pseudo looked-after system for children once they're adopted, but we do need to be able to ensure that adopters and services, where necessary, can continue to access the services that they need, which are linked to their early childhood experiences. We don't have that arrangement in Wales currently. That's something that I think would be worthy of some consideration.

Okay. I'm being drawn back to referrals, unfortunately, because that's the reality on the ground at the moment, and we know that around half of those who are referred to CAMHS actually meet the threshold and get the services. So, we're very aware as a committee that there's a layer, a very broad seam, of people beneath that who don't get to CAMHS but clearly need particular support and services. So, for looked-after children particularly, do we see those children being referred to school counsellors? What happens, because there is a worry that's been articulated to us that school counselling services are diminishing—those services are evaporating, many of them, and really they're just being left high and dry?

The reality for the majority of the children who we look after is that, yes, they would have access to school counselling services in the same way as any other child would. What a number of local authorities have done—as Care Inspectorate Wales, as now known, in an inspection two years ago highlighted—is that local authorities have created solutions themselves to this issue because they're not able to access services for children who may not have the diagnosis, but their presentation is actually the same as the children who do have a diagnosis. I think that's one of the dichotomies, always, with this area of work.

A number of local authorities have funded and employed psychologists themselves, and they have funded solutions to some of these types of issues to provide that support for children. One of the things that we raised in our paper, for example, is very often being ordered by the family court to provide therapeutic solutions. Local authorities are paying for those solutions, because they are unable to access them through CAMHS in a timely fashion for children, and that is a real drain on a local authority resource that, again, as all will be aware around this room, is a diminishing resource.

Our colleagues in the judiciary—I would hesitate to speak for them, but very often we find ourselves in a position where we are being ordered in to commit for long periods of a child's life in order to ensure therapeutic interventions. All of us will have examples of paying for those rather than being able to access them through CAMHS.

I know you said you don't want to create a sort of pseudo looked-after children service in this respect, but should looked-after children be given some sort of priority within the system, then, and if so, how?

I personally believe so, and I think that priority needs in some way to be extended to those children who have left care, but will still retain some adverse impact from their early childhood experiences.

Tiers of systems I struggle with, but I do think for looked-after children, given that the reason that they become looked after is trauma, and therefore they are a group of children who will always have a need for a service. And given the resource issue, it has to be for me a prioritisation for looked-after children and, as Suzanne says, for those children beyond the period of that looked-after status, then, for an adoption.

I think there is significant evidence. NICE can quote numerous reports of that evidence that looked-after children have a far greater chance of developing mental ill health. I think Sally referred earlier to our arrangements for the health of looked-after children being rooted in the postwar period when we were all very conscious of physical health. We weren't conscious of emotional well-being and emotional health, and I do think there is potentially an argument for considering whether routine assessments of children and looked-after children should include an assessment of their emotional well-being as well as their physical well-being.

In recent years, as we all know, all local authorities in Wales, and children's services particularly, have undergone a considerable transformation of services—let's put it mildly—under great financial pressures and increasing demand. We have had to, by necessity, change the way we do things. That has involved working in a multi-agency way with partners across health and across regions, and providing resilience for families by creating multidisciplinary teams. Here is one aspect of that that is not quite as integrated as perhaps it could be, and I suppose that's one of the messages that we need to get through today—that we need to include this as part of that multidisciplinary approach.

Thank you.

Suzanne, can I just ask—? Obviously, you will be aware that our predecessor committee did an inquiry into adoption, and it was a very strong message from that inquiry when we spoke to adoptive parents that they felt they weren't getting the support for the emotional health of the children that they'd adopted. Are you saying there hasn't really been any improvement, then, since that time in adopted children being able to access those services? 

Yes, I would say that there's been no discernible improvement. We continue to talk to adoptive parents, and most recently, in the autumn of last year, we were supported by the Institute of Public Care to do some small-scale research, and the messages coming back were exactly the same: 'It's a battle', 'We can't get it unless my child fits this particular small label' and 'I can't get a service'. The regional adoption services are in the same position as local authorities then, in terms of needing to find ways to fund alternatives for parents so that there is some service available so that things don't escalate into acute crisis. But, inevitably, that does happen in some situations still.  

Okay, thank you. The next questions are from Michelle. 

Good morning. The House of Commons Select Committee on education found that the lack of stability in placements for looked-after children in England was making it very difficult to provide mental health care to children who were looked after. Would you say that experience is being duplicated in Wales? 

I think there are two things in here. First of all, there's a chicken and an egg—the stability of placements itself. Placements become unstable because children have behaviours that carers find very difficult to manage because of emotional health, so you go round in something of a circle. We do know—and we absolutely know—that, sadly, children do move placement and they move across authority, and if they move across authority, they move across health board boundaries, and it becomes immensely difficult. Continuity of services for children if they move, particularly if they move authority, becomes really difficult for them. So, absolutely, I would concur with that, and I'm sure colleagues would concur that that is a really difficult issue for us. 

I think it doesn't take away from the fact that we struggle for all our children—be they in a stable placement or be they moving, we struggle to access the appropriate therapeutic services for our children. It is accentuated if they have placement moves, yes.  

I think part of the problem that we have is that it is a bit like having to e-mail your internet provider when the internet is down, really. Young people have these needs here and now, and if we're not able to address some of the emotional behavioural needs, reduce risk, manage behaviour, support professionals, support the team around the child, what you can see is the child spiralling away from that stable placement that they need.

I think one other point that I would add, really, is in terms of the cost-benefit analysis. Meeting need now and working with a team around the child has been proven through research to be effective in terms of prudent use of resources, and is the right thing in terms of outcomes for children and young people. And I think, so far, what we've commented on is about the service and system as it is now. I think regional partnership boards offer us an opportunity to look at how we could do things differently, and generate for us some structure around how we could look at developing more integrated teams around the child, where the starting premise is that all looked-after children have emotional well-being and mental health needs, and will need access to expertise at points in their journey. That would divorce us from having to have this dialogue about, 'Should a council provide a service, at what level, and to which needs do we need referrals?', because the assumption would be that the set of expertise will be there for those children and young people, and the team support for them.  

And children move placements; even if they move from Newport to Merthyr to Pembrokeshire, they have the same social worker. Whatever the faults in social services—and I have no doubt there are a myriad of those—they do retain the same social worker, the same team manager, the same service manager, the same head of children's services. Their health services don't follow the same trajectory. So, in terms of what Annabel's describing, what you want is the team to travel with the child, rather than the child to keep having to hop from one system to another, and whilst it may not be perfect in children's services, at least with children, when they're out of county, the same professionals know them in the local authority. That's not the case with health.

The cost-benefit analysis and the importance of the stability of placements has been clear within the adoption service as well, and I speak as the chair of the National Adoption Service, where considerable research has been done about the importance of putting in those resources for support now in preventing the escalation and the need in the future for much more expensive intervention when the children become older and, indeed, when they become adults, of course, and then becoming problems for the adult services as well. So, it's all about that cost-benefit analysis, which Annabel has said, and I don't know if Suzanne wants to say more about that.

I'm not sure I can say any more. I think the point has been well made—that, for adopted children, at the point they're adopted, we need to continue that investment in ensuring that their early childhood experiences don't adversely impact on their outcomes and their life chances. The fact of an adoption order being granted and a placement with a new family doesn't, of itself, mean that that's all sorted out. It can in some circumstances, which is why we don't want to force services on people where they're neither wanted nor needed. But actually, we know that at least a third of our adopters do need some support and services going forward, and that, at various points in an adopted child's life, things will bubble up and settle down, depending on what support is available.

Okay. Next question—Michelle.

Thank you. Did you—? Sorry. You've spoken about the difficulties—that provision of CAMHS support is more difficult when a child is moving from one geographical area to another. Have you had any conversations with the health sector about how that can be improved? Can you elaborate a bit more on the precise difficulties that you experience when looked-after children are going from one area to another, or indeed from foster care into residential or vice versa?

In terms of elaborating a bit more, can I just say that we've got a lot of questions to get through that I would like to get through? So if we can maybe have, unless you've got something to add, just one person.

Just one of us, then?

Yes, thank you.

Who's going to go then? Go on, Sally.

All I can say is that we struggle on every level to access the support for children, whatever sort of placement they're in. And, I suppose, to reiterate, whether they move or not, we struggle to access the service. When they move, it just complicates that process. Yes, we have all had discussions on an individual basis with health colleagues, and, again, there have been numerous discussions at a strategic level, and sometimes you can make that work, but it's not a given—it's not a given for any child that either they can access support, or if they can access support, that that support is portable with them, if they have to move placement.

Okay, thank you. Julie.

Thank you very much. We had evidence from the British Psychological Society and the applied psychologist, emphasising how important it is not only to look at the medical diagnosis of young people accessing CAMHS, but also the social, psychological, family and contextual factors that impact on how the young person presents themselves clinically on admission. Is that sort of approach embedded in CAMHS? Is that how they respond?

We do come across some really excellent practice, and we must point that out—that there are examples of holistic assessment involving professionals from a range of disciplines. But, of course, what we're highlighting is that there are barriers to getting there in the first instance and then, access to further treatments and interventions may be driven by a diagnosis. So, the medical model, just to repeat something, does still continue to dominate in a way in which—. What we're saying today is that a more psychosocial, emotional model is much more suitable to meeting the needs of these children and young people.

To illustrate, if you look at the governance and structures around that, looking at what we know to be a crisis in care for children's services, we have now got the ministerial advisory group, with a series of projects running under that looking at the national fostering framework, for example, and the issues affecting us around residential care. But an area for improvement is that 'Together for Mental Health' has another project structure reporting up to a delivery assurance group, and I think what that illustrates is that even at the highest level there is a separation in terms of a clear vision—where we agree it's the well-being outcomes. And we're going to sign up to that shared understanding of well-being and positive outcomes at the very highest level.

Thank you. So, how well integrated, would you say, are NHS and local authority therapeutic teams?

They're not.

They're not at all.

I think in some ways you could almost argue we've gone backwards. I think there was a time when there were social workers in some CAMHS provision. We were struggling, when we met earlier this week, to find examples of where that continued to be the case. I think in part my argument would be it shouldn't be how many social workers you have in CAMHS teams, it should be how many psychologists and psychiatrists do you have in local authority teams. I possibly could be expected to say that—

And are there any?

No.

Not one in local authority teams.

I think there are examples of people who work with teams, but I think we would really struggle to find any—

But not working together.

People work together. They work together for individual children and they work together, for example, with complex needs panels or Brighter Futures. But I think in terms of—I suppose as we touched on a few moments ago—a consistent, agreed, default position for all children of that multi-agency holistic approach to meet their well-being needs, no, that's not there.

Sally is correct. I think that the place where we would get nearest to there being some kind of certainly not integrated but shared work is in the example of what happens for the south-east Wales adoption service, where there is a psychology department funded by the health board that provides a certain number of hours per week to the adoption service. They work very closely, they spend time in the service, they deliver direct assessment and support to families and children as well as consultation to staff and are involved in training of staff and adoptive carers. That type of approach actually works very well and the early evidence for the project and the feedback from those service users who benefited from it was very, very positive. I think arguably that service could be expanded. If one health board can invest in that, one wonders why others can't. That service also acts as something of a broker into specialist CAMHS and it does tend to be the case that, when that service says to CAMHS, 'Actually, this family do need a service', that seems to ease the likelihood of that being made available. There are other examples in England of looked-after children mental health services where you have a range of professionals—psychologists, psychiatrists—working together, people who are specialists in neurodevelopmental disorders, because that's the other part of the jigsaw, really, in terms of the type of issues looked-after children are likely to experience.

You will know of the regional social services and well-being partnership boards that have been set up and are now in their third or fourth year. It's arguable—well, it's almost unarguable—that the boards so far—and I speak as the chair of the Cwm Taf board—have been largely focused on adult services. Good work has been done so far on integrating some, where health and adult services within the local authorities meet—you know, that central ground. Some really good work has been done in building accommodation strategies and in trying to reduce delayed transfers of care and hospital admissions and discharges. But, not enough has been done—and we've challenged ourselves in this, and you, I think, could challenge us to do more as well—to make sure those regional partnership boards are ensuring more integration and co-operation between health and local authorities, and the third sector, of course, around these services as well for children.

If I might just very quickly add, please, there is a range of workarounds, and we should see it for what it is. So, there are examples of local authorities buying in clinical psychology services, buying in speech therapy services, buying in interventions, spot purchasing individual therapies, in a way that are remedies to the situation that we have now, as opposed to a consistent, national, integrated approach. That would mean if I'm looked after and, for example, Merthyr Tydfil is responsible for my care but I live in Ceredigion, I know that I can expect to access the right services at the right time.

I mean, you do call for more access to psychological services, I think, in your evidence, but are there long waiting times for those psychological services at the moment?

We just don't get the package of therapeutic support that looked-after children want and need, and I suppose what Annabel refers to is that, very often, what we need to access, we need to access in a really timely way for children—

It's a package.

It's a package. It can often be quite specialist. It can be linked to sexually harmful behaviours or particular examples of trauma, but we are buying those because we find it so difficult to navigate the way through to access them with our health colleagues. I mean, again, I suppose, like referrals, the waiting times almost become specious for us, because—. And I think we're probably at fault, perhaps, at times, because we take an easy route, on occasion. It's easier to buy than to try to navigate, and quicker.

Particularly around the courts.

Yes, particularly around that. And once the court is involved, then there is no option, very often.

Right. Thank you very much. Obviously a long way to go, then.

Do you want to go on to secure accommodation, Julie?

Yes, sure. Going on to secure accommodation, you call for one national, integrated approach to assessment and support for young people who require secure accommodation that focuses on responding to the crisis and a safe and sustainable exit. How would you like to see this developed across Wales?

The number of children who require secure accommodation in Wales on welfare grounds is very, very small. So, in 2016-17, it was only 22 children across the whole of Wales who entered secure accommodation on the basis of a welfare order. Those numbers will be higher for 17-18—we know that already—but nonetheless, this is a tiny cohort of children. What we will be asking for is that—. In order to obtain a secure welfare order for a child and then a placement, you have to go through the court, you have to have a care order for a child, and the court then grants the secure welfare order. What we would be asking is that it is an automatic position for those children that CAMHS is also involved—in terms of the assessment, the assessment of the need, their therapeutic need—whilst in placement, and then, equally importantly, on discharge and step-down from those placements. Because what we currently find is that—. I mean, just looking at that cohort of 22, for example, they inevitably are children who are going to have significant needs. Whether they have a diagnosis or not, they have emotional needs. They are very often children with self-harming behaviours, behaviours that are injurious to others, behaviours that put themselves at risk, and yet, again, we find it really difficult to automatically get a position where those children are jointly assessed, and that's what we would be asking for. It's a small, tiny cohort of children. So, I think, in terms of resource, whilst there is an implication for resource, it's not thousands of children—it's really, really small.

I think the other thing we would be asking for is a continuation of that beyond the secure order, and looking at what happens to those children in placement once they come out of secure accommodation, and how we continue to care for them, because their needs don't go away. The other element that is linked to that is a much better understanding of the group of children who end up in hospital beds, as opposed to the children who end up in secure welfare beds, and I think some further exploration of the needs—the similarity of needs—between those children, the overlap—. Very often the dispute there is about whether it's a hospital bed or a secure bed, and how those two things work together. There is significant work being undertaken about the need for secure accommodation in Wales and that population, but I think it needs to be far better tied into what we're doing with our health colleagues. But that starting point of a shared assessment would be really valuable for those children.

Thank you very much. The committee did visit Hillside as part of the inquiry, and one of the things that we were told was that they urgently needed a step-down sort of accommodation, and there's a possible building in the grounds. What is your view about that?

There is an urgent need for step-down accommodation for secure—. I mean, there is an urgent need for accommodation for looked-after children across the board, particularly adolescents, and whilst secure accommodation is the sharp end of this, the need for accommodation—. I mean, Annabel's already referred to—and I wouldn't want to use the word lightly, but we are approaching something of a crisis, not just in Wales, but in England. The president of the family court is now running a whole investigation called 'the care crisis', and we are living this now. So, in terms of step-down provision, that would be one element of this, but it's also the provision for children before they need secure accommodation. We struggle on a daily basis with placements for this cohort of children and we also struggle for secure placements themselves. All of us have experience of having a secure welfare order and having no bed at all, and a number of authorities have had to cobble together arrangements for children who have met the threshold for secure accommodation and we've been unable to secure beds for them in England and Wales.

So, where do they go?

They go to a range of places that we put together. We held a child in a bungalow for three weeks with staffing from agency whilst we waited for a secure bed. We're not the only local authority to have done that.

Right.

In terms of step-down as well, and the provision, I agree and concur with the points made by Sally, but what I would express is the view that the step-down arrangements are likely to be highly unique, highly bespoke. There will be commonalities that feature, but they need to be designed around the specific needs of that unique individual young person and setting up a provision for a group of children may be less successful than setting up some excellent practitioners who can develop bespoke responses.

We want those children to come home, don't we? That's the other thing, that we would want children to be in their home area, and, again, whilst Hillside serves a certain population, a number of our children don't go to Hillside and, obviously, for our north Wales colleagues, a significant number of their children will go to arenas across the border.

Thank you. 

Hefin.

Can I ask your views on the Welsh Government's children and young people continuing care guidance 2012, particularly with reference to ongoing movement to adult services? Sally. I'm happy to critique it—

I have a little experience of it, which is linked, obviously, to our region, and that is that it's very difficult to access support and services for young people under that provision. In fact, at present, I tallied up—. I have none in the local authority that I work in. 

It doesn't work.

It's not successful.

So, the First Minister announced on Tuesday that this is going to be replaced. So, you'd welcome that? 

Yes, greatly. 

Absolutely welcome it. I'll give you one example. It's that, in the olden days, way back when local authorities, health and education very often came to what were called tripartite arrangements, where for children who needed those very specialist placements—very often children with learning disability, physical disability, autism and emotional well-being needs—and a tripartite arrangement was agreed, my local authority had one such child, and that agreement had held for a number of years. That child was assessed at 17 as being able to transfer to an adult placement at 17 and a half, which was absolutely right for that individual child. It meant he was able to go to where he was going to be for his adulthood early. The tripartite arrangements ceased. For six months, the local authority bore the whole cost despite trying to negotiate in terms of it. At adulthood, he immediately became eligible for continuing care.

I've experienced this with a constituent. 

Yes. And I think Annabel's point is absolutely made: I think, if you went to most of the 22 local authorities, currently accessing funding through those arrangements is extremely difficult, nigh impossible. 

Okay. So, with the review now announced—. Are you aware of the review of the guidance? 

I wasn't of the reviews, no.

It's news. 

It's news. So, welcome news. 

Right, okay. So, it appears to be in the very early stages. What involvement would you expect to have in order to improve the guidance for children and young people, particularly with regard to mental and emotional—

We would really welcome an opportunity to have very significant involvement in that guidance and an exploration of understanding that in the future. 

What form would that take? What involvement would that be? 

We'd like to be part of whatever review was taking place, be that panel, be that representation—however that would look we'd like an approach through the Association of Directors of Social Services Cymru and the Welsh Local Government Association to look at how we could be part of that. 

Okay. And what particular headline—? Is it too simplistic to say three headline things you'd like to see change? 

Shared understanding around well-being would be a really important starting point, because from there we can access those benefits around integrated services. That would be really helpful.

Okay.

I think it's about shared responsibility for children. Whilst corporate parenting is, very clearly, that the local authority holds that, I think there needs to be a really shared understanding that it's not children's services alone that holds—that it should be across health and education colleagues. So, I think that would be a really key message: it's a shared responsibility. So, you get into these ludicrous tautological discussions, which are, 'Well, the placement has to go ahead, so you have to pay while we make a decision'. And you're, 'Well, we know what your decision's going to be'. You just go round and round. It has to be a shared responsibility for children. Children deserve that. So, I think that would be a really clear one.

I think the other one will be about a shared acceptance, as Annabel says, of the needs of children, and again not tying ourselves up in knots in terms of, 'How much does a plaster cost? How much does this cost?' It would be actually an acceptance, 'This child need this placement'.

Although the current document says that it isn't a prescriptive tool. But you think it still doesn't work.

No, it doesn't work.

Okay. Thank you, Chair.

Darren, on this.

What are the barriers, then, to them making a timely decision? Why does it take them so long?

I don't know. Perhaps you could ask. I think it's difficult, isn't it? Financial decisions are difficult. These are very expensive placements. As a head of children services, a third of my entire budget goes on placements, and these types of placements are the most expensive. So, I think there's a financial implication in them.

Well, at the end of the day, it's the taxpayer picking up the cost, no matter which organisation pays, isn't it?

Absolutely, yes. At the end of the day, it's all our money, isn't it? So, I wouldn't know what the barriers were.

You know, I've been an Assembly Member for 10 years. I've heard the same stuff every time any committee like this looks into these aspects of different services, and it's very frustrating, because we know that there's legislation now, and there are frameworks in place for pooled budgets. We know that it's possible for the NHS, or for local authorities, to embed members of staff into each other's teams. Why is this still happening, given that those things are in place? Do we need something much more fundamental in order to make things work?

I think we probably do need something more fundamental. Like you, this is actually the third time I've given evidence in relation to children's emotional well-being. I can look back to 2002, when I first gave evidence in relation to—. And this was the same discussion. 

Exactly the same.

This hasn't moved. So, I would absolutely echo your frustration. Again, I'd have to take some responsibility for that, as a senior manager in a local authority. But I also think, for looked-after children, in particular—I hesitate to use the phrase, but we're left holding the baby. We have no choice; we have to care for those children. So, we end up doing it. So, I think, in some senses, it's almost like we have to do it because we can't not do it.

You've got no choice.

We've got no choice.

I think the other feature is that that change on the ground takes a long time to achieve because the legislation may have changed—

Ten years?

Well, yes, and absolutely, but actually I think that is the reality. We're three years into a national adoption service, and certain things have changed, but I don't think practice on the ground and understanding has changed enough yet. I will often say, 'It's taken us three years to do this—three years?', but, actually, when you're in it and you're trying to do it and you're working hard at it, there are lots of things that are pulling you back into the old way of doing things because everybody is very comfortable with that.

And much of the response to the Social Services and Well-being (Wales) Act has, as I said earlier, been around adult services so far—I mean in terms of collaborative working now, not in individual organisations. So, more needs to be done, and I think we all need to be talking about welcoming a lot of the work that's been done in adult services, but now saying, 'Well, how are you going to collaborate better now to resolve some of these matters with children?'

And also recognising that it's not just health, it's education, for children.

Of course, yes. Can I just ask, then, given that you've said that things will take time and the focus has been a bit-by-bit sort of approach in terms of implementing the new Social Services and Well-being (Wales) Act, how long is it going to take before local authorities and health boards have pooled budgets specifically that are used for the sorts of situations, Sally, which you described earlier, where you're having to pick up the tab for eight or nine months, perhaps, before someone becomes an adult or where you've got a young person who's very vulnerable, needs a secure or special sort of placement that would not normally be procured for any other child by a local authority—the NHS would pick up the tab? When and for how long are you going to be able to—

I think what's interesting about the pooled budgets element in this is, absolutely, what you welcome is the consistency and a way to do it without the squabbling. One of the dilemmas at the moment is that what you would be pooling is a local authority budget, by and large, because—

In terms of accommodation, but I'm talking about the clinical needs side of things, yes?

There isn't—. We're not getting that support and resource for this group of children. So, for the children that we currently have in secure accommodation, for example, that very small cohort, the vast majority of them won't have had any specialist support.

Even though their clinical needs require them to be in that place?

Well, their presenting behavioural needs would suggest that they would need it, but they don't have a diagnosis, so their needs are seen as behaviours rather than a diagnosis of a mental health disorder. 

And that's because of the problems in accessing psychological therapies and getting proper—

That may well be illustrated by us saying that I'm not sure you would be able to evidence a waiting list for those things because if that provision isn't available to us then you're not counting the clock on any waiting times, which adds weight to the point Sally is making, which is that a pooled budget is based upon the premise that there are two resources to pool together.

You've said that these are small numbers of children. Are you able to provide those numbers to the committee in order that we can—?

In terms of the children who require secure accommodation, absolutely, we have those resources— 

Across Wales, yes?

Oh, yes, absolutely, those resources—those numbers are well known and documented.

But those ones who require that provision because of a mental health issue, primarily a mental health issue.

Social Care Wales are currently undertaking a piece of work to look at the 22 children from 2016-17 and then going into 2017-18 to look at their particular needs, to look at where they came from, to look at the outcomes from those children. That work will identify that need. The heads of children's services—. I mean, the 22 children; you know these children. As a head of children's services, you know the children who are subject to secure orders. You know everything about them. So, in some ways, it's a very easy group of children to be able to access information about, but that piece of work from Social Care Wales will undoubtedly illuminate this further.

Okay, thank you.

Can I ask about attachment services? There is an attachment service in Gwent that's been developed. Have you got any evidence of the benefit of that? Is that something that you'd like to see elsewhere in Wales?

The attachment service in Gwent's been really welcomed. It was developed by the psychology services in Gwent and developed on the back of integrated care fund funding, which was really welcome. In terms of some of that funding being used appropriately for children's services, we're beyond grateful. I think what we're really clear about is that the individuals involved in developing that service have had a really flexible proactive approach to local authorities and to others, to colleagues in education, for example, and so have really sought out ways to work with us.

I made a decision to go on the training that they were doing with my staff, and it was great. It was really, really helpful, so, I think, nothing but praise for the development of that particular service. And that service does follow a model that I think we've kind of touched on, which is not about necessarily referring children and having a direct appointment service for children. It is very much about an enabling and consultation service for staff. It's about a whole approach for staff groups and for whole teams. And, again, it takes time, because to train whole staff groups—. My own local authority, for example, we've made a decision that our residential units will go through that process first, followed by our disabled children's team, because we felt that's where the first need should come. But a really welcome development and a really strong and positive use, and gratitude and beyond to our colleagues in psychology services for doing that.

Have you got any comments on that, Suzanne?

Only that I'm aware that it is a really positive addition. It works very well with the psychology service that's available to the adoption service, and there are some people in common that work within them. That type of approach isn't available in other parts of Wales. And certainly, in terms of adoption and attachment, adoption staff or our colleagues in the voluntary sector are actually in the business of trying to raise awareness in schools and sometimes in health provision, so that, actually, there is that level of awareness of attachment issues where it needs to be. There's a long way to go in terms of that.

Thank you. Llyr.

I'd just like to ask a few questions briefly about training, because we've had clear messages in evidence that teachers, particularly, require greater training because they're in the position that they are, in terms of identifying early signs of emotional and mental health issues, particularly in relation to initial teacher training, that there should be greater emphasis there, because there's going to be a greater emphasis in the curriculum as well. I'm just wondering whether there are any priority areas of training for teachers, particularly from a looked-after-children point of view, that you'd be keen to see developed.

I think training around attachment is really key, and a good segue from the earlier responses, really. What I see are opportunities to bring that training together. So, if we train professionals together who work together, we know that there's going to be consistency around the knowledge base of the skills, and being able to train in terms of how individual young people's responses need to be. So, as I see it, there is training available. It's positive, but there are opportunities to integrate that more in a way that we've talked about integration in other ways today.

Interestingly, the Gwent attachment service have also worked with the pupil referral unit. That same model is being used across a number of disciplines, and I think that sort of model of training for staff across a range of agencies, including teachers, is really, really helpful.

And is the training—? Do all foster and residential carers, for example, have training around this area? 

Yes. Absolutely.

In all parts of Wales?

Yes.

The fostering well-being programme, which will be evaluated by Cascade in the near future, is bringing together that training into one. So, foster carers will benefit from training with teachers who teach looked-after young people, speech therapists, clinical health professionals, social workers—a social worker for the foster carer and a social worker—. There is a model of delivering that that we can look forward to it being evaluated in the near future.

So, you're pretty content in relation to what's there, just that you need to be able to provide it to more people, or is that—?

There are opportunities for improving consistency.

Suzanne.

Can I just add that there are sometimes some difficulties when the training is voluntary as opposed to mandatory? Because you do find that those schools that are more welcoming and interested, and are able to manage more difficult children, will rush to have that training for their staff.

There are other schools that are less of that ilk that won't want it, won't seek it, and therefore we don't change those schools because they don't receive the development and the training. So, I think there is something about how—without being totalitarian—you can make sure that that is actually delivered through the system, where it needs to be.

Finally, then, we're all aware that local authorities are under the cosh financially. Have you seen any evidence that local authorities are reducing investment in early intervention and prevention as a result of those pressures?

I suppose it depends on your definition of early intervention. Many of us would say that universal services are the earliest of all interventions, and because of austerity, of course, much of our universal services have been hit by cuts: libraries, day centres—all of these things that are part, we would say, of maintaining resilience in communities and families—have all been touched by austerity.

Changes to grant funding to things like Communities First, we will wait to see what impact that will have, although the legacy fund is welcome. At that very basic level, that earliest prevention level, yes, there have been changes there that we probably wouldn't have wanted to have to make, but in terms of the statutory provision of services, we have maintained, and I think it's fair to say that local authorities have increased their budget allocations towards this area in the last 10 years, as the numbers of looked-after children have increased by 25 per cent in the last 10 years. Local authorities have responded and put resources there to meet that, but it's just keeping pace each time. We've had to change the way we do things to meet that, never mind the human resource element as well, and the pool of expertise that we've been talking about, which is also limited.

Okay, thank you.

The drain on local authority resources in terms of placements is significant, and inevitably that takes resource away from front-line social workers.

Okay, thank you. The final question, Michelle, on the family courts.

I think you've already answered it.

Yes, we touched on that.

Yes, thank you for that.

You're welcome.

Okay. There's nothing you want to add to that in terms of the impact on local authority budgets of having to pick up those services.

Well, we could probably stay here all day [Laughter.]

I am coming back next month to the Public Accounts Committee, which is investigating that exact matter.

And so am I.

Well, that will be a very useful overlap. Okay, well, can I thank you all very much for attending this morning and for answering all our questions? Your time is very much appreciated. As is normal practice, you'll be sent a transcript for you to check for accuracy in due course. Thank you very much. The committee will now break until 10.45 a.m.

Can I welcome everyone back for our next evidence session, which is with CWVYS—the Council for Wales of Voluntary Youth Services—and the Wales principal youth officers group? I'm very pleased to welcome Sianne Morgan, who is development manager with Volunteering Matters; Alison Mawby, who is project manager at KPC Youth in Pyle; Jo Sims, who is chair of the principal youth officers group; and Steve Davis, vice-chair of the principal youth officers group. If you're happy,  we'll go straight into questions. If I can just start by asking you about the Together for Children and Young People programme, you've got a lot of expertise in working with young people, yet you're not involved in the programme. Why do you think that is?

I think formally we might not be, but, locally, at the coalface, we might be. Our practitioners have—and I'm speaking generally; all local authorities and organisations are slightly different, but our practitioners all have their own networks—professional networks, professional links—with CAMHS workers, with primary mental health teams, et cetera, and, when you're working with young people in distress at the coalface, you usually know who to speak to for advice, support and guidance and signpost to additional services. So, whilst I don't feel we might be formally involved in a policy framework way, I do think at the coalface we probably are heavily involved with the agenda and are part of what happens, certainly at tier 1 level, in terms of young people's emotional well-being input and support level, if that makes sense.

If I could add to that as well, I completely agree with what Steve's just said, but I think also one of the reasons why, potentially, we've not been involved at that strategic level and clearly involved in, necessarily, the plans at a local level is that there is a misunderstanding or a lack of understanding sometimes about how youth work practice can impact on the emotional and mental health of young people. Often, the services that are seen to provide that support are those that are more clinically based, so it is often that there's just a lack of understanding, not necessarily a lack of willingness to work alongside youth work practitioners and youth services, but a lack of understanding about how that can support the work.

Okay, thank you. And to what extent do you think having access—for young people to have access to open-access universal youth work provision—how important is that in terms of ensuring there's early intervention available?

I think it's quite crucial because whilst—. The Welsh Government does an annual audit and reach is variable between locations, but if, for example, at one particular location 25 per cent of the young people are accessing open-access provision at some point during the year, for those young people, that service may be—they're accessing it for a reason, and that may be a real lifeline for them and a real source of support for them. It's when you get to 8 or 9 o'clock and the youth worker's shutting the building and the young person's hanging behind because that youth worker's the person that they have a strong professional relationship with, someone they feel they can trust and someone they feel they can speak to. The young person doesn't always have looked-after status. They might be invisible in school, and for most young people who are not formally engaged in one of the statutory services, it may be the only way that they can articulate or the only opportunity they have to articulate what's going on in their life, and the only opportunity they have to talk to a professional person about what's going on, and have the confidence that the person will listen.

If that open-access provision wasn't there then that's one less opportunity to intervene early and to make a difference.

Okay, thank you. Okay. Michelle.

Thank you. Good morning, everyone. Do you think that experienced youth workers would be able to provide a service to schools to support them with children and young people who are in mental distress and have issues?

Yes, most definitely. We have examples where that's already happening. Across Wales, many independent 11-18 counselling services are actually managed by the youth service as well, but, even where that isn't happening, there are youth workers that are based within school settings or work very closely with the school settings to provide support for young people—lower-level support, in terms of what would be needed in terms of emotional and mental health support, but, again, it's about building up that trusted relationship where there's no expectation on that young person, it's an equal footing, there's no judgment involved in that relationship. And so, again, it can be a place where young people feel safe to go and could be what's needed to help them build up the confidence to even look at accessing other types of services that they need.  

Would anyone else like to comment? 

I just want to add that, from a peer-led approach, I think young people can also be part of the solution in helping with schools. One of the projects that I run is called 'Mind Matters', and it's about young people gaining awareness around mental health and well-being for young people. They've been going into schools and delivering peer-led workshops, these young people, which raises the awareness then, really, about whether they need to progress on and seek additional support. So, it's having that intervention first at that stage before they look, I suppose, because sometimes they don't know what to look for or what choices are available. So, by having these young people raising awareness about it, it does help them in the long term.   

Do you think that youth work providers should have an input into the new national curriculum, and to what extent do you think you should have that input?  

Yes. [Laughter.] Yes, as a PYO group and as a wider sector, we feel that's really important, from the starting point that, in terms of the new curriculum and the overarching priorities of the new curriculum, youth work could be key throughout all of it. But, although we are involved at a strategic level—so, for example, as chair of the PYO group I sit on the strategic stakeholders group that looks at the overall development—we feel that, as a sector with an awful lot to offer in terms of learning, so that not more of the same is developed—. Ultimately, Donaldson's report is looking at a different, more holistic approach to learning, and, as a youth work sector, that is what we do. Ultimately, within the curriculum that we provide, it is about working with young people holistically, but also enabling them to learn, to develop. So, on a practical level, we think that we have things to offer when the curriculum is being developed.  

Llyr.

Are you feeling that what you're offering is actually making a difference and having an impact because, clearly, the work you do and the work that happens in schools need to be mutually complementary? So, are you confident that your input is actually having a meaningful influence on that process? 

I think we feel collectively—and I can speak on behalf of the PYO group, obviously—that there's more that we could be involved with. We are having opportunities at various points to comment on the development, but we feel that probably there are opportunities further where we could be directly involved with the development of those things.  

I promise I'm not going off on a tangent; I'll bring it all back in the end. The curriculum is changing. The formal education school curriculum is changing. Do you feel that the work you do and the curriculum that you work around in a more informal education setting need to evolve as well to reflect some of those changes, and, if so, is that something that you're currently looking at, or is it going to be, 'wait and see what happens there first'? 

I think it's incumbent upon us to not work in isolation from schools; schools are our partners. And, again, I'm trying to be general about PYO as a whole. There is a different range of alignments. Some of us are very embedded in schools in the way we practice. But I think it's incumbent upon us to not be spoon-fed and to work with the schools as partners in developing opportunities to take the new curriculum model forward and play to our strengths. So, for example, we would deliver the C-Card scheme in the community, so why do we let teachers struggle to deliver sexual health lessons in school? Why don't we support them with that expertise? That would just be one example. 

So, I think it's incumbent upon us not to wait for the tide to come and go past us. We must be proactive and work with schools as partners for the sake of the young people.   

Because I was just wondering how live and dynamic that relationship between formal education and informal education, if you like, is on a policy level, but also on the front line. You mentioned earlier the unique nature of the voluntary relationship between the youth worker and a young person, which, very often, means that the young person will present with issues to a youth worker rather than maybe a teacher or parent or the health service. I'm just wondering, in terms of training: are you confident that youth workers have the skills and the information to identify at what point they actually need to refer this to services or are they empowered enough to be able to deal with those situations?

I think they do build up a good relationship, a healthy relationship with the young person. They get a good knowledge of the young person through the amount of time they spend with them. Obviously, it is a voluntary engagement, so that person is coming because they're getting something out of the provision that's actually on offer.

I do think that youth workers are equipped. Obviously, you've got some more experienced youth workers than others. But, obviously, the range of issues—. Often it's something that's been building up that they get to know—. We often say that, our provision, somebody can come in one night and they've got such a good knowledge of that young person, they know if they've had a good day, a bad day, if something's affecting them. I think it's the position of trust that enables more work to be done with them. If needed, we can then refer them to specialist agencies. So, what we need is to know more about what is going on locally—the referral systems—to give them the best opportunities to get the support they need.

I would agree completely, and I think, in terms of training, it has been an area, in terms of—many services are reporting that the level of type of need that a young person is presenting is increasing and more of those young people are coming through who need more and more emotional and mental health support. So, it has been an area where we have, as a sector, recognised that there's additional training needed for youth workers that may historically not have been needed to the same degree. We obviously all have standard safeguarding training in terms of at what point we need to refer things on, but there has been more bespoke training, looking at how to skill youth workers in identifying when an issue is clearly something that is more around mental health and what low-level support can be put in place, initially, but then at what point it needs to be referred on. We've got a number of examples of the kind of training that's being developed and delivered and is planned to be delivered in the coming year as well.

So, there's that type of training, isn't there, in terms of identifying the signs and knowing how to handle those situations. But also there's a role for youth workers in actually promoting an understanding, amongst the young people, around issues of well-being and emotional well-being and mental health, et cetera. There are programmes, there are packs, available. Are youth workers, generally, you feel, well enough resourced and well enough skilled to be able to do that as well? There's always more we can do, I suppose.

I would say there's always scope for more training, for more awareness-raising within the youth work team as well.

But that would require additional investment.

Additional investment in the actual training and also, obviously, the capacity of the team to actually attend the training.

I think what's quite important to remember is that, very often, with the various projects, the youth workers are funded to do a particular type of work and so, often, the support around emotional mental health is a side product rather than the purpose of the project. We've got examples here, in terms of projects, where that is their purpose, but, for many others, in terms of universal youth services, very often, the support around mental health is an add-on to what the core purpose of that project is there to do.

Okay, thank you.

Okay, thank you. Darren.

I just wanted to ask you about the links that youth services have with the health service, if that's okay. So, obviously you've got some strong links with local authority practitioners, if you like, particularly with schools in some respects, but what are the links like with the health service? I don't know who wants to start. Jo, you're nodding your head.

Yes, I think it's fair to say that it's different in different areas. So, you have some examples where there is close collaboration with the health service. You have some examples where there are multidisciplinary projects and services happening where the youth service and health are working together very effectively. But then you have others, where, in some areas, it is more of a—. And particularly in more recent times where there are developments of pilots and then, so, the youth service has been asked to be a part of those. In other areas, you'd have no connection between health or the youth service at all, I would imagine, as well.

So, does anybody want to add to that? So, it's inconsistent is what you're saying—in some areas it's good; in other areas, it's not so good. Do we need to have a framework that makes it more consistent? What do youth workers do in an area where there isn't perhaps a good relationship with mental health services, and particularly specialist CAMHS services? How do they ensure that the young person who they're working with is getting appropriate support? Can you make direct referrals, for example, or do you have to send them to their GP and have the long, convoluted, difficult process of getting a young person to engage?

Usually, you have to go via the GP in most areas. There may be examples that I’m not aware of that are different but, generally, it's via the GP.

It's just the way it works for you to get to CAMHS et cetera. 

There's a huge reliance on youth workers understanding the processes that need to be followed, and to be able to explain that to a young person as well, obviously.

I think for the referral route to mental health service provisions, you need to have a GP referral first anyway. So, CAMHS or other people will come back to us and say, 'Have they gone to their GP first?' So, we've always got to go back to the young person, saying, 'Can you set that up first before you can take the next step?'

I just want to say that we've got a really good relationship with health provisions, especially in Torfaen, with some of the projects that we run. Because we're in the voluntary sector, obviously, youth work is not a sort our first and foremost purpose; it's volunteering. So, we work with the primary mental health team in Torfaen. We also work with the Aneurin Bevan university health board, but they are on the project-specific that has a purpose then. But, like I said, the relationship is really good, but it's not replicated then throughout in other areas either. So, there are shortfalls and gaps.

So, do you think there are opportunities, perhaps, for the health service, through broader engagement with you, to take pressure off themselves, if you like, by supporting you, equipping you to do a better job, perhaps with some of the low-level interventions, to build resilience in young people? 

I believe the models out there that work on the principle where a primary mental health worker, for example, might work with a couple of youth workers, and the youth workers are able to do sessions—say, anger management or cognitive behavioural therapy programmes—that they're trained to do. When the youth workers feel a bit stuck or see it as being a bit above their ability or whatever, then they can have a discussion with the mental health worker about how to take that forward. Those kinds of models—. As Jo said earlier, there are different models out there. Those kinds of models do appear to have benefits. If you have a bit of knowledge of those models, you can see there being an exponential value of people—. Not all young people who are presenting in crisis have a mental health diagnosis but they need some kind of help and intervention, and the practitioners need a bit of extra skill and support to help with that.

So, you've mentioned that a number of models are out there. Which model would you point us to as being perhaps particularly attractive?

There are models where services may commission a mental health practitioner or a primary mental health worker to be closely linked to a service. There are models where there is a youth health team—not in my area, but I'm aware that there is a youth health team that'll pull funding across the county for CAMHS—and youth workers and other staff who work closely together to work with young people. 

I can't speak to any particular model and wouldn't know enough about any particular model to advocate one over the other.

Okay. 

I just want to add that I think it's hard to gauge then as well, because I think that any sort of support and intervention needs to be tailored and bespoke to the needs of that individual presenting those issues. It's no good sending them to a sort of project to have CBT support if they're not presenting in that type of area. So, I think it needs to have a look—a holistic view of what other services and provisions are locally available to these young people so that they're not having to wait long term on waiting lists and things to get any other specialised services.

I would agree, and I think that's where youth work is of huge help, really, because it's not a therapeutic approach; it is about listening to what the young person needs and wants, and working with them to look at where they need to go next. So, I would say there is definite merit in considering how health services can look at working with youth services, whether voluntary or statutory, however that works really, because, in terms of a preventative approach, we're quite confident it works, really.

Is there work that can be done, perhaps, to encourage the health service to refer to local youth organisations if a young person comes in, presents with a problem, and they may need to make a referral to secondary or tertiary services, where they could say, 'In the meantime, we want you to engage with these people and those people, and you might like to think about having some support in getting together with some youth organisations'?

Yes, and we have examples of where that's happening already. We have GPs referring into various services already. There are developments where there's a link person, linked through GPs, and then they are looking at taking on referrals, either during waiting times or because that individual doesn't necessarily fit with any particular service.

But that's not widespread, it's—

It's not widespread but it is happening. Again, the issue is around how existing youth services resource that process, because very often sometimes the young person doesn't neatly fit into the funding stream that they have to support young people. 

Okay, thank you.

Thank you. Hefin.

With regard to transition? Yes. We've heard that transition from child services to adult services needs to be a managed process. Do you think that that is occurring at the moment?

Can I just feed in? I've got some feedback from Mental Health Matters based in Bridgend and they say there's a recurring theme that young people transitioning from being on the youth side, the youth services of mental health, into the adult services find it incredibly difficult, and sometimes can get lost within the system. They find it difficult to get because the support is decreased from what they were getting at the youth level, and they're often expected to do even the most basic things—making their own appointments, taking over all responsibility for themselves, and they find that even that is impossible; it's out of their realm—a reminder call and everything would be needed. When they're in the youth service, everything is not spoon-fed to them but it was a lot more accessible to them—a lot more support is given. I think it lacks then once it gets to the adult services. So, it's particularly that gap, I would say, for 16 to 18-year-olds.

We would mirror those comments. The same exists for general services for young people when they're transitioning from 16, 17, 18 up to the age of 25. From a youth service side of things, we obviously see young people as being young people up to the age 25, at least, and very often the services disappear at the age of 16, 17, 18. So, whilst you have a reduction in general support, when you're looking at targeting specific provision around emotional and mental health support, that then exacerbates it because the support as a whole is disappearing at that point at well. And you're talking about a point when young people then are potentially becoming more independent, have less support from their family, have to live on their own, or are becoming young parents, so it becomes very difficult.

With that in mind, are you aware of the 2012 'Children and Young People’s Continuing Care Guidance' that the Welsh Government issued?

In terms of what the expectations are?

Yes, the idea is that it also identifies where there are gaps during the continuing care process, but it should also link in with adult care. Do you think it's sufficient?

I think the issue is always around resourcing. So, at a local authority level, I know within our local authority, and others, we are continually, every six months, reviewing the type of support that's needed and the gaps that exist in terms of support for young people.

So, the guidance, particularly—do you use the guidance?

Not specifically that guidance. We use a whole range of guidance. Our review of services, actually, is led by the 'Youth engagement and progression framework', but we use that as a kind of starting point for looking at all services for young people.

Okay, because the purpose of the guidance is to be multi-agency, and although there is a health board emphasis, social care should be part of it, and also education and many other agencies that need to be part of a continuing care package. My view is that that guidance doesn't affect that, but the First Minister announced on Tuesday that they're going to replace the guidance. So, would you, as stakeholders, expect to have an input into that replacement process? Would it be helpful to do so?

I think it would be helpful, given what we're discussing right now in terms of the transition and our understanding in terms of the feedback from young people—that they feel that they're not being supported properly. Yes, it makes sense, really.

Okay. And the issues that you've raised should be fed into the process that leads to the replacement of that, because there is your opportunity, I'd say.

Yes. An example is with the development of the inreach pilot that's happening at the moment in some local authority areas. Blaenau Gwent happens to be one of those local authority areas. We are being involved in looking with health in terms of looking at where they're initially mapping out what exists, but that's the first time that's happened, because of it being a pilot area, rather than linked to any guidance that already exists.

Okay, thank you.

Thank you. Julie.

Thank you. I think you have covered this question, slightly, already, but in your paper you make reference to the lack of early identification of mental health issues for young offenders. Do you want to just tell us more about that?

I think that was in relation to feedback that the Council for Wales of Voluntary Youth Services received from the Media Academy Cardiff, and one of the things that they're saying is that the early intervention, really, is about—. There was a lack of structural funding for staff to help and identify those types of issues, especially around mental health, and to obviously support any sort of post CAMHS generally, then—they thought it was too late. What they are looking for, or what they've said—the focus, really, is on more of a prevention approach, as well as the intervention. The youth workers engage directly with the young people within that setting, and can support that process, then, even further.

Right. So, that's referring, again, to generally being able to get attention and help, rather than anything specific.

Yes.

I think one other thing they highlighted, really, was that, once you're within the system of the youth offending service, you may be able to access mental health resources in a timely manner if the particular youth offending service has the resources. But even though it's a statutory requirement, not all are able to deliver this, as there is a geographical inequality already across Wales. Young offenders who do not reach the level of intervention for a youth offending service—which, in the main, is the majority in the prevention service that are offending—do not have equality of access to mental health resources, and often have to wait considerably longer to access mental health—. They gave an example of a young person who had experienced a bereavement, and they often have to wait over a year for therapeutic services. It's often the case that young people who are experiencing mental health issues, whilst waiting for services to begin, deteriorate with regard to their mental health and often reoffend. I think the feedback—this is from Media Academy Cardiff—said: it means it's often better for them to reoffend, so that their tariff means they can get higher up to access youth offending service resources, and this also means that organisations working across prevention services are then challenged with the 'So what?' conundrum where, if they do recognise some mental health support is needed, there are no services readily available to refer to.

Right. So, they're in a better position for the help if they offend—

If they offend, yes.

—which is a rather depressing situation.

Yes. I think their thoughts were that, if structural funds could include young people within prevention in shorter time frames, it would help to prevent further offending and criminalisation of young people. It would also mean that young people's mental health could be supported earlier, meaning fewer resources needed further down the line, so that young people can live a happier, less stigmatised life. Those were their thoughts.

Thank you.

Are there any other questions from Members?

Just one, really. You mentioned stigma there, and that is a key issue, really, for this whole discussion. Presumably, as a service, you're doing what you can to tackle some of that, but is enough being done on that front? Because we're all very comfortable talking about physical injuries, let's say, when we're talking to someone—'Oh, I fell'—and we don't discuss the mental health side.

I know it's kind of a different service, but with the introduction of independent counselling within school settings, I think that the language of emotional and mental health has become probably more acceptable, but young people always feed back in terms of the fact that they find it difficult to talk about it, and so do professionals as well. So, I think it's an ongoing issue, really, that needs to be not underestimated, because there is a stigma attached still for some young people, either with their families or the people who support them as well. Would you agree with that?

Yes. I'd just like to add that the stigma is massive for young people, because a lot of it comes from, I suppose, the family background as well, where they were afraid, or it was a bit of a taboo subject to talk about within the family environment, like, 'Oh, my mother had a mental breakdown', or something. So, it's not something that was talked about. However, with the local media now, there's a lot more awareness around it. Families, parents, guardians are starting to talk more openly about it, so young people feel that they can identify then what some of these mental health issues are and what they really mean, you know?

But I'm just wondering if enough is being done of your—. It's coming back to the special relationship that the youth service has with young people, rather than the more formal classroom teacher-pupil relationship, and whether enough is being done to utilise that, or to maximise the value of that special relationship in order to get some of these messages across.

Again, I can only go back to saying that I think it's patchy, you know? It's not consistent, ultimately, and rather than looking at that from a point of it not being welcomed, it's about a lack of understanding of what the positive impact of youth work can be in this area.

Okay, thank you.

And in terms of stigma, have any of you had any experience of young people saying to you that they felt reluctant to use school counselling services because they felt that there was an issue of stigma there, because they'd have to go out during class time, their friends would see them going, et cetera? 

Within my own service area, we manage the school independent counselling service within our youth service, and that's an ongoing battle within every school, I would say. You have to revisit regularly with the school, with the school staff, with young people about what the purpose of counselling is, how to run the service so that it doesn't feel stigmatising, so that it's not obvious to people that they're going into counselling in the first place. You know, from our own perspective—I can only speak on behalf of my own local authority—it works very well, but we regularly have to revisit that because as staff change, as young people move on, you have to revisit and look at those messages and make sure it's really clear and to make sure the service is run in the most accessible way possible, taking into account all of those things.

Okay.

I would echo that and support what Jo said. Again, anecdotally, in my own local authority, we have a youth worker in every secondary school, which is partly funded by the school, and I know from the conversations I have with heads and senior leaders in schools that it is a valuable resource. Children can be reluctant to speak to a school counsellor, and they see, as the leaders in schools, the youth worker as a resource that's a safe place for young people to go and talk. They might be involved in more formal aspects of personal and social education delivery and things like that, but in between times, they know that that's a safe place for them to go and speak about what's going on in their lives. It's part of the jigsaw, if you like, for the school. 

Okay. Well, can I thank you all for attending and for answering all our questions this morning? We're very grateful to you for your attendance. You will be sent a transcript to check for accuracy in due course. Thank you very much.

It is possible to just leave a few notes? I've got a bit more feedback from Bridgend and I know, obviously, that time is limited. 

Yes, by all means, if you leave them with us—yes. 

And one thing that didn't come up, and I have feedback from Menter Bro Ogwr that they feel that they are unaware of any provisions currently supporting young people through the medium of Welsh, and also leaflets, et cetera. If I can just leave those, is that okay? Thank you.

Yes, by all means, if you leave them with us—

Thank you very much. 

—then we'll see that they're circulated to Members. 

Lovely, thanks. 

Thank you all again for attending. 

Okay. Item 4, then, is a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting, and we will reconvene in public at 1 o'clock this afternoon to continue taking evidence on this inquiry. Are Members content? Thank you.

Can I welcome everyone back to the afternoon's session and item 6, which is our fourteenth evidence session in our inquiry into the emotional and mental health of children and young people? We're taking evidence from the Royal College of Paediatrics and Child Health. I'm very pleased to welcome Emily Arkell, head of policy at the royal college; Dr Simon Fountain-Polley, consultant paediatrician; Dr Catherine Norton, consultant paediatrician; and Dr Shabeena Hayat, senior community paediatric registrar—. 

Sorry; my surname's Webster. You've got my maiden name there, but that's okay.

Oh, okay. Okay, sorry about that. Thank you all for coming, and we're looking forward to hearing from you. If you're happy, we'll go straight into questions. The first questions are from Michelle Brown.

Good afternoon, everyone. Do you think you have a really good understanding of the demand for mental health services among children and young people in your areas? If you don't, if you're not happy with the information you have, do you have any comments about how data gathering could be improved to provide a more accurate picture?

I think, from the acute perspective, the ward sisters kindly helped out with some data collection over the last six months, so we know that, in my part of the world, in west Wales, we had one to two young people admitted a week with overdose or self-harm or suicidal ideation. Once a month, we had a young person in who was admitted for medical care of their eating disorder. So, from the acute perspective, we do have a feel for how many young people and children that is. What we don't have a feel for is all the other children who don't make it to hospital. There are lots of emotional and mental health problems out there that are difficult to put a number around, and that's something that we probably need some help with. Data collection is a bit poor when it comes to finding out exactly what the requirement is in Wales for young people, and children for that matter.

Would it be an administrative burden to—? Would it be too much of an administrative burden on the relevant professionals if they actually started gathering that data?

You'd need to look at your data collection systems because, at present, the systems that collect data from areas such as community paediatrics are limited in their capacity. For example, in Cardiff and Vale, we have an IT system called PARIS, which does not code by diagnosis. So, you would immediately have a problem with data collection. That is something that we'd hope would be addressed by the new all-Wales system that's under development and in process. So, that should improve your data collection. It's the same around things like neurodevelopmental diagnoses. There are proposals, but at present the systems are quite poor.

The other thing just to mention is that the British child and adolescent mental health survey is being updated again, but the last data collection was in 2004. So, that data is very much out of date. For that report to have been published in 2004, it must have been at least probably four years out of date then. So, now it's another 13 or 14 years on. So, that is long overdue, but one thing that the college has consistently called for is for that to be updated on a regular basis, so not to have gaps of 13 or 14 years to be left for that to happen. So, one thing we would definitely like to see is some more regular updating of the prevalence of mental health conditions of children presenting, or children who are identifying themselves as having problems and issues, and for that to be published on a more regular basis.

How often would you like to see that data updated?

It at least needs to be done, I would say, at least every four to five years to be able to gather that data and for that to feed into service provision, so services can be configured and developed properly to be able to respond to the need that's out there.

Could I just add that? You'd also need to be careful because, if you're talking to doctors, we think about a medical diagnosis, but a lot of the distress that we're hearing, a lot of the concerns that have been raised, are not about diagnosed medical conditions; they're about distress and conditions that may lead to a diagnosis but may not. Perhaps the bigger bulk of concern is around that area, so you'd have to be careful what you were actually coding to and referring to. So, if we did get a system across Wales, which is in process, that would address some of that, does that system then talk to colleagues in education, in children's services, to get that bigger picture of the real state of Wales in that way? Because that is probably what we need to understand, because the actual diagnosable is the old description of 'the tip of the iceberg'.

Does anybody else have any comments?

I think data collection is the same for all parts of the work we do, whether it's specific to children with mental health problems or children with all the other things we see them with. So, there's a lot of work that could be done for improving IT systems. Because the ideal situation is actually a live system, which you can dip into to see what's happening with trends over time.

Okay. Thank you.

Llyr.

Yes. Hi. I just want to ask a few questions around training, if I may. You say in your paper that the thresholds for accepting referrals to CAMHS have had to change, but that this means other services, like community child health, need to be better equipped to deal with the mental health issues. So, do paediatricians and other people—other professionals—within child health have adequate training to help them with managing children and young people with mental health issues?

As a trainer, I'd like to answer that, if I may.

Ideal. Okay.

So, the simple answer, 'No, not enough'. There have been some movements towards cohesive working between CAMHS and paediatricians in order to provide some training. Over the last two or three years, we've had a senior paediatric registrar from the community service go out to spend six months with CAMHS, and I'm currently in that post at the minute. So, with that opportunity, I'm able to see both sides—the service provision from both angles. But, moving forward with that, I think if all community paediatricians were able to get some form of training with that specialist area, particularly children with learning disabilities, then that would be beneficial. But every single doctor would require some form of training, whether it be through resources or study days. That's something that I do know there's discussion about, but we would definitely encourage more of.

Okay, because I've seen reference to the creation of MindEd, which is a resource for professionals. You will know more about them than I do. I presume that has a key role to play in this respect, but you're suggesting that you'd like to see something embedded into more general training for people in the sector, yes?

Yes, of course. So, online resources do take time. So, trainees would have to do that outside of their work commitment and the allocated study days. So, again, that is a provision there that is useful, but I think nothing replaces the experience that is handed on from senior clinicians onto trainees' case presentations, to allow you to really understand how you would approach that child and that family who are presenting crisis in your clinical practice.

I've actually brought some leaflets with me about the MindEd programme to leave with committee members and the clerk. It's a consortium of different royal colleges that have come together, and other organisations, to put together an e-learning portfolio. So, any professional, really, who comes into contact with children can do some online training, particularly around signs and symptoms and to know what to do if they've got a child in front of them who they think has got mental health issues. It's all online. It's all included in here. The take-up has been really good, so I'll make sure you've got copies of these before we go at the end of the session.

Thank you. Thank you very much. So, what needs to happen, then, to ensure that there's greater priority of mental health factors in general training for practitioners? Who should drive that?

Are you talking at a trainee level, or are you talking about the training of consultants?

Well, it's probably both, isn't it? Because, you know, those who have come through the training clearly haven't had the level of training that you're suggesting they should.

I could comment around consultant staff who have gone past a training level.

Yes, who are in post and—.

I think something that we have to bear in mind is the capacity of the services. So, a challenge would be, in many ways to consider: what does a community paediatrician do? I don't think there is any doubt at all that the voices of community paediatricians are saying they are concerned about rising issues in relation to mental health and emotional well-being. That is not in dispute. They are also, I think, open to training, and they are open to much more collaborative work with other services. The common theme that you hear back from people is capacity. So, for example, in my role as a community paediatrician, I use the visual description of the Olympic rings, just to help—I work visually. So, one ring of my work might well be emotional health and well-being. Another ring of my work will be complex disability—all the children who may have syndromic disorders. Another ring of my work may be neurodevelopment for children presenting with autism and autism spectrum disorder. Equally, another ring of my work will be all the additional learning needs work that's coming through, and potentially around the designated education clinical lead officer. Another ring of my work will potentially be safeguarding and provision of all your sexual assault services and your safeguarding. That is a huge remit for one individual, but that is being duplicated. So, to put on top of that a request to have the capacity to do specialist training puts a burden, because in all of those other elements of those rings, you will also be doing—. So, you first have to consider: what is the capacity for training and in what form that will be delivered? 

The challenge that I would get back from my colleagues most often is, 'I will do the training, but you then need to put me in the position that you also have training around what services are available and what I do once I've identified something'. Because once you have the knowledge and the understanding, you want to take action. You have a duty of care. And what happens next? So, to my mind, anything that is about training is not simply about the provision of an online course or a study day; it is about giving somebody the opportunity, in their job, to attend and take on board that training, and then to actually operationally deliver that training. That has to be seen as part of the bigger picture.

Just to add to what Cath just mentioned, last year, the college produced a report about community paediatrics and some of the gaps in the workforce. So, community paediatricians will cover a population, on average, of 89,000, but in some parts of the country as a whole, across the UK—which obviously includes Wales—there will be gaps of nearly 10 per cent in the vacancy rate for consultant community paediatricians, and that's obviously really high. It's nearly one in 10 posts that are vacant. So, just going back to what Cath was saying about capacity issues, if you've got that vacancy rate replicated across Wales as well, then the pressures on community paediatricians to be able to deliver services is really quite high.

I think, as well, CAMHS has, unfortunately, become quite compartmentalised, and there are probably a number of reasons for that. One is that there are not many of them to deliver a service, so they have to think about what they can do and what they can do well. But there has been some push, as well, from various initiatives from Welsh Government, about what's required now, and so that forces them into a certain position, which means that a gap opens up between those of us who work with children in other ways, and I'd include teachers as well in that and social workers; there are a whole load of us who try and do our bit for children and young people. So, if we start focusing too much on training us, for example, that does mean that we're not doing the other things we're trained to do. And that has an impact on capacity for lots of different professional inputs for lots of different reasons.

So, although training is important, someone like me needs to be able to spot if there's a problem, but I also need to be able to find someone to help that family or that child or that young person, and I may continue to play a role in that, but sometimes, these kids need specialist input, and getting them into specialist input is a problem, because again, it's capacity. But there are also some very different thresholds to maybe five or 10 years ago, and that makes life difficult for families. We're all in the business of helping families in a holistic sense, so, training—although it is important, I think there are some bigger issues when it comes to children and young people's mental health issues around prevention, around society and about how we react to them.

I would agree, because one of the things that we've heard quite clearly as well, is that other people within that wider support structure also need training, and teachers have specifically been raised on a number of occasions here, where they don't feel empowered enough to be able to maybe necessarily identify some of the signs, but also then to know where to go or what to do to deal with them.

But also, there's the aspect of training young people, or being empowered to be able to train young people around greater awareness of emotional well-being and mental health issues as well. So, I presume that you would agree that we do need a greater emphasis on training teachers and those kinds of professions as well, who are also part of this wider network. But, are there any particular aspects of this issue that you would like them to focus on in terms of training? I'm just thinking of teachers; is there any particular area, other than the general stuff? 

Well, I think being able to spot an issue. But again, it's more about what do you do once you've spotted an issue. Who is there to be able to help the family? It's being able to signpost to a service. Because, being frank, there isn't much of a service at that sort of low level with emotional health problems. In a way, if you've got clear clinical depression as a young person, it's easily identified where you are helped, but for that big group below that level, where they have got some emotional health problems, which may be temporary, may become long term—it's that group of kids that we struggle with, to be able to help, and to stop them going on to have more severe mental health problems.

Okay. That is a clear message that we've heard consistently across—although how we do that within the confines of the resources and diminishing budgets and everything is a challenge, clearly. But a lot of people are suggesting there's a cultural change needed as well, rather than just—I won't say 'moving the deckchairs', but, you know, reconfiguring money.

There is something, though, in—. We often use the word 'signposting'. There's actually a plethora of resources out there. There's the MindEd, and there's MindEd for Families, but equally, in the primary mental health services, they signpost families from the point of receipt of referral, because there may be a wait. So, there are multiple online—. It's not that there's a lack of information, and it's not that—. I think the schools are amazing, to be quite honest. I go into schools a lot in my job and I'm really impressed by the care and consideration a lot of those teachers give. I think they go above and beyond. But I think people do get to a point where they need some guidance. It's almost that hand-holding that we're short of, and I think people tend to revert to a medical model, because you will get common sense, but you won't necessarily get the most expert opinion. But it's something about the capacity in the system to guide people, rather than it just being online or written information and resources. 

I agree with that, but what we're trying to identify is: how do we achieve that? Who would do that? Are we looking at school counsellors, those kinds of people, working with teachers? Because that's a diminishing resource as well. We're hearing from teachers that they don't—. On a practical level, many areas barely have access to that kind of service anymore.

I think school counsellors are helpful if they've got the correct training to be able to manage the issues they come across. There's some evidence that online resources can help families, but online resources often are more successful when there's a face-to-face element, or a clear human element, rather than just, 'Look at this website, read it, do it'. Things like chronic fatigue syndrome are better—there are successful online resources when there is another person who is behind that online resource. So yes, it does mean more people getting involved with managing mental health problems and emotional health problems in children.

Thank you. Julie.

Thank you. I want to ask some more about community paediatricians and the role. Some of that has been covered, really, in your answers to Llyr. I was interested in what you said about the gap that exists, the 10 per cent vacancy level. Would that be replicated throughout the UK?

Yes, it is. And I can certainly share the details of the report that we published last year, which goes into more detail about where those gaps are. We would definitely be able to provide the committee with the in-depth information about the situation in Wales as well. We've got a workforce team that specifically looks at these issues, and we'd be able to pull that information out for you.

So, Wales is no worse than anywhere else in terms of vacancies.

Off the top of my head—I would have to go back and check—but I would imagine it would probably be a similar picture across the UK.

Is that a high percentage to have as a gap?

I think whether it's a high percentage or not, it's a gap, and so that has a clear impact on the families we see. But I think, again, it comes back a little bit to what you said, Cath, about the medical model. With a lot of community paediatrics, and acute paediatrics for that matter, the roles that have traditionally been done by doctors in the modern world probably are better done by other healthcare professionals—specialist nurses, for example. If we looked sensibly at how we can use our current resource, because I get the feeling there's not much money around, then that means us looking differently at how we provide services. And it also maybe means us having to have a very clear look and difficult conversation with the public about how we provide a service and how, if we disinvested in some areas and reinvested in another, then you'd get a much better longer term outcome. So, for community paediatrics, specialist nurses in the management of ADHD, for example—they work well in places where they use them and, because they're based in the community, not in a clinic room somewhere, they're able to get in under the skin of a problem and able to manage it a bit more appropriately.  

So, what would you see the community paediatrician concentrating on? 

You're the community paediatrician, Cath, so—

I think the best community paediatrics is still when you work as part of a closely integrated team, and the things that the paediatrician needs to concentrate on—. It's twofold. One is where there is clearly a medically defined element, which there will be, and they would work in collaboration there, for example, around disability with therapists, with dieticians. What an appropriately trained individual offers is a unique holistic overview, because one of the challenges of increasing specialisation is that you get individuals who are extremely good between their lines, but the challenge with children with complex needs and with varying developmental issues is they cross all those areas. So, you still need a paediatrician with that overarching expertise across safeguarding, across disability, across cognitive development, across behaviour and emotion to actually have an overview. But that person works by far at their best when, for example—. Something that would make an immediate impact in community paediatrics would be enhanced administrative support. I know, in many ways, that's the area that got most depleted, because you wouldn't have taken out clinical roles when there was financial pressure, and it's often admin. But, actually, I could double my output if I wasn't doing admin, and I think most paediatricians would be able to evidence the amount of unnecessary time spent on admin as a consequence of pressures within the NHS on NHS core admin. I'm sure that's true of many professions. So, that would be an immediate change. 

The next part is that you work in paediatrics collaboratively across agencies. So, it is that sense of integrated teams where you're working not just with CAMHS—obviously, you need to work collaboratively. Some of the best models are where CAMHS and child health are housed together, where you're working collaboratively with education coming in and with therapists coming in. And then you have to bear in mind that any transfer isn't going to happen overnight, so we have ADHD specialist nurses. We've even got them prescription-trained so they can do prescriptions. But at the moment, because they're still in a cohort of training, they get, for example, three quarters of an hour for a follow-up, whereas I get three quarters of an hour for a complete initial assessment. So, it takes time to get quick. Even if you introduced a new workforce, you're not going to see an overnight change, so you'd have to consider having perhaps a 10-year strategy to bring people in to strengthen that workforce, to strengthen collaboration, to strengthen your IT systems across agencies. It's doable, but you have to get some of the core elements in, and I totally agree that not all the roles delivered at the moment by a medical practitioner are ones that you need a medical practitioner with, but I'd start with your admin and I'd work up from there.  

Right. And housing—you know, community paediatricians being housed with CAMHS, does that happen often? 

It's good if it does. Nothing replaces face-to-face contact. 

But is that a pattern throughout Wales? 

It's a pattern—. Well, Gwent, so AB, co-house the two. Cwm Taf co-house. Cardiff and Vale will be co-housed. For Swansea, you've got a slightly different geographical footprint. 

In westest Wales, the CAMHS team used to be part of our children's team, but then they were separated out into the adult mental health team. My personal view would be that that was a retrograde step, because we used to work a lot more closely. As I say, as paediatricians, we're very used to working with other members of different teams. 

So, the message is the team approach and be together where you can be. And is this being looked at anywhere in a—?

A team approach is the core feature of the neurodevelopmental services. They should be services representing CAMHS, child health, education, all your therapies. But they are, at the moment, just very much nuggets that we need to grow and nurture. So, you've got the core, but how those develop will be told over the next coming years, dependent really on how much support we give them and how much we nurture them.

Llyr.

We've heard that some children and young people in mental health crises, who are maybe self-harming, are held on paediatric wards. Is that the case, and if it is, is that appropriate?

Yes, that is the case. I think there are two elements, though. For some children who take an overdose or self-harm, there may be some medical needs that need to be sorted first, for example treatment of overdose. So, it's quite appropriate that they come into an in-patient paediatric area then. Once they've been managed medically, they need the CAMHS team to be available as soon as possible because in-patient wards aren't the best places for children who've self-harmed. So, in some areas, we do have CAMHS input quite quickly. In my neck of the woods, that's the case—within 24 hours, we, most of the time, have a CAMHS assessment. That's not the case everywhere in Wales.

Then there's another aspect to this probably, which is, again—. In Glangwili Hospital, we've got what we call the Rainbow Suite, which is run by CAMHS, but it's a self-contained unit in effect—it's one bed, in effect, but has an en-suite. So, that is contained within the paediatric ward, but it's managed by the CAMHS team, and it's a safe space for children with not just overdose, but, say, serious suicidal ideation, when they need to be kept safe. That's not the case across Wales, and some of those children and young people end up on adult wards and that probably isn't appropriate, as they get exposed to all sorts of different risks when they're in an inappropriate environment.

I'd just like to add that I am aware that there's one hospital in Bridgend where they have 14 beds for children who can be admitted for self-harm, but the psychiatrist—from their point of view, they follow NICE guidance, which suggests that children, because of their reduced ability to self-regulate after self-harm, do need to have an admission that is at least 12 hours, if not 24. So, the question is, across south Wales and north Wales included, whether there is that ability to have trained staff, who are trained in mental health to be able to provide support for the nursing staff on those wards—that's the big question.

Yes, and the fact that you're asking it suggests that you're not convinced that that is the case.

Absolutely—in my opinion.

Okay. So, you would assert that there is a gap in addressing the needs of children and young people with physical illness who also have mental health needs in some places. It's patchy, then, isn't it—inconsistent?

It's unclear from the CAMHS specification—sometimes that's described as the CAMHS liaison service, and the language is used differently in different places and that is definitely a gap in certain areas.

Okay. So, do we know the number of children and young people with mental health problems who are being cared for in general paediatric settings across Wales, and whether that's increased or decreased over recent years?

If you look at the evidence over the last few years then, yes, there does seem to be an increase in children admitted with self-harm or overdose. I asked our sisters to have a quick look for me and at the moment, we've got one to two young people with some sort of mental health crisis on our general paediatric ward each week. So, that's a reasonable—. And that, I imagine, is replicated—. Glangwili hospital is a medium-sized district general, and in somewhere like Cardiff, the numbers might be slightly more. But that's going to be the pattern.

But the recent trend is clearly—

There is a trend upwards.

And it's persisted despite the introduction of things such as CAMHS crisis teams. I don't have it to hand, but we've had a presentation recently to our liaison around CAMHS paediatrics in Cardiff and Vale, and it's highlighted an increased demand on accident and emergency department with self-harm and increased work and effective delivery by new CAMHS crisis teams, but still a persistent increase around admission. One of the challenges there has been multi-agency working because sometimes what you need is actually children's services around a child in need, you know, a well-being assessment, to actually look at the home environment. So, again, it goes beyond CAMHS and paediatrics straight back to that wider environmental factor.