Y Pwyllgor Plant, Pobl Ifanc ac Addysg - Y Bumed Senedd

Children, Young People and Education Committee - Fifth Senedd

10/01/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Darren Millar AM
John Griffiths AM
Julie Morgan AM
Llyr Gruffydd AM
Lynne Neagle AM Cadeirydd y Pwyllgor
Committee Chair
Mark Reckless AM
Michelle Brown AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alistair Mitchell Ditectif Prif Arolygydd, Heddlu De Cymru
Detective Chief Inspector, South Wales Police
Caren Weaver Nyrs Argyfwng, Bwrdd lechyd Lleol Cwm Taf
Crisis Nurse, Cwm Taf Local Health Board
Carol Fradd Arweinydd Gweithredol i Ysgolion, Samaritans Cymru
Functional Lead for Schools, Samaritans Cymru
Darren Rennie Ymarferydd Tîm Triniaeth Ddwys Gydgysylltiedig, Bwrdd Iechyd Lleol Addysgu Powys
Co-ordinated Intensive Treatment Team Practitioner, Powys Teaching Local Health Board
Dr Mark Griffiths Cyfarwyddwr Clinigol, CAMHS, Bwrdd Iechyd Lleol Aneurin Bevan
Clinical Director, CAMHS, Aneurin Bevan Local Health Board
Emma Harris Swyddog Polisi a Chyfathrebu, Samaritans Cymru
Policy and Communications Officer, Samaritans Cymru
Jonathan Drake Prif Gwnstabl Cynorthwyol, Heddlu De Cymru
Assistant Chief Constable, South Wales Police
Melanie Jones Nyrs Gyswllt Argyfwng CAMHS, Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg
CAMHS Crisis Liaison Nurse, Abertawe Bro Morgannwg University Local Health Board
Nick McLain Uwcharolygydd, Heddlu Gwent
Superintendent, Gwent Police
Sharon Stirrup Rheolwr Gweithredol CAMHS, Bwrdd Iechyd Lleol Addysgu Powys
Operational Manager CAMHS, Powys Teaching Local Health Board

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Llinos Madeley Clerc
Clerk
Sarah Bartlett Dirprwy Glerc
Deputy Clerk
Sarah Hatherley Ymchwilydd
Researcher

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle y mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:30.

The meeting began at 09:30.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Good morning, everyone. Can I welcome you all to today's meeting of the Children, Young People and Education Committee? We've received apologies for absence from Hefin David. Are there any declarations of interest Members would like to make? No. Okay, thank you. 

2. Ymchwiliad i Iechyd Emosiynol a Meddyliol Plant a Phobl Ifanc - Sesiwn dystiolaeth 9
2. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 9

Item 2 this morning is our ninth evidence session in our inquiry into the emotional and mental health of children and young people, and I'm very pleased to welcome Samaritans Cymru to our meeting this morning, and in particular Emma Harris, policy and communications officer, and Carol Fradd, functional lead for schools. Thank you, both, for attending, and thank you also for the written evidence that you provided in advance. If you're happy, we'll go straight into questions, and the first questions are from Llyr. 

Thank you. Bore da. I was very interested in the resource that you have, the particular pack that you have—DEAL the acronym is, isn't it—the developing emotional awareness and listening pack for 14-year-olds for use in schools. We've heard a lot of evidence in our inquiry around the need for early intervention, and this is an example of the kind of approach that maybe should be looked at being utilised more widely. I was just wondering what assessment or evaluation you might have made of it as a resource and what that tells us really about how effective it might be.

Okay. So, the DEAL evaluation is under way; it's taking place now. It ran from the 2016 September academic year through till last year, and it's been evaluated by Swansea University. What we do know is that over 2,000 pupils took part in the pilot. It was five schools in Cardiff. We know that a number of them are still using the resources, and Fitzalan and Cardiff high schools are actually implementing them in their curriculum. And the feedback has been so far very positive—that they were very easy to use but, most importantly for this, that the children and young people are much more confident in talking about their mental health. 

Okay. So, you're pretty content that it's doing the job it was intended to do, subject to having that final assessment completed.

Yes, absolutely. 

Okay. That suggests, or there has been a suggestion, that the current personal and social education framework isn't really delivering on this front in schools. Is that something that you'd agree with?

Yes, absolutely. I think the one thing that we have found from our experience with DEAL is that the staff who are now actually delivering DEAL within schools did not really feel confident to do in-house training, because there is a training package for teachers built into DEAL. So, as part of the pilot, what we actually did was that a senior member from each school came to a training session, and we did the training session for DEAL, and then they went back to schools and cascaded. And I think this is a problem—that there is a lack of confidence in teaching staff about being able to present such difficult topics to young people. 

Well, that was going to be one of my questions around—

Oh, sorry, I anticipated. 

No, I'm glad you've anticipated it. So, clearly, that has been something that has been flagged up to us in terms of skills and confidence levels amongst teachers in being able to deal with some of these issues. So, as you say, that training is embedded into the DEAL programme. How much of a time commitment does it need to undertake that training for a teacher, because we also hear that there are pressures on their time as well, and that if you take them from one thing—

Yes. It could be done in an inset day. It takes about four hours—was it, Emma, we allocated?

Yes, it was only about half a day. It was short but invaluable. 

Well, yes, clearly. Okay. But the curriculum, of course, is being reformed in Wales, as we are very much aware. Have you had any discussions in relation to this agenda being incorporated into the new curriculum?

We've had numerous discussions. One of our issues is that the PSE framework is really robust, and it does actually include a lot of focus on health and well-being. The learning outcomes are focused on a better understanding of mental health. The problem is that it's the responsibility of schools in Wales to implement the framework and include the broad remit that it covers, and because of that reason, and because of mounting pressure on numerous topics, such as first aid, sex education or mindfulness, actual core emotional mental health lessons are often excluded. And what Carol's saying is completely right: one of the other things that runs alongside that is that schools are not confident enough to teach mental health and emotional health in case they're presented with questions around 'I'm feeling suicidal' or 'I'm self-harming'. It was only a half day and it left so many teachers much more confident to tackle those questions.

09:35

But the curriculum, of course, is more widely being reformed, isn't it? And there is going to be a health and well-being area of learning and experience as part of that curriculum. Are you involved in any way in the shaping of that?

We've had discussions with numerous—. You know, we've met with policy officers, we've met with AMs, we've discussed it, we've publicly called for mental health education to be compulsory, and that is our main point today. It's great that health and well-being is weaved through the PSE framework, but the new curriculum offers such potential for reform now and in the future because, if emotional health programmes are compulsory and they're viewed as preventative, then that in turn will reduce pressure on child and adolescent mental health services and reduce pressure on mental health services in Wales.

And do you see DEAL as being maybe the basis of a lot of that?

Well, we think it meets all of the needs because it's a complete package. We've already said it includes the teacher training. It covers things like exam stress, building resilience, coping strategies, social media. Hopefully, it will be something that teachers could pick it up, so long as they've got the confidence to deliver it, and it would go a long way to then the teachers recognising that emotional health can be well supported by them rather than that early referral to CAMHS and overloading the system.

Okay, and finally from me, if I may, why 14-year-olds specifically? We're hearing evidence as a committee that there are problems emerging earlier, in primary school even. Why 14 and not maybe 10, 11 or 12?

Well, when we first developed this, this was the age at that time—because it's been out a few years now—that we identified as being most at risk. Of course, as time is going on, we are also seeing the emerging trend of much younger children being affected in similar ways. Like all organisations, we have to look at our resources and best utilise them, and this was the area where we felt there was a gap, whereas primary schools at one time were really well supported. Perhaps that needs looking at, but we would have to put considerable amounts of funds into developing another younger area. It can be developed for younger people, and people are using parts of it as high as 17 and 18-year-olds. We were just making new videos, for example, which are suitable for the older age group, to support talking about resilience and social media particularly, because we perceive the need there.

Definitely. So, while the DEAL resources, from a Samaritans perspective, are 14-plus, we think that lessons in resilience should still be available from other agencies for younger children. We definitely see the need for that.

Just before I bring Mark in, can I just clarify, Emma—? Llyr asked you about your involvement in the new curriculum, and you referred to the lobbying and things that you've been doing, which, from my point of view, is very welcome and appreciated, but has anyone who is actually involved in designing the AoLE in this area actually made any attempts to involve an organisation like yours, which has a programme already running in the development of that curriculum?

They have, and I was trying to think when you asked that question when that was, when we met in Cathays Park. That probably was a couple of years ago.

It was about 18 months ago.

We were consulted and we did present the benefits of DEAL. We have continued to try and engage since, but we haven't met recently, no.

We have worked very closely with Healthy Schools, and they've been very supportive of us.

Emma, I think you suggested a tension or trade-off between including core mental and emotional health in the curriculum and programmes such as mindfulness. Isn't mindfulness, however, something that is complementary and would support core mental and emotional health?

It certainly is, and I thought that as soon as I said it, but the reason I flagged mindfulness is because, quite often, mindfulness—it's not a gimmick at all and there are obviously wide, proven benefits of mindfulness in mental health and mental health for children. The problem is that some schools will get offered the initiative of using mindfulness and it will be the option of a talk in an assembly session or one PSE, and they'll take up the offer because it's seen as beneficial, but having one mindfulness lesson, or a couple over a term, my point was, isn't the same as embedding resilience and wider emotional health in lesson plans.

09:40

Okay. But if there were lesson plans, and there was a regularity to that, then mindfulness could be something that would happen. You can't just have a couple of sessions, and say, 'That's done.'

Yes, which happens a lot. I think mindfulness, if anything, would definitely complement, sit alongside, or be included in emotional and mental health lesson plans. But, yes, it shouldn't be a tokenistic add-on to a term in order to tick a box—that they've done some well-being.

And you suggested that, if core mental and emotional health was integrated into the curriculum, this would reduce demand for CAMHS. Do we have evidence for that? Is there potentially a risk that, by raising the salience of the issue, by talking to children and teenagers a lot about it, then some people who may not previously have thought, 'Well, I need help', may actually then seek referrals?

I don't think so. I think, in terms of evidence—so, we know from talking to schools that there is an over-referral to CAMHS because of low-level issues that schools aren't equipped to deal with, and children and young people aren't equipped to deal with them because they haven't been taught healthy coping mechanisms. So, they're put on a list, they're thrown into the CAMHS system when they didn't need to be. That also exacerbates people who are on the list for severe emotional health problem or mental health issues and who need psychological therapies. I think also, because we've seen an increase in depression and anxiety, or more low-level mental health problems, that shows that there's an over-referral to CAMHS and a need for emotional health in schools. Because a lot of these low-level problems are linked to anxiety around cyber bullying, social media—things that could be dealt with in schools. There was a review published in 2015 in The Lancet. There was some research into a trial in Australia [correction: in 10 European countries] on 168 schools that undertook a suicide and self-harm teaching programme, and the evidence showed that it reduced suicide attempts, it increased help-seeking behaviour and reduced anxiety. I'm happy to share that report, but we would definitely stick by that.

Thank you, Chair. Can I just ask you about school counselling services? Some of the previous evidence that we've heard from the schools themselves is that they really value school counselling services, but there's been a reduction in the provision of those services sometimes from local health boards, and it seems to be very inconsistent, from one local health board to the next, in terms of the number of hours that a school counsellor might be available. But, to deal with some of these lower level issues that might be presenting themselves, having the opportunity for a school counsellor is obviously quite important. Do you have a view on school counsellors and the role that they might play in crisis prevention?

Yes. I think they're invaluable, and I think we are the envy of people in England—the people I come in touch with in schools in England—because, of course, they don't have that compulsory aspect that we have in Wales. I think school counsellors are overwhelmed. In a similar way, in universities, the counsellors are saying to me that they are overwhelmed by the number of young people coming to them. And, with the cuts in university, they are cutting down on counsellors. That's one of the first things: counsellors and nursing staff are being reduced. And I think, particularly in America, they use counsellors a lot in schools, and, if we reduce that, I think the pressure on CAMHS will be even greater than it is now.

So, as I understand it, every school has access to a counsellor. Is there a set number of hours per week that you have a view that these should be available, or what sort of scale or access do you think is required in order to build the resilience in to prevent people going on to more serious crises?

Well, I think the counsellors can deal with a higher level than perhaps a form teacher could, because a form teacher is the first point of contact. The young person comes into their class, a form teacher who knows their children would recognise that there is something wrong that they could deal with there and then. And I think this is where we're losing it because perhaps, for me, it's the teaching element: that they really don't feel confident in approaching them. They might say, 'Are you okay?', but whether or not they probe any further—. And perhaps the tendency is to say, 'Would you like to go and talk to someone?', rather than they deal with it themselves.

Yes. So, you think there's a role for school counsellors to support and encourage teaching staff in particular to perhaps take a bit more responsibility themselves and to coach them—

09:45

I do. Yes, I really believe that. But I think it starts in teacher training, where they would feel confident in just approaching them, and maybe having teachers—. I know it was mooted by the previous education Minister that there should be teachers who are specifically trained to do this, who are not counsellors, but really have a big interest in the emotional well-being of young people.

In the same way there is an additional learning needs co-ordinator in each school, or someone else with a responsibility.

Yes, absolutely.

Someone with a guidance qualification. So, it would be a specific teaching qualification around counselling, emotional support, PSE.

And just alongside the counselling question, another thing, just through engagement with healthy schools and actually going into the classrooms, I think what we've heard as well is that some pupils are unaware of the school counsellor, when they could access them, or how. That often might be because of stigma; they might not say they know they have a counsellor, because they don't want other classmates to know that. But I think that, quite often, it's seen as something they can't access, or they should only access it if they're really in distress. They might not know that they can go and talk to the counsellor for low-level anxiety, for example.

And it takes them out of the classroom, as I understand it, as well, which again means that attention is magnified on the individual actually going to see somebody.

Do you think school nurses have a role here as well, or—? There's less of a stigma with school nurses, is there?

Absolutely, because they often talk to a school nurse, not just about physical things, but about their emotional well-being. And, of course, we know that if they have emotional problems, they can manifest themselves as physical problems. So, the school nurse is ideally placed to spot those problems and bring them to the attention of perhaps the guidance teacher, or the counsellor, or the form teacher. It's very much a team approach, isn't it? Everyone working together on such critical issues for us.

Okay. When the committee surveyed young people in Wales in secondary schools, they told us that they would like there to be more openness about mental health in schools and that they thought that that would reduce stigma and make it easier for young people to seek help. Now, we know that, albeit with good intentions, some local authorities, such as Bridgend, have a policy where schools in that area are not permitted to discuss suicide. Have you got a view on that kind of position?

Yes, definitely. Again, I just feel the need to highlight that I think this is linked to a lack of training and basic understanding around mental health, and suicide especially. We hear that a lot, not just with schools, but that idea that talking about suicide increases the likelihood of suicide, when it's actually the opposite; it reduces the likelihood of suicide. So, we disagree that schools shouldn't be permitted to talk about suicide.

Back to The Lancet review that I referenced, that evidence shows that embedding lessons around suicide and self-harm actually reduces attempts and increases help-seeking behaviour. So, that's what we want to see: help-seeking behaviour on the increase, and I think the only way we can do that is by talking about suicide and self-harm more openly. And at the training day that Carol led with the five schools, those questions came up a lot, didn't they?

They did, yes.

You know, 'Someone in my class is self-harming; I don't want to talk about it because I feel that opening that up for discussion will encourage other pupils to do the same', and it only took half a day for us to myth-bust that.

So, do you think Welsh Government should be doing more to ensure that there is guidance given to schools about the appropriateness of discussing suicide, particularly where there's been a suicide in that school, or a suspected suicide?

Well, I think there should be consistency, and I don't think that—if some local authorities are saying, 'We're not talking about suicide', and all the evidence is opposing that, I think then that there should be some central body that says, 'No, that's not right; you need to be discussing this.' We all know what happened at Bridgend, and I can understand why they are like that, but they need to be really aware that what they are saying is perhaps not right.

I think they do need to be providing more guidance, definitely, because when we are involved with schools, Samaritans have a step-by-step service, which Carol is involved with, where we go into a school following a suspected, attempted, or completed suicide and we work with the school to get through that. Our support has been—well, we've been told—invaluable to schools. And that really shows the need to talk about it, not close it down.

09:50

Just briefly, the evidence you mentioned in relation to talking about suicide, or reducing the risk of suicide, is that talking or discussing suicide with people who are specifically trained to discuss the issue or is it just generally across the piece that if you discuss it with a member of staff or someone that you trust that it's less likely to happen?

I think teachers need to be equipped with the right language and skills to be able to talk about it. I think the review was on teachers, not specially trained staff or anything like that. I think a basic level of training would suffice.

And is that something that you could do as part of your initial teacher training?

Yes. So, I think one of the most prominent calls we've focused on is embedding basic mental health training, which should include talking about suicide, into initial teacher training, so that all new teachers are equipped to talk about it. 

I just wanted to ask about the role of the media and the internet in glamorising suicide. There's been a lot of controversy over this Netflix series, hasn't there, 13 Reasons Why and speculation as to whether that's fuelled, perhaps, an interest—an unhealthy interest—in suicide amongst children and young people? What is your view on those sorts of things and how we can tackle that?

Samaritans work extensively with the media through our media guidelines. So, that series is a good example because we responded to that series, we worked with reporters surrounding it because it breached our media guidelines anyway. I think that suicide as a topic needs to be out there in the media as a discussion point when it's healthy. Quite often, we see it reported on negatively. Many elements of our media guidelines are often crossed. For example, we say that method shouldn't be referenced or specific details surrounding the act because it can cause relatability in someone vulnerable. So, I think it's just about carefully monitoring the media, as we do. I think we need to keep doing that and working with other agencies to make sure that programmes are created responsibly. But, at the same time, I think it's also getting a discourse going in the media about suicide and self-harm in a positive way. So, there is scope to show that programmes that deal with it sensitively are actually doing a good thing, but others, who are more sensationalist, that's what we try to work to—.

And do you think there's anything the Welsh Government can do to support schools in particular, perhaps to help navigate young children through potentially negative exposure about suicide in the media or perhaps on Netflix programmes or other tv things that might—?

Well, within our step-by-step service, one of the things we discuss with headteachers when we go in—because this is a specific service to support senior management within a school, and we offer our media guidelines, and it's something that I know the Welsh Government have promoted and have supported. In fact, it was one of the positive outcomes that came out of the tragedy in Bridgend that many of these guidelines were developed to try and reduce the impact of suicide because we know there is a contagion effect, which, when we go into schools, is one of the things we talk about with senior members of staff: about talking to the media, about making sure that what they say follows all our guidelines to prevent this contagion effect, so that young people are not exposed to things like, as Emma said, the method by which the person completed the suicide.

I think our advice in general to schools, colleges, universities and other institutions is if there is a suicide or suicide is sensationalised through a story, we often promote the idea of counteracting that with a support piece. So, a general—. If there's ever been a run of suicides that have been reported on, we may have worked with, say, WalesOnline to put a help-seeking article, 'How to spot signs you're struggling to cope', 'Where to turn'—signposting. So, I think as long as we continue to tackle it behind the scenes, the job of other institutions is to try and counterbalance it with a positive piece that doesn't need to comment on the suicide at all, it just needs to offer more support to those who may be feeling similar feelings.

09:55

Yes, thank you very much. Good morning. I wanted to ask you about early intervention, and really to ask whether you feel that any of these local authority cuts have had an impact on children's mental health and whether you've seen a deterioration in services.

I think we would probably need to do some more research on that. I think there's not enough investment in early intervention services, and that's obviously what we call for. I think there's not enough access to talking therapies and there's not enough low-level support in communities. I think that's mainly why our main focus and call are on emotional health in schools, because that's primarily where we work with children and young people. Obviously, Samaritans is an adult service, but from a policy perspective, we do have this cross-over with children and young people because of our work in education. So, we would want to see further investment in early intervention services and I would imagine that cuts to it are detrimental to young people's mental health. From our work with schools, we know that that's needed.

We do have a service where we can go into primary schools as well as secondary schools to talk about emotional health with age-appropriate materials, but of course that's heavy on human resources so we are limited to what we can offer, although we have over 200 branches. The demand, particularly for primary schools, is increasing, and we are trying to respond to that and build up our resources for them. But, really, if we could possibly come up with materials like DEAL for primary schools, the teachers could deliver it, because they're the people who know their pupils best. This is where it all stems from, really.

Yes, equipping the teachers is one of your key messages.

Absolutely. I think so, yes.

Earlier on, the school counsellors were mentioned. Have you seen a reduction in school counsellors?

We're not aware of—. We don't get any figures about counsellors.

We don't get figures but what we do get is a very patchy landscape. It differs greatly between schools. Some are utilised, some are not. Some are understaffed, some are under-resourced. I just don't think it's a consistent service across the board. So, that's a concern. 

Well, I was at the meeting of all the senior counsellors from Wales a few weeks ago and even at that meeting where they were reporting back it appeared that some are very active and others are perhaps not so much because they feel the pressure of what they do in schools doesn't really allow them to network and to develop their systems better.

And, obviously, as you say, with children, you're concentrating on the schools. Do you have any views about what would be the most important thing to develop outside the schools that would help with children's mental health?

I think it comes down all the time to the teaching staff being well equipped—

Definitely, because when we do talk to the staff, you mention the word 'suicide' and they just—. You can see them withdrawing. 'How do we tackle it? How do we talk about it?' It does frighten them because very few of them have had the personal experience, and they need to know that it is safe to talk about it, it is the right thing to do and how to approach people. They can be skilled up to do that.

I think wider than that, if we were moving out of schools and education, to children and young people's mental health outside of school, there are a few things. I think, firstly, there needs to be an increase in socialisation—community groups, access to support networks, because loneliness and isolation are factors for children and young people. They're a high-risk group, as many people wouldn't realise. Obviously, there's quite often a focus on older people or men, but young people are a risk factor, and I think they need more access to good community support networks. Other than that, I think there needs to be some investment in research into the effect of social media on young people. The World Health Organization did a report last year that found that, from 44 countries, Wales came fourth on screen time [correction: screen time for boys]—the amount of hours 11 to 15-year-olds used screen time. I think that's contributing to loneliness and isolation. I think it's causing anxiety and depression. There's a proven link between those, and I don't think we understand enough about the digital world that children and young people are born into. I think we need to understand it better in order to help.

10:00

No, this is throughout the UK.

And you said that the Samaritans was an adult service. What do you do if teenagers or children call your helpline?

We do get very young children calling as well. We do have a policy that we link with Childline because of our safeguarding policy, and we know that Childline can then intervene; whereas, of course, with the Samaritans, we have a confidentiality policy. We allow young people to make decisions. We do try to persuade them to seek help and we can help them if they ask us or if we ask them for information, but basically, our policy is that we do actively suggest that they contact Childline as well, but then we also give emotional support over the telephone, or particularly with e-mails and our SMS services.

Childline Cymru saw a 20 per cent increase in 2016 in calls relating to suicide. As Carol said, we still get a high proportion of calls from teenagers and children. It might sometimes be because they don't feel that Childline is for them because they don't see themselves as a child—they're a teenager or an adult. So, those statistics themselves show that there's a worrying increase.

When you try and place more positive stories in the media, are you able to draw on people who come to the Samaritans service and perhaps have been through it, or is that not something that you're able to do? I assume the media may be more willing if there's a face or a personal story to focus on. Can you assist with that or not as an organisation?

We're currently working on case studies for Wales. We do have case studies that we use in Wales and in regional UK press of people who've used the Samaritans—not so much younger people, but then we wouldn't do that because it's not meant to be for younger people. But we do have case studies that have proven to be successful. We use them especially around campaign times and they're all on the website. At the moment, we're trying to identify people who would be happy to talk about their experience in Wales. So, hopefully that's on the horizon.

After they've been through and been supported by you successfully.

We have had calls from young people who, if you say to them, 'How did you know about the Samaritans?', they will say, 'I saw a poster up in school' or 'The Samaritans came to school and talked to me'. So, this communication between us and getting the message across in schools is really important to us, because we want to encourage them to use us as well as all the other means available to them. Sometimes, they only talk to us because they know that nobody's going to know who they are—it's completely anonymous; whereas, if they're going to school and they talk to their counsellor, obviously that's help-seeking behaviour in that they want something to be done there and then for them. So, there are different, you know—

You raise concerns in your written evidence about the length of time that children and young people have to wait for access to psychological therapies. What would you like to see done to expand access to those across Wales?

I think, again, harping back, we want to see early intervention embedded in schools, because, as I said earlier, I think that that would reduce the strain on the waiting list and the amount of people trying to access psychological therapies. Hafal did a survey on young people waiting lists and their experience of mental health and a lot of people going into CAMHS and accessing psychological therapies would have benefited from lower-level, counselling-type support, as opposed to psychological secondary services. So, I think it's back again to emotional and mental health lessons in schools.

You also refer in your evidence, notwithstanding the Welsh Government's targets in terms of treatment—26 weeks, 56 days and 28 days—. I think you were saying, and I wonder if you could clarify this, that this is evidence that you've just presented in this paper rather than being publicly available evidence from the Welsh Government. I think it says that over 1,000 children and young people are waiting over six months for the first appointment. Is that correct and is that your own data?

No. That was from Mind, I believe, or it may have been the Hafal survey that I was just referencing. I can find out either way.FootnoteLink I think it's referenced in our support. The waiting target is obviously welcomed. The problem is, that's not often based—. It's based on the first time a child or young person goes into the GP surgery and then the first point of contact from there. So, it could be the GP and then their first referral session, as opposed to the waiting time between their first GP session and their first counselling session. So, sometimes it'll seem to be quite low, whereas that's referencing the point at which they get referred to the necessary service. There can be a lot of people waiting six months to a year for the actual eventual support they need of counselling—six months to a year.

10:05

What impact does that have on a child or young person's life in terms of the proportion of their life that that waiting time is, and the size of that waiting time compared to the progress of their mental health issues?

It completely worsens mental health. For those with higher-level severe mental illness, obviously that's going to worsen it. Also, for those who are experiencing lower-level anxiety, a year on a waiting list can turn that anxiety into something far worse than it needed to be. It could've been dealt with early on through a range of talking therapies or support in the community. We're really calling for—. The 28-day target needs to be met with, because we hear all the time people who are on waiting lists who call the service, who are experiencing distress because they're on that waiting list, and it just increases distress.

I think young people as well are much more impulsive. They're waiting and they suddenly think, 'I've had enough of this'—they tell us this on the phone—'I don't see any future.' Impulsively, they take their own lives. They just don't wait. They can't wait.

It's so bleak that those who—. They go to a GP because of anxiety because maybe it's been recommended by a teacher or someone else; the parent takes the child to the GP for anxiety. If that child is then on a waiting list for a year, there's stigma around that because they might think, 'What's wrong with me? Why am I waiting a year?', because why would anyone wait a year for something that's wrong with them? So, they end up feeling that they're different from everyone else. They've been thrown into this system that they didn't need to be in. It could've been dealt with in the classroom.

Thanks, Chair. I wanted to ask you a couple of questions in terms of what you say in your paper on support, follow-up care, once discharge from hospital has taken place following admission due to a mental health crisis or self-harm. You say that it's very important that that appropriate follow-up care is provided within seven days. Could you tell the committee why you've come to that view, why that seven-day period is that important?

If someone's attended A&E due to self-harm or a suicide attempt, the following seven days is the period where there's the highest risk of suicide. So, if they're not given follow-up support within those seven days, suicide attempts or ideation is increased. It's crucial that support is given to them as soon as possible.

So, there's a lot of evidence around the importance of that seven-day period.

Yes. What we referenced in our response was, according to Mind Cymru, there's only one health board in Wales—that is Aneurin Bevan—that records how many people get follow-up support after they've been discharged. So, obviously, that's a real concern because we have no idea how many children and young people have just been discharged and that's it, that's the end of it. And back to early intervention again, for those who have self-harmed, and that may be a sign of anxiety, left without support a year later, that might be something far worse.

And as you say, because the health boards aren't recording the information, for all but one health boards we have no idea whether appropriate follow-up care is provided within that seven-day period or not.

Absolutely. We just don't know.

Okay. I wanted to ask you as well about mental health crises, because we'd heard that NHS care in that situation of crisis is very patchy across Wales, and that the number of under-18s going to our accident and emergency departments because of such a crisis or self-harm has substantially increased. Is that your experience? Would you agree with that picture? 

10:10

Yes, we would agree with that picture. Obviously, as you'll see—I know they're giving evidence today—there's a call from South Wales Police, because there's been an increase of 33 per cent from 36 to 48 in young people who have been detained. We definitely think that is the picture. There's been an increase. I often think it's because those attending A&E in crisis, the reason they go to A&E is because they don't have a crisis care plan because they haven't had the right support or interactions with secondary services in the first place. They have had anxiety or depression that's gone untreated, and back to maybe impulsivity, they end up self-harming or trying to take their own life, and there's no other place for them. 

And you would agree as well that the NHS services across Wales are very patchy in terms of how adequately they respond to those situations. 

Yes, definitely. It is patchy across Wales—it's certainly not consistent. 

Obviously, we want to reduce the number of people going unnecessarily into in-patient facilities if they don't need to be there, but that means we've got to have excellent community-based teams. And you mentioned earlier on, Emma, young people with suicidal ideation, suicidal thoughts emerging, they've got this preoccupation with suicide—how effective do you think that the Welsh NHS is at dealing with those sorts of issues in the community, in particular, when someone hits that sort of crisis?   

I think all the mental health teams are under huge, huge pressure from all our callers, both adult and young people. They struggle to get the support they need. This is what they're telling us. This is only anecdotal, I know, but they continuously say, 'I've rung the crisis team. They'll get back to me or my psychiatric support will be there in a week's time.' And, of course, when people are feeling like this, it's an immediate one and I don't know how that can be overcome.   

Because—. You'll have to forgive me; I can only speak from the patient experiences that have come before me in my own constituency. As I understand it, if a young person presents with suicidal ideation in an emergency department and there is some sort of community service that is promised, it's not always delivered in the way that it was promised when they turned up in the A&E department, usually with a parent demanding they become an in-patient because they're in such crisis. And generally, the emergency services in north Wales, from my experience, are very good at saying, 'Well, let's get some service in the community for you because we don't have sufficient bed capacity', or whatever it might be. But that community service is also under such pressure that it isn't always followed up and delivered, and it knocks the confidence of the young person and their family in the service and engaging with them in the future. Is that a repeated story in other parts of Wales, or is it just something that you—

I think all our callers are saying the same thing, really, and, of course, the number of callers has gone up. Within a year, we had 0.75 million extra callers—in one year. So, I think this is a general reflection of an increase in poor mental health and support within the community is—. But they're seeking help from us and other organisations.  

So, it's good that they're seeking help, but it's not so good that the support isn't there to follow up once the—. You know, you've got to strike while the iron's hot in terms of giving support, haven't you?

Yes. CITTs need to be consistent. I think they can effectively manage younger people who are experiencing suicidal thoughts; it just needs to be consistent. And the fact that it's based around the young person's own home, family and environment is really important, because family is such an important factor in a young person's recovery. 

Yes. Obviously, there's a lot of focus on adult mental health. Do you think that Welsh health boards have sufficient focus on the mental health of children and young people within their crisis teams, and the plans that they are developing? 

10:15

I think that's something that the mental health teams would need to answer. Ours is only what we perceive when people call us, which maybe is not a fair reflection on mental health services, because they often say, 'Oh, my GP was great', but then, of course, they've got this long waiting time that Emma has referred to. And parents often call us and say, 'My child is in distress, what do I do?'

But, obviously we've got the mental health care crisis concordat, haven't we? Do you think that that sufficiently focuses on the mental health of children and young people?

I think it has done great things, the concordat, and it has obviously been supported in fantastic ways by Mind Cymru, for example. I think the focus on stopping children and young people being detained in police cells completely is a really good focus. But, as South Wales Police have responded to this, I think they need to be detained in places of safety other than clinical settings. I think the focus is good, I just think it needs to be more consistent; there needs to be more of a focus on housing them somewhere safe where they don't feel stigmatised.

Thank you. Okay, we've come to the end of our questions, so thank you very much, both of you, for attending and for answering all our questions. I think the committee has found it a very, very informative session. So, thank you very much for your time. You will receive a transcript to check for accuracy in due course.

Thank you for allowing us the opportunity to talk to you all.

Gohiriwyd y cyfarfod rhwng 10:16 a 10:29.

The meeting adjourned between 10:16 and 10:29.

10:25
3. Ymchwiliad i Iechyd Emosiynol a Meddyliol Plant a Phobl Ifanc - Sesiwn dystiolaeth 10
3. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 10

Can I welcome everyone back for our next evidence session, which is witnesses who are working in the field of NHS emergency duty teams or crisis care practitioners? I'm very pleased to welcome Sharon Stirrup, who's operational manager for CAMHS at Powys teaching health board; Darren Rennie, co-ordinated intensive treatment team practitioner in Powys teaching health board; Caren Weaver, who is a crisis nurse at Cwm Taf university health board; Dr Mark Griffiths, clinical director of CAMHS at Aneurin Bevan university health board; and Melanie Jones, who is the CAMHS crisis liaison nurse in Abertawe Bro Morgannwg university health board. So, can I thank you all for attending this morning? If you're happy, we'll go straight into questions from Members, and the first questions are from Julie Morgan.

10:30

Thank you very much, Chair. Good morning. We've been told that mental health crisis services have been under immense pressure and that, on occasions, throughout Wales, there have been no acute mental health assessment beds for children and young people available. We've been told that. We've also been told that there has been additional money put in by the Welsh Government and that, in fact, services across Wales are patchy. So, really, we'd like to have your views of how the services are, basically. So, I don't know who's going to start.

I would like to say that, certainly, in the Cwm Taf area, we don't have a huge number of young people needing admission, but the dilemma that we face isn't necessarily about accessing the bed in terms of it being available, but in terms of the actual assessment process, which we find difficult. So, a young person might present at the general practice or the accident and emergency with their story of the crisis, then require a crisis assessment. We then have to have a further assessment from a consultant in our area to be able to refer into tier 4, and then a further assessment from tier 4 to be able to access a bed. So, it's actually the referral process, the assessment process, that is more challenging for the young person to face, and for ourselves, rather than the number of beds available. It's very stressful for a young person and family to have to go through so many assessments.

So, are you saying that there are too many assessments being done?

Yes, I think that when someone is in a highly agitated and stressed state, having to repeat their story over and over again, at a time of crisis, is very difficult and stressful for them.

To add to that, one of the roles I have as the clinical director is I sit with the national group of clinical directors, and we've been a very active group over the last five or six years, particularly. The processes of admission are being looked at strategically and we are looking to refine these and make them very much more accessible, because we have made major developments across Wales around eating disorders, and pathways into the south Wales unit and the north Wales unit are being worked on, as the other acute admissions are. There are also very clear processes with the Welsh Health Specialised Services Committee, the commissioning body. Where there aren't any beds available, there is no major delay to use the private sector, although it is the goal of everyone in Wales working in the acute end of mental health that we only use out-of-area placements when it's absolutely necessary, and those are beginning to go down, based on the better co-ordination of the locality teams with their enhancements, which have been clear across Wales, and we're going to be able to tell you about, but, also, how things join up towards the regional units and, where necessary and, hopefully, less and less, the use of beds in England.

That is exact data, I'm afraid—WHSSC have that data. But, I think it's about 20 or 30 a year, around that area.

We all, also, with our adult mental health teams, are required to look towards holding beds, if necessary—designated beds that can be properly staffed for under-18s around the different health boards. Different progress is being made. And also, with paediatric beds, arrangements whereby certain paediatric beds can be made functional for acute mental health presentations, where necessary, or adult beds to be properly staffed. So, there are designated beds to make sure that, for very short-term periods of time, young people can be safely cared for if they need to be in hospital. But, we're going to talk about the alternatives to admission that have been enhanced.

We're very similar to what Caren said initially in Powys. Our numbers requiring an in-patient bed are very small, but, sometimes, if there is no bed available in Wales, then we have to go to England, which was taking up a lot more time than it is now that we have refined the process. Again, we're looking at alternatives to hospital admission, because often it might be a social care issue. It's difficult to know from that initial assessment which area it is. So, we're looking at how we can work with colleagues in social care at providing a short placement as opposed to a hospital bed. Sometimes, young people go into hospital only for a few days and then they come out of hospital again. The process is lengthy. We have to get a psychiatrist from Powys to assess that in person. Then, that has to be agreed with the gatekeeper to the in-patient beds in Wales. So, again, they have to assess, and that can take—. Well, we had one young person that it took nearly a week for her to end up in an in-patient bed.

10:35

So, the young person had to wait a week, in an acute situation.

It was almost a week between—. Well, she went to a district general hospital, to A&E, but there was a long process. I think it's recorded before in previous meetings.

That's what is being reviewed.

There's going to be a review, certainly for the south Wales unit, where more regions and different health boards use the Bridgend unit, whereas it's only one health board up north that is using the in-patient unit there. The idea of a regional team to actually manage the unit and so to actually look at all the processes is to make sure they're as lean and as speedy and as accessible—whether that be for an acute eating disorder presentation, or any other acute presentation.

There have been improvements in terms of the timely response within 24 hours. That's the agreement from the in-patient ward that somebody is, if they have to be in a hospital setting—within 24 hours of them being there. And, certainly, from our experience in Aneurin Bevan, the in-patient unit team, they are responding within a day, and actually the availability of beds is really quite speedy. And in fact, I don't know if you've heard from the in-patient units themselves, but, in terms of the UK-wide benchmarking, the south Wales unit has the shortest length of stay, so they are actually having beds more available. So, the trend of people having to go into England is getting less, and that's a number of factors. And I think the assertive outreach teams that are available, and the crisis responses that have been enhanced, are meaning that people are cared for at home. So, this is not a solved problem, but there are plans in place to make it easier.

Yes. So, would you say that, generally, the needs of young people and children are being met?

I could give some specific data from Aneurin Bevan—

Yes, this is absolutely in crisis. Our service is connected. We have community teams that link very closely with partners and primary mental health care services to receive referrals, but we also have a layer of tier 3 specialist functional teams. We have the day unit, which can offer crisis function for up to eight to 10 people a day. They get a multiple package of support and therapies. We have an eating disorder team, a specialist team, which sees all of the 96 referrals we get each year for eating disorders, and they get a very rapid assessment, and we have innovative practice. We have an emergency liaison team, which is the first point of call, with five nurses—I think very similar to the crisis, we've been discussing the different models. We have a duty clinician phone, which has been in operation for two years. So, any referrer—any concerned referrer—can ring in our extended hours, 9 a.m. to 7 p.m., and we took 421 calls in 2017. We now are able to offer out-patient appointments, and so 191 of those calls were arranged in out-patient. This is often before self-harm has happened, and, actually, we are then able to put together a very detailed risk assessment with an onward referral to the team, or signposting elsewhere for support, and 174 of those have been on the same day. All of that kind of responsivity that's been enhanced has meant a use of paediatric bed days, which prior to the team in existence two years ago was over 600 a year of paediatric bed days for post-overdoses or threats of self-harm and suicide, that's gone down to 242 bed days, because we're able to see people often before self-harm and link them in to the rest of the specialist CAMHS service. Our crisis outreach team, which is an 11-person team, as an alternative to admission for those who might go—. We've been in operation for three years and it's very similar each year, but, the last year, we prevented 44 admissions as part of our assessment and when we review our practice. So, 44 admissions were prevented and they were managed within their own home setting. So, dovetailing those kinds of teams—. It's about sustaining that and making sure that we can keep the recruitment to full recruitment, but that feels a real step forward.

10:40

Is that outreach team that you mentioned—is it the community intensive therapy team? Is it the same? 

There's a little bit of confusion. We're all versions of assertive outreach. In England, they talk of assertive outreach. They have principles in common. It's very intense work, it's building on family strengths, it's extended hours, it's multiple modalities of therapy being offered—very flexible, very responsive. We've all committed in Wales to those principles but we've got different names. There is a CIT team, which is an intensive therapy team, and the three health boards in Swansea, Cardiff and—. They all have the CIT name. In the west, they have a CAT team. We have a COT team; up north, they have a CITE team and—.  

Darren is a CIT worker. 

So, we're CIT, CAT, COT, CITE, but we're all working on the same principles. I think there was a confusion initially when we were ehancing the funding, and it was Sarah Watkins then who was saying, 'You all sound different', but we had a number of meetings to reassure that we were working on the same principles and delivering the same functions. 

So, whatever they're called, are you confident that they're adequately resourced to meet the need that's out there and to provide what I presume is a 24/7 intensive cover, crisis cover?  

We were hugely grateful for the money, because it was ring-fenced for crisis and we've absolutely used it. Recruitment has been difficult, I think, and the teams now, I think—I know our teams are absolutely at capacity. Our liaison team I've just referenced—

At capacity in terms of what they can handle or in terms of full complement? 

Well, in terms of demand, I've got graphs that show since 2010 the urgent emergency demand on services has gone from, in 2010, 50 a year to 500 a year and so the actual requirement—. So, there's an increased demand but we've been able to meet that, but we've just had two sickness, a maternity leave and a sickness, and we're really struggling. So, we feel that we've—. That's Aneurin Bevan; I think other areas might feel a little bit more under-resourced for the demand. 

In Cwm Taf, we work slightly differently. So, the CIT team doesn't offer 24/7 in our area but as crisis we are in addition to them. So, if they have cases that they have to refer to us to be able to help that young person out of hours then we'd manage cases that way round. 

And that's the same in the Swansea, Neath Port Talbot and Bridgend area. We've just gone to a seven-day service. We've gone from five days to seven days, starting in December. We've got a full team of nurses but we've got sickness now. So, we've got to see how it goes over the next—. 

So, are you achieving the immediate response, the 48-hours response rate, then? Are you confident that that's happening?   

I know that, in Cwm Taf, we're the smallest crisis team, so we cannot deliver seven days a week at the moment, so we're focusing on out-of-hours work Monday to Friday, inclusive of all bank holidays. So, no. That's a longer term plan that we need to be able to look at. We have our partner agencies from adult mental health crisis teams that assess our young people out of hours at the weekend and then refer back into us to pick up on Mondays. 

So, is the service providing an alternative to in-patient then? Is it effective in that respect? 

Yes. We know that from the figures that we have of in-patients.  

Within the Powys area, where the CIT team works, the core of our business is also not seven days a week unfortunately, and again that's been due to issues of staffing. We haven't had a demand for that service to run seven days a week. We work nine to five, the same as the CAHMS team, and the core of our business would be working very proactively with care co-ordinators to try and prevent crises from happening. And then we do have facility to work outside of that, at weekends and in the evenings, if the need arises for there to be a crisis intervention.

10:45

Can you quantify in any way what level of additional staffing resource you require, then, to be able to provide the service that you'd—well, there are two things, that you can actually afford to provide or that you would like to provide?

In Powys, we did start to have—. When we had the moneys initially, we had our crisis practitioners working and our CIT workers working over the weekends until 8 o’clock at night, but there wasn’t the demand for that, and that left us short in the week. So, it's about—. The geography of Powys makes it very different to other places.

Powys would be very different to other areas, yes, of course.

I think we have to be creative about how we use our crisis practitioners to support our CIT workers and our other workers in the specialist CAMHS team and prevent, have a good plan in place, a good risk management plan, good contacts, so that we don't wait for the crises to happen; we pre-empt what might happen.

I wonder if I could come in. In terms of the data that's been captured over the last few years of our emergency liaison team, which were doing extended hours during the week and Saturday, Sunday, and then, out of hours, consultants like myself, we've always been there to support A&E physicians and the junior psychiatrists that cover the patch. Our audit showed that the demand wasn't enough; it was, on average, one young person a weekend. Actually, what we decided was that, in terms of how that affected the rota for a five-person team, it meant that, during the week, all the functions that we wanted them to do, they couldn't do it. So, actually, with partners, we explained the data, we said that it's really not cost-effective to provide that, and, in fact, in the previous model, these young people were being covered, they were getting assessments, they were getting care, but it was not—. So, we actually have withdrawn our weekend cover, and I know that was something that Sarah had said, that we don't want to be paying for teams that are just going to be sitting idle, not working; we need to go where the work is. And I think that, our team, we started with 11 whole-time equivalents for the crisis team, but what we found was that our big demand was in the tier 2 to meet our four-week targets and to do the borough work, so we have redeployed one whole-time equivalent from that team. So, it feels that we've almost almost got enough, but it only takes some problems with vacancies for everything to be over demand.

Okay, thank you for that.

Now, we know that people with mental health problems are three times more likely to attend A&E, so how well-equipped are staff working in A&E departments to deal with children and young people, particularly, who turn up?

I think that, ideally, they would really benefit from training in those mental health issues that affect young people. I think, when we speak to A&E staff, they recognise that there is a need in themselves to have the training, and I think that, in an ideal world, part of the crisis team's job would be to be able to provide that training, because we have such close links with A&E. It's very much needed.

So, what elements of that are currently in the system?

We have started providing some education on what we offer and how we offer it and why we offer it, but we would like to extend it further to be able to address specific mental health issues and look at how best to respond to those issues.

I mean—. Sorry, am I talking too much? [Laughter.]

No, you go first, Mark; I'll go afterwards.

We looked at all the functions that the liaison team had, and actually linking in training, and not just with front-line A&Es, but with school counsellors. So, there is a lot of self-harm, but a lot of it, actually, appropriately, is going to be managed by support within schools and in the tier 1 services. But, actually, with the support from our expert assessors to provide reassurance, what we found is that the relationships with the paediatric wards, the A&E departments, and with adult mental health have improved with a dedicated team functioning, because they can spend longer—and the multi-agency work—and there's been an awful lot more, within the same day, multi-agency meetings, where there are very complex cases, where there are social difficulties as well as mental health.

But that becomes a capacity issue, that, actually, the core work is the risk assessing and planning safety plans and onward referral, and it's when the numbers get less. It's those who are additional, who are hugely important, but can't be prioritised above the core work.

10:50

What we've done in Powys is that we've had quite a few challenges because some of our young people go to the district general hospital in Shropshire, in Shrewsbury, which is England. What we've done over the last year, when we've had young people in crisis and they've had to go to A&E, is that we've had learning events, where the staff from A&E, from CAMHS and from children services have come together, looked at those specific cases and come up with an action plan so that we are going to be meeting and delivering training with them—both meeting with the CAMHS service there and A&E staff too. So, we've been proactive in looking at what solutions we can come up with around the difficulties.

So, are there mental health liaison services available in every A&E department at the moment—is there somebody or some service available?

Every CAMHS service now is committed to this liaison. It's called different names, but it's that emergency response—the first-line emergency gatekeepers to do the assessments and, where necessary, to be in A&Es or for those young people to be diverted to where they can be seen in a more child-friendly environment.

But those would be all-age services because, clearly, you've got the broader service, but then you've got the focus on children and young people as well, which demands other skills very often.

Where it wasn't an all-age service—. I think there weren't many services like the rapid assessment, interface and discharge model. You might have heard that there is a RAID model that comes from old-age mental health and it's extended down into adults. There are only a few places in England where it is an all-age service because to have the specialism and expertise to better work with children and older people—. But there is the commitment and the ring-fenced money and the requirement for us to remodel to make sure that we all have liaison teams, functioning slightly differently, but they're based on the same principles. So, I think we can confidently say that they exist across all of the health boards in Wales now—those dedicated teams.

I just wanted to ask you, Mark, about the increase that you've had in referrals—I think you said from 50 to 500 or so since 2010. That's obviously a significant increase. I assume that part of that is because people are becoming more familiar with referring to your service. Part of it might be because people are more regularly presenting in crisis because of waiting times for psychological therapies, perhaps—I don't know. Part of that might be, because there are no in-patient beds, people might not be getting the support that was previously unavailable as a result of your service out in the community. Would I be right in assuming those things—or put me right, if I'm not?

I would question a few because, actually, over these last few years—. We're not here to talk about how we've remodelled. I certainly know in Aneurin Bevan that we're now seeing 88 per cent of young people considered routine by referral information within four weeks. There was a time, quite a few years ago, when it was much bigger than that. So, there's been a corresponding, and that's for the same—. We see about 1 per cent of our population; we've got capacity to see that, but, previously, people waited ages and ages. Now we can responsibly meet the need of 1 per cent. So, that trend has been happening. So, it's not that we could see—. In the past, it was the case that our waiting list went up because we were focusing on the urgent end, and that had to be a priority, but the cost was that the less urgent emergency cases got left. That hasn't been the case because we've been doing the two things at the same time.

In terms of the increase, there is an increase in self-harm and that's worrying for society. In terms of whether that indicates serious mental disorder and does it indicate suicide, thankfully there isn't a major increase in suicide. But there is a lot of concern. Some of the increase in referrals is a lot of concern from families and from referrers that we, at the moment, need to be dealing with specialist assessments. But, actually, in terms of those who come in requiring ongoing therapy, which we do have available because increased access to psychological therapy is better than it's been for a long time, most people don't need the specialist forms of therapy; they get diverted elsewhere for support. So, hopefully, this part of the training and helping people to be able to manage what is a phenomenon, which is self-harm, and is some signal of distress, but is not a signal, necessarily, of a mental disorder—.

So, what proportion of those children and young people that your intensive teams would see would be on a waiting list for an assessment, or a waiting list for psychological therapy?

10:55

Very few. The emergencies often arise not because things have got worse. And I know that is a perception, that, if people wait too long—

Yes. Well, that's what we've heard from other wittnesses.

People aren't waiting long now. We've been down at four weeks—80 per cent of our service, four weeks—since early last year, and we're sustaining that.

So, you're saying the majority of individuals would not have been known to mental health services before.

No. No, not the serious problems, where admission is considered and we put in our alternatives. That isn't a major trend. There are obviously a few people who were waiting, but it's often that the referral information didn't let us know how serious it was in the first place.

So, why would that be the perception of many of the other witnesses who we've heard from, including the Samaritans this morning?

Because it used to be the case.

Right. So, it's a historic thing and it's not going on now. Are you able to evidence that with some hard evidence from your statistics and information that you collate as teams?

We certainly do have information.

Because I think that would be useful for the committee to see.

I would say there is definitely a percentage that may be already waiting, or under the care of CAMHS, but, again, for a crisis team we are seeing a large proportion of young people who are not known at all to services who present.

Yes, and they're not presenting with a mental health disorder. It's most often emotional distress in response to social situations.

Right, okay. But you're able to provide that information to the committee.

Thank you. Good morning, everyone. I wanted to ask about ways that you think that access and early intervention can be improved. The mental health crisis care concordat brings together different agencies to improve access. Do you have any view on the types of early intervention services that could be delivered by partner agencies, working together to alleviate the pressure on A&E?

I think that, from our point of view, for Cwm Taf—and I think it's probably similar for ABMU—if we were able to work more closely with partner agencies and extend our liaison work, then everyone would have a better understanding of mental health and how to be able to support somebody who is hitting a mental health crisis, or certainly experiencing emotional distress. I think that's what we would like to see.

We have discussed in Powys, because we are very reliant on our partner agencies in Powys, because there are not huge amounts of people there, about how therapies that we might be using in the CAMHS service, especially with emotional regulation—so DBT—about how our colleagues in partner agencies can have an understanding of what that's about so that they can be supporting that. Because somebody's not going to be in therapy every day. So, for partner agencies to have an understanding of that piece of work, that can help to support that young person and prevent them from drifting into crisis.

I feel that we need—and we're not far away—to have specialist services that are fit for purpose, that can actually respond to those whose needs can only be met by a specialist service. But, in our role, I think we can offer strategic guidance, but also indirect support, through training, consultation, so we're not an ivory tower specialist service that can't be accessed, and we need to be moving towards—I think the exemplar model is north Wales. We know that, in Aneurin Bevan, we've been building our specialist service, but the single points of access, and the joined-up work within the mental health Measure terminology—the Part 1 scheme—the joining up of not just health agencies, but then also wider agencies, to be able to provide where the needs are, in a joined-up way, and then a flow of people, in terms of referral processes, that they don't have to wait, and go through lots of different—. We talked about that for getting into hospital, but actually you need that very quick access and identifying those who really need to go straight into the specialist services. I think there was a trend, and Mark Drakeford used to speak very clearly about it, which seemed to be that it was assumed there was a lot of misinformation and the expectations on services, specialist services—. We can really only cater for about 1 per cent, but we know, consistently since epidemiology has been looking at this, that 20 per cent have emotional behavioural problems, but, actually, the more targeted interventions that could, hopefully, meet 5 per cent to 6 per cent, we can work indirectly but very closely with that. But we've still got a large amount who need support, but they don't need specialist support. So, it's a joining up. It's about a joining up and smooth processes, I think, and we can't directly see everyone, but indirectly we need to really support. 

11:00

Anyone else? Are there any barriers to that actually happening?

Resources within the teams, as they are,  themselves. We've spoken about the numbers that we have within the teams to be able to provide a crisis assessment, because, ultimately, that's what needs to happen, but the work is bigger than that. It's about the longer term work and how to best support that young person in the community, skilling up partner agencies to be able to be part of that support and risk management. 

And Sue Bailey, who was the expert adviser to the Together for Children and Young People programme, was very clear that, with specialist CAMHS, what we can do to help is be there, but be available through consultation, training and support. And that's been discussed at the national level, because, in the benchmarking we're only held to assessment and treatment targets and all the very specialist core work. But it needs to be seen as legitimate—the consultation time that we need to better job plan, and we need the capacity to be able to do this work, otherwise, by the demands of the system, we end up being ivory tower because we just do what we can do because that's what we're held to. And, actually, if we are going to be accessible, which I think is the way forward, it needs to be legitimised. So, rather than, 'How many cases have you seen today?', it's, 'How many forums did you attend where you supported other people to support?' And the benchmarking organisers have agreed that they will be capturing data on consultation activity, so we need to get our team job plans developed to reflect that that is a legitimate piece of work. But, at the moment, we're not being held to that.  

I just wanted to add that I think one of the barriers is like what Darren alluded to earlier, which is about people's perception of CAMHS—that they're inaccessible, that they've got huge waiting lists, when, in fact, we're saying, 'No, we're meeting our targets. We've not got those waiting lists anymore.' And I think there's a huge piece of work to do there to inform people, to raise their awareness. We're having a CAMHS service review in Powys, and we've met a lot with children's services, education, and they've been invaluable to not only open up our eyes to what people are offering and what's planned, but so that they can also see what we can offer. So, that does a lot to bring down that misconception of what people think. 

Can I just ask a little bit more about this issue of the waiting, because it's very inconsistent with the messages that we've received from elsewhere? I know that good progress is being made in terms of getting a first appointment within the four-week period. The issue seems to be the wait which follows then for access, particularly to psychological therapy. So, are you telling me there's no problem with that second leg of the journey, as it were?

It's probably very different in different areas, to be honest. I know that, yes, in Cwm Taf, we have been able to see young people faster for the initial CAPA assessment, and there is a little bit of a delay between the therapies actually starting and—

When you say 'a little bit of a delay', how long is that delay?

I can't say. That's—

Because most people are waiting beyond four weeks anyway still at the moment, for that initial first appointment, and then there's this second leg of the journey, for which we have no clear statistics because they're not published.

We can provide you with the statistics for Powys. I've not got them with me at the moment, but we can provide them. 

Well, you must have an idea of the wait at the moment. 

It's based on need, that first choice appointment. I know there's a discussion around what is psychology therapy and who can deliver it, and I think, in Wales, there is a bit of a sense that it can only be a psychologist and that's not true. We have very highly trained professionals of all sorts of disciplines that offer evidence-based, really good-quality psychological therapy. So, I don't know if there's a message that there's not enough access to psychologists. There aren't enough psychologists, that is true, but that doesn't mean that there isn't access to psychological therapy. And the CAPA model, which you might have heard people like us talk about is a lean model for CAMHS. It's the choice and partnership approach. It's not a medicalised model. Instead of assessment and treatment, it's a choice. And that choice appointment is therapeutic in itself. It's based—

11:05

So the therapy starts the moment you come in the door. It isn't just a triage assessment and then you have to wait, because there are therapeutic elements built into that choice appointment and there are things within that session—there are suggestions, there are therapeutic suggestions, there is a kind of bringing in of what else is there to support, within the family—the resources, but also outside. So, it feels a bit of a false dichotomy to say 'from assessment', because the way we are currently working is that it's part of—. The therapy starts—so there isn't a big distinction because that therapy—. It's about when that next phase of partnership starts, and if it's too long that is an issue, but we know that, within Aneurin Bevan, that's within four weeks of the first appointment, and if someone has urgent needs, it's much sooner than that. So, it isn't a big hidden wait, but therapy has already started as well.

But do you think we are missing a trick then in Wales by not really having any proper data on what's happening beyond that first appointment?

We're being held, and it's every couple of weeks. So, as the clinical director, it's to assessment—the length to assessment. And, absolutely, to have meaningful data, you need the length then to what the next phase is. But we need to understand that it isn't a straight medical model where it's assessment and treatment, but there can't be big internal hidden—

I know individual patients will have different pathways, and I know that individual patients will have different home circumstances et cetera, but we're talking about vulnerable young children and kids, aren't we—children and young people—here? There has always been this perception that waiting for psychological therapies has been far too long and that that has been part of one of the problems that we needed to try to deal with. The target for assessment has been very welcomed and good progress is being made, although, as I say, still, almost twice as many people are waiting beyond the four-week target at the moment than are getting their assessment within the four-week target, but because there's a complete lack of information about what happens to them after that point, it's difficult for us to determine whether things are satisfactory or not. The evidence we've received from others, including the Samaritans this morning, who've been saying good progress is being made with this four-week target, is that people are then left in limbo while they're waiting for the next stage of their more intensive support, perhaps, to begin.

But from our perspective in Powys there is a wait for psychological intervention. Some members of the team deliver that, some might need more specialist intervention, which means they might wait longer. There have been peaks and troughs over the last year. I monitor that after our team meetings, and it's generally reliant on people leaving—you're waiting for new staff to come in; people going on maternity leave—you can't cover that post. So, it is very up and down. It has improved compared to what it was, but it could be—

I just want to be sure that we're talking about—. In terms of the new targets, there are the routine cases—I know that routine are still heavily in need because they need a specialist service—and then there are urgent, and there's absolutely no wait. People are seen within the same day and then their follow-up care is the next day, the next day, the next day. So, that cohort of young people do not have to wait at all, but then there is, for those who are defined as routine, a wait, and I absolutely accept that you need good data.

You made the distinction then between urgent and routine. Earlier in your evidence I think you referred to less urgent emergency cases, and I was just a bit nervous about that. Could you give me some examples of what you might mean by that?

We've come in line with adults. We used to have—. An urgent case was four weeks. That was CAMHS. We were held to that; it was pretty arbitrary, four weeks, but there still were cases that needed to be seen on the same day, and we would always mobilise ourselves to that. But that was the target, and there was a 16-week target. We've now gone in line with adults so that the urgent is two days and the routine is four weeks, but there isn't an emergency category for CAMHS. That's why I kept saying 'urgent emergency', because, actually, they get a response often within a matter of hours for those most—when there is an emergency, but, sorry, that's why I'm saying 'urgent emergency', because— 

11:10

Could you give me a little more perhaps about how you manage that as a clinical director? I think, as a committee, we're a little concerned that we don't have much in the way of data, and what we do have is from going to each individual health board and it's not necessarily comparable. Could you perhaps help us by saying a bit more about how you manage that internally and how you ensure your staff are prioritising seeing people as quickly as they need to be seen?

Well, we have two main gate-keeping processes. We have our team leads for the community teams, who will look three times a week at the referrals that come in, and those that have 'urgent' on them—. And they are also screened on a daily basis and if there's something that suggests clearly suicidal intention with depressive symptoms, urgent psychotic symptoms or a life-threatening eating disorder—those are the three things that are the red flags that they will immediately go to our emergency liaison team, the duty clinician phone can be used, the response is immediate, and then in come the eating disorder team, the crisis outreach team, me; I'm the crisis consultant for our service so I oversee all of those teams to make sure they all dovetail together. So, I'm available for that straight away as well. So, it's within the same day. So, things can come in through the emergency phone directly to the duty clinician, who is one of the liaison clinicians, so they can gate-keep for the service and they can also determine—. It is a kind of triage assessment on the phone—just enough questions to determine, 'Is this urgent emergency?' In which case, then we're responding. 

But, for some, the referrer has talked about it as being urgent, but once we find the information, actually, we downgrade it to maybe routine but they need to be seen by us or 'Actually, this isn't a specialist service at all. You know, you had concerns, but they're not requiring this.'

What about the other health boards? We heard earlier that a young girl was waiting a week in Powys to get a hospital bed. I mean, is the picture as good in the other health boards as we've just heard from Aneurin Bevan?

The young person who was waiting a week was waiting for assessments from in-patient psychiatrists and community psychiatrists. As far as our response goes, perhaps, as a duty—.

Darren Rennie