National Assembly for Wales

Good morning, everyone, and welcome to the Children, Young People and Education Committee—a virtual meeting this morning. In accordance with Standing Order 34.19, I've determined that the public are excluded from the committee's meeting in order to protect public health. In accordance with Standing Order 34.21, notice of this decision was included in the agenda for the meeting, published on Monday. This meeting is however being broadcast live on Senedd.tv, with all participants joining via video-conference. And as usual, a Record of Proceedings will be published. Aside from the procedural adaptation relating to remote proceedings, all other Standing Order requirements for committees remain in place. The meeting is bilingual, and simultaneous translation from Welsh to English is available. If we become aware that there is an issue with the translation, I'll ask you to pause for a moment while our technicians reset the system.

We've received no apologies for absence. Can I ask if there are any declarations of interest from Members? No. Okay, can I remind the committee then that, if I drop out for any reason, it's been agreed that Dawn Bowden MS will temporarily chair while I try to rejoin?

So, that takes us on to item 2, which is an evidence session on the impact of COVID-19 on children and young people with representatives of the health sector. And I'm very pleased to welcome Professor Ann John, professor of public health and psychiatry at Swasnea University Medical School, and chair of the national advisory group to Welsh Government on the prevention of suicide and self-harm; Professor Alka Ahuja, consultant child and adolescent psychiatrist and national clinical lead at Technology Enabled Care Cymru and public engagement lead at the Royal College of Psychiatrists Wales; Professor Adrian Edwards, who is professor of general practice at Cardiff University, director of the new Wales COVID-19 evidence centre, director of PRIME Centre Wales and a part-time GP; and also Dr David Tuthill, who is a consultant paediatrician and officer for Wales at the Royal College of Paediatrics and Child Health.

Thank you all so much for joining us this morning. I know that, David, you may have to leave, as you're on service. So, we really appreciate all of you making time this morning to talk to the committee. We're going to go straight into questions and the first questions are from Siân Gwenllian.

David, would you like to start?

Thank you so much. I hope you—. Siân, you ask about the current impacts of coronavirus on the physical health of children. So, physically, coronavirus doesn't seem to affect children very much. It's a very—for want of a better word—ageist virus, which affects the elderly much more. What it has done, in the way it has affected children, is displace their activities: schools have closed, they've not seen other children, and it's really resulted in a very different way in which paediatrics and child health have been affected—the mental health of children, I think, has been severely affected. 

Last year, I was on for the children's hospital; in winter, I would have had about 30 children; 10 or 15 would have been young babies with bronchiolitis. I'm on today; I've got 19 children in, eight of whom are predominantly in for mental health issues, which is about twice what it would have been before. I'm just a general paediatrician—there are other branches—but I think, looking at the figures the Royal College has collected, normally we've got about 5 per cent bed occupancy with mental health issues; it's about 12 per cent to 15 per cent. These are very rough figures that need final work on, but it looks to me at least double the mental health impacts coming in, whereas the acute infections have been less.

We've also had concerns about the physical health of children, because they're taking less exercise et cetera, they're more indoors, and also we've had children—. Some children have needed to—in inverted commas—shield, to protect themselves from infection, but a very tiny, tiny number, and we've had far more harm done by inappropriate shielding, of parents worried about that or perhaps receiving letters saying they should. Really, for the vast majority of children—they've never needed to. So, I think it's been what COVID has displaced.

Siân, there's a small number of children that get something called paediatric multisystem inflammatory syndrome temporally associated with COVID-19. If I call it an inflammatory condition, perhaps occurring a week or two or three weeks after they've had COVID. It appears to be similar to a condition called Kawasaki, which is an inflammation condition. It's really quite new to us. Obviously, we've only had it for a year, we're getting better at treating it, children are being entered into trials, but the long-term outcome of that—so far the children seem to have recovered well, and I hope that will happen, but I have to give a tiny note of caution that we, obviously, can't tell you yet. So, I think COVID rarely affects children seriously, physically, but it has a lot on their mental health and the displacement of activities.

Thank you. Adrian, would you like to come in? We'll just wait for you to be unmuted.

Thanks very much. I fully support that appraisal of the range of impacts. The other one that we might just throw into the mix is the possibility of long COVID illness. I guess it's largely unknown at the moment for the same reasons that David has just explained. However, just to let colleagues know that UK Research and Innovation has commissioned a series of research projects on long COVID illness, including one in children, which is led from Great Ormond Street. So, that's early days at the moment, but there is an evaluation now under way on that issue.

Okay. So, in terms of the physical effects of coronavirus, you're saying that it's very limited in terms of the actual effect of the virus, but the longer term physical effects—maybe we're not quite sure about them. But you're obviously saying that the pandemic is having an effect on the mental health and well-being of children and young people. How much evidence is there now around this? How much data do we have to support what we all know is happening?

Shall I bring Ann or Alka in first on this? Ann.

It's very complicated to assess what the impact is, and part of that is because most of the studies that have been done—they've got different sampling. If you go out and ask people what we call a 'convenience survey', it's only certain sorts of people that respond, and sometimes some of the information we've got comes from parents, and sometimes it comes from young people. So, it's quite a mixed picture. But a really well-designed survey carried out in England showed that, in 2017, about 10 per cent of young people up to the age of 16 had a probable mental health problem. And in July last year, it was 16 per cent. So, that's one of the most well-designed studies we've got.

There was another study that looked at families, and the parents replying there basically said that in children up to the age of 11, behavioural problems were much worse, and I think that probably leads into the issues that David was talking about—that's about seeing friends and being able to play outside. Whereas for some teenagers, they were actually happier, and I think that's where we have to think about it. For some young people, school can be quite a challenging place, and they've been more comfortable not being in school. And when you try and unpick all those studies, what you see is that young people have experienced the pandemic differently, depending on their backgrounds, and, really, it's the ones from more deprived communities, it's the ones who had pre-existing mental health problems, who have suffered disproportionately, I think, during the pandemic. So, while, I think, when we're thinking about recovery, we need to think about young people on a whole-population level, I think we need to have very concerted interventions for young people living in poverty who had pre-existing mental health problems.

How much evidence is there from a Wales perspective? Is there specific information, specific evidence, around what's happening in Wales, and especially in the more disadvantaged areas?

So, one of the studies that we did looked at contacts in the health service—so, primary care, emergency departments and hospitals in the cell databank—and what you saw at the beginning of the pandemic, and we saw it across the board, was a huge drop in contact for things like mental health problems and self-harm. Where the concern is there, is that that huge drop signified unmet need. Now, where a lot of clinicians were talking about seeing an increase, sometimes that increase was about the proportions. So, although the numbers had dropped, actually the proportion of young people who were contacting services for, say, self-harm, had increased. So, in one study across lots of countries, it went from half of contacts to 57 per cent of contacts, and I think some of that fed in to people feeling that things had increased.

There are Wales participants in various whole-population level surveys—so, the Mental Health Foundation is running one, but there are a few being run—and they show a similar picture. But, I guess, if you think of the 12 regions of the UK, Wales is consistently—for poverty, we have higher poverty indicators, and so, I think, what that says to me is that we'll have higher needs to address.

Alka wanted to come in.

Just to add to that: we have seen more and more unwell children and young people being referred, compared to when the pandemic first started. But we're also aware that what the pandemic has done is unveiled a lot of social inequalities that already existed—issues around free school meals, issues around seeing increased mental health problems in socioeconomically deprived people, you know, places where there was unemployment, a high risk of COVID, which brings a lot of anxiety and fear among children and young people. So, I am mindful that, although we are seeing more and more mental health problems, we shouldn't be pathologising the normal reactions our children are having to adverse events. And it has been difficult. You know, there have been job losses, financial pressures, but more and more research that's coming from England is showing what young people are more worried about is missing out on seeing their friends, missing out on seeing their family, not being able to go out, doing normal social activities. So, I think there is concern, and we are seeing more unwell children, but I'm also mindful that, if we go on with the agenda of, 'It's going to be a tsunami of mental health referrals', that's actually going to instil more anxiety among referrals and our children. Because people will start believing that we are going to be unwell, whereas, I think, if we give it a more positive outlook and think about how we instil hope, how do we validate what's happening—it is bad, but it will pass away and things will get okay. And I think there has to be a shift, which we are already seeing in terms of language.

The Minister said yesterday about having well-being check-ins. So, we're shifting away from going into school just for education. You know, schools are talking more and more about well-being week, mindfulness Mondays, well-being Wednesdays. So, I think what research has shown is that, when young people have mental health, social, psychological well-being, they tend to attain better rather than pressurising them and pushing them towards doing the mock exams, having the exam pressure, needing to achieve. So, I think what we need to be doing is providing more and more opportunities, as things ease out, for them to have some sort of a normal life, catch-up on their football matches, their play dates and parties, which they have missed out on.

So, I gather there is a grey area, if you like, isn't there? There is normal COVID anxiety that we've all felt. I remember feeling that very, very strongly right at the beginning of the pandemic when I was thinking about my 90-year-old mother, and it was a normal reaction, and I think it's important that we do say that—that it is normal. But then there's a grey area, I take it, and you're the experts there. I don't know whether others have got comments on that—on the COVID anxiety and the difference between that and mental health problems.

Okay. Ann wanted to come back in, then I'll bring Adrian in, and see if David's got anything to add.

One of the things—. So, I think Alka brought up a good point, is that one of the things I started worrying about is that we were advocating so strongly for young people, that we were almost making it sound like it was so bleak for them. I was involved in focus groups with young people, so we actually asked them, 'How does it make you feel that we're all talking about this—one, the risks to your mental health but also the issues about the future in terms of the sectors that have been most affected, like the hospitality sector, are the very sectors that young people work in?' And what they all said was how important they find it to hear adults advocating for them, because very much at the beginning of the pandemic, it was like they were the problem. There was a real focus in the press that they were the problem. But I think you're right: it's important for us to talk about what are usual responses to what was a very stressful experience that completely changed the way they were living, and had a lot of uncertainty attached to it.

So, two of the things that come out strongly across a lot of studies, but also work we've done is, one, a lack of motivation—and I think the sorts of things that Alka was talking about in that return to school are the things that we'll have to manage—and then also that worry about sitting with anxiety, which I think, as you said, we all felt that uncertainty, and learning how to manage—. There's guidance out there from Emerging Minds about learning to sit a little with uncertainty and learning to manage it.

Okay. Thank you. I've got Adrian, and then I'm going to bring David in, and I'll bring Alka back in.

Thanks very much. Just to pick up on a couple of those points. I'll preface this by saying, of course, I'm a general practitioner, and here I am in a field of specialists who know much more about the subjects than me. So, I won't delve too much into mental health illness, except to say that—picking up on Siân's point there—as you say, there is this widespread normal COVID anxiety that pretty much everybody has experienced, and, as you say, there's a grey area essentially into what might have previously been identified as mental health problems. But then, of course, it is still a problem that we could try to address for everybody's COVID-related anxiety, and, obviously, here when we're talking about children and young people in particular. So, we might come back to thinking about what is or isn't known so far about what can be done to help.

But just picking up also on an earlier point that colleagues were talking about, there is some data about reduced use of services for sure among children and young people. Just to remind ourselves what that then translates into, I think, in both physical and mental health problems, is delay in diagnosis or presentation, diagnosis and management. And that can have all sorts of impacts, depending, of course, on what we're talking about, but likely to lead to more severe illness, and sometimes dangerously so and tragically so. I don't want to describe too much about individual situations, but we experienced it in my practice in Torfaen. A child died with undiagnosed type 1 diabetes. We can think about other serious illnesses like severe asthma and risk of mortality, and, of course, particularly vulnerable groups. I'm wondering about whether there were any data on children with severe disabilities and severe cerebral palsy, et cetera, and whether they've been particularly affected by, essentially, a lack of access to healthcare during this time, or changed and restricted access. So, anyway, I think the point about delay I would just bring into the conversation at this point as well.

Thank you. David, did you want to come in on this?

I suppose a couple of things. I know one of your later questions is about access to services and I've got a few points on that, unless you wanted me to pick it up after Adrian's comments now.

We're going to come on to access to services, but I know that the royal college has been very vocal. Professor Viner in particular has been very vocal, hasn't he, about the impact on children and young people?

He has and what the children and young people have been telling us, I think, echoes what the other participants have said, that it's affected them in different ways. There's not one homogenous way, it's a broad way: children are different, their families are different, the environments are different. I think we're not going to go back to normal, but we're going back to a semblance of normal vis-à-vis schools opening. I think that's probably going to be a helpful thing for the majority of children. I absolutely echo Ann's point that not all children get on in school, and I fully take that, but I think that normalisation—. You know, if you open up a play park, transmission outside, well, children, I think, transmit a bit of COVID, not as much as, say, adults, and certainly not as much as maybe teenagers, but young children, I think, probably transmit less. So, there are safe activities where we've got outdoor areas, play parks, that sort of thing, schools; I really think we should be opening them up.

A learning point for the future is: what did we get wrong? It was probably shielding a lot of children that didn't need to be. Let's hope we don't have another pandemic for a long time, but not doing any harm when children were always a group that was probably going to be at low risk of physical harm.

Adrian was just picking up the issues with long COVID. I think that's going to be an interesting area. As children's doctors, we often had children having, if I call it a post-viral fatigue picture, and I suspect for our cohort it may be like that, rather than the kind of classic, which I think Adrian may have far more experience of in the adults than we've had in children. But that's really an area we've just got to get some further data on. We don't have enough yet. That's going to be a challenging issue to see exactly where that goes, but, again, my impression there is that it should be led in primary and secondary care as to how you care for these children, almost like a post-viral fatigue, rather than a super tertiary centre doing lots and lots of investigations on a child.

Okay, thank you. Alka, you wanted to come back in. 

Yes, just to add to the point about schools, because I think we need to be mindful that a lot of children and young people have actually found it much easier being at home, so whether it's the school pressure, being exposed to bullying, what does it mean about having to go through the exams. Some of our children with autism have actually found it less pressurising not having to socialise and be in those social situations.

The other point I wanted to mention was about the severity. When the pandemic first started, a lot of people preferred to hold on to thinking that it would pass away and they would access care, but what we're seeing is that's resulted in people now presenting in a much more severe state. We've seen more eating disorders presenting with physical complications, and that may have been because of the whole message around healthy eating, the excessive exercising, and that's something that we need to be mindful of, how we convey these messages, because children and young people interpret them very differently. You know, the restrictions that were there on shopping. But then again, talking to colleagues across the country, what we saw was Christmas time can be quite difficult for our eating disorder young people, but this time we didn't see that many referrals, because whether it was not having so much food around the table or the family around the table, which often can be very pressurising to be part of it. So, I think there are things that we've learned and as data comes through we'll understand better what worked and what was not actually helpful in the way that people have dealt with the crisis.

Thank you. Siân.

I think we've delved quite well into that, and we'll come on to other aspects, won't we?

Lovely. Thank you. Well, I've got some specific questions now about suicide and self-harm, which you touched on, Ann, in your earlier answer. I just wondered if you could give the committee a picture, really, of what the emerging evidence is about the pandemic’s impact, not just on self-harm but also on the risk of suicide for young people.

Early on in the pandemic, there were concerning signals and we were watching closely, but what we’ve seen with suicide in young people in England and Wales towards the end of last year is that suicide rates are no different at the moment. Now, I think the problem we’ve had—. So, from a lot of other countries and from some data in England, what we saw was actually, shortly after the pandemic, a reduction—what appears to be a reduction—in suicide. Now, some of that relates to, and you see it in other pandemic situations, and in SARS, is that there’s almost a coming together in the community that results in a reduction. However, the links between unemployment and recession and suicide are really, really strong, and that’s for adults and children living in households with financial adversity. And so what I wanted to say is that I think the data has been reasonably reassuring, but I think the effects on the economy we’re beginning to feel now, and so I think now is the time that we have to be really vigilant and mitigate those effects.

If you look at data from Japan, Japan is a very different country to here, but they had a similar picture. It looked like there was no change early on in the pandemic, but they’ve started having increases in suicide rates since about August, and the latest data from Japan shows that children and adolescents are seeing the biggest increase. If you think about the pandemic and all the effects on the economy, it’s not happening in isolation. So, prior to the pandemic, we were seeing increases in children and young people, particularly older adolescents, in anxiety, in depression, in self-harm and in suicide since 2010. And so I guess my biggest concern is that the broader effects of the pandemic on children and their families are going to entrench those existing trends. So, I think it’s really important, going forward, that we take action to mitigate those factors that we know impact on that.

Thank you. Adrian.

Thanks very much. That’s very helpful background from Ann. I suppose what I’m wondering is, even if perhaps numbers are relatively stable from year to year, despite the pandemic, unfortunately these events are still happening. I’m wondering whether it may be happening to a slightly different group of children and whether it actually relates to the previous conversation we had about those who are doing better out of school and those who are doing worse out of school. Those children for whom school was very stressful, whether it be bullying or whatever other issues, they may well have been the children leading to these tragic events previously, but maybe less so right now, whereas other children who require more of the support and external validation of being at school and in groups, whether they might be the ones who are more at risk at the moment. And there might be similar issues then with the employment issues that Ann was also talking about in the slightly older teens and early 20s. So I’m just wondering whether there’s any information about that, Ann, in those data.

Ann.

At the moment, no, but I think what you’re suggesting is everyone’s concern. If you look back on the mental health data, it is those children and young people with existing mental health problems and those living in socioeconomically deprived conditions that seem to be the ones that have experienced worse mental health, but also not experienced the levels of recovery. So, some of the research that is out there has shown that mental health deteriorated and then started slowly coming back to normal. We don't really know what's happened during the second lockdown. However, that recovery isn't back to normal for the whole population. There has been some recovery, but that recovery has not happened to the same extent in children from the backgrounds that we're talking about, and I think that translates to what the concerns are with suicide and self-harm. So, absolutely, there was that analogy early on in the pandemic, wasn't there, that we're all in the same storm, but we're not in the same boat? And we need to think about that really clearly when we're thinking about our recovery programme, both in terms of all children in schools, but what we do in a more targeted way.

Thank you. Does anybody else want to come in before I go on to ask about mitigations? No, okay, thank you. Can I ask, then, Ann, you mentioned the need to mitigate the risk of suicide and self-harm, and I suppose some of those are obvious things, aren't they, when we're talking about deprivation, for the Government to do, but could you just maybe flesh that out a bit, what you think the priorities should be for the Government to make sure that we do really mitigate the risks as we come out of the pandemic?

On a broad level, I think for children and their families, it's about having those welfare safety nets and ensuring that they continue. It's about making the choice to have active labour market policies, it's about thinking about older adolescents, and ensuring that we have systems where we give employers incentives to employ older adolescents; that we make sure that all post-16s are offered employment educational training, so that we hold them through this time.

Then I think there's the issue about what's happened with services that we've talked about and help-seeking, so I think we need to be very proactive in encouraging help-seeking. So, although the stigma associated with mental health problems and self-harm I think has improved somewhat over the last few years, it still completely exists, and I think when you compound that with people either wanting to protect the NHS and not be a burden, combined with the stigma, I think we need to be very proactively encouraging help-seeking in this age group, because there are things we can do.

I think we need to think very specifically about the risk factors that we know are associated both with mental health and suicide and self-harm behaviours. So, it's thinking about some of the things that we know have been exacerbated by the measures taken in the pandemic. There is evidence from crisis lines and other organisations about increases in domestic violence, some increases in alcohol consumption, so these are the contexts that young people are living in. So, when they contact services, we need to be properly doing what we call psychosocial assessments to understand what the underlying issues are.

And then I think in schools, in that return to school, educational attainment is protective for mental health and suicidal behaviours, so attainment and catch-up is important, but we have to really balance it with ensuring that we focus on well-being and social connection, and understand that those young people that we've talked about, there's going to be a lot of uncertainty and anxiety about going back to school. And what's coming through in a lot of focus groups with young people is them talking about, 'Are we going to be expected to just go back and go back to normal straight away?' And I think we need to recognise as a society that this has been a major, transformative event, and young people will have had a lot of out-of-the-ordinary experiences during that. So, the expectation that they will then return to a full school week, normal curriculum, I think is expecting too much.

Thank you. Alka.

I think in some ways, the principles we spoke about, of 'Mind over matter', would be much more relevant now in the given circumstances. We've got an opportunity to influence the curriculum, and we know that mental health and well-being is very much embedded—it's going to be embedded in the new curriculum. So, I think it's empowering the teachers as well, who've probably been through a lot themselves during the pandemic, to support these young people. Because there are going to be mental health issues, but it's also being mindful of how there can be a gentle introduction back to normality, and each one will be at a different pace. How do we support these young people who probably will need more support, and some will be bouncing back to normal fairly quickly?

Thank you. Can I just ask, Ann, about the task and finish group that the Welsh Government has set up to look at real-time suicide surveillance? The health committee, following the inquiry we did on mental health, called for this work to be progressed as an urgent priority. The Welsh Government accepted the recommendation, but cautioned that the work is complex and timescales need to reflect that. Have you got any comments about the kind of pace on that, given what we know now about the threat of the economy really impacting very badly on people's mental health?

I sit on the task and finish group. For those who don't know, part of the difficultly with understanding and responding to suicide deaths in real time is that we don't have the data, because there has to be an inquest. So, often, there are delays of months. A real-time suicide surveillance system has two important aspects to it. One is ensuring that we can support families and friends involved with any deaths for a young person—that's the bereavement support—and two is understanding what's happening in real time rather than a year later, which is when the Office for National Statistics publish their stats. This work is really progressing, but it involves police and coroner data, often, and that involves lots of data-sharing agreements. So the data analysts have been brought together and there is very much a commitment to progress this work, which I think is really important, but it's bringing something together almost from scratch. So, there were areas in England that had very functioning real-time surveillance, which is why we understand what happened to suicide rates in young people. So, I absolutely agree with the committee—I think this is a really important piece of work, and I know that that work is being taken forward.

Thank you. Okay, if nobody else wanted to come in on suicide and self-harm, we're going to move on to some questions from Laura on well-being, play, physical activity—the kind of things that we've touched on already. Laura.

Thank you, Chair. I'd like to start by talking about the impact of this first, and your observations, and then, maybe we'll move on to some questions about how we deal with it going forward, if that's okay.

So, obviously there's been a massive impact on the lack of physical activity, opportunities to play and socialise for our children and young people. Parents working, home schooling, having multiple children to look after, less engaged parents, urban settings, rural settings—it all impacts in some parts on the amount of physical activity that the children are getting during the pandemic. As Ann John said, it's exacerbated problems that were already there, but children are used to playing in groups in school and socialising with each other, and doing a certain amount of exercise and that sort of thing. What I've been massively disappointed with is the lack of emphasis on physical activity and its importance during home schooling. I have children of my own going through it, and I've noticed that. I'm just wondering, firstly, David mentioned some statistics at the beginning, and I'm just wondering whether you believe that the lack of physical activity has impacted on the mental health statistics that you talked about at the beginning, and whether also everyone believes that, as well as the mental health impact of a lack of exercise, it's also impacted on physical health conditions, and a rise in that. Thank you. 

Thanks, Laura. David, did you want to come in first on that? 

Thank you. Sorry, I was just having to take a phone call but, Laura, I think I got most of your question there. I guess from a general paediatric perspective, I can't tell you—. The royal college doesn't have data on how many hours of exercise children are doing a day, but I would find it staggering if it wasn't significantly less than before the pandemic. We look at the playing fields, they're empty. The sports, the football grounds, we've all seen that with our own eyes. I don't know if Ann, Alka or Adrian have got research they could quote from their research backgrounds on where that is, but I'm sure that's less. The clubs are closed, et cetera, et cetera. Children are then probably snacking more because they're indoors having their high calorie, low-quality foods.

So, the measurement data—there have been schools' data that are collected on the body heights and weights of children at set points. We get some out-patient data. I suspect you will see a gentle increase in obesity, which obviously would have some long-term impacts. And I know that a couple of months before the pandemic, Welsh Government was launching a healthy weight strategy to try and mitigate against that on the pre-existing things, and I share your concerns, Laura, about the way we would try to encourage exercise—[Inaudible.]—the good way we were trying to encourage exercise and those lifelong issues, from healthy pregnancies, breastfeeding babies, a healthy diet, a mile a day at school—you know, the whole package. I think it's a community issue to try and help there, rather than focusing on bariatric surgery for everybody—I obviously exaggerate that point, but it's a community issue, isn't it, that we want to support in the community.

The exact link between mental and physical health I think is—. There may be greater experts on this call than me, but my own feelings is, yes, I think it's a package of all, isn't it? You may find again, just as Ann was saying, that families that are most resilient, in a way, and in an advantageous position are probably still the ones who have dragged the children out to walk through the park, and then done something different. I think we should really try and emphasise that—family exercise, the family cycle ride, the family walk, whatever it be, to encourage that. So, I share your concerns. I can't quote you chapter and verse on exact rates, but I think we've seen it with our own eyes, these effects, and it'll be both the short-term effects and then the long term. Funnily, I was just having a chat with the cleaner down the corridor just before on my way in, and his children, of course, they're at home, they haven't been to football clubs and his daughter's ice skating club is closed, and they're really, really wanting these things to open. And I think the outside things—I'm not an expert on transmission—but I would suggest that the benefits for children are vastly greater than any risk to them.

Obviously, children are one part of society and they've sacrificed a lot in terms of their schooling, their clubs, et cetera, for the benefit of society, and I think we really want to try, as soon as it's safe to do so, to get the low-risk things up and going. Outdoor activities, to my mind, I think they're probably low risk, and they would have so many benefits. So, I think that issue is all part of one; I don't think there's mental and physical—I think they're part of a continuum, personally. So, thank you. 

A hundred per cent. 

Thank you. Who else would like to come in on this? Adrian, have you got any comments on this? 

Thank you. Just to say that our Wales COVID-19 evidence centre has just started formally this week, so we're clearly getting up to speed and looking around at what other similar organisations there are. And one that we're reaching out to at the moment is called the international public policy observatory, funded by the Economic and Social Research Council, across the UK—it has its home in each of the four nations—and we're having discussions with them.

One of their particular focus areas is around mental health in children. They've been doing a range of discussions but also evidence reviews. One document that they picked up was the Welsh Government report on embedding a whole-school approach to mental health, which I'm sure colleagues have probably led on in that area. One of the programmes that I might just draw to attention—and there may be learning to be gained quite soon—is, in Northern Ireland, there's some thinking about a community-based approach, which is looking at enhancing children's emotional regulation for both physical and mental health, and they're working through organisations, workplaces, community groups and also through online sources as well to try to work at community level to exactly restore these problems that we've been talking about. So, that's as far as we've got so far in identifying some of the resources and knowledge that's around, and so just to draw that to these colleagues' attention. We'll be trying to find out from them, in the next few months, what experience and value they've gained from it.

Thank you. Ann, you indicated, then Alka.

There's no doubt that mental and physical health are closely interlinked, both ways. There's also no doubt that outdoor transmission is much less than indoor, poorly ventilated, crowded situations of transmission. Now, as the pandemic has evolved, all those decisions about what we can and can't do have had to evolve, backwards and forwards. What I think is really essential is that, as we go forward, we put an emphasis on young people being able to be outdoors as soon as is possible, both to make those social connections but also to impact on their physical health, which is so closely intertwined. 

One of the things that's happening as part of the Northern Ireland initiatives that Adrian was talking about is a real discussion over what happens over the summer holidays. So, there was a bit of a push at one point that people would have catch-up lessons. What they're talking about in Northern Ireland is having clubs and meetings where young people will do social and play things over the summer. Now, it links back to something someone else said. Some of our young people are in families where they maybe won't need those things, because their families will take them out, they'll take them to do things, but other young people aren't so much in that situation, and having something structured to gently return them to that sort of activity and outdoor play is something that they're really thinking about in Northern Ireland.

Thank you. Alka.

There is definitely a relationship between physical and mental, but it's also balancing the messages we're giving, because some of our eating disorder patients, as I mentioned before, have misinterpreted the things around exercising, healthy eating, which has resulted in more physical complications. The winter situation didn't help, because people couldn't go out and were being stuck at home, but we do know that a lot of families were making it a family exercise with Joe Wicks or whatever was happening in terms of, you know, yoga—that was available. So, obviously, it's thinking about how the messages are delivered.

We're working closely with the curriculum group in Welsh Government around Celebrate Every Body. This was some work we had done in Aneurin Bevan, talking about body image, not only to high school children, but also how we incorporate these messages to primary school children who are talking more and more about disturbances in the way they look, identifying with role models, which is not always appropriate, and the whole thing around social media, which I could probably—. I could spend the whole day talking about that. So, I think we need to be careful about how we balance these messages, as well.

Thank you. Laura.

Thank you. I agree with all of what you said. It's good to hear David and Ann say that they recognise the importance and the links as well, and that children need to get out exercising ASAP, and Government restrictions need to reflect that. It is important that they do. I've got a 10-year-old son. I've noticed that he's put on weight. I work from home and I get him out as much as I can; I'm all for physical exercise and the importance of it, and he's quite an active person, but it's nowhere near the amount of exercise that he was doing in school, in after-school clubs, and through that, meeting his friends and socialising. The whole well-being impact is massive, as well as the physical impact and what I can see physically on him; it's so big for children, I strongly believe. So, looking to the future now, I think it has exacerbated problems, but maybe it has highlighted problems in the pandemic that we needed to sort out anyway. I think that physical education has been falling off the scale for a long time in the school curriculum. Do you think there is now more evidence to support the greater need for physical exercise during our school days?

I know this mile a day in school thing had started, which is great, but do you think more could be done? And in different ways, as well, because not everyone likes rugby, football or cricket. I'm talking about all of the different forms of exercise within a school day. Do you think there should be greater emphasis on that now? Do you think it's a good way, when the schools do go back and during the summer, that not only on the educational catch-up, as it's called—? It's important that we catch up children in terms of using physical exercise and in promoting greater well-being—as you said, there's a strong link—but also physically help them, because I know we've got a massive problem with obesity here in Wales. So, all of that sort of thing.

We have been talking in the Senedd about getting that balance right. Do you think that there needs to be a balance between the two, not just educational catch-up? And do you think we should talk about the word 'catch-up' in a different way? Do you think that's damaging to children? Thank you.

Thank you. Yes, I think it'd be really useful for the committee to get your views on—you've touched on this already—the kind of narrative that's developing, really, and how we give that positive message to children and young people. Who'd like to start? Ann.

The word 'catch-up' has an inherent loss in it, in the same way that the word 'lockdown' sounds like prison and in the same way that we talked about social distancing and not physical distancing. It's almost like once these phrases catch on, it's really hard to stop them. Hopefully, this might be soon enough that you can, but I know lots of us tried to start going, 'Physical distancing, physical distancing', and it didn't catch on. Similarly, if you say, 'Stay-at-home order', nobody understands what you're talking about, so I do think language is really important, because it just conveys so many other messages. So, I absolutely agree; I think 'catch-up' is not a good way for us to be talking about it, because of how much it links to loss and being behind, but whether that horse has bolted I don't know.

I do think that we need to have a balance of that sort of physical and social connection activities. I also think we maybe need to think smarter about how we build those things into young people's days. It's about making it easier for them to walk to school, having those things in their day that make them more active. Those are things like school crocodiles or having a walking-to-school week, so that the kids who maybe don't do that suddenly realise that, actually, it's very easy and possible. As you said, not all children want to play sport. PE, for those who maybe aren't as sporty, is not something that they would necessarily look into, so I think we need to think very broadly about physical activity for young people.

Okay. David and then Adrian.

Thank you. It was just to emphasise Ann's point there. Laura, I agree with what you're saying, that it's part of a package, but I think it's that wider viewpoint. How do we get children to cycle to school? Well, we make sure that there are safe lanes, there are the 20 mph zones and we make cars electric. It's that bigger package to look at it across the piece; I think that's absolutely vital. If I were to say, 'Oh, they have to have an hour a day at school of dance or exercise', or whatever it may be—I call it 'sweaty exercising', which is when the heartbeat goes up; that's what I tell children—what has it displaced? There may be others in your education committee who are going to go, 'Well, hang on, then they can't learn about physics'. I think it's that broader view, but I absolutely would support the school.

But one of the things, when I'm seeing families, is to say, 'Well, what's the kind of incidental exercise you do?' I try and cycle to work. Today, I'm sitting down in front of you. In the clinic at the moment, because they're remote, we're often sitting down. So, I'm trying to build that into my day. That's the solution for me. What's your solution as a family? If you walk to school, or if you take the bus, could you get off a stop earlier? That's trying to build it in to a societal norm, and it will be interesting to see—. I can only speak for the developments in Cardiff, because, obviously, I've not been anywhere else recently, but you look at the changes in the town, where you've now got cycle lanes. Can we make those into schools to make them safe? I would say that one of the things that has taken off is the cycling side of things. You see far more families out than you did before because of the lower rates of cars. That would be something that we really want to change and to sustain post COVID, if there is such a thing as post COVID, and I think it's perhaps too early to say what that means. When it's a lower rate is perhaps a more realistic one. Thank you. 

It's clearly a crucial discussion to have about the relationship between well-being and play or physical activity and how we can enhance that. Obviously, we're talking about the majority of age/year groups here, but what I just want to put into the conversation also is about the really youngest children, and in particular infants, by which we mean under one. If you're under one, you were born in the pandemic. I'm sure we all know friends and family who are in that situation, and it drastically limits the opportunities for interaction. Again, I'm a generalist—I'm not a specialist in neurodevelopment or anything—but one would assume that there's value in studying the impact on children's neurodevelopment—these one-year-olds whose only interaction with people has been on Zoom calls, which is potentially pretty significant, one would think, but it needs to be studied. Then, we also may need to identify this group as it comes through into nursery and so on with different social skills, perhaps, that need specific attention to play and the impact for well-being. 

Thank you. Alka, did you want to come in?

I was just going to mention, now that Adrian's raised the point about neurodevelopment, that there is some work that is going on in England specifically looking at the COVID generation, the children who were born during this time, and how we assess their social interaction and communication. Because even in clinic, we've seen some of these children coming and just tapping on the screen thinking that everything is going to move, everything is going to play music the moment they touch it. So, I do think that is something that, obviously, we'll learn as we move forward. 

Okay. Thank you. I think we've covered this area, so we'll move on now to talk about access to services during the pandemic, and some questions from Dawn. 

Thanks, Lynne. When the committee reported following its inquiry last year, one of the things on access to physical and mental health services for children that we were asking for was improved data on children accessing those services. Is that picture beginning to emerge now, in terms of the number of children accessing physical and mental health services through the pandemic? I know, Adrian, you touched on this briefly earlier on in terms of you had a concern with a patient of yours who died with diabetes and so on. So, it's kind of looking at that, looking at the services that are accessed, and whether the demand for those services is hidden, really. 

I'll bring in Ann, who indicated first, then David, then Adrian, if that's okay. 

In Wales, we've got a system called the secure anonymised information linkage databank, which can link primary care data, hospital data and emergency department data. My team has looked at the mental health and self-harm aspects. So, there is the potential to look at those things. I can only speak to the mental health and self-harm contacts, but that saw, for children and young people, the same dip in contacts that we saw across the board, and it was partly to do with 'protect the NHS', partly to do with the fact that people were fearful of contacting services and contracting COVID and didn't want to be a burden. Now, some of that is returning to normal, and as Adrian, David and Alka have all pointed out, we've got the issues about unmet need, we've got issues about late presentation. For some of these young people, we've missed an opportunity for early intervention. People will be presenting with more severe symptoms.

So, absolutely there's been an impact on contact with services, and you see that also with out-patients. I think it's really about trying to address that going forward. One of the things you see in contact with services is you see a socioeconomic gradient. Often, children from more deprived families will not be accessing—. It's the inverse care law; those most in need won't be accessing services, which is about travel and context and being in a family that has the ability to manoeuvre the system. Given all the things that we've already said about the differential impacts on these families, I think we need to be very proactive—. And we're going to learn lots of lessons about doing that through vaccine uptake. I think we need to be very proactive about ensuring all the things that you brought up in 'Mind over matter' about the missing middle and contact with services. I think they're so much more acutely important now.

I'm not going to comment on primary care or mental health, because you're going to hear experts talking about that, but I guess from a hospital-based perspective, there have been quite a number of effects, both with speciality interests and if you look at surgery—general paediatric surgery or children's palate surgery. There was a period when that stopped because of the worries about the use of theatre availability, so that's added to their waiting lists.

If you look at community paediatricts, several of the junior staff there were transferred into other areas and some neurodevelopmental assessments, I think, were a problem to have done. As a general paediatrician who does a lot of allergy, we've tried to do a lot of clinics over the internet or by telephone, and that works to a point, but at some stage, you often have to see the children. Say your child has hayfever, I can hold you over the telephone, but I can't actually do any blood tests or skin-prick tests, which will help me advance your care into a different direction. So, there's been a period of sort of holding rather than going on and pursuing—not for everything, but it reflects that heterogeneity that Ann was referring to right early on of all sorts of things.

Adrian pointed out the death of a child he'd had and we had some college data saying there were delayed presentations early on—diabetic ketoacidosis and I think some tumours as well. And, again, COVID caused more harm by what it stopped coming in than ever—. In Wales, I'm not sure there are any deaths due to COVID in children, but across the country, I think there are about 10 over the entire pandemic. Forgive me, I'll need to go and double-check those figures, but it's incredibly unusual. Whereas we've seen deaths like the diabetic ones—that knock-on effect of COVID has been a real problem.

Safeguarding referrals—I think they dropped by about two thirds to three quarters. And that worries us. We've got an iceberg we probably see the tip of with safeguarding and how big it is underneath, I don't know, but we could all have our own feelings about that. That tip was much smaller and I don't think the iceberg got any less. In fact, as Ann was talking about alcoholism and issues like that, it may be that it's got bigger. So, I think there are some concerns about the safeguarding side as well.

Neuro assessments, I've mentioned. One of the other things you were asking about in the questions that we've been shown was about vaccination rates—and I'm not talking COVID ones; I'm talking general children's vaccine rates. My understanding is that they dipped initially, and we're normally around the mid to low nineties overall for our vaccines. I think it dipped to the high eighties and I think now it's pretty much back to where it was. So, although I was quite concerned initially that we'd then see a resurgence of other things, I think that's held. Adrian may have some comments to make on that from a primary care perspective. So, again, I think we've seen a wide variety of different things. We've tried as best we can in hospital to mitigate what we can, but we did see some delayed diagnosis that's a concern.

Going forward, I think it give us some new models. I think some of the remote consultation is fantastic—it's safe for people; it's ecologically better—but there's a time that, actually, that's not good enough, that you really do need to put a hand on the tummy to feel, or you pick up something when you see the child and you think, 'Actually, with this child, there's something else going on here'. That's actually more difficult to do over Zoom, or whatever media you use, sorry. So, I think there's a vast variety of different things. We will try and catch up as best we can, and that strategy for catching up, I know, as a college, we're engaged with and have had some consultations as well. So, I hope that reflects that broader perspective from a hospital. As I say, I'll leave primary care and mental health to others, just to avoid duplication. Thank you.

Thank you. Thank you, Adrian.

Thanks. So, to develop a couple of those points from a primary care perspective, as you say, the numbers of consultations is one thing, the nature of the consultations is another one, which has clearly changed dramatically in the landscape and is still very, very different. The same with primary care—probably, most practices across Wales are doing their first contact on the phone, and then, sometimes in person and sometimes on screen with various platforms.

Now, my impression, it's interesting to look at data, but it's actually pretty hard, I think, even with the wonders of SAIL Databank, to work out what is a consultation. There's been an event, but whether it was on the phone or in person—it's actually pretty hard. But anyway, in principle, we'd like to look at what was the nature of the consultation. My impression is that the children were probably the first to stop accessing the services, if you like. They were the first to leave, and I think the point is they're probably the last to re-access services as we get back to somewhere around normal levels of activity. I think there are still very, very few children coming through, presenting with problems. And then there are other knock-ons that we talk about. Nevertheless, that needs to be thought through and to understand the data.

There may be opportunities around digital technologies as well. We know that children socialise digitally and, obviously, the experience over recent months is that they're increasingly learning to learn digitally, and probably, a way forward is around blended approaches with both digital and face-to-face. So, there clearly are emerging fields around use of technologies for education and clinical management, particularly for children with long-term conditions. The evidence that I've seen, genuinely, does show some impact on hard outcomes—reducing urgent and emergency care use, for example. So, I think those are areas that we can make more of. We need to understand more about what's going on with teleconsulting. I think that probably will be a subject that we'll be seeking to review pretty early on as a high priority in the evidence centre, but we are currently identifying that work programme.

Thank you. Alka.

The picture is still emerging. We have some trends that we did notice, and being a clinician working in out-patient clinics, we saw quite a drop in referrals early on when the pandemic started, and this may have been because people thought this would pass away—'Let's hold on to things'. People were keen to come back face-to-face when things get back to normal. Also, mindful that a significant amount of our referrals come from schools, so when schools were shut, we were not getting those referrals. That didn't mean that these children didn't need help. And although they started to pick up in the summer time—the referrals started coming back—often, in the cases of neurodevelopmental assessments, the school's observations are a vital part, and we know that the way things are with lockdown, schools are not going to be the same for a long, long time. So, how you continue doing those observations and assessments is going to be a challenge. We're working nationally with the team looking at remote assessments, specifically for neurodevelopmental disorders, and this is something that we want to make futureproof, because the demand's going to be even more with the impending waiting list.

It's interesting also to note that a lot of referrals to Childline and NSPCC have increased significantly. So, what is happening there? Why are children going there and they are not coming to the NHS? And is that the message—'protect the NHS, don't access services because it's for people who've got COVID or people who are really unwell'?

In terms of technology, I know we're going to cover it later on, but to mention some of the feedback that we've had, because we've been doing quite a robust evaluation and it's coming up to a year next week, which is a bit scary. Having had feedback from 37,000 patients, carers, professionals—. We've done about 140,000 consultations nationally. What we've found is that some of our most anxious agoraphobic young people, who probably wouldn't leave home to engage with services are engaging much better. Talking to looked-after children themes, they've had 0 per cent DNA rates. Their engagement virtually has been exceptionally good. They've never had this sort of engagement with their young people. Some of our families, where there have been childcare issues, where parents have got their own mental health difficulties—as Ann was referring, the ones who need us most, often, don't come to see us and are now engaging, because there's an option to do virtually. Again, there's this whole issue around the digital divide and how we reach out to people who need us most, but I think more and more of data's becoming visible, and we know that, if people have to change three buses to come from Carmarthen to see somebody in Cardiff, it's going to be easier seeing them from home, because it's that whole thing about connectivity and how we address those issues.

Thank you. Ann.

I just wanted to add a couple of things to what Alka said: so, we're doing some work with an organisation called Kooth, analysing their data, and they do online provision of web chats and counselling and peer-to-peer work for young people in mental health. And, for young people from ethnic minorities, whenever I'm doing my sort of work, it's often hard to recruit them into studies; you don't really see them in trials. When we look at the routine data, it's hard to find them. And we looked at the data of this organisation, and a fifth—so 20 per cent of the children and young people accessing this service—were from ethnic minorities. It was amazing. And I think one of the things we need to learn, going forward, is that, actually, as well as teaching being blended, accessing services will be blended. So, face-to-face or online will be different at different times for families and children. But if we recognise that, we have to address digital poverty, because if we go down that road, particularly, I think, in Wales and in some of our rural communities, we'll create another divide. And so, I think we need to be really mindful of that going forward.

Thank you. Alka.

And again, picking up on that and the specific work, we're looking at digital divide, because even some of the myths that were around ethnicity and the BAME population not being able to access, you know, have  been dispelled very quickly, because a lot of them anyway access family abroad using social media, Facebook, Skype, so they are quite savvy, but what they might need help with is interpretation services. So, how can we provide that?

In terms of rural-urban divide, Wi-Fi connectivity is a problem even in—I live in Cardiff. With everybody home schooling and everybody working from home, the moment the kids start their Xbox, the Wi-Fi falls off and you're out of a meeting straight away. So, I think those are the issues that probably need to be addressed. 

But in terms of age, what has been interesting is, we've seen the above-65 have actually embraced it; 21 per cent of above-65 are not going to go back to old ways of working. It's been a steep learning curve, but I think there's been a massive overnight shift in people using technology, and using it not just for accessing clinical, they do grocery shopping, buying clothes online. So, I do think that we need to bank on these and pick up what we've learnt from COVID moving forward, and not just stick to the thing that is going to be a digital divide, but it's how do we address it if there is one there.

Thanks for that, that's really interesting. So, what I'm hearing is, on the remote consultations, the blended approach is really the way forward, with or without the pandemic. There are circumstances where that will work; there are circumstances where it won't, when physical examinations are needed. So, I understand what you're saying. What I'm not clear on is whether you were saying that the access to the services was about the same in terms of the reduction, the drop, as in adults, or whether it was more in children. I wasn't sure that I picked that up. Is it about the same, the drop in access to services?

I've got Alka, then David. Oh, you're muted, Alka. There we are. That's great.

I think, initially, there was a drop but, come summer, our referrals picked up once schools started opening up and primary care. So, I think, in terms of neurodevelopmental referrals, we are having more or less the same amount of referrals we were having. We're getting more and more unwell young people being referred to us, so I think referrals are picking up, but what we're seeing are more severe conditions, and that may have been because of delay in accessing help, or it may have been the impact of COVID. And that will, again, unveil as we move on and get a better understanding of what the pattern and data shows us. 

Sorry, I think what I was trying to ask was whether the dip in access mirrors the dip in access from adults, or whether we've seen a sharper decline in access from children—that's really what I'm trying to get at.

David.

I don't know the adult data, so I may not be able to answer your question, sorry—

Sorry—yes, sure.

But I think it's likely to be different in different specialities. I think we had little dips in our referral rates, but I've carried on doing out-patients, as I said, remotely, rather than face-to-face, and I haven't seen my waiting list shrink because for six months, nobody's been sent to me—it's not been like that. So, I think there's—. Part of the work we've been able to do, part of it we're doing in new ways, but part of it has built up, because, as Adrian was saying, the nature of the consultation hasn't enabled me to do, you know, the skin prick tests on the child because they're in front of me, giving that answer; I've had to wait until the next time or defer it six months until they see me again. So, that makes that appointment inefficient. 

Okay. I've got Adrian next, and then Ann.

Just to say very quickly that my impression is that it has been more pronounced with children than with adults.

Thank you.

In primary care, then. 

Yes, primary care.

Ann.

There was a study done using English data looking at self-harm presentations, and the gradient of the drop in presentations to primary care for young people was much higher. The age group they looked at was 11 to 30. So, yes, the drop in young people has been steeper, as Adrian said.

Okay. So, what would be the areas, the specialisms, if you like, that would be the greatest concern to you in terms of children not accessing services? Again, Adrian talked to us earlier about a diabetic patient—so, it's diabetes, cancers, certain neurological conditions. What are the specialisms that would cause you the greatest concern?

Who'd like to start? Alka.

I suppose, from a mental health perspective, as I've mentioned, we've seen the eating disorders presenting with a lot of physical complications, which is always bad news, because they're landing up in the paediatric ward needing very often nasal gastric tubing, needing to be restrained, which, obviously, has been quite a common pattern. We've seen the ones with serious mental illness, the depressed, bipolar disorders, schizophrenia—again, it's not that common in young people, but they're the ones who have probably not accessed help and are now struggling because they obviously didn't have the medication or the support they needed. So, I think, from a mental health point of view, the serious mental illness group is the one that is more worrying for us.

Okay, thank you. Who else would like to come in on this? David.

I think there were some—. Again, from a general paediatric perspective, the college studied some of the delay in acute presentations, and there were, just as you alluded to, things like brain tumours or diabetic ketoacidosis where they probably would have come in before, and there was a—. I have to be careful that I don't reveal too much personal—. There were other cases where harm was done—sorry, I can't say the one I was just thinking of. I think there was also—. Across the piece though, if you were, say, a gastroenterologist, you're probably seeing children with Crohn's disease or colitis having a delay in the diagnosis because the diagnostics have been slower as well.

Of course.

That's not a criticism, I'm just—. Because it all takes so much longer now—

And I was also—. Sorry, David. I was also thinking about post-diagnostic autism services as well. So, that seems to be an area of concern as well.

Yes. I think I mentioned in one of the areas I was speaking about before, the neurodevelopment and the community paediatrics—absolutely. And by that neurodevelopment, I would include autism. rather than singling that out particularly, I think it's the neurodevelopmental service—[Interruption.]—yes, I would want it to view that as across the piece. And I think, when I was saying—. There are some hospital acute bits and, say, for our surgeons, when they're able to do operations—. The community people, because some of their staff were taken out to other areas into adult wards, they had delays, and also, they were forced to go—well, I don't mean forced, sorry, 'forced' is the wrong word—we all moved to remote learning, and that enabled them to do some of it. And that affected the neurodevelopmental areas as well.

Sure.

Okay, thank you. We are running short of time, would witnesses be okay to run on by about 10 minutes? Okay. Great. Thank you. Ann.

So, I guess the importance here is about thinking about what was before. It would take 10 years, on average, for a young person with a mental disorder to be diagnosed and receive treatment. Three quarters of all mental disorders present before someone's 24 years old. We have huge issues in transition between child and adult services, and all the contact issues that we're talking about will have exacerbated the pre-existing problems. We know that if we can pick these things up early enough on a child's trajectory and intervene, it makes a huge difference to their long-term trajectories. So, I think it's very likely that what we've seen will exacerbate problems that are long-standing in the way that we manage mental health in young people, and so, I think, going forward, we need to have a real focus on it.

As we've said, not all children need primary or secondary care services, well-being initiatives and things that are delivered in school would be appropriate, but for those that do, we're going to need to do better.

Thank you. Alka, and then we need to move on to workforce.

Just to talk about the post-diagnostic support, and some of our families have struggled because, again, with the special schools and the autism resource spaces, there wasn't much support available during the pandemic for these children. But I know some of these children have equally done well at home, not having the pressures of school. We've been working again closely with the Welsh Local Government Association, and I suppose technology's opened many more options that we probably didn't have. You've got virtual groups that are now supporting these families. We've got our first group coming next week, which, again, we can do across boundaries, because when people don't have travelling factored in, we can open it to parents in Gwent and parents in Hywel Dda. There are issues around sleep, meltdowns that people have struggled with.

Our therapists have done exceptionally well in terms of technology, and I think speech and language have moved to doing almost 99 per cent of their work virtually, and they will continue doing that. I think one thing that we need to be mindful of is the feedback we've had from families that it's been very empowering for parents to have that engagement and first-hand experience of working with the therapist and their child, which often in the past didn't happen. We were talking to some of the speech therapists running a tertiary service in Cardiff, where they would send equipment—this is children with cleft palate, children with communication difficulties, severe learning-disabled children—where the equipment would be sent to schools, and schools would work with the children and parents would come later on in the picture, whereas now the equipment is sent home, parents open the box, play with it, get the child engaged and that has been really, really quite empowering from the parents' point of view. Thinking about bringing care closer to home, that's going to be something that we should be working on and seeing how we can take it further in the future with us. 

Thank you. Okay, we'll move on now then to Suzy and some questions on workforce. 

Thank you, Chair, and thank you, everyone, this is a really interesting evidence session, I've got to say. Just going back to Laura's questions, I suppose one thing to mention is, of course, we don't have a shortage of qualified PE teachers in Wales. We're struggling with other types of teacher, but not with those.

Can I just ask you about the redeployment of child health medics? So, that's in mental health and in physical health. We knew that was happening and I was very interested in what Alka had to say earlier about, perhaps, people not presenting because they thought they shouldn't be bothering the NHS with their problems at that particular time. Has a combination of those two factors—patient choice and the redeployment of staff—had a more serious impact than it might have had had the workforce not been redeployed?

Who would like to start? David, then Alka.

Suzy, I think we may need to view them as two different questions, in a way. If a child came in to us—I'm looking from the acute hospital perspective, not mental health, sorry. If a child came into hospital, was there a lack of staff to treat them? I don't think that was the case. In which case, that would imply that the outcome's then worse. Our staff were redeployed and, in a sense, our workload has changed. I think I alluded to the workload I've got on the ward at the moment. It's completely different to every other ward. I've been a consultant 25 years now or whatever it is, I've never had a winter where I've not had a ward full of bronchiolitis. This is completely different to anything I've ever had. On the mental health one, children with those needs, it's double the numbers in there. So, it’s really very different. I think there was an issue with people coming in because they were worried for their children that hospitals were a 'dangerous place'. Our royal college tried to put that message out to families with a national media campaign to say, 'Look, if your child is unwell, come to hospital because they need to be seen. Full Stop. And you'll come to more harm because of not coming than you would if you were there.'

The issues about staffing redeployment, it happened in different bits of Wales in a different way, but broadly speaking, I think about a third of paediatric units, or half of them—or probably all of them to some degree—had staff moved. Predominantly it was junior staff and, locally for us, it was foundation year. I think in Gwent it was some senior house officers. So, there were junior staff who were moved across, which would have affected their training. My understanding is that all of those are now back into their paediatric placements. So, I think there was a lot of that movement in junior staff, but the consultant presence was always there to maintain a safe service in what was a very different presentation. Our admission rates dropped quite dramatically, particularly over the summer, to a lot less than they normally are. I think they've crept up over the last month. I would  say I'm at about two thirds of what I would normally expect in the winter. I've got 20 children; I'd normally have about 30, and I think a lot of that now is the bronchiolitics. But there's still a gap where the children with mental health issues are in a bigger number and there must have been some of the others that aren't.

Before I—

Does that answer your question, Suzy? Sorry.

Well, yes, before I bring Alka back in, I suppose what I was getting at is, and you said it yourself, because numbers of admissions dropped even though the types of presentation were different, it was almost like a green light to redeploy staff. I'm just trying to work out whether it's a chicken or egg situation here. Were staff going to go anyway because COVID was so demanding, or were you easy pickings because your numbers were dropping?

My understanding is that decisions were taken as COVID was evolving to move staff to meet the extreme needs on the adult wards. And I think a decision—and it wasn't my decision, but there was—. It's probably easier to move a junior doctor who is more in training and has got less expertise, in a sense, to an adult ward than, say, someone like me who is highly trained in paediatrics, but hasn't done adult medicine in 30 years. Okay, I could put something into that, but I'd probably be a bit useless, whereas they could be maybe more flexible in the task if they've got senior staff overseeing them to do the task and keep the ward running. It's a very good question, and I think the timing of when interventions were done will be a key thing. My experience on the ground was that I think the junior doctors were sent as COVID was evolving, or before it, prior—. So, I think it happened contemporaneously, and I don't know that I could tell you which was the chicken or the egg, Suzy, sorry.

Well, coincidentally then and we’ll leave it at that.

Yes, concurrently. 

Alka.

I totally agree with David, because although staff were redeployed and there was staff sickness because a lot of them were self-isolating or were COVID positive, I don’t think care was compromised in any way in terms of numbers, because what we realised early on was mental health was flagged up as a priority. So, for us, it was business as usual. So, although the referrals were lower, I don't think we were too thin on the ground to cope with what was coming in. So, I do think, obviously, as the picture evolves, we'll have a better understanding of what happened at what stage during the pandemic. But I can confidently say that it wasn’t that the workforce was struggling to deal with the demands on the service.

Well, that’s reassuring, and that's from primary care all the way through, presumably, yes?

Adrian.

I guess primary care, by nature, in small groups, is going to be patchy. Some practices were clearly very heavily affected, if several staff got ill at one time, whereas others, like my own fortunately, we rarely had lots of staff off at one time. So, I think it's probably quite variable.

Okay, well that chimes with previous pieces of evidence and inquiries that we've done. I suppose the flipside of this, then, is now to ask what workforce do we need in the short term in order to meet that unmet need that people were talking about earlier, and the different profile of need. And has that affected the longer term strategy for changing the workforce, effectively, to meet the needs of the 'Together for Children and Young People' findings, for example? If there's going to be an investment in mental health in particular, has that now been compromised because of short-term responses?

Who'd like to start? Alka.

I think what we really need to be mindful of is the mental health and well-being of the staff, redeployed or not, because the pandemic has affected all of us, and the staff have witnessed things that they probably have never witnessed in their lifetime. So, I think there's a lot of holding hands and TLC that will be needed from a staff point of view. Retention is going to be a challenge, and I know the colleges will be in discussion with Health Education and Improvement Wales and Welsh Government, specifically in terms of the mental health workforce, which has always been stressed, even pre COVID. I think there's a choice whether we want to do more of the same or more with the same, and how we adopt technology. I'm not saying it's going to replace everything we do face to face, but in terms of remote consultations, apps and online therapies that are available—obviously we're mindful they have to be evidence based. And I know at this stage, homeworking sounds like a nightmare, because everybody's wanting to get back to work, but I suppose we have to separate homeworking with the added home schooling and everything else and the social isolation. But the feedback we are getting from staff is that if that was incorporated in their job plan, having the option of working one day from home and the rest of the time in base, issues around childcare, making jobs more attractive; how do we attract the retired clinicians to come back, if we're going to give them an option that they can work remotely? I think those are the things that we need to be thinking about, how we're going to be retraining and recruiting staff in the future, because the demand is going to be a pressure on us as we move out of COVID, whenever we do.

Thank you. Ann.

I think Alka makes a really good point about how we need to ensure that we look after the staff that we have, because there's lots of evidence emerging about the impact on their mental health, and things that cause moral injury, all the decisions they've had to make. But I guess when you think about the workforce in mental health, there was a report that came out of the University of Birmingham two or three years ago that basically showed in order to meet demand, we would have to have 150,000 mental health care workers across the board in England and Wales to meet the lack of service provision that we've had over the last decade. We can do something to address that, but we're not going to be able to address that whole gap, and so lots of the things that Alka talked about in terms of transforming the way we deliver services, making use of psychology students in certain jobs, being smart and agile about how we do it is really important. But we also need to focus on prevention. I think the only way that we will be able to meet that need is if we also did—. It's not just about trying to address those problems when they've happened, but thinking about those things, which is everything that you did in 'Mind over matter', about the whole-school approach; finding those kids who have adverse childhood experiences, who are experiencing bullying, who are in households with domestic violence; making sure that families who are—pregnant mothers, those early years, that we're doing everything that we can to prevent these things before they happen.

Thank you. Suzy, are you okay? Because I'd kind of like to move on. Very quickly.

Okay. Basically, it's just about competition. As we emerge from COVID, we've heard the demands of mental health, are you worried, David and Adrian, perhaps, that the physical health of children might get left behind in the narrative on all this?

David.

I hope not. We had been engaged with HEIW about some workforce issues over the last two years. I'm very struck—. We're in an interesting time coming out of this, and whatever coming out of COVID means, where we can do—. We've had a reorganisation of paediatric services—again, if I talk just from the hospital side for a second and leave the primary care one there—there's been a reorganisation of services with fewer units, and I think that makes it more sustainable in terms of the number of paediatricians you've got delivering care. Whereas before, traditionally, you'd have had people coming into the units, now, some of that care—as we've been hearing from other speakers—we can deliver remotely, and I could see a child in Aberystwyth and do a remote consultation there, and maybe get the local team to do a blood test for me. So, suddenly, that expertise that's held here could be equalised across Wales if the digital technology enables it. I think it's going to be a really interesting way forward. I don't think there's going to be any less physical illness. I think we're seeing fewer children coming in with head injuries and sports injuries, because they're not doing it. In a year's time—well, hopefully, a lot less than that, please—they should be back to there and we'll know—. I don't think there will be any less physical work.

Ann, you were talking about prevention. [Inaudible.]—there are some prevention things we can do. There are also some new treatments coming out. Like everything in medicine, it moves on, and there are some more things that at the moment we don't do in Wales, we don't do in the UK much, but other centres are doing that we probably should move into doing, and that would take probably more nursing resource, a little bit of paediatrician—. This issue of having primary care and putting resources in schools and stopping it right at the beginning, as Ann was saying, preventing it happening, for me as a paediatrician, that's getting women to breastfeed from birth. That helps children have a better—. Just right from the start, and healthy pregnancies, not avoiding foods in pregnancy, giving children a wide variety of food—all that basic stuff is prevention, prevention, prevention, just as one example. 

Thank you. We're going to move on now to our final set of questions, from Hefin David. 

We can take some positives from what we've learnt about health services in the past year. We saw services adapt very quickly to the pandemic and provide transformational care, in many cases. The vaccine programme is a very good example of that—building a vaccine programme from scratch. So, have we learnt anything there that would suggest that other services can adapt and transform in the same way, particularly with regard to children's services? 

Who'd like to start? Adrian, then David. Everybody's come at once. 

Thank you. Yes, I think it's a really important thing to think through. It does build on some of the points that were just raised in the last discussion, I think, around the changes that are going on. So, yes, it has clearly been sometimes called a 'focusing event'—the pandemic has focused our minds on the opportunities for change. The previous question was about whether certain groups or persons with particular conditions may be left behind. I don't think so in primary care; I think we're actually yet to fully realise the opportunities of further change. We're moving at various speeds from the old-style model of a general medical practitioner seeing everyone with everything, to a more diverse workforce in primary care with a range of skill mix of people operating at the top of their licence; for example, mental health practitioners, advanced nurse practitioners and pharmacists, and so on. And I think we're still yet to fully realise the opportunities of that. So, I think there's more change to come, and I think that will derive benefits. 

Thank you. David. 

I think Adrian's point there about team working and developing team members has been something that paediatricians have been keen on for a while with nurse practitioners here. Just mirroring a situation in primary care in a different way I think is going to be a way we should continue to develop. The access to digital technology—I think the IT infrastructure still needs to be greatly improved. We have just after five years of moaning had computers changed, which enables us to do some remote accessing for out-patients. It used to take 25 minutes to log on to a desktop computer. That's just unworkable. And so in doing this, I think that money has been poured into different bits of it, which is great, but I think making sure the IT is absolutely supported is going to be a really key thing to do these changes that we're talking about, and empowering team members. 

I think I have detected perhaps an attitude and shift of people being perhaps a little bit happier to accept a degree of risk, whereas a lot, sometimes management have been, 'Oh, we can't possibly do this because there's a risk of one in a million of anaphylaxis; you'd better not do this at Llandough—you'd better bring them to the children's hospital'. And now, I think there's a kind of, 'Okay, maybe we should do this', and I think that's something we should do—perhaps be a little more realistic, a little less litigious and a little less—. I don't mean there isn't a risk, but there's a reasonable balance. Of anything we do, there's a pro and con, and I think sometimes it's been that the naysayers have worked too much to stop progress happening before. I hope maybe one of the good things about COVID is that it's pushed that, 'You've got to do this, let's get on and do it', rather than, 'Oh, what are the barriers?', 'Here's another barrier I can stop you doing it with.' 

Can I ask, then, has that led to us getting closer to getting more care out of hospitals and into primary care community settings? Is that a consequence of the pandemic? 

Hefin, I think—. Sorry, your microphone went a bit funny for me. I think you were saying—

I'm going to turn my camera off, I think. That might help.

Were you asking does it help transfer more care into primary care? I think that was your question, was it?

Yes. Yes, that's exactly it.

I think it enables—. I think we want to do as much as we can in primary care, but there are some things that I'm going to do better here because I'm the paediatrician, and Adrian, who is a general practitioner, would know much more about adults than I do, so I wouldn't dream about looking after—. So, there are some things that—. We've got mutually complementary skills. I think maybe we can deliver—. From my side of things, I would see us able to deliver more care in the community, say doing it digitally or remotely, rather than—. I think the switch would more be done in primary care, i.e. children not being referred in, if that's possible. That's probably more a thing that Adrian could comment on. We want to do as much as we can in primary care, but there are still going to be issues that we are going to come across, and I'm not sure they're going to be needed less with the technology, but we just may be able to see people in their homes initially and then advise on where things go from that. I don't know, Adrian, what your feelings are on that.

I'll bring Adrian in on that point, then, and then—

Oh, sorry. I beg your pardon. I do apologise. [Laughter.] Sorry, it just flowed out naturally.

And then I'll go to Ann and Alka. It's okay. Don't worry, it's fine. [Laughter.] Adrian.

Yes, I agree with that. I think it's about finding the balance, really, isn't it, where the skills are right to provide the service. Ultimately, that probably comes down to workforce development. It's back to the same issue, really, of ensuring there is a sufficient diversity of skills in the workforce so that, as you say, some roles that might have been done in hospitals—in quotes—in the past, can now be done in the community, or, indeed, potentially vice versa. So, I think there are issues about maintaining the education and, indeed, volume of delivering a workforce, to enable these new models of care. There really are significant issues. We're trying to adopt the new models, but actually it's still pretty difficult to find the staff to do it differently. There was a question, also, about educational and training needs and how that's been impacted in the pandemic, and I think just to say very briefly, I think that is an area that we will be looking into with undergrad and postgrad education impact and mitigations.

Okay, thank you. Ann.

So, I guess not to repeat what David and Adrian have said, I think the investment in infrastructure is really important. We can have all the staff that we want, but without a system where we can deliver these sorts of transformational changes that we can see, particularly in IT, and that's not just on the health service side; that's for patients as well. So, I think there needs to be a real focus on developing that infrastructure. And then, since those many years ago when I worked clinically, medicine has transformed. It's much more collaborative. There's much more working across different services in the way that David was talking about working in the community. One of the problems that can arise from that is people falling through the gaps in different services. I think the workforce needs to change in that you're going to need people who sit much more between those two services. You've seen it very much in mental health, in that we now have mental health practitioners, often community psychiatric nurses, that sit in primary care. They span those gaps between primary and secondary care. You also see it as a really useful job when you're spanning specialities in secondary care. So, I think, as well as new ways of working, we're going to need people with skill sets that span things that were very traditionally siloed.

Okay. Thank you, and I'm going to give the last word, then, this morning, to Alka.

I think, Hefin, what we've seen is that the workforce has been really resilient and adapted and stepped up and stepped down, and I think we really need to acknowledge that. There have been some wonderful leadership examples where people have just overnight taken on leadership roles. The digital transformation has shifted our mindset, and we need to hold on to that. I'm aware that infrastructure is something we probably need to bank on, because without that we cannot do any of this. But also thinking about telehealth and telecare: how do we get the remote monitoring? How do we get people to send their blood glucose levels across or their blood pressure readings across, which is going to be quite empowering for the public but also makes the job easier for the healthcare workers?

Training opportunities—you know, we used to do training for 100 people face to face, but doing it virtually has enabled it to be open to 1,400, when we did training in May. This was not just healthcare; this was doing it jointly with education and social care, which, again, we know has advantages. When we train together, we tend to work better together because we're all singing from the same hymn sheet. So, multi-agency working has been fantastic in some pockets. How do we spread that good practice?

Access to second-opinion services and tertiary services—that's been enabled in the comfort of your home. So, I do think we need to hold on to all that we've learnt. Obviously, with digital transformation, how do we sustain it and how do we build on the lessons we've learnt to take it forward, post COVID? That's going to be our challenge now.

Thank you—thank you very much. We have more than run out of time, so I do thank you for being willing to stay on. It's been an absolutely fascinating session, so thank you all very much for attending and for all of your answers; they've certainly given us absolutely loads to think about and to pick up on. Thank you very much to all of you for your time this morning. You will be sent a transcript following the meeting to check for accuracy, but thank you again for joining us—diolch yn fawr.

Thank you.

Okay, item 3, then, is papers to note. Paper to note 1 is a letter from the Deputy Minister for Health and Social Services to myself regarding safeguarding referrals and looked-after children. Paper to note 2 is a letter from the Minister for Education to the committee regarding the impact of COVID-19 on children and young people and their return to education. Paper to note 3 is a letter from the children's commissioner to the committee regarding her review of the Welsh Government's exercise of its functions on home education and independent schools. Paper to note 4 is a letter to myself from the Deputy Minister for Health and Social Services: a report on the compliance with the duty under section 1 of the Rights of Children and Young Persons (Wales) Measure 2011. Paper to note 5 is a letter to myself from the Minister for Education regarding implementation of the Additional Learning Needs and Education Tribunal (Wales) Act 2018. Are Members happy to note those? Thank you.

Can I then propose, in accordance with Standing Order 17.42, that the committee resolves to meet in private for the remainder of the meeting? Are Members content? We'll now, then, proceed in private.