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

Children, Young People and Education Committee - Fifth Senedd


Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Darren Millar AM
Hefin David 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

Albert Heaney Cyfarwyddwr, Gwasanaethau Cymdeithasol ac Integreiddio, Llywodraeth Cymru
Director, Social Services and Integration, Welsh Government
Dr Dave Williams Cynghorydd y Prif Swyddog Meddygol ar Seiciatreg Plant a'r Glasoed, Llywodraeth Cymru
Chief Medical Officer's Adviser on Child and Adolescent Psychiatry, Welsh Government
Joanna Jordan Cyfarwyddwr Iechyd Meddwl, Gwasanaethau Corfforaethol a Llywodraethu, Llywodraeth Cymru
Director of Mental Health, Governance and Corporate Services, Welsh Government
Kirsty Williams AM Ysgrifennydd y Cabinet dros Addysg
Cabinet Secretary for Education
Lowri Reed Uwch-swyddog Gweithredu Llesiant, Llywodraeth Cymru
Senior Well-being Implementation Officer, Welsh Government
Vaughan Gething AM Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol
Cabinet Secretary for Health and Social Services

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Llinos Madeley Clerc
Michael Dauncey Ymchwilydd
Sarah Bartlett Dirprwy Glerc
Deputy Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle 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 09:36.

The meeting began at 09:36.

1. Cyflwyniad, Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
1. Introductions, Apologies, Substitutions and Declarations of Interest

Good morning everyone, and welcome to today's meeting of the Children, Young People and Education Committee. We've received no apologies for absence. Can I ask Members whether there are any declarations of interest? No. Okay, thank you.

2. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc: Sesiwn Dystiolaeth 21
2. Inquiry into the Emotional and Mental Health of Children and Young People: Evidence Session 21

We'll move on then to item 2, which is our final evidence session in our inquiry into the emotional and mental health of children and young people. This morning, we are taking evidence from the Welsh Government. I'm delighted to welcome Kirsty Williams AM, Cabinet Secretary for Education, and Vaughan Gething AM, Cabinet Secretary for Health and Social Services.

Can I ask you to introduce your officials, please, for the record?

Of course, Chair. A slight change to the players on the pitch this morning. Unfortunately, Ruth Conway, deputy director, support for learners division has lost her voice, so I'm this morning joined by Lowri Reed, who is the senior well-being implementation officer.

My officials will introduce themselves.

Good morning. Albert Heaney, director for social services and integration.

Good morning, I'm Dr Dave Williams. I'm the Welsh Government and chief medical officer's adviser on child and adolescent mental health.

Thank you. Welcome to you all. I should just place on record that Huw Irranca-Davies has had to send apologies. Before we begin, I thought it might just be helpful to outline how we intend to approach the session this morning. As we've discovered during the course of this inquiry, for emotional and mental health for children and young people to be delivered well, it needs to straddle education, health and social care services. So, that's the reason why we've invited you to have this joint session this morning, so we can explore the extent to which this approach is being adopted.

In the first part of the session, we're going to focus on education, resilience and well-being. At approximately 10.30 a.m., we will break for 10 minutes before turning our focus on primary mental health services and specialist child and adolescent mental health services for the last hour or so, and at that point Kirsty Williams is going to leave us. We've got a lot of questions to cover. We're going to go straight into questions now, but if I can just make an appeal right at the start for brief questions, and we want to get to the heart of the detail, but brief answers as well, please.

So, if I can start by asking Kirsty Williams: what do you think the main successes have been of the Together for Children and Young People programme and what remain as the biggest challenges in the early years resilience and well-being and early intervention and enhanced support work streams?

I think it is right to acknowledge that there's been a slight delay when the work streams have been brought together, and I think there's a very logical reason for bringing those streams together because of the overlap of the various work streams. I think there has been a slight hiatus, but there is now real progress and, I think, pace happening.

We recognise that this is an NHS-led work programme and strain of activity, but it's been really important that education officials from Welsh Government have been involved in that process. So, they've been part of the work streams. They have participated in a mapping and evaluation exercise that took place last year. Lots of that work has been led by Pembrokeshire's head of inclusion, Nichola Jones, who is the lead education link from the local authorities in that particular work stream.

On what the successes are, there have been issues around training resources that have been made available for early years practitioners, which I think have been really valuable; new directories put together so that people in schools have a directory of services in which they can look to get help from; but I think that it's the professional learning and the dissemination of best practice and impact that is the most important element of that work.

What's also important as well is, as we develop our new curriculum, our area of learning and experience health and well-being group and our pioneer schools that are working on that part of our new curriculum have had access to, and their work is being informed by, the team that is working on Together for Children and Young People. So, they've had an opportunity to participate in workshops with the health and well-being group so that, when we're looking at the curriculum side of things, there is input into that as to the research base, the understanding and the importance of this particular area.


Okay. Thank you. You've referred to the work that your officials are undertaking with the Together for Children and Young People programme. Could you just give us a little bit more detail on that, but then, very importantly, tell us how you work together at a political and strategic level to increase resilience and well-being amongst children and young people? Because we know that we no longer have a children's Cabinet sub-committee. So, can you just explain to us the mechanics of how that's working? I'd be interested to hear the Cabinet Secretary for health's perspective on that as well.

Okay. Well, 'Prosperity for All' has mental health as one of the underpinning themes that run through all the Government's work. So, there is a very clear steer from the First Minister—an expectation from the First Minister on Cabinet Secretaries—to work collectively across Government on those themes. So, myself, Vaughan and now Huw, and previously the late Carl Sargeant, meet on a regular basis, not in a formal sense but looking at areas of work where, together, we can make a greater impact for children. So, those meetings continue.

I see myself as an advocate for the school system in bringing to the attention of colleagues in health and social care some of the impacts that services in those areas have on educational standards and attainment. We talk regularly about the need to have enhanced wraparound around schools, that teachers should not be bearing all the load for a failure in social services or the health service to be able to provide those services. So, we meet to discuss those issues.

Most recently, for instance, Vaughan and I met with the Children's Commissioner for Wales to talk about her concerns and points that she'd raise about the integration between Together for Children and Young People and the curriculum, and we were able to meet together with the children's commissioner to discuss those particular issues. So, I think we work closely together. The most obvious, perhaps, impact of that is the inreach project of CAMHS, which I'm sure you'll want to talk about in greater depth later on.

Yes, and I think it's important to highlight not just the formal conversations, but the informal conversations that take place. I'm certain we will go on to talk about the inreach project, but that came from a conversation between myself and Kirsty about conversations she had had with headteachers and about progress, and we then agreed to have a further meeting with officials to look at a way to do something. That's then gone on to become the inreach pilot.

We jointly fund the adverse childhood experiences hub as well. So, you see some specific formal areas where we're deliberately working together, with joint funding going in, to try and look at the person in their context. So, it's about understanding not just what each of these service areas need to do together, but recognising how that child lives their life in their context with their family and their community, and how you support that whole person. All those services have a responsibility, but how do you help other people to make their own choices as well? Because that's the point about broader resilience. It isn't something that the state gives to a child. It's actually how that child is brought up and their experience through life.

So, I actually think that all of the formal structures that exist—'Prosperity for All' and all the things that fall from that—but actually, it's about how you have a culture of working together and expecting, 'I need to know what's going on here.' And equally, when I look at things that come across my desk, I regularly say, 'These other people within the Government need to know about it, so I want to check that they know that this is going on and see if they've got a comment on it.' It's not just this area; there are a range of others as well where we have to talk to each other, and I'm pleased to say that we do. I think we'll see, through time, a more joined-up response from the Government as a result.

Okay. Thank you. Was it on this, Julie, or the inreach?

Yes, just very quickly, really. You mentioned in your introduction about the fact that there was no children sub-committee, and I wondered if you thought that would be a help in terms of communication—if there was a children's sub-committee.

I think that, when you look at the re-organisation that's taken place, about the fact that Huw, within his portfolio, has got clarity in children, social services, and he's part of the health team, and we recognise the need—not just the desire, but the need—to make sure that we have conversations across Government, I'm not sure that we need a formal sub-committee. What we need to be able to demonstrate, though, is that both the formal and the informal relationships are making a difference and that the children's agenda in all the parts of Government where it is, is being taken forward. People will judge us on what happens, won't they, on the level of need and demand that exists and whether we're able to do something about that, both in terms of meeting the service challenge, how we try to get ahead to change people's life chances at an earlier point, that point about early intervention and prevention, and that isn't just an issue for the two of us in front of you, and if Huw was here as well—it's an issue across the Government.


I think what's important for me is that there is an understanding and a willingness, across portfolios, to meet when we need to meet. There's nothing inherently wrong with having a children's sub-committee, but one of the dangers might be that those conversations would wait until the formal timetabling and agendarising of those meetings, whereas I can honestly say, hand on heart, when I have felt the need to raise something, whether that be with Vaughan, or whether that now be with Huw, on a whole range of issues, then those meetings are arranged really, really quickly. We can have that in-depth discussion on those particular subjects, whether they are, for instance, safeguarding, issues around elective home education, how we can integrate the foundation phase, the early years education offer with the childcare offer, or how can we have a comprehensive early years intervention that spans all the programmes that the Government is committed to and then the impact of education in that.

The relationships are more important than a formal arrangement.

Yes, and making sure that nobody feels inhibited or there's any kind of barrier to those meetings taking place, and I can honestly say, hand on heart, I've never asked to see one of my colleagues and found that to be difficult. It's happened very, very quickly.

That's important for our relationship with stakeholders, as well, of course, about the way that we work together, that they see that that's actually happening, and the way we interact with them as well. Colleagues in local government need to know there's a consistent message from the Government, as do the third sector and others as well.

It's absolutely right, what you've said about stakeholders, and stakeholders have told us that they think that the links with education are absolutely fundamental, but they've also expressed frustration to us about the Together for Children and Young People programme, and the focus within that, because it's health led, on actually driving forward that education agenda. How do you respond to those frustrations that have been raised with us?

It's one of the issues the children's commissioner raised at our meeting, actually. I think we were able to helpfully point to some of the work that we're doing and, actually, both the difference and the complementarity between the curriculum reform on the one hand, and, on the other hand, the Together for Children and Young People programme, which is about improving part of our health and care services. As Kirsty said, we have representation from the directors of education on the programme board. They are partners in that. We have directors of social services being represented, the third sector and others, too. That's where the importance of the work streams really matters, to make sure that all those things are being fed into some of the detailed work that's going to the board.

I wouldn't try and tell you or anyone else that therefore means that everything is perfect. I'd always recognise the need for further improvement, both in terms of the conversation, how people feel valued in that happening, but, ultimately, in whether we're providing the right services to help deliver better outcomes. So, I recognise some of the frustrations that are there, but, actually, I think we've got a much better story to tell about where we started before Together for Children and Young People, where we are now and our prospects of being able to continue to work better into the future. So, I wouldn't say that people don't have frustrations, I wouldn't say that they're all completely unreasonable, but what I would say is we've made significant progress already, and we know there's more for us to do, as well. I think that essential honesty has to be there from our side as well as stakeholders'.

You'll remember, Chair, when I last appeared before the committee when we were talking about education reform and curriculum reform, Professor Donaldson, who, of course, chairs the implementation board around the curriculum, a board on which the children's commissioner sits, says that any concerns about that are brought to that group. Where they are legitimate, and there is progress that should be made, then he ensures that that happens.

I think the issue is, though, we do have to recognise designing a curriculum is very, very different from Together for Children, and although we absolutely want to ensure that there is cross-learning, and where there is complementarity, that that is recognised and utilised, we also have to recognise that they are different things, too.


Good morning, everyone. How much of a higher priority is Welsh Government placing on the well-being of children and young people, and how is this reflected in the new education action plan? That would be primarily a question to you, Kirsty.

Enabling objective 3 places a very, very strong and very clear emphasis on my expectation, the Government's expectation, about well-being in our schools. If you look at previous plans, there was little if any mention of well-being in what the education system should be about. We also, in the purposes of our new curriculum, are very, very, very clear that one of the purposes of the curriculum—what we expect our children to have gained from their time in Welsh education—is the fact that they will be happy and confident citizens able to play their part in their world.

So, I think we've been absolutely explicit and clear around our expectations in that. I recognise, and there is lots and lots of academic evidence, that children with higher levels of well-being generally achieve better educational outcomes and qualifications than those who have lower levels of well-being. So if we're interested—and I am definitely interested—in raising standards in our schools, I cannot afford to ignore issues of well-being in our classrooms, and making those linkages between high levels of well-being and what that translates to in terms of educational achievement, and also recognising that we don't want to medicalise that, recognising that children in their lives will go through difficult and challenging times. I can't prevent children losing a parent through bereavement. I can't prevent children's parents splitting up. But what we can do is create an atmosphere in our schools—and that goes way beyond the curriculum—an atmosphere in our schools when children are facing those difficult things, then we have built in them a resilience to help them overcome, and if they're struggling to overcome challenges in their lives, then there are services at various levels for them to go through. We can't reduce the attainment gap and we can't improve standards for our children if we ignore well-being.

Okay. Thank you for that. How significant is the increased emphasis on well-being in Estyn's new inspection framework and the school categorisation criteria? The categorisation criteria in the Estyn inspections have been seen to drive culture in some cases. Are you hoping to replicate that with a greater focus on well-being in the Estyn inspections?

Well, people don't need to suggest that Estyn categorisations drive culture; they do drive culture, absolutely drive culture, in our schools. Therefore, a more sophisticated way in which we look at well-being, both in terms of how Estyn judges that—and in the past, Estyn have just judged well-being very crudely; sometimes just, 'Are the children in school?'—and the way we look at categorisation, looking beyond just raw data to a more critical self-evaluation of what is actually going on in that school, I believe will help drive and reinforce the importance of well-being.

But it's difficult to measure. I have to be absolutely honest about how do we come up with a set of criteria and measurements that can really give us a handle on this. So, what are we doing? We have committed that, by the autumn of this year, we will have new ways of looking at well-being. One of the outcomes of Together for Children has been a well-being toolkit, to look at it, and we're working internationally to look at how other countries try and capture this data in a reliable form. So, I was, in the autumn of last year, with the Atlantic Rim Collaboratory, which is education systems from across the world, working with people like Andy Hargreaves at Boston College, Pasi Sahlberg from the Finnish system and other experts in this area about how we can create a set of data so we can better capture and measure in our schools issues of well-being.

One of the ways in which we do currently look at data is via our school health research network survey, and the Welsh network of healthy schools. Now, the survey happens twice a year [correction: every two years]. We've had a big push this year on getting schools to sign up to the survey, so we can get that data. I'm pleased to say I think we've got just about every high school in Wales now participating in that survey. We've changed the nature of the questions in that survey, so that they are much broader based, about how children are feeling about their lives and what's going on in those lives. And the benefit for the school in participating in the survey is that every two years they get a really detailed snapshot of how their children are feeling, and student voice and listening to children is a crucial part of how we can get this right in terms of measuring well-being. 


Okay, thank you. When education professionals participated in our survey, 33 per cent of them said that their school or college meets the emotional, well-being and mental health needs of their students. Only 22 per cent said that their school or college has a mental health policy. To what extent does that demonstrate, in your opinion, the extent of the challenge facing you?

It's a big challenge. I think some of that frustration, if I'm honest—there's a number of elements to it. Are we providing enough professional learning for the teaching staff in the school to feel confident about these issues? Does the school as a whole feel that they are able to interact with social services and healthcare services in a way that is really timely and meets the needs of their students? And I think we'd all acknowledge there's more work to do in getting that right.

We do not require schools to have a mental health policy; we don't require that of schools. What we do require of schools is a behaviour policy. Now, I don't want people to think that I am associating bad behaviour and mental health, but what we do know is sometimes children's mental health or emotional difficulties do play out in behaviours. So, our expectation is that we require a behaviour policy, and that behaviour policy should talk about and should demonstrate how the school will meet the needs of children's mental health and well-being, because sometimes that is displayed in behaviours that are exhibited in the school. I don't want to say that children with mental health problems are naughty—that's not what I'm saying—but what I am saying is that, in the behaviour policy, our expectation is that the school would set out how needs are met. 

Both the academic evidence and some of the witnesses we had before the committee stressed the importance of a whole-school approach, and I just wonder: how in practice does Welsh Government go about looking to obtain that whole-school approach when it comes to issues about emotional and mental health for children?

There's a debate to be had, isn't there: can you leave this to one set of professionals within the school? The evidence from the Public Policy Institute for Wales and the work that was done particularly in the primary sector demonstrates that it's much more effective if you can get the whole school community to address these issues. So, for instance, let me give you an example: the Welsh network of healthy schools. This is quite a long-running programme that looks to improve the whole school and the atmosphere in the school in addressing issues around health and well-being—so, that's not just mental health; that's physical health, although there are close correlations, as we know, between physical health and mental ill-health—through to the student voice in the school, so students feeling empowered and being able to have a role in how their school is run.

That's a very practical example of a project that we run, and that's delivered with healthcare professionals and social service professionals [correction: via health and education partnerships]. So, it happens in schools but it is supported by local authority and healthcare [correction: public health] professionals in a local area, and we have an increasing number of schools that have been able to work their way through the various steps to get that accreditation—so, there are various steps that schools take to get to that final accreditation. I have got examples, if people are interested, of the most recent schools in their area that have achieved the final accreditation. We haven't got any in Torfaen, I'm afraid to say, Chair, but there are examples across Wales. So, Mark, for instance—Gilwern; I'm sure you're familiar with the primary school in Gilwern. It's a very good example of a school that recently reached the highest award for the healthy schools network. One of the particular strengths in that school is pupil voice and pupils really, really being able to have a say about how their school operates and any concerns that they have then are being addressed by staff. That was held out as a really good example of how pupils' well-being could be enhanced.


I'm glad to hear that positive example. One of the issues I think we faced in the inquiry is we found a number of health-based witnesses where everything seems to be going well, and it's all well integrated and the systems are working, and we listened to that evidence, but then, when we talked to teachers and headteachers, we had less-than-positive reports. And, in particular, I think we had one session that included a head of a primary with particularly low funding coming from a relatively well-off area. Other schools had brought in well-being and mindfulness and were experimenting with a number of programmes, but actually, in that less well-funded school, they'd had mindfulness that had been cut back. They weren't able to have counselling. I think the school nurse might come once a term, and there simply were not the resources for the primary school funded below £3,000 a head per year to implement these measures, compared to schools that might be getting £4,000 or £4,500 because they had a less well-off demographic. Are middle class kids not expected to have these problems?

No. Middle class are not not expected to have these problems, but I'm sure you'd be the first to recognise that, actually, there is a direct correlation between a child experiencing ACEs, or the likelihood to experience ACEs, and issues around deprivation. We know that deprivation can have a massive impact on a child's mental health and well-being. Now, I'm not here to debate how an individual headteacher, who is the professional in charge of the budget of that school, utilises the budget to meet the needs of his children, but let me absolutely clear that it has got nothing to do with funding. In any primary school in Wales, year 6 pupils will have access to counselling. And that's a provision that is available across the country, regardless of whether your school is in a relatively affluent area of our country or whether your school is looking after and educating children from some of our toughest communities.

And the same is true for the school nursing service. Now, Vaughan is in charge of the school nursing service, but all schools, again, have access to that service, regardless of the nature of the children that they're talking about. Now, I absolutely understand that sometimes people feel a bit uncomfortable about sometimes a focus on a particular type of child who may be experiencing problems. As I said on bereavement and divorce, all children are subject to those, but I have to say, Mark, that if we get our staff in our schools right for supporting those children, that will have benefit to every single child in that school regardless of their background. If we get it right for those children with the more severe and complex problems and needs, we will be getting it right for every child.

Self-harm, eating disorders—are they correlated with poverty, or actually are they more correlated with high family incomes?

I don't have that data in front of me. We do know that there's a direct correlation between deprivation, poverty and the experience of ACEs. But as I said, nobody is immune from mental distress and mental ill-health, but I can certainly look to see whether we have any statistics that would assist you in that.

Again, what is important to recognise is that all schools, regardless of where they are or the communities they serve—in a secondary school setting, all schools have access to counselling as a low-level intervention, and those counsellors have the ability to refer into more specialist services if that is felt appropriate. In our CAMHS inreach service, the pilots have been specifically chosen to represent a wide range of settings, because we want to understand what works best where. Crickhowell High School will be regarded as a school in an affluent area, so they're included in the pilot, but so are our high schools in Blaenau Gwent, which are in some of our more deprived communities. We are running the pilot in Ceredigion, so that we understand the challenges of delivering this service in a very rural setting, as well as a setting where that service should be, for many people, available through the medium of Welsh, because we want to understand how we get underneath that particular issue—as well as our pilot in the north. And those pilots have been deliberately chosen so that we have a mix of environments, a mix of settings—urban and rural, Welsh-medium and English-medium, more affluent and less affluent, so that we can understand what works best where.


We had evidence, I think, from schools that there are at least examples of when counsellors were referring children to child and adolescent mental health services and those referrals were not being accepted and they were required to go through the GP. We took evidence from GPs and they were saying that they would be comfortable with having school counsellors making direct referrals to CAMHS, where they had the expertise to do that. Is that the intention—that school nurses and school counselling should be able to direct children, where appropriate, to CAMHS or would you always expect that to go through GPs?

We think there is an issue in one health board area, where it isn't working as it should be and not in accordance with the framework of CAMHS.

We think there's a challenge in the Abertawe Bro Morgannwg University Local Health Board area and it's an issue that officials are on to and are addressing. That is not what should happen—there should not be a challenge in referring a child into CAMHS from the school. We want to make sure that that's consistently applied across the country. That's different, of course, from the assessment that then takes place on whether there is a CAMHS need and how people are signposted to additional forms of support.

Finally from me, some teachers lack the confidence to deal with what they perceive to be mental health issues. We look for this whole-school approach, but there seems at least a danger that mental health and well-being issues are compartmentalised as a health issue within schools and that teachers perhaps who have the best relation with the children affected don't feel confident to step up and help mitigate those and signpost as appropriate. What more can Welsh Government do, including through your departments working together, to address that and support teachers and help them develop that confidence?

That's one of the aspects of the inreach pilot, actually—to support teachers in that, to grow levels of confidence in those schools so that teachers know what to say, what to do, and if they feel that it's beyond their level of competency, who else within that school or who else in other services can then best reach the child. As we are developing our new curriculum, you'll be aware that there is a continual professional development strand alongside the curriculum and issues around how best we can ensure our staff are well-equipped to deliver the areas of learning and experience on health and well-being. That is an important part of our curriculum development, developing, as I said, those professional learning opportunities for staff so that they can address these issues.

But we have to recognise that teachers are not mental health professionals—they're teaching professionals, so we have to ensure that there is a system around them that allows those people with the professional skills that are appropriate to be able to intervene and support them in a timely manner. We also have to recognise that, for some children, school and the teacher will not be the place where they'll want to talk about these issues, so we also have to think about how children can access support in variety of ways, because, for some children, they don't want to see a counsellor in school, especially if it's quite obvious where the counsellor is and everybody sees you going into the office and you're suddenly targeted or labelled. So, we've got to be mindful that sometimes school isn't the place to do this work—there are other places to do it. So, for instance, in my own constituency, children have access and can log on and register with Kooth, which is an online counselling service that is available in the evening.

I wonder also, the school nursing side—should that be stepping up and playing a greater role?

We've got a school nursing framework in any event about how we try and meet the healthcare needs of children in school. But going back to the point that Kirsty just made, you can't say that there is a simple answer and you just equip schools and then it'll all be fine. It's about recognising how children live their lives and have different attachments and different people who they trust. Lots of that trust will be invested in people around the school. But, actually, for a number of those children, that'll be the last place that they would want to go to discuss these issues. So, we have to think about having a variety of sources who are actually able to talk to each other about how you help people to navigate the system rather than expecting people to know every single different access point. So, that's about how we try and signpost people to the right place and the right support. That's got to be the priority in all of this—how you get people to act at the top of their game and recognise their professional responsibilities for that child, and how they work with other professionals, whether they're from health, education or somewhere else, but ultimately, how we make it easier for that child and that family to get the right support.


And what's really important from the whole-school approach is that the whole-school approach is not an intervention approach, it's actually a promotion approach. So, we're talking a lot here, aren't we, about how you intervene once the problem develops? The whole issue around having a whole-school approach is, actually, that that whole school promotes well-being and promotes positive mental health. Yes, it intervenes if somebody develops a problem, but it's how we can use the school to promote, and stop those problems arising in the first place. So, this is not just about an intervention, this is about positive promotion of health and well-being for the child in the round.

Yes, I just wanted to ask you—you mentioned earlier on, Kirsty, about the correlations that there are between poor mental health and the causes of poor mental health, and one of the correlations that was brought to our attention during the stakeholder meetings that we held recently was the direct correlation between the advent of social media and the self-harm epidemic and mental health epidemic, really, that we're starting to experience in our schools. At least children, if they were feeling bullied or intimidated by their classmates, were getting some respite in the evenings, for example. Now, of course, it's 24/7, with many kids posting until the early hours of the morning, sometimes, because they've got unrestrained access to these things.

So, can you tell us in particular: is that something that you recognise as a problem? And if so, what specific actions is the Welsh Government hoping to take through the different pieces of work that you're doing in order to address this issue and the responsible use of social media by children?

Darren, I absolutely accept the premise of the point that you're making, and I don't need to be the education Secretary to know that; I know it because I'm a mum of teen and pre-teen children, and I see it in their everyday lives.

We're doing it through a whole variety of ways: everything from our emphasis on the digital competence framework in the curriculum, through to resources that are available. So, for instance, if you logged on to Hwb, if you had your—. John's got his iPad there, and Julie. If they logged on to Hwb now and clicked on the 'Zones' section, you would have an internet safety and online safety module and resources that are available for teachers.

I was in Afon Taf secondary school in Merthyr—is it? Yes, I think it was. Yes, Afon Taf in Merthyr, last week, to watch a year 8 online safety lesson. Oh my goodness me, it was just so heart-wrenching to watch, because they were watching a movie all about a young girl who was encouraged by a boy to take a picture of herself and to send that picture to that boy, and the consequences that would roll out of that. They would watch a bit of the video, they would stop, they would then discuss—you know, 'What choices could you make here? What would be the consequences of making those choices?' And then they would watch a little bit more of the film, and it would roll out, and, in the end, the film divides into two: what happens if she had sent the pictures and what happens if she hadn't send the pictures, and the impact that that has for all of the children in that school—not just the two protagonists, but all of the children. So, we're doing some very, very practical things in our schools.

What was interesting from the feedback from the teachers at that school was that they said that, absolutely, social media was the scourge. They said that, back in the day, it was verbals in the playground that they had to worry about in terms of bullying and bad feeling in the school. They said that, now, it was all the stuff going on social media, and they gave the example that only the day before, they had sorted out the skirmish between pupils that had been kicking off on social media, sorted it out, reconciled the pupils, dealt with it, only for those kids to go home and their parents to start in on the social media that night. So, again, it's more than just dealing with the parents here; we have to find programmes around positive parenting, which Huw looks at, actually to understand the behaviour of everybody in a child's life and the impact that that has. As I said, the school said, 'We thought we'd sorted it. We'd sorted it with the children, only for it to kick off that evening when the parents got involved in social media.'

I'm grateful for that update on what you're doing on those particular issues. Can I just ask as well about these professionals who link into the system? You mentioned the school counsellors. We did hear very strong evidence that there's increasingly restricted access to school counselling services from the panel of headteachers that came, and they weren't just from the one particular health board that the Cabinet Secretary for health referred to; they were from a range of health board areas, and they were all saying that they were having restricted access to counselling services at a time when demand for counselling services was actually on the up. We simply relay the evidence to you in terms of that. They also suggested that some children were discouraged from going to counsellors because of the stigma that might be attached. They said that, very often, school counsellors are only available during lesson times; they'd be called out of the lessons to go and see the school counsellor and that that in itself was a deterrent to people being able to see them.

Again, the stakeholder group that I met with suggested that a better model might be giving them a different title, incorporating their work within—family support workers or something like that, where there has been some good success in addressing some of the parental support issues for kids too. I wonder whether you could just respond to both of those particular issues.


Well, look, I'm not aware that there's been any reduction in the support that the Government's put into counselling. I'd be interested in some of the specifics around that, because, actually, we've made a clear national offer about counselling at the top of primary school and into high school as well. And after that, in terms of people's willingness to engage in those services, we recognise that it is difficult. In some schools, people accept that it's a normal thing to do; they've managed to create a culture where they think it's quite normal to go along and have a conversation with a counsellor. In other schools, we know that's different. So, there's still lots of stigma that attaches, and I think the name sometimes can help in terms of changing it, but I wouldn't think that that in itself is going to resolve all issues. It's still part of our broader challenge of our conversation around people being prepared to seek support and recognise that that's quite a normal thing to do. It's about how a school sees itself in its whole context with its community. So, I'd be really interested in some of the specifics that you're referring to so that we can respond to those properly, because I don't think that we'll be able to do that in a general sense here.

I'm sure that we'll be able to relay those to you, but do you accept, though, that if someone's taken out of their school lesson in order to see a counsellor, that puts further pressure on them in terms of keeping up with the workload et cetera et cetera?

Yes, and it can highlight whether someone is potentially vulnerable and if they've got an issue, and actually not every child is—some children aren't particularly pleasant to their peers, and that's quite normal in one sense and in other ways it goes beyond that as well. So, there's an issue about how sensitively that support is provided. Again, I'd be interested in specific examples of that, thinking about how we get around that and on top of that. So, there's a challenge there for the school about how it runs and how it provides that service as well as those professionals within that school and how they interact with each other. From the child's point of view, they're all part of the same team when they go into that school, and we need to make sure that that's organised in a way that is sensitive and effective.

Yes. I'm sure, Chair, that the Cabinet Secretary and his officials monitor the evidence that's given to this committee, and it was very strong evidence, really, that we received in the oral evidence session from the headteachers.

Well, we'd want to know how anecdotal that is or whether it's a real system-wide challenge. That's important for us to know, isn't it?

I would expect—I'm sure we both would—that any feedback on the accessibility of counselling services and children's experience of that counselling service we'd want to feed back to those delivering the service. We have to listen to children as to how best we can design a service that makes it more likely that they're going to want to engage in it. You're quite right: we can make it easy for children to engage in that service or we can make it harder for children to engage in that service. So, the evidence is really valuable, and we'd want to feed it back in. But that goes to the issue, doesn't it, about the stigma around mental health, Darren, and getting children to talk about mental health more generally and reducing that stigma where possible?

Welsh Government does have a counselling group, though, doesn't it—a group of officials who—

So, have you had any feedback on any of these issues that the committee is raising from that group that meets, I'm assuming quite regularly, to look at school counselling?

I haven't. I've received feedback from conversations with the children's commissioner about the need to be mindful about how children can access these services, but I'm not sure—. I haven't received any feedback.

So, what does that counselling group do, then? Is it just to sort of—?

I chair the group, and we meet on an annual basis. You know, getting everybody together from across Wales is quite tricky. But I'm in contact with them by e-mail. You mentioned stigma in schools. We have had quite a lot of conversations about counselling rooms, what they should look like, accessibility, privacy—that sort of thing. I think pretty much every local authority also provides counselling in community settings, because they do recognise that not every child wants to access counselling through school. So, that is something. Online counselling, which I know is delivered in Powys—because of the rurality, you know, it's just a bit easier. In Cardiff, I think, interestingly, because for some communities in Cardiff there's a stigma about going to seek outside help, getting help through an online thing is more acceptable, if they don't want their parents or family or anybody to know they're getting that help.


And the online service in Powys, children refer themselves. They don't need a referral from a teacher. The children themselves can refer themselves into that service.

Given the value of online services, why aren't they available across the whole of Wales, then?

It's a choice that the local authorities make as to the best way to deliver.

Well, why aren't you encouraging them or provoking them to make those available? You've got a national counselling service in our schools. Why can't an online version of it be available?

It is down to the local authorities to choose the model that best suits them. Where they have particular challenges, that's what they've decided to do.

Forgive me, but the Welsh Government issues directives to local authorities all of the time in terms of the shape of services and the availability of the specific ways in which services should be available. Given that you recognise that these online services might be a useful way for people to engage with counselling services and you recognise that there can be a stigma for some people, why can't they be universally available?

Because we also recognise that it is the professionals on the ground in those local authorities that are best placed to make a decision about what service meets the needs of their children locally. There is no—

Darren, if you'll let me finish. There is no service that universally meets the needs of every child, and therefore you often need a mixture of approaches. Because, for some children, online might not be best. The ability to go and sit in a room and talk to someone might be what's appropriate for that particular child. So, there's no one thing that is absolutely the perfect model. Whilst we set the expectation to local authorities that this service will be available, then, it is up to them. Now, we disseminate best practice. The group is there to talk about experiences and how we can do things better. But there is no—. I don't think it's right to say that 'This is absolutely the best model' or 'That's absolutely the best model' because it will depend very, very much on each individual child and the stage of that child. So, for some of our younger children in year 6, actually talking to a person might be the most appropriate thing for them. When you're 16 or 17 and you don't want to talk to anybody, then maybe online and doing it anonymously is the best thing for you. So, we can't say 'It has to be this' or 'It has to be that'.

But we've got a national nursing framework, a national counselling service, national curriculum. We've got all of these national plans that are being implemented—and I commend the fact that we've got those national plans to end postcode lotteries in terms of access to services—but what you're telling us is that whilst, yes, for some people, an online service might be better than the face-to-face service, that online service is only available in pockets of Wales rather than across the board.

Because that's the decision that has been made by local decision makers.

Darren, we're not going to get agreement on this. It's something that we can pick up in our recommendations. I want to move on now to talk about the inreach pilots in more detail. Julie.

Yes, thank you very much. I think you both jointly announced these inreach pilots last September. Could you give us the timescale and what's happened so far? Perhaps you could tell us that first.

Well, we expect them to be up and running early in the next financial year. So, from 2018-19 onwards, we expect they'll all run for the full two years. And, as we announced, we'll both have learning during the pilots, but then an evaluation at the end of them. As Kirsty's outlined, we've deliberately chosen places to run the pilots that undertake a range of different settings and different contexts, so we can actually learn from them, and also slightly different models as well, because we want to try and evaluate the relative success of them and then would there be a national roll-out and, if there was, what would that be: would there be a range of choices about how to run a service, or would it be that there is a national model to run to? The important thing is that we recognise that this is an area where we need to work together, and we need to support the school to better support our education professionals, the whole school team, children, and actually where that support could and should be provided.


So, is the purpose of the pilots to skill the staff within the schools or to look at basing health professionals within the schools?

Well, it's largely about how we support staff to do their job within the school, because we've just heard in the earlier questions about some of the challenges of school staff members not feeling well equipped to deal with all of the challenges. So, a lot of it is about how you help equip those members of staff with those skills, and an understanding of how the services work as well. So, actually having CAMHS professionals going into schools to try and help staff within the school setting about the challenges they face and how they can do their part of their job, and when to pass that on to a different service.

And it's also about increasing the liaison with that service. One of things that's been identified is that sometimes schools find it difficult to make that connection between the low-level counselling staff recognising a child needs additional support, and then enabling that child to seamlessly move into higher levels of support—so, a very important liaison service, making sure that those children whose needs can't be dealt with in the school setting need to be able to move into other services more quickly.

So, there will be intensive liaison in these pilot schools—much more so than would normally be available.

Well, these are CAMHS professionals. That's the whole point, that these are—. We are our recruiting specialist CAMHS professionals to be in the school.

Yes, so they would actually be based in a school, that's what I mean.

Yes. What they're doing is they're based in a range of schools. So, it's about the high schools in those particular pilot areas and the feeder primaries. There's a specific focus on transition because that can be quite a stressful time for many of our children as they move from primary to secondary sector. Naturally, there can be a lot of angst for children as they move from a familiar setting to an unfamiliar setting. In some of our rural areas, you're talking about moving from a very, very small rural primary school, where you might only have a couple of classes, to a much bigger environment. So, there's a particular focus on managing those links before transition, because we think that can be a particularly stressful time for children.

Is it the intention then that those staff will stay on in those schools after the pilot has finished, or is the idea that you're going to have upskilled all the staff so that they'll no longer be needed?

There's going to be an evaluation at the end of that project. If that evaluation demonstrates that having those professionals in those roles has been advantageous, subject to budget discussions and finding resources, it would be my expectation that those roles, if it's demonstrated that they've made a difference, would, in some cases, carry on, yes.

If I could just come in here, in certain areas of Wales, there are already CAMHS workers who regularly attend schools. We came back to it a bit earlier—that importance of good relationships so you know who they are and are used to talking to them is vital to both upskill but also provide confidence in that system. What we're trying to do is: what is the prudent way of doing that to make sure we upskill and, more importantly, increase the confidence of staff? Because there are already excellent teachers who provide for the emotional health and well-being of children, who children will be able to identify support them, but, sometimes, they're not aware of those skills. We need to make that the normal way of teaching, and we need to support that by having an easy access to the conversation with a CAMHS professional and move away from the only way you can get a CAMHS professional is if you get them to sit in the same room as you to do something to the child.

Just a brief one. As part of our inquiry, we obviously visited CAMHS units. One thing that struck us in north Wales was the education unit that sat alongside the CAMHS unit—obviously, it had a great deal of expertise as well, particularly in terms of supporting people with mental health problems with their education—and they felt that their unit, as a resource for the wider area, was not being utilised sufficiently well, I think it's fair to say. To what extent do you see those education units that sit alongside CAMHS, where you've got teachers who are professionals, who have developed an expertise in working with young people with emotional and mental health problems and getting them through their education, being a resource? Because they're not at the moment. 


Well, they should be, Darren. In a self-improving school system, which is what we are aspiring to have in Wales, that expertise should be being widely spread. We should be exploiting that in those particular areas. I'd be very interested to have a look at that myself and what are the barriers to ensuring that other professionals in that area are having the access to that learning. Because, in a self-improving school system, there is learning from one another, because there's only so much you can drive from the centre—that should not be happening.

Those units are owned by the individual local authorities in which they're based, aren't they, effectively, so I suppose there would have to be some sort of recognition that they might be supporting people from outside of their area, somehow.

Yes, but the regional consortia should provide a conduit for that collaboration, should they not?

But there's no formal arrangement in place at the moment, is there? Well, that's certainly the feedback we had.

We would expect all good practice to be being circulated via the regional consortia, but I'm very willing, on the basis of this committee report, to pick that up and to look and see whether there is more that we can gain and get out of the system by ensuring that that expertise is not corralled into one place but is made much more available.

So, Hefin will have to declare an interest, because I think you're still a governor at Trinity Fields in Caerphilly. Now, that's a really good example where Trinity Fields is a hub of good practice for that particular area because of the expertise that they have in that particular school. They're almost missionary in their zeal to ensure that that practice is spread out to other schools in their area. That should be the expectation across the system.

Thank you, Chair. We've spoken about the need to develop this wider culture around schools, or within schools, to support issues for children suffering from mental ill health, et cetera, but I want to focus specifically on the area of learning and experience that focuses on health and well-being, and the more formalised part of that within the new curriculum. I was just wondering if you could give us an update on where we're at with that, really. 

We've spoken about the important role of experts—a wider array of experts around the school, if you like, the broader school family and expertise there—and I'm just wondering, in terms of the pioneer schools, in developing their work, to what extent are they, on a practical level, at the coalface, engaging with those other experts and professionals in developing a lot of this work.

Okay. Gosh. You'll be aware, Llyr, that during the autumn the AOLEs were developing their 'what matters' statements. That thinking and that development has now been shared with the curriculum and assessment group, because we're doing the assessment alongside the content—so, how can we assess what the children have learnt in the content. And, of course, that's also being looked at in the coherence group. So, in the end, because we've got six areas of learning and experience, there could be a lot of stuff that goes into each one of those six and then you'll have something at the end that is completely unmanageable and schools won't be able to do. So, we're in that process at the moment.

The latest thinking has been shared with expert groups for feedback. We are particularly looking at the moment at the digital learning council—so, the digital elements of it—and the literacy and numeracy panels. Because, of course, we're not losing our focus on literacy and numeracy. So, the 'what matters' statements and the population is now being looked at for the literacy content, the numeracy content, the digital content, and the foundation phase—so, actually how are you going to do this in the foundation phase.

Members, if they want to keep up to date on where we are with the curriculum, the Welsh Government website has an update, as of the end of January, on where we are at the moment. And, of course, in that work, Public Health Wales and a range of organisations from the health service and health professionals have been feeding into those discussions around 'what matters'.

But that's at a slightly higher level, isn't it, I believe. What about the engagement on the ground level in terms of the pioneer schools? Because we've all acknowledged that the teachers don't necessarily have the expertise to be able to grapple with some of these issues, but then it's those very people who are actually formulating this new curriculum from the bottom up.

Yes, absolutely. I can give you some examples—I can write to you with some examples, if you want, of particular outside organisations. But, in developing these areas and this thinking, we work with a number of organisations. The last time I saw Dave, we were 

at the Heath, were we not, with the Royal College of Psychiatrists, with a number of local high schools from Cardiff, and the children's commissioner, looking at the impact of exams and whether education itself was a stressor, and what could we do about the education system—you know, was it improving people's mental health, or was it a detriment to people's mental health? The Royal College of Psychiatrists, working very closely with a number of schools to develop their work in this area—so, that's just one example of an outside organisation with real expertise, and professionals, helping inform delivery on a day-to-day basis in our schools. Very interesting, because the psychiatrists themselves couldn't agree on whether education was a source of well-being or whether it was detrimental to our children's well-being, but it was a very lively debate and an opportunity for children themselves to talk about these issues.


Good, good. Okay. I'm glad. But we have had evidence from the children's commissioner, or the children's commissioner has expressed frustration, really, that there is insufficient alignment between Together for Children and Young People and curriculum development. We've spoken about this high-level co-operation just now, and her word was that it's 'baffling' that the working groups for those two projects aren't working more closely together.

Well, since her evidence to your committee, both Vaughan and myself have met with the children's commissioner, and to be honest, if I'm being blunt, I did ask to give some specific examples of where she thought that was the case and, actually, very specific examples weren't forthcoming. Where there is exact evidence, I'll act on that, Llyr. I want to act on that. But I think we were able to give the children's commissioner a level of assurance about the nature of the work that was going on as a result of that meeting, which was subsequent to the evidence that she gave.

Thank you, Chair. Going back slightly to some of the issues we discussed earlier, how can we make sure that the right balance is struck between school staff providing help and assistance with emotional well-being and mental health issues, but also referring on and enabling access to more specialist services where they're required? How can we make sure that that happens consistently in our schools—that the right balance is struck between school staff providing necessary assistance and the more specialist services becoming engaged?

What we've tried to express this morning is that there are a number of ways in which we can support children in our schools. On a day-to-day basis, those staff have an opportunity to support children. I see it in my own daughter's education. There's one particular member of staff, if anything's gone on in the day or anything's bothering my daughter, she knows that that's the person that she feels confident to go and have a chat with, and that member of staff has got the professional expertise and the experience to be able to settle that low-level stuff on a daily basis.

The counselling service is there, and then, for those children who do need extra support, there is that higher tier. In many cases, it works smoothly; in some cases, it's clearly not working as smoothly as we would like. The inreach project is an example to see how we can do it better, but I think it's important to note that 88 per cent of children who access the counselling service within those schools do not then require an ongoing referral to the CAMHS service. And that's what we want, isn't it? We want to be able to support children at the lowest possible level and not to medicalise them and not to escalate those issues where we don't need to. And what we do know is that they will escalate if we don't intervene early.

So, they're much more prevention and early intervention, which is the approach as well—. What happens outside the school, as well, the challenges that children then bring into school, that's part of what we are trying to describe, as well as what happens in a school setting, and then the judgments that are made about how you best support the child—. But I wouldn't just say it's all about the judgment of the member of staff, but I think it's about how we have the right system around that whole school, that whole family, to try and make sure that judgments are made in an appropriate way. We will learn more as we're going through—not just more evidence about the counsel givers, and if there are wrinkles you've identified for us then we'll definitely look at those, but also, then, you can't understate the potential importance of the inreach pilot in helping to better equip staff to do their job within the school, to feel better supported, to be more confident and to know how to liaise with the mental health service outside of a school setting if that's the right thing for the child. But that's the point: is it the right thing for the child, and how do you get it done as early as possible?


And, to some children, it isn't about mental health maybe in the terms in which we're talking about it today. What we're seeing increasingly in our schools, and what schools are having to respond to in some of our youngest children, are issues around attachment disorder, and, actually, what do you do then if you've got a child with issues around attachment, and therefore the deployment of nurture groups within a primary setting—you know, you don't need to medicalise that; there are things that you can do within the way in which you organise your school and you staff your school to be able to provide that support. And, increasingly, I think issues around attachment are going to really, really come to the fore for our youngest children going into schools, and that's why we need the cross-sectoral approach between social services and family support, good parenting support, and then that's reinforced then by an environment in the school and the deployment of resources in the school, such as a nuture group for instance, that can best support that child. 

Parenting and early years, before we get to the school—all these things do add up. That's why it is a complex picture, and we'll see more of this, because we know our society's changing, we've got social media, all those different challenges have come in, so we will have to review what we're doing, and whether it's being effective enough with the challenges that we are seeing in our community. So, the inreach pilot won't resolve all ills forever.

A final question, then, from John on the links with health, education and social care. And brief answers as well, please.

Okay. If we could, then—are you confident the right arrangements are in place between health, social care and education on the ground, as it were, but also within Welsh Government Cabinet?

I feel confident about the working relationships we have across the Cabinet. Can it be better on the ground? Of course it can. Absolutely, and I wouldn't want to sit here and say everything is perfect. That's not the case. There are things that we can do better in many, many, many ways. Speaking to teachers and headteachers, too much of their time is spent chasing some of these relationships, and that's why we have this commitment to work together.

No. We wouldn't be looking at improvement action if we didn't think there was a challenge to resolve.

Okay. Okay. Right. Okay. Well, we've come to the end of that particular session. We haven't got through everything, so, if it's okay, we will write to you, and if you could reply to us as quickly as possible, that would be really very much appreciated.

So we're going to break now until 10.50 a.m. Can I thank Kirsty Williams for her attendance? You will be sent a transcript to check for accuracy, and we won't be seeing you after the break. Thank you.

Gohiriwyd y cyfarfod rhwng 10:43 a 10:50.

The meeting adjourned between 10:43 and 10:50.


Welcome back everyone. We will continue now with our evidence session, this time focusing on primary care and specialist CAMHS, and the first questions are from Michelle.

Thank you, Chair. How would you respond to evidence that local primary mental health support services continue to be dominated by an adult rather than a child-centred service provision model, and that they lack suitably trained staff with a background in child and family work? How would you respond to that?

Well, local primary mental health services are an all-age model, and the key points apply to children and adults, but we did specifically in 2015-16 invest an additional £800,000 a year, that's been recurrent since then, to improve primary care children's provision, and also will be using some of our additional provision going into CAMHS as well. So, we recognise that there's been some variation in how services have been implemented, and so we want to understand that variation itself and look for further improvement. But I wouldn't accept that the challenge is that there needs to be a different child-centred provision; we need to meet the needs of children appropriately in their setting, whether that's a family or a community or an individualised circumstance.

Okay, thank you. A recurring theme in the evidence we’ve received is the lack of support for young people and children for whom specialist CAMHS services are either inappropriate or unavailable. What plans do you have in place to address this so-called 'missing middle', and by when will these plans be implemented?

There are a couple of things to talk about here. One is that we do recognise that if someone goes through a referral into CAMHS and they're told, 'CAMHS isn't for you', we need to be able to signpost that child and their family to the right part of our service. And so it's about making sure that both the lower level needs we were discussing, for example, in the school system, are there and are comprehensive, but also that we have primary care services as well. It goes back to some of the preventative work that Public Health Wales have been leading on on the ACEs agenda as well.

So, the NHS delivery unit will be undertaking work over this year to try and understand both the variation that exists within primary care services, both on access and delivery, and also to then look at what health boards and their partners need to do, because the range of services we're talking about are, for example, delivered in a community setting and the third sector as well, because we want to make sure that we make it, as I said in the earlier session, as easy as possible for children and their families to get to the right point of care. So, that work will be undertaken over the next year, and I'd expect to report both to this committee and your colleagues in the health committee about the work and the outcomes that I know will be of interest to Members about not just about the work being started, but about where it actually leads and what we then do. So, there will be choices for us to make about how much we say is about disseminating best practice, how much is about giving guidance we'd expect people to take account of, and how much is going to be directed as well. We'll need to work out the balance of all of those ways of trying to deliver system improvement. 

Okay, thank you. Moving on to psychological therapies, the importance of therapeutic interventions as an alternative or an addition to more medical interventions has been emphasised throughout our formal and informal evidence-gathering sessions. It's been also acknowledged, though, that access to therapeutic services is inconsistent across Wales. So, in your opinion, what more needs to be done to address that?

Well, some of it goes back to the work that I've just indicated we're going to have done for that assurance on the level of variation that exists, and how we can resolve that. Because, of course, we've invested more money in the service areas, so we've got, 2015-16, an additional 41 whole-time equivalent staff to provide and support interventions, because we want to make sure that there's a proper balance between where it is the right thing for a child or a young person to have a medicine, that that is provided, but reviewed appropriately and managed appropriately, and, where it isn't the right thing, that they don't default into medication. That's a very clear direction from ourselves, and I think that's broadly supported by healthcare professionals as well because it's about appropriate prescribing, and that prescription sometimes is about the therapeutic and the talking therapies intervention as well. That's why we're looking at the work on the review, looking at what works in different parts of Wales better than in others, because I don't just want to talk about the national picture in Wales; I want to be able to understand if there is a different challenge in one health board area in Wales, why that exists, what we can do about it and then going back to, 'Is that about guidance, is is about best practice, or is it about direction of what we say should happen?' 


Okay. Thank you. The children's commissioner and others have commented that investment in psychological therapies hasn't translated to improved access, and that there therefore seems to be a continued over-reliance on anti-depressant medication without signposting to other support. How would you respond to that, and how will you be acting on it?

I'll bring Dave in to talk about some of the detail, but broadly, I don't accept that, because if you look at where we were a few years ago when Sue Bailey came in to do a review of CAMHS, we recognised that we were in a really difficult place. Too many children were waiting too long to actually access, to actually get to the point of having an assessment, and then to carry on with a therapeutic intervention. We're in a better place now. The investment we've made has made a difference. And that's the point: it has made a real difference. Our challenge is how we get to the point of having an acceptable level of performance, where children are seen promptly and supported, and to be able to do that consistently. And if you look at where we were, the old waiting-time target we had and the standard, well, that was 16 weeks. That was too long; we recognised it. So, we have a much more demanding standard now, and it's about getting to meet that appropriately. And that's what our intervention and our support needs to deliver. So, we have made real progress, but the recognition is that we still need to do more.

When the programme started, there were 200 [correction: around 200] CAMHS professionals in the whole of Wales—fewer than the number of physiotherapists I manage in Aneurin Bevan. And of those, only 50 were medics. So, actually, psychological therapies has always been a mainstream of what CAMHS delivers. However, each health board had a slightly different profile. What we've done over the course of the programme is, first of all, define what the functions of a specialist CAMHS and a local primary mental health care service should be, and part of that is improving access, improving consultation and improving liaison, but actually having far greater consistency in the level of care and the sort of care we offer to every child across Wales.

With children, some of the evidence for psychological therapies has come from adult models, so problem A requires psychological therapy B. That doesn't always fit for children because the way children process information means that the psychological framework by which you manage the family or the school is more important than actually what you do in the same room as the child, although that's an important part. We have established a professional group to say, 'Okay, what does the evidence base say, and what should we make sure that every child has access to regarding therapies where condition A requires therapy B?' But we're also starting to look at what are the psychological models that we need to be incorporating in the way we raise our children through school, through social care, through CAMHS, and how do CAMHS professionals support that, how do we train the staff to be able to do that consistently, and how do we provide the necessary supervision and internal supervision to do that.

We've done that and we are just about to become part of the Matrics Cymru, which is the adult psychological therapies model, and some of the potential new moneys coming on to support psychological therapies in the future is not all about adults; it's about including children as well. So, that's the direction we're going in, and that group is already established and has active buy-in from multidisciplinary professionals across the health boards.

Cabinet Secretary, we were told by primary care practitioners, by teachers and other education staff, that some of them found it almost impossible to get a CAMHS referral accepted, whereas we're told by psychiatrists who are emphasising the importance of not over-referring to CAMHS. Are you confident that everyone who should be involved with developing and monitoring these referral criteria has been, and is this an area you will personally look at further?

Well, I think there are a couple of different things there. There's the challenge we discussed in the previous evidence about whether there's a challenge in referrals not being accepted from groups of professional staff, and that's an issue that, as I say, we're on to, and that should not be happening. The CAMHS framework for improvement has set out a range of people who should be able to refer into CAMHS, but it's not exhaustive and there could be local variation, and that should not mean that people are taken out of that, and that's an issue I'm definitely interested in and want to have some assurance on myself.

That framework for improvement will be reviewed though; we're due to review it in 2019 because we want to make sure that it's still appropriate. We have to have points in time where we take a step back and say, 'Is the improvement journey that we're on, and is the way in which we're running that still the right place to be?' So, at this point in time, I think it's important that we make sure that the framework that we have is properly implemented consistently. It's then about whether people actually get to have the sort of access issues that I know will come up in the range of the questions that we're going to have about how fast the referrals are processed, and then if someone’s referred into CAMHS and actually carries on with the CAMHS service, how quickly that therapeutic intervention continues, and if they're not, how quickly they're signposted somewhere else. That's our broad challenge and, of course, I will continue to take a significant interest in it because we're investing significant amounts of money in this area, and that's got to be to make a difference for children and their families.


And for those who are not accepted for a specialist CAMHS referral, are there sufficient services, but also sufficient integration and signposting of those services, in place to ensure that those children and young people are picked up and given what they need?

We think there should be, but as you'll have heard from the earlier evidence, we think it's a work in progress, as ever, because you've highlighted an issue where that might not be the case. But about 68 per cent, I think, is the last figure we had, of CAMHS referrals that are accepted, so the great majority are accepted. And it's then what happens to that just under a third of children who aren’t and how they're signposted. Actually, our current evidence is that those people are signposted to a different form of intervention and support. The challenge is: how rapidly does that then take place, how consistently is that done across the country? And then, is it really meeting the needs identified? Because if a child doesn't have a need for CAMHS—. And let's not forget that, I think it was in 2016 that children and young people themselves said that they reckoned that some people were being inappropriately referred in, so we shouldn’t be shy about saying that we still need to do something about this and make sure that the CAMHS rules are appropriate. But then, if they go through and it's found at the end that 'Actually, CAMHS isn’t for you', how do you then still meet the need of that child and their family? There are a range of interventions and support mechanisms around that, and, again, that’s part of the review. You talked about the missing middle, well, that's the part we need. What are local primary mental health services for children and young people? What are the other different interventions and how do we make sure that we understand the context of that child? Because that may be different, say, for a looked-after child, compared to the child from a middle-class family or a child who lives in one of our more deprived communities—understanding how you support that person in their context. Because there will be variation in how that’s done, because otherwise you're not going to be able to deliver the right sort of intervention for that child.

If we can move on to talk about waiting times now. Obviously, there has been a marked reduction in waiting times in recent years, which is very welcome. But despite having met the 28-day target in March 2017 in all health boards, only three met it in November 2017 and the target hasn't been met nationally since March last year. How confident can we be as a committee that the investment that's going into specialist CAMHS is going to actually deliver that 28-day target most of the time for children and young people?

It's obviously an important issue and it's one that I've recognised in scrutiny on the several occasions that I've been here. I expect to have questions on this, not just for this inquiry, but more regularly until we consistently meet that target. It's a matter of undisguised disappointment that having achieved the target, our service wasn't able to maintain that. So, we're looking at why that's happened. We've put some extra money in to try and resolve some of the backlog in this year and our information suggests that real inroads are being made into that backlog—in south Wales in particular, where there's been a real challenge in doing that.

I've got some confidence, based on that information, that we'll see real improvements this month and I hope that that should then be carried forward into March as well. We do then think that, because of the way some of the model has changed slightly in dealing with it, that we should be able to maintain a much higher level of performance because, of course, we've changed the waiting time target from 16 weeks to four weeks. That's the right thing to do. If we'd kept it at 16 weeks, we'd be able to report that we're meeting the target, but, of course, that wouldn't be meeting the need of the child. Scotland meets their target, but they have an 18-week standard. So, we've done the right thing in having a more demanding target; we've put increasingly more money into that. Our current information, which has to be validated in the official statistics when they come out, shows that we are making real progress, but I think there should be a level of confidence that you're going to see improvements through the end of this financial year, to the end of March, and I absolutely expect that to be maintained as we go into April next year and beyond, because that's the reason why we invested the money. It wasn't to have a one-off improvement and then to explain away why it can't be maintained. And it won't just be that I'll have questions to answer if that isn't the case, but, actually, obviously, it will be part of my scrutiny of health boards and their partners if they can't maintain that as well. So, there's no getting away from the importance of this as an issue for me personally and for the service as a whole.


Because, when you came to committee previously, we asked when we could expect these targets to be met, and you told us that, obviously, we were part way through Together for Children and Young People and that that would take time. Now we're kind of at the end of it and looking at an extension, are you able to give us any indication of when we can expect that waiting-time target to be met? Is it going to be at the end of the programme, at the end of the first end of the programme, or the extension of the programme?

Well, we're expecting the target to be met more consistently from April onwards on a national level. We expect there'll still be some variation between health boards, as some have longer lists to get through than others. But I'm expecting to see that real and sustained improvement, and that's got to be the point. Because otherwise we could direct resource to try and meet the target, but if that isn't sustainable, then actually that isn't the right thing to do, as we'll then just have another bounce back of too many children and young people waiting too long. It's got to be consistent improvement. So, I expect we'll see much more consistent improvement through the end of this financial year and into the next one, and I expect to see that consistent improvement being maintained as well. That's the expectation that services have and they understand that, and it will be part of the conversation that I have directly in accountability meetings with chairs of health boards as well. It was certainly raised at my last meeting with chairs when I last met them individually, and it'll be raised again at their end-of-year appraisal process, and again. So, they will understand that there is a direct ministerial interest in this area of performance.

Okay, thank you. And do you think that we are measuring the right things? Because we know that the current target relates to from referral to assessment; we don't have any data on what happens to the young people after they've had that initial assessment—so, whether they're waiting for CBT or other interventions, or how high-quality the interventions they're getting actually are. Do you think that we are measuring the right thing? Are there any plans to become more sophisticated in looking at the quality of outcomes for young people?

Well, yes, it's a general point about the whole of the mental health arena, actually, including children and young people, in thinking about, 'Well, how do we not just measure the waiting times part of it?' But it's a consistent part of our conversation about healthcare measures anyway, because time is the easiest thing to measure. And, actually, the time to a therapeutic intervention makes a real difference, so it's an important measure, but it doesn't tell you everything, as you've outlined in your question. So, that's what we've said about having a more useful set of measures. And there is work already ongoing about the data that we collect and whether that'll tell us more useful things.

We'll also need to think about both qualitative and quantitative information and how we then present that in a way that is both meaningful and robust as well. So, there is work that's ongoing, and I want to look at how that's actually undertaken in a way that will give real value, not just to the public, but within the service as well. Because, actually, our targets do drive behaviour, and what I don't want to do is to introduce a new set of measures that actually drive behaviour that isn't ultimately in the interests of the person who needs the service. So, we've got to be careful about what we do, and that's why we are developing that work.

I expect I'll have more to say over the next year about core data sets, to make sure there's more data available, to make sure it's easier and more consistent to collect. In the past, we've had challenges about the information itself—you know, the CAMHS target included people who had neurodevelopmental needs, as it were, and didn't have any CAMHS. Taking those people out made it more accurate and it changed the numbers, but, actually, we've got to wear some of the flak for saying, 'You've changed the figures', because, actually, that was the right thing to do and there's a more accurate set of figures there. We're going to, Chair, have other changes introduced in the measures we collect and we publish; we've got to have some confidence that we'll drive the right sort of behaviour to then meet and live up to that new data set that we'll be publishing.

Okay. Can I just finally, then, ask about waiting times for primary mental health services? Because we've had a mixed picture of evidence on that, really. The health boards have painted quite a rosy picture of access for young people, whereas the Royal College of General Practitioners told us that things were really very difficult. Are we actually complying with the Mental Health (Wales) Measure 2010 in terms of access to primary mental health for young people in every health board in Wales?


No. There isn't a consistent picture across every health board, and, again, that's part of what I have highlighted in meetings with both vice-chairs who have responsibility for mental health and primary care, and it's also something that I've highlighted in that appraisal process for chairs of health boards as well. So, I wouldn't sit here and say, 'Everything is fine, don't worry about it', but it's about understanding the level of consistency, or lack of it, that exists, and what is happening in each of those local health board areas.

The delivery unit has specifically started to look at this. Yes, the overall picture's very interesting, but what about the under-18s? And that work was started about 10 months ago where it became apparent that the capacity for children's assessments was less than it should be, and all the health boards have been ensuring that the capacity and that waiting time is addressed so it comes down that under-18s have the same response as all ages. So, that is actually being looked at at the moment.

That's the NHS Wales delivery unit.

The NHS delivery unit. Okay, thank you. Maybe if we could have a note on that, I think that would be really useful for the committee.

Okay, we're going to move on now to talk about crisis and out-of-hours care. Julie.

Thank you, Chair. I think the committee accepts that there have been improvements in both these areas, but we have had evidence that young people are still admitted inappropriately to adult wards and to non-specialist paediatric wards, they often don't have follow-up support, and there is a lack of in-patient beds when there are emergencies. This is what the committee has been told. So, what is your view on those reports that we've had?

Well, I'm pleased you're recognising that there's been real progress and improvement—

—and, as ever, we recognise that not every part of the service currently consistently meets the level of care that we'd want it to, but we're thinking about the number of admissions, from December 2016 to November: there were only 46 across Wales in that whole period of time. So, you are talking about a small number of people with particular needs, and there's a particular issue in looking at what's happening in north Wales. We've reduced out-of-area placements and we—.

Bed shortages are not a national challenge: part of our challenge is about getting people to the right part of the system. You know, we don't have—. Of the two Welsh in-patient units that we have, the average occupancy is less than 100 per cent—it's 74 per cent in north Wales and 83 per cent in south Wales. So, there's a capacity—[Inaudible.]—around making sure people get to the right part of the system itself. There's something there about, you know, 'When does that referral take place?', 'How do we organise our crisis care teams?', and there is a recognition from the Government that we're not suggesting that everything is fine and people have just got it wrong. So, it is about us understanding and then wanting to review—'How does it work in different parts of the country?' and how to look at health boards working together on that, because, otherwise, if we said to every health board, 'You have to run your own service', I'm not persuaded that that would be the right way to direct health boards. They will need to talk to each other about how to run those services on crisis care and everything like that, and how we prudently make use of those resources as well. That's part of our challenge, and that's part of the work that we are doing with the health service to understand what then does need to happen and how we set some useful measures for when we expect that the take place.

Do you have the figure—? You said 46 admissions. How many of those were not appropriate where they were placed? Do you know? Have you got those figures, or could you let us have them?

I think we might not be exactly comparing the right thing. Sorry—you start.

Those are the numbers of children and young people who ended up on adult beds. The vast, vast majority of those were 16 and 17-year-olds—

And the majority of those were for short periods of time for 16 and 17-year-olds, and when it's accepted that you don't—. If somebody comes in at 11 o'clock at night, you wouldn't transfer to Bridgend, you would keep somebody in for a short period of time until the assessment—. And some of those people—. We've already spoken about the fact that children in crisis are viewed as being a CAMHS problem very quickly, and sometimes when you find out what the cause of the crisis is, it isn't necessarily the CAMHS service that can solve the problem that's caused the crisis. There are a handful of younger children, most often in similar circumstances, where they require an in-patient admission and if they're coming in in the early hours of the morning it would not be appropriate to do so. We know that bed occupancy is better, we know that crisis teams on the ground have started to make a real impact on the length of stay in the in-patient units. We know that, in my health board, they've made a real impact on paediatric bed use, for example, for self-harm and learning disabilities, so we have one extra paediatric bed every day of the year thanks to our crisis team in Aneurin Bevan health board. So, we know the system is working better. We are always going to struggle with some people having to stay in an adult bed or a paediatric bed temporarily when we only have two units because, prudently, it only makes sense to have two units for a population of our size.


No, I think no-one's arguing that there are not improvements, but it's testing, you know, how it actually is. I do find it concerning that 16 and 17-year-olds are being admitted to adult mental health settings.

I think there is a whole conversation about how we look after that 15 to 25-year-old transition age group and what the best service is for those children in crisis and maybe the lack of options there. That's a piece of work we need to take forward in the year ahead. Every time it happens, a serious incident form is filled in. It is reviewed by Welsh Government. A narrative is required, and we find out whether there was reasonable—. And, if necessary, we feed back to the health board to say, 'These are the actions you need to take to stop these sorts of things happening.'

And does that happen in one part of the country more than any other, where these admissions have to take place?

There was a particular problem in reporting in north Wales. Part of that was because their 136 suite is on an adult ward, so the process of having an assessment for a mental health—if they're brought in by the police—. It was on an adult ward, and they were reporting that as an admission. Well, obviously, it's not an admission; they're being brought in for an assessment and it's an appropriate local placement. So, some of it was a reporting issue and we've addressed that. So, that's decreased the numbers still further.

I know that you said in the preamble that people often didn't have follow-up support. I don't know whether that's a picture—'often' suggests that's it's a more common than uncommon issue. I'd really be interested in evidence about the detail of that, because I'd want to understand how large a challenge that is in the evidence that you had presented and to be able to respond to that, because that is an issue that I'd be concerned about because any person—a young person or an adult—should have follow-up support afterwards. So, I'd be really interested in the detail of that. That would be really helpful for me to see.

Thank you. And are you able to tell us the age of the youngest child who was admitted to an adult bed?

I think it was 13 or 14, was it?

That's very rare, actually, that it was a child as young as that, but we could let you have that detail.

And that was taken up by the health board.

I'm particularly concerned about the number of out-of-area placements for in-patient care, particularly in north Wales, of course, where we have a situation in Abergele where the unit is operating under capacity and there are beds closed there because of issues particularly around staffing. I'm conscious that that is one particular reason why people are placed out of area; another reason being that they might need to access some specialist provision that isn't currently available here in Wales, which, you know, is something maybe that I can pursue in a minute. But going back to the situation in Abergele, we were told that it's down to workforce issues and issues recruiting, and I'm just wondering in terms of workforce planning and the way that the Welsh Government is supporting Betsi Cadwaladr to try and get the Abergele unit back up to capacity, maybe you could give us an update on what the situation is and potentially by when you would hope that that particular ward will be fully operational.  

Obviously, some of the undercapacity is because of lack of recruitment and some of it has been sick leave. So, it's been working on those two things and offering support for that. Actually, over the past three to four months, the capacity of north Wales to meet their own demands has improved. So, the numbers of out-of-area placements from north Wales has decreased significantly by improving the co-operation between the community and crisis teams and getting the service working effectively so that the numbers now are far closer to what they need to take. We're anticipating, over the next two to three months, that, first of all, people will return and that the staffing requirements to run the service as was six months ago—we'll be back where we were then.

There's a wider piece of work that is ongoing between—. There's work going on in social care, there's work going on within the NHS, to look at how we manage complex children. The Welsh Local Government Association is doing some work on this and the NHS is reviewing its provision of secure care and out-of-area in-patient care that's funded by the Welsh Health Specialised Services Committee to see, (a) how we get a better community system to stop them going out of the area in the first place, but (b) to see, given the rise in certain types of problems that have occurred over the past five or 10 years, whether we should be starting to develop our own resources within Wales so we don't have to send people outside.


You've told us that you're hoping we'd be back to where we were about three or four months ago. Of course, that isn't where we want to be, though, is it?

No, no, no.

Because there have been 10 out-of-area placements since April last year—so, it's fewer than 12 months—which wouldn't have happened had the beds not been closed in Abergele. So, we don't want to go back. We want to move forward.

It's not really how it was—. There were a number of different issues, apart from staffing, in the system around the unit as well that made the 10, actually, if you review the cases. Ideally more of the admissions should have been able to be managed within north Wales. So, a number of different interventions had been taking place.

No, they weren't, but that was quickly picked up by both the Welsh Government and also the NHS CAMHS network, which reports on this every two months, when it meets, to say why a population of 1 million is producing this number of out-of-area placements when a population of 2.2 million is only doing this many.

Yes, because the difference between north and south Wales was striking, I have to say.

Yes, so that was picked up, and that's being addressed—and they're all the different areas that needed to be addressed.

Sorry, so when do you expect, then, for the whole ward—the 12 beds—to be available? Because we were told if the 12 beds were available, then, you know—.

We'd be able to use that—

Yes, there wouldn't be any out-of-area referrals other than the specialist placements.

The specialist ones. I don't have a definite date. It's been moved through by WHSSC. We can get back to you on that one.

So, on the specialist stuff, then, what plans, if any, do you have to look at developing some of those facilities in Wales? Because, clearly, they're very, very small numbers, and we appreciate that and it's fully understandable, but it's something that we've raised previously in different contexts. It seems to be one-way traffic, really, where people are moving to England for services. Maybe we should be looking at—. Because there's a whole other ward in Abergele, with seven beds, that's empty—it's not being used. But maybe we could be offering those services to people across the border as well.

And that's precisely what the NHS secure care committee is reviewing, with the aim of coming up with options by the summer of this year to say how we take that forward, but linking in with the work the WLGA is doing on the commissioning of complex care as well. Because it's clear that some of the needs they present and the sort of care required have health, social and educational needs that, whilst each individual department might not have a critical mass that would make it sensible to develop a service, combined together, it would absolutely make sense for Wales to develop all of these services internally.

Will there be sort of regional focus or an eye on regional focus?

No, there will be regional focus because it needs to be as accessible as possible to all.

I just want to ask a little bit more about the Abergele situation, if I can. Obviously, this was a flagship unit, £15 million spent on it, opened back in 2009—it's never operated at full capacity, has it?

Why has it taken so long to get the recruitment levels up? It's almost nine years, for goodness' sake.

Because recruitment across CAMHS is massively difficult and, actually, the in-patient service end is the most difficult to recruit to because—

So, why aren't positions being advertised at the moment, then, on the Betsi Cadwaladr website? Vacancies—they're never going to recruit if they're not advertising, are they?

I think there are a couple of bits to this. So, the commissioning of in-patient services are done, on behalf of all health boards, by WHSSC, and they do that according to what they see as the sort of demand profile over the period. The beds that have been brought into action both in the south Wales unit and the north Wales unit were expected to meet the current demand in the system for the types of conditions that we hoped to be able to manage within Wales. At the moment, we have not made a decision to try and deal with very, very specialist cases. That's the piece of work that's being looked at with the more complex cases. So, I think WHSSC and ourselves believe there is capacity in the system, with the beds that are commissioned, to meet the current demand when the units are staffed at the level they are expected to be. So, north Wales has a problem at the moment because they've had a key consultant off on long-term sick. When they have gaps in that sort of provision, it does cause quite a blip in their ability to meet that provision. It may be that we would get to a point where we would commission those extra beds and staff them, but that has to be done on the basis that we know that those beds can then be filled. Because there are times in the units actually where we seeing the demand for in-patient services dropping as the community teams work better, and, if we end up with a fully-staffed range of additional wards that are hardly used, that's a really expensive waste of resources. So, it has to be done quite carefully. So, those beds have never been commissioned, because, in order to meet the normal demands in the system—we [correction: WHSSC] think we're just about there in terms of, if they're operating properly, they would meet those, apart from the most special cases.


Yes. Fifteen million pounds was spent to meet the capacity in terms of the demand needs at the time, but they've never been used.

That was before the onset of the development of the community services, which have had a real impact.

I'm sorry; I don't accept that. We know that we're sending people out of north Wales. I mean, I'm just giving you the facts, and you've heard some of them from Llyr Gruffydd as well. The facts are that we are sending people out of north Wales who could be treated in that unit if the recruitment was right. And I appreciate that we can't always factor in long-term absences from individual senior consultants. I understand that. But it's not been nine years that that consultant's been absent from work. You know, why on earth hasn't there been a ramping up of the recruitment on that ward? It was nursing recruitment that we were told was the problem some years back; now we're saying it's more of an issue in terms of consultant recruitment. There's not a single post advertised on the NHS Wales website. I'm looking at it and there's nothing for north Wales. Nothing. So, to me, that suggests that there's not much effort being applied in terms of trying to secure people and to recruit people in in order to make this extra capacity available.

What we'd need to be sure of is that the capacity we were creating would then enable us to bring back, or not send out of Wales, what are now, actually, greatly reduced numbers—there has been a blip in north Wales, but, actually, it is a far more limited number of young people than it was some years ago—and that they would meet those needs, because, as I think we've already said, sometimes people are being sent out of area because they have very specialist needs.

I understand that, but we're nine years on, for goodness' sake.