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

Children, Young People and Education Committee - Fifth Senedd


Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Hefin David
Julie Morgan
Llyr Gruffydd
Lynne Neagle Cadeirydd y Pwyllgor
Committee Chair
Mark Reckless
Michelle Brown

Y rhai eraill a oedd yn bresennol

Others in Attendance

Angela Hopkins Cyfarwyddwr Interim Nyrsio a Phrofiad y Claf, Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg
Interim Director of Nursing and Patient Experience, Abertawe Bro Morgannwg University Local Health Board
Carl Shortland Uwch-gynllunydd, Pwyllgor Gwasanaethau lechyd Arbenigol Cymru
Senior Planner, Welsh Health Specialised Services Committee
Carole Bell Cyfarwyddwr Nyrsio, Pwyllgor Gwasanaethau lechyd Arbenigol Cymru
Director of Nursing, Welsh Health Specialised Services Committee
Dr Alberto Salmoiraghi Seiciatrydd Ymgynghorol, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Consultant Psychiatrist, Betsi Cadwaladr University Local Health Board
Dr Jane Fenton-May Is-gadeirydd—Polisi a Materion Allanol, Coleg Brenhinol yr Ymarferwyr Cyffredinol
Vice-chair—Policy and External Affairs, Royal College of General Practitioners
Dr Peter Gore Rees Seiciatrydd Ymgynghorol Plant a Phobl Ifanc, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Consultant Child and Adolescent Psychiatrist, Betsi Cadwaladr University Local Health Board
Dr Rob Morgan Swyddog Gweithredol, Coleg Brenhinol yr Ymarferwyr Cyffredinol
Executive Officer, Royal College of General Practitioners
John Palmer Prif Swyddog Gweithredu, Bwrdd lechyd Lleol Prifysgol Cwm Taf
Chief Operating Officer, Cwm Taf University Local Health Board
Liz Carroll Pennaeth Nyrsio, Iechyd Meddwl ac Anableddau Dysgu, Bwrdd Iechyd Lleol Hywel Dda
Head of Nursing, Mental Health and Learning Disabilities, Hywel Dda Local Health Board
Melanie Wilkey Pennaeth Comisiynu ar sail Canlyniadau, Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro
Head of Outcomes Based Commissioning, Cardiff and Vale University Local Health Board
Nick Wood Prif Swyddog Gweithredu, Bwrdd Iechyd Lleol Aneurin Bevan
Chief Operating Officer, Aneurin Bevan Local Health Board
Rhiannon Jones Cyfarwyddwr Interim Gwasanaethau Cymunedol ac Iechyd Meddwl, Bwrdd Iechyd Lleol Addysgu Powys
Interim Director for Community and Mental Health Services, Powys Teaching Local Health Board
Robert Colgate Cyfarwyddwr Meddygol Cyswllt, Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru
Associate Medical Director, Welsh Health Specialised Service Committee
Rosemarie Whittle Pennaeth Gweithrediadau a Chyflenwi, Cyfarwyddiaeth Iechyd Plant Cymunedol, Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Head of Operations and Delivery, Community Child Health Directorate, Cardiff and Vale University Local Health Board
Warren Lloyd Seiciatrydd Ymgynghorol, Bwrdd Iechyd Lleol Hywel Dda
Consultant Psychiatrist, Hywel Dda Local Health Board

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Llinos Madeley Clerc
Sarah Bartlett Dirprwy Glerc
Deputy Clerk

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

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

Dechreuodd y cyfarfod am 09:00.

The meeting began at 09:00.

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

Good morning, everyone, and welcome to this morning's Children, Young People and Education Committee meeting. We've received apologies for absence from Darren Millar and John Griffiths, and Mark Reckless and Julie Morgan will be joining us shortly.

2. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 17
2. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 17

Item 2 this morning is our seventeenth evidence session into the inquiry into the emotional and mental health of children and young people, and I'm very pleased to welcome the Royal College of General Practitioners this morning, in particular Dr Jane Fenton-May, vice-chair, policy and external affairs, and Dr Rob Morgan, executive officer. Thank you, both, for coming this morning. It's good to see you both. If you're happy, we'll go straight into questions. 

If I can just start by generally asking you about the fact that GPs are the gatekeeper of services and often the first point of contact for people with mental health concerns, and you're also the link with other mental health services. Do you think that the expectation that primary care can support and help young people with mental health problems is realistic and achievable?

Yes, from my point of view, I think we should be the first port of call and I think we do provide a very important assist for parents bringing children to perhaps reassure in some instances, but then to subsequently refer on. I suspect, in the question, it's the degree to which that support continues until children can either access more specialist support, or perhaps continue with us for further reassurance.

So, if the expectation of support is to a degree that, perhaps, might go outside our competencies, then it's not going to be achieved, because we'd always try and work within our competencies and recognise that point at which we need more specialist services. Once we refer into specialist services, we're always there in the background anyway, for parental concerns or further assists if people need re-access or further advice. So, I think, in terms of your question, being clear about the extent and the duration of support is important in the context of the child who presents in front of you.

May I just come in? I think that is for children whose parents bring them, but we do have a group of young people whose parents may not present them when they have, perhaps, well-being and mental health issues around their care. And they don't very often come and present to GPs, because getting to the GP can be difficult, and so, from that point of view, the school services are exceedingly important, and enabling children to seek support for counselling for the group of mental health issues that wouldn't be treated by the child and adolescent mental health services is essential.

Also, there is a need for teachers to be able to refer into a route that doesn't involve the GPs, because they have a better or a different understanding of the way that children's behaviour is shown in the classroom. They need to be aware of children who are underperforming because they have mental health issues and be able to advise the child or refer the child to different services. And that may not be the GP type of services, so counselling in the schools is exceedingly important and the school nursing service is very important. So, that can link in either back to the GP or to more specialised services.


Thank you. One of the things that the committee's heard from young people through our surveys and visits is that their experience of going to the GP about mental health issues shows that the service is patchy. It depends on the individual GP often and the level of expertise or interest they have in mental health. Do you think there are a need for better GP training to ensure that all GPs have the right skills and knowledge to support young people with mental health issues?

I think GPs can always benefit from a little bit more training in lots of things. The trouble is that we have to cover a huge range of things. Mental health is very high on most GPs' agendas. If you don't have specific services where you can send somebody, it is quite difficult to actually engage and feel that you're going to progress them. So, like any service, if you feel that you're stuck and this is a case that you have nowhere to send them to, so you're not feeling that this patient needs CAMHS or antidepressants, but needs talking therapies, and the talking therapies are not necessarily available for the young person, you're stuck with this patient that you can't manage. Now, it may be that some GPs are more skilled in doing some sort of counselling and support for that young person than others, and that is a very personal thing, and it may not involve teaching.

But the other issue—and I'm sorry if I bring it up—is workload pressures. We do know our GPs are very overworked. The whole primary care team is currently overworked, and so having that time to sit with the young person and tease out the fact that they're coming for the fifth time with a sore throat or a bad toe, which you're not quite sure is due to the fact that they have mental health problems, they're being abused at home or they're depressed, or they're being bullied in school, is actually very difficult. So, some of that time pressure could be relieved. And it's not just the GPs; it's the whole team, because, as we start using other people to deal with minor ailments, they need to be able to pull out these frequent attenders and start thinking, 'Why is this child coming again or being sent by their parents or being brought by their parent for some very minor problem, and is there some background—mental health or family problem—that is causing all of this problem?' That is what, when you're pressurised, you don't have time to tease out.

That was going to be the gist of my question, really. When you are a parent with a child, or a child attending by themselves, understanding mental health difficulties is a process, and, therefore, a 10-minute, 15-minute appointment isn't going to address that. You said that it takes many sessions. So, that, actually, is making the problem worse.

It is, but that's sometimes how you pick up that somebody has a mental health problem, because they have come—

So, they're not necessarily referrals; they're actually presenting with something else, physical.

Yes, and in general practice we talk about people who have door-handle problems—so, they've come in, they've done the whole consultation, they've used up the whole time, and you think, 'Well, there's something else going on.' As they go to the door handle, they say, 'By the way, doctor—', and they only say that if you've done well in the other bit of the consultation. Otherwise, they go and see somebody else in the team, and so that's what you have to also be conscious of—somebody is going shopping.

Is that a common term, 'door-handle problem'? Is that something that GPs—

It may be my jargon.

It's a concept, I think, that we'd all recognise. It's the thing that a patient might say on their way out, and patients often have the opportunity to say that, because they've achieved rapport during that short time. I think, on your point about whether that delays things for the individual, I'd probably say not, in my experience. Even though I may have probably spent a short time with someone, I've hopefully, in that short time, built up a bit of trust that allows them to come back next time.

So, you're relying a bit then on primary care services having permanent GPs in practices as well, then, rather than locums, if you're going to build up trust and relationships.


I think continuity of care is the essence of what we do, and it's difficult for patients if they are faced with a different doctor every time. So, I think ideally, for a new patient, regardless of their age, continuity of care for specific problems is useful.

In terms of the question earlier on about training, I think training is a good idea, and raising awareness is a good idea, but we're all patients, and we probably select those doctors who may have had exactly the same training but suit our personal characteristics—we've built up a bit of a rapport, had some experience of them in the past, though their training qualifications may be exactly the same. So, in terms of young people's experience being patchy, it's very dependent on that interaction between the doctor and the child, or the doctor and the young person, as to how they get on, and training may not come into that.

As part of this inquiry, I get this overall impression of the service. Now, you've painted a clear and what I'm sure is a very real issue around the workload of GPs and the difficulty of actually having the time to spend with some of these young people and children. You've mentioned the importance of school nurses and school counselling services, but, of course, in evidence we've heard that those services are few and far between and it's a diminishing resource. So, how would you characterise the service at the moment, because the overarching impression that I get is that really the service is on its knees and it's diminishing when in fact demand is increasing?

I'd agree with what you're saying. I haven't really seen much change in that impression, despite all the good work that's gone on and trying to revitalise things and put services into schools. We're still having the same discussion amongst ourselves as colleagues as to there not being enough people to meet the increase. And there is an increase in demand, and we're recognising things perhaps a lot earlier than we would have done years ago. There are not enough people to meet that demand in a timely fashion, and that's what it all boils down to in the end: the pressure on waiting times that then spills back onto parental or a young person's anxieties and problems, which subsequently affects their functionality, which brings them back to the GP, who's trying to do the same things as they might have tried to do a month ago. So, yes, the people who are working in the service, I think, are working flat out, but there are not enough of them to meet the demand, I don't think.

So, the bottom line is that, to break that vicious circle, if you like, we need more boots on the ground in different guises.

Simplistically, that's what I feel. You know, I spoke to our primary mental health team this week and I think it's just one person—one whole person. There may be two people doing the job, but it might be one whole person, and that's a lot of work. You can't criticise someone for having a waiting list when there's increased demand but there's only one person to see that demand.

In Wales now, we've got new neurodevelopmental services. How aware are GPs of the new services, and do you have a direct referral route into them?

It's an interesting question. When I thought about this, I thought: what exactly is that, then? But, of course, I do realise what it is, and my understanding and my experience is that we don't particularly have a direct route of referral in, and whilst I might just send a letter off to a local community paediatrician, I realise that isn't the route in and it's actually through the school service. I'm sure that awareness isn't complete across Wales at all. So, I think that development has been quite a quiet development, certainly from my point of view at ground level, and, just speaking to colleagues, I think their experience is quite varied, again, across Wales, and perhaps that understanding that it's actually through the school that you get access into that service isn't perhaps widely known or as accepted as it might have been given the fact that I think it has been going on for quite a while.

So, children and young people are frequently referred to GPs from their schools. Has the Royal College of General Practitioners had any involvement with the new Welsh Government's initiative to ensure specialist emotional and mental health support being more widely available within schools? 


As far as I know, we haven't been invited to sit on any groups, and we haven't given any evidence to any particular groups, apart from you.

Is the initiative something that either of you are aware of, even if you haven't been officially consulted? 

I did know that there was some review going on, because I did sit on a group looking at transition services from CAMHS, and we weren't discussing the neurodevelopment group. So, they were doing something different and, as far as I know, there was nobody from the royal college of GPs on that group. 

We heard—. Sorry, Chair—

I was just going to clarify that there's a new Welsh Government pilot that is operating in parts of Wales, where they are putting mental health support into schools to try and improve that link there, really. I think that's what the question refers to, rather than neurodevelopmental, really. It's like a pilot, really. 

Because we've heard some, perhaps, complaints or observations from schools that, at least in some instances, schools say they make referrals to GPs for assessment and potential treatment, and those referrals are then bounced back to the school and you each deal with that in your counselling service. Do you see that as a problem? 

I think it is a problem, because the trouble is that sometimes you get a parent that comes in with a child and they say, 'Oh, the school says he's disruptive in class.' When you need that evidence, so you need the evidence from the school in order to actually forward it on to anybody if you were a GP—because you can't just have the mother saying there's a problem; you need the evidence to show what sort of disruption is going on—and actually having some liaison with the school producing those reports—. There used to be at some stage somebody who could do that kind of thing, but sometimes that doesn't seem to happen now. I think it's due to cutbacks in some of the schools. 

I think it is a problem, and it's something that I've had personal experience of, of parents coming from a school and me saying, 'No, no, it's the school that does this now—go back to the school.' So, I think that is a very real experience of children and parents. I think that could easily be solved by perhaps a greater degree of clarity and a well-defined pathway through, perhaps, education, or through some form of advertising, so that everyone is clear on what the system is at this current time, because it changes, and it's changed in my locality in Bridgend. It has changed over the last five years, in that it was through the schools and then back to the GPs. Now, it's, I think, back to schools again. So, I can see that parents are perhaps buffeted a little bit.   

When you have a school and someone's going to the counselling service and they consider there's a mental health issue that needs addressing, should they be allowed to refer that directly to a contact at CAMHS, or should that referral always have to go through the filter of the GP? 

I think it depends on the context of the child. Obviously, it would depend on the degree of confidence in the school counsellor, and the degree of illness in the child. So, obviously, the school, I think, is the best place to make that assessment, and a direct referral through to the primary mental health team is the most expedient way of doing things. As long as you've got trained counsellors in schools—and I'm not sure if that's across the whole patch—there shouldn't be a problem with that. But, any counsellor, there'd always be that little bit of uncertainty where perhaps mental illness is to a degree that might need more specialist services, and as long as the competencies are okay in that counsellor to recognise that then perhaps a direct referral is more appropriate—. If they feel not confident in their competencies, then I'd be quite happy for them to say, 'Go straight up to the GP.' A child that may be hearing voices or threatening self-harm at that moment—if there's not a direct route, a pathway in, I suspect that would be sent to us at the moment, but, if there were better pathways, if there were perhaps more confident counsellors who felt they were working within their competencies, that route is certainly possible.


Yes, thank you, Chair. I just wanted to ask a few questions around the Mental Health (Wales) Measure that was passed in 2010, which strengthened and expanded mental health services at a primary care level, and I'm just wondering to what extent the CAMHS services across the different health boards are working to the standards that were set by the Mental Health Commission.

I don't have information about all the areas or specific places, but I know—

—that some of the primary care support services didn't have all of their services available for children and young adults because they didn't have suitably trained members of staff to deal with children's mental health as opposed to adult mental health. 

And that's what I was leading to actually, around this criticism that they're not child-centred enough. You believe, or do you—? Is that your experience?

That's my understanding from doctors.

Yes. And how do you think that could be changed? How could we improve that then in terms of the focus on children and adolescents?

Well, we'd need to put in some training for the primary care staff so that they were enabled to deal with children, I think, because a lot of them are adult-trained staff who haven't had the training in children, and so they don't see that they—. Or their licence doesn't enable them to treat children and young adults. 

Okay. During the post-legislative scrutiny of the mental health Measure, you published a paper saying that some GPs refer directly to community mental health services

'because LPMSS are just another assessment'.

So, I just want to ask, really, what concerns you have about the number of assessments being undertaken before patients can access specialist services. 

I think some children do go through a lot of assessments, and I know that—. I can remember one young girl that I had who had, actually, very serious physical problems, and she had mental health problems as part of that, and she had to be assessed to make sure she hadn't an eating disorder, even though she had a muscle-wasting condition, before she would be accepted by the CAMHS service—well, she had depression because she had a muscle-wasting condition, not an eating disorder. So, it can be very difficult when children can't get from one service to another service without being assessed. I don't know whether it has—. That was a few years ago that this particular young girl—

And what impact is that having on the children and the families then? Clearly, it's not—

Well, it doesn't help—if you have to keep taking a child to a different assessment, and that might be at a distance, so you've got travelling time, travelling costs, and you're trying to raise other children, go to work, and all these kinds of things, this can be very disruptive. And, if some of the patients are maybe assessed as in-patients—and there is a limited number of in-patient beds for CAMHS, and, obviously, there's a waiting time for those; those are only for the very seriously ill patients. 

So, you would you say then that the functioning of specialist CAMHS has been disrupted by its inclusion within the provisions of the mental health Measure?

I don't think I can answer that, but I think probably it may have been disrupted. And the CAMHS service is an exceedingly small service. That's one of the problems. So, any change is very disruptive to it. 

Okay. Can I just ask? You mentioned that specialists CAMHS is only for very serious cases, but we know that there's been an issue going on for some time, really, that too many young people who perhaps need support elsewhere are actually referred to specialist CAMHS because there really isn't anything else for them. Are you saying then, from what you've said, that there's a better awareness now amongst GPs of when they should make that referral to specialist CAMHS, and that it's only maybe more appropriate children who are now being referred to that route?

That probably is so, that only the tip of the iceberg are getting to CAMHS. We do have other means, sometimes, of supporting them, but the services, as we say, are limited, and mostly that is things like school counselling. 

Thank you. Good morning. You've stated that GP counselling services aren't available to children and young people. Is that the case across Wales?


I'm not aware of any area that particularly has that service. Certainly, the primary mental health team can provide brief intervention, and they're very good at that, but, long-term counselling, I'm not aware of that.

At what age can children and young people access GP counselling?

I think 18, when they become adults.

Right, and are there any instances where children and young people are being referred to the third sector for counselling?

There's certainly third sector provision. It depends how you might define counselling, but certainly support and perhaps some interventional work with families can happen: Action for Children might be able to provide something. But I think, again, I wouldn't be able to say with any certainty that that exists across the whole of Wales. We're often left with perhaps parents or young people who we would often refer into the early help team, who will invariably take them back through to the schools. We often don't know what happens after that, and that may be because there are generally good outcomes. But I think that the provision of service outside of that pathway is very sparse.

There isn't feedback very often from some of these services to general practice. The other group that I know that does counselling is—Tŷ Hafan does bereavement support for siblings, and I think Marie Curie is now extending their bereavement services to children and families to help support people who have had either recent or past bereavements. That's a subtly different group, but quite an important group, particularly when we're hearing more about young children having bereavement issues around loss not of their parents, but of their grandparents, and often they feel a bit shut out from that grieving process because they're one generation removed.

To what extent are GP services available in Welsh? Not GP services, sorry, GP counselling services, I should have said.

I did try and find some information about that recently, and I don't know.

I don't think it's widespread. There may be more Welsh counselling services up in north Wales than there are in south Wales. But actually getting translation services for counselling is hugely difficult. I have tried it for other languages apart from Welsh, and, once you put a translator in the room, actually, you break that dialogue between the counsellor and the patient, and it's quite difficult apparently.

Do you have any views on how that situation could be improved, how we could increase the level of counselling services being offered in Welsh?

Well, obviously, we'd need to ensure that we have Welsh-language counselling courses, because I think it's really important that the counsellor has experience of doing the counselling in Welsh as well and probably in the regional Welsh—you know, a north-Walian counsellor might not get on very well with a south-Walian patient because of the local dialect issues that may be used in a very personal counselling situation. I don't know what information there is about counselling services or what training services there are in Welsh.

I think it makes sense that, if you're in a very vulnerable position, to be able to communicate in your own language—there's a great advantage to that, in allowing people to really understand what your problems are.

Okay. If I could move on to psychological therapies, frustrations around the waiting times for children and young people to access psychological therapies have been made clear during this inquiry. Is it fair to say that there's been an improvement in the timeliness of assessments for children and young people in primary care but that there continues to be a lack of provision of psychological therapies? Would that be a true comment?


So, your comment is that people are being seen quicker for assessments but perhaps not getting the subsequent treatment.

There's been an improvement in the timeliness of assessments, but there's a lack of provision of the actual therapies.

I'd probably agree with that to some degree. I think we still, perhaps, would prefer patients to be seen sooner than they are being seen, and in the face of increasing demand, as we were saying earlier, I still think there's significant waiting times and lag times before people get that first assessment. And it's that first assessment that often allows parents to realise that help is at hand and it can take a bit of pressure off a fraught situation. To subsequently then be told there's a waiting list again for counselling—it just doesn't help their confidence in an end to their problem, really.

I think there's a problem for talking therapies across the board, but I think it's probably worse for children and young people, because of the difficulty of having people to provide the services who are child-trained.

And what sort of impact is the restriction in accessing psychological therapies having on GP and local primary mental health support services' ability to manage people with common mental health problems without referring to CAMHS?

I don't think it's a very satisfactory outcome, because what it unfortunately results in is that families will continue to re-attend the GP, who really perhaps can't do anything else apart from support and try to reassure during that time. There's the possibility that that child's illness could escalate to a point where they actually meet the threshold for CAMHS, or in some instances a GP might refer into CAMHS just because it's something else to offer the parent, but CAMHS will invariably return that and say, 'This doesn't meet the criteria: refer back to the primary mental health team', which the parents are already in the system waiting for.

Certainly, there's some anecdotal feedback to us that, even when GPs feel that those criteria are met, the referral comes back subsequently, after some time, to say, 'Doesn't meet our criteria: refer to primary mental health'. I just wonder if there'd be a quicker mechanism of having that referral rejected at an earlier stage so parents and children aren't waiting even longer in a bit of a black hole of referrals without actually seeing anyone.

There are very good systems in adult, both mental health and general health, where e-mail advice, helplines and things like that can direct us very quickly to the right person who can deal with this clinical case. That might be very dependent, in child and adolescent health, on local networks, but it certainly works in adult networks. Those helplines are very much up and running, mental health liaison workers or gateway workers—it's a phone call: 'Okay, where does this person need to go?' But that doesn't really exist, as far as I'm aware, across the patch in Wales.

Again, just on a local level, from a jobbing GP's point of view, there's a helpline in Bridgend that's open during certain times when we can speak, as GPs, as professionals, to the primary mental health team, and that's really useful. But I'm not too sure if that exists across the patch completely, and that might be very staff-dependent. 

Can I just clarify, then, if you're saying that the primary mental health teams can't offer counselling to young people—? But you did say earlier that some young people can be helped by the primary mental health service. What form would that help take, then, if it's not counselling, and we know that they are going to struggle to get access to psychological therapies? What would that service look like for a young person? 


So, someone who may have a specific, well-defined mental health problem that's just, perhaps, related to one single issue—that problem might be amenable to something called 'brief intervention', so a short series of repeated visits over a short period, to just overcome that one problem. But a child who perhaps has quite a complicated emotional and mental health background is going to need a much longer period of support that we might recognise as more typical cognitive behavioural therapy—you know, just talking therapies, perhaps involving other family members. That does need input over a prolonged period of time, and if the primary mental health team is making assessments as well as trying to offer brief intervention, you can see that system gets very quickly filled up. Does that—?

I was just wondering whether you had any involvement in the development of the new referral criteria for CAMHS in Wales, which is due to be available from the end of this year, I think.

Again, I don't think we have.

It's strange, listening around the table, we seem to be hearing the same things, aren't we? What you're telling us isn't any different to what we're experiencing. Certainly, I think being involved telling the stories is useful, and sometimes, from a front-line point of view, we might have answers that are a barn door to us, but unless you're in a discussion with a wider team, you may not realise how feasible that is. I suspect you have to be in that discussion to realise that. 

Okay, thank you, Llyr. The next questions are from Michelle on medication.

Thank you. Our predecessor committee raised concerns about the prescribing of antidepressants, ADHD and antipsychotic drugs to children and young people. The Welsh Government tried to address this by issuing a health circular. Has this had the direct desired impact, and has there been a change in the prescription of medication to children and young people since the circular?

When was the date of the circular?

It was issued after the predecessor committee raised concerns about this, and the Welsh Government did some research on it and then issued a circular, so it would have been a few years ago now.

Okay. I'd probably say, to a degree, 'yes', but there are always those instances where you can say, 'Oh, but what about so-and-so? What about this situation?' I think, to be fair, thinking about ADHD treatment and the methylphenidates, things like Concerta, there's definitely been a change, in our awareness, of practice over the last few years: more monitoring and explicit directions around the prescription of quite potent drugs. That would be my own personal experience. I think that has improved. Whether that was due to that circular or not, that's a bit more difficult to say. I think there are still instances where perhaps there might be an expectation of secondary care, primary care, to prescribe drugs that, really, are out of our experience and out of our competency. So, there would always be a bit of reluctance in that, and again, unfortunately, that might have a spin-off for the parents, that they can't access drugs in the locality or in a timely fashion.

I think paramount to all this is patient safety, and it's very difficult for GPs to prescribe drugs to, let's say, perhaps, a parent, who says, 'I've been to out-patients, and this is what they've suggested.' So, I think there is evidence that things have improved, but there may not be a complete watertight experience that GPs may not feel confident prescribing drugs that should really be the responsibility of consultants, and perhaps improving our communication around those drugs might help that.


Can I just say that I think GPs are probably much more cautious about prescribing some of these drugs to young people because, as paediatricians would like to tell you, children are not just little adults? You have to take into account the developmental issues that are going on with the young people as well, and particularly ADHD—giving a drug is not the only answer. It may be one of the answers, but it should be part of a whole management of the condition for the child rather than just giving them a tablet. It's not a miracle cure; it has to be in a background of other sorts of treatment to manage the condition.

Can community intensive treatment teams have an impact on GP services?

Again, unfortunately, my answer would be that I haven't seen any particular evidence of that, and that may be because teams were working effectively anyway. Thinking of the patients who have severe mental illnesses and who are heavily reliant on secondary care input, that top tier I think are relatively well supported. There may be the odd instance, but it's that lower tier where the difficulties might arise and trying to define, 'Well, who actually fits that group?'

Okay. We know that more and more young people are unfortunately self-harming, and also suicide rates among young people are going up. Can you give us some insight into how confident you feel GPs are when somebody comes to see you saying that either the child says that they're feeling suicidal or have been self-harming, or the parent comes? Are you confident that you've the right pathways then and know exactly what to do about that young person?

I think most GPs probably do feel confident. I think the problem is that the young people don't have the confidence to necessarily come. Their parents may come, but they need to bring the young person, and that doesn't always happen. And I think the teenage group particularly are very shy of going to the GP. Some of that is due to—. In an urban setting it's not too difficult to walk down the road to the GP, but in more rural places you actually have to get to the GP, you have to get past your mother's friend who is the receptionist, you have to get past all those other people in the waiting room, and because your parent has always negotiated the appointments for the GP, you probably don't know the system. So, we need to have a very easy way, which is why I go back and think about school nurses and school counselling services that are accessible for young people and teenagers to get the help that they want in an environment they feel much safer in than coming to a GP surgery, which, let's face it, they've probably only been dragged to when they've had a vaccination or a nasty thing stuck in their ears and their throat because they've had a bad throat. So, it's quite frightening, I think, for young children to come to a GP.

So you don't see that as partly your responsibility, do you, in terms of reaching out? 

It is part of our responsibility, but they're a difficult group to reach. I mean, we've had the same discussion about things like family planning services, which has an impact on their emotional well-being as well. But how do you get to those young people who don't necessarily see you as that friendly, supportive doctor? However friendly and supportive you feel you are, unless they have that relationship with you, which they haven't developed as a little child, because it's always been parentally controlled at the point of either vaccination or being sick, they don't realise that the GPs have this more encompassing, caring job to do for them.


Okay. I think this is an important point. For instance, I've seen one constituent who took their young teenage daughter to 12 different GPs complaining that they were suicidal before they got a referral. So, are you saying that most GPs do know what to do in that kind of situation, and can you just describe to us what the pathway would be then for a young person who presents with suicidal thoughts or self-harming?

Well, I would try and talk to the young person with their parent, try and maybe talk to them without their parent as well—sometimes that's quite difficult—and then, if they seem to be suicidal, I would make a referral to the mental health for young people, but I'm at a loss to think why somebody would have to go 11 times.

Yes. I think what we are faced with as GPs is that we are gatekeepers. If I were to refer everyone who came into my surgery claiming to be suicidal, either adults or children, that gate would be open much more often than actually I open the gate. It's difficult in that situation to reflect on personal experience, and what you must—

I know, but what I'm trying to get at is what the pathway is. Have GPs got a clear understanding across Wales of what they should do if a young person presents either self-harming or with suicidal ideation?

I'd say 'yes'. And I would say that if you're acutely worried about a child, then that child needs admission, regardless of the age. If you are less acutely worried, you would be referring to and contacting mental health services as urgent referrals, and you'd hope that that would be picked up and responded to within a short space of time. I think your question was about confidence about the pathway, and perhaps that confidence could be shaken by what happens subsequently. What would be common experience amongst GPs is that, if that assessment's been made that perhaps someone doesn't need an acute admission because they may not be psychotically unwell or at direct risk of harm that day, we'd probably be seeing that child the next day, the day after, subsequently the next week, until the secondary care services could actually engage with them. So, I think I'm confident that GPs are recognising—. Obviously there are exceptions, but I'm confident that GPs are recognising those children who have suicidal intent or who are at direct risk of self-harm at that point. I'm confident that they could act appropriately in those circumstances, and my only doubt is about the certainty that it's a consistent response across the patch.

Just on the transition to adult services, clearly, it's not as seamless or smooth as we'd like as often as we'd like. I'm just wondering if you could tell us what role GPs play in that process and particularly in relation to providing continuity and support for children and families.

One of the problems is that, for some of the young people—. There haven't been transition services for attention deficit hyperactivity disorder, for example. It is improving. But somebody who needs specialist services should be referred to adult specialist services rather than to a GP to assume the ongoing management of that care. We should be able to know what is happening and treat the other parts of the patient—so, if they've got physical problems as well as their mental health problems, to have ongoing support and care for those. So, we should know what's happening about the transition, but if somebody is needing specialist care, they need specialist care as an adult as well as as a young person and child. They don't need to be just discharged and for it to be assumed that a GP has the specialist skills to look after them. That, unfortunately, sometimes still happens.


I think different young people will reach that level of being able to be transferred at different ages, and it would be very patient-dependent. To serve them best, I think there should be an easier transition that a consultant would say, 'Well, we'll see you in three months' time', but that appointment is actually being arranged in an adult service. Whereas what tends to happen is, 'We'll refer you to adult services', they disappear into a black hole and in the meantime there's a continuity of care, which GPs will provide anyway—back to the GP. You'd think that the process could be a lot more seamless, and the clinic appointment could be generated so that the family, the child, knows exactly that, 'Yes, I've got an appointment, and this is the team I'm going to see.' Whereas what we often experience in general practice is, 'Can you see us? Could you prescribe for us because our appointments haven't come through?'

So, in effect, in terms of continuity of service, there isn't any—you're shunted from one service to another. It isn't that seamless sort of process that I thought it was, to be honest.

That would be my impression, and there may be patients who would say, 'Doctor, well, that didn't happen for me', but that would certainly be my impression.

Thank you. Are there any other questions from Members? No? Okay. Well, can I thank you both very much for your attendance this morning, and for answering all our questions? You will receive a transcript to check for accuracy, following the meeting, but thank you very much for your time this morning. The committee will now break until 10 o'clock, but if Members could not rush off, please. Thank you.

Gohiriwyd y cyfarfod rhwng 09:51 a 10:02.

The meeting adjourned between 09:51 and 10:02.

3. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 18
3. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 18

Welcome back, everyone. Can I welcome the witnesses for our next evidence session on our inquiry into the emotional and mental health of children and young people? We've got a panel of health boards here. I'm very pleased to welcome John Palmer, chief operating officer, Cwm Taf Local Health Board; Melanie Wilkey, head of outcomes based commissioning, Cardiff and Vale University Local Health Board; Rose Whittle, head of operations and delivery, community child health directorate, Cardiff and Vale University Local Health Board; Angela Hopkins, interim director of nursing and patient experience at Abertawe Bro Morgannwg University Local Health Board; and Nick Wood, chief operating officer, Aneurin Bevan Local Heath Board. So, thank you all very much for your attendance this morning. If you're happy, we'll go straight into questions from Members. The first questions are from Llyr Gruffydd.

Thanks, Chair. Good morning. I'm just wondering, maybe to start, if you could tell us what the main changes are that you think 'Together for Children and Young People' has delivered and where you think maybe more progress is required.

Okay, thank you. Do you want me to kick off, colleagues? I think it's probably fair to say that it's been quite a dramatic change and I think a relatively good improvement.

The most important thing, perhaps, has been the implementation of the choice and partnership approach that's now operating across a number of the health board domains. That has had a big improvement for us in terms of performance, so I'd certainly pick that out. I think the second thing is the establishment of referral criteria at a national level, and I think that's beginning to have a significant impact. We now have crisis teams that are appointed across most of our system, and I think that's again having a very big improvement for us. And then, the development of the first episode psychosis service, I think, has been very, very important for us as well.

So, when you bring those four things together, I think we are beginning to see an aggregate improvement in performance across the Welsh system. Certainly, for our network within south Wales, we have seen a significant improvement over the last three years, where you've seen us go from waiting lists that were, at one point, about 3,000 people and now we're looking at waiting lists of about 600, with about 300 patients at the moment over 28 days. That target has changed immeasurably over the last three years, so we've moved from a 26-week target to a 28-day target. So, I think, now, we find ourselves in quite a different position as a result of those aggregate changes that obviously changed our system quite significantly.


So, where's the progress required then? Because there are a lot of positives, clearly, but there are bound to be a few areas where you think maybe more could be done.

I think there have been, as John has said, some significant issues there around specialist CAMHS and the referral criteria, but where I sit in community child health in children's services, we've got the primary mental health element, and I think there is just something about the whole system working together and making sure that, whilst we've got really good, clear referral criteria for specialist CAMHS now, what we don't actually do is have children that don't quite fit anywhere. I think the challenge, the remaining challenge, really, is to make sure that we've got a coherent pathway that is clear for referrals and actually meets the needs of all children.

I think I would support John's view that the implementation of CAPA and a more lean model of referral into the system has probably been the most progressive element of what we've seen at a health board level in terms of access arrangements and the way in which patients can now access the service. I think, going forward, the challenge we've got to tackle is: where do we refer some of the younger people who are a lower level perspective? We were talking outside about—what we've seen is, consistently now, more children being referred into the primary mental health service. Numbers there are growing rapidly, and it's where we then link them into a more therapeutic and behavioural analysis and counselling, rather than a high-level intervention. What we're now seeing is probably only about 1 per cent to 1.5 per cent of children going into a specialist CAMHS referral. But if you say you've got 100 referrals, and only one or two are going, it's what we are doing with the other children who've got that lower level who require some form of intervention that's probably not necessarily by a clinician, but it may be therapeutic, it may be counselling, it may be talking therapies—all of those things. That's a big challenge now, how we start to scale up some of those services so that we meet the needs in a much more rapid way.

You are asking your own questions now, in effect, because that's where I was going to go, really. How do we do that then? Because, clearly, it's been a key message coming from the evidence that we've received as a committee—this missing middle, if you like, that aren't unwell enough to receive the specialist services, but they need support. I'm not saying there's a vacuum there, but, clearly, there are deficiencies in terms of access to certain services there, so what would you see as your role within that sort of structure?

I think that, just from a Cardiff and Vale community perspective, we have lots of partnership arrangements. So, I think my reflection is that there are lots of services out there for children and young people, providing really good support, but, somehow, the system needs to be more joined up so that you need specialist support for those earlier interventions in order that they feel confident and so that what you don't have to do is then refer on again, if that makes sense, so, it's much more of a system. 

Because referring is the easy answer, in a sense, isn't it? It's, 'Well, I don't know, so I'll have to refer.' We've had evidence from schools around school nurses, school counselling services, all that kind of thing, but, of course, the message we get in that evidence is that those are diminishing resources. They are few and far between, if, indeed, available at all in some places. So, clearly, there's a gap there that needs to be addressed. Would you agree with that?

I think there's a definite consequence of the period of austerity that we've gone through over the last five years. I think you see it written through the evidence that's been put in by each health board that it's very clear we've felt the pinch of reduction in social work capacity, educational psychology and, where local government has been under pressure on its aggregate budget, I think it's unavoidable that pressures go onto the largest budgets. Having said that, I think, again, you'll see in the evidence that's been put in by each of the health boards that there's a good theme of developing partnership working, commitment, through mental health partnership boards, to really work collectively, and some of the stuff that you just mentioned there around school nursing developments and mental health first aid, group activities in school environments—that sort of stuff—is coming through the system. I just don't think it's coming at enough scale, to be frank with you.

If you look at the blend of investment that we've seen come into these sorts of services over the last three years, you see significant increased investment in neurodevelopmental services, which gives you a behavioural angle and a therapeutic angle that then links in to the school system, and that's probably where the biggest connection is between services. You've seen greater resilience come into the specialist CAMHS service, alongside a much increased expectation about performance delivery, so moving from 26 weeks to 28 days. 

We're beginning to see, I think, more grip across all the health boards around our learning disability services, which do have a connection here as well, but there's a lot of work to do on that front. You can see some promising statements of intent on that at the moment, but I think we need to be held to account around resourcing. And then you've got other things like psychological therapies, forensic services having some investment as well. I think if they're an area for us to push in terms of our planning in our integrated medium-term plans, and for further conversations with Welsh Government about areas for resourcing, I do think it's that tier 0 provision that we really need to focus on.

If you look at our general performance now, if you look at the local primary mental health support service, you can see that every system is under pressure on that front, and I think probably Aneurin Bevan have got some of the most developed activity around that space, but we are all trying to improve our performance there. We're using a blunt tool in the main at the moment, which is that we're using waiting list initiatives to ramp up our activity. That's probably not clever enough, really, so I think it's fair to say that tier 0, integration with partnership arrangements into local authorities, wider third sector, is going to be really important for us in the next cycle. But I do think we've built some foundations to be able to get into that over the last three years. 


So, in Cardiff and Vale, as part of the Together for Children and Young People activity, we commissioned a service from the third sector for early intervention and emotional well-being, and we've seen an increase in referrals into that system. We commissioned it jointly with some of the young people from the youth councils and youth forums across Cardiff and the Vale, and that's had a really positive impact because it's relatively open access. They run group courses on things like living life to the full and emotional regulation, and they offer some one-to-one support, and we're also using it as a little bit as step-up and step-down from CAMHS services. So, I think that we'd like to extend those sorts of services and integrate those better with some of our partner services. And, obviously, we're engaged with the Families First recommissioning now to try and make sure that we're making those links, and that actually what we're doing is not duplicating effort, but making sure that the services that we do provide support each other in the right way. 

One of the other ways that we're looking at this as well, in terms of making sure that the whole system is working for the child, is the area that you touched upon: education. So, in ABMU, via the Western Bay regional partnership, which is multi-agency, and multidisciplinary, we've developed liaison workers. Those liaison workers are providing a really good function because there is somewhere for the school counselling service, for example, to refer a child for a view, rather than just immediately going to a GP referral, which can frequently end up in a very specialist referral into the CAMHS service. So, that system there is looking at what, often, emotional support is needed for the child and the school—the education system as well.

So, we have some liaison workers who are engaged in that work and other liaison workers who are engaged in training. So, they're putting more training and education in, so that school counsellors, teachers, health visitors, school nurses are upskilled again, because this is a new area for them. They went into their career for a particular reason—teaching, for example—and we are now expecting them to engage a lot in psychological assessments and support for children. So, we do need to give them almost a new pack of cards to actually draw from.

So, the liaison service is actually supporting across sectors there, so that anywhere that the child might access, there is an increased knowledge and awareness of the alternative referral routes for support, whether it's into the third sector, as some of my colleagues have described, or whether indeed it is appropriate to refer into a specialist CAMHS service. So, it's about supporting the system as a whole. And I think the Western Bay regional partnership have recognised that that is a requirement, from a multi-agency and a multiprofessional point of view, for that large area where we have quite significant challenges with some of the children, particularly around the Swansea area. 

Melanie mentioned the project in Cardiff and the Vale, the third sector one, and I know that there's a project in Gwent, Changing Minds, which the committee has visited as part of this inquiry. But that's lottery funded and that's coming to an end. Have the other health boards got a third sector partner that they can refer to for that more universal support?


In Cwm Taf, we've got good integration with the third sector. So, we've got a number of service level agreements in place with third sector supporters, not just on CAMHS, but across the adult mental health arrangements as well. We run to about £700,000 a year spent on those kind of SLAs. So, we do have a broad range of third sector support in place.

Thank you. Okay. The next questions are from Michelle.

Thank you. Good morning, everyone. Evidence given to our inquiry suggests that significant work remains to be done to ensure that health services and education services collaborate and co-operate to support children and young people with mental health and well-being issues. Do you agree with that and what barriers do you think that may be in place preventing that collaboration from taking place?

I think I've probably answered part of that question already. I think if you look at just the aggregate resourcing position, we know that we've had real challenges in recent times in terms of reaching into services that would have traditionally meant that we could protect specialist CAMHS services to a degree, and allow our educational psychology services to deliver in the way that they need to. We also know that we've concentrated a fair degree in developing school nursing models over the last couple of years and there are some promising signs about how they are developing. We know that where, on the neurodevelopmental front, we're delivering group activities into schools with good community linkages, we do tend to get a better sense that we're getting fewer referrals coming through the system, because we're building resilience and we're giving children assets that they can use to perhaps live happier lives in their communities rather than finding themselves in a place of crisis. That's work that we continue to need to scale. I think that, if we were trying to identify areas where we wanted to continue resource and build up tier 0 services, it's going to be around that kind of stuff.

Some of the things we see referred into specialist CAMHS on an increasing basis now are around self-harm and attachment, and they're really not things that we can deal with very well in a specialist CAMHS system. What those presentations do require—and indeed this is what young people tell them themselves—they want peer-group activities, they want locally supported activities, where they're engaging with community nurses and school nurses who they trust and have a relationship with. So, for us, I think it's about building those kinds of services into schools and into communities. So, if we wanted to target a place with our education colleagues, it would probably be around that kind of area. That then allows us to focus on what we can really do in terms of prudent medicine in a specialist CAMHS space.

I think, as well, we need to think about social services as well as education. We've started to look at some specialised services for looked-after children. We've got a very small resource, but that's identified that, actually, we need to be providing some more support in line with our local authorities to provide support for children on the edge of care, making sure that we're retaining and maintaining placements for young people, and so that's an arena that I think that we would really like to get engaged with. Rose can perhaps speak a little bit more authoritatively about the service that we've got. But then it's about how we make sure that we're very clear about the accountability, because you've got professionals involved in this all the way through, who have a specific accountability in line with their profession, so it's very difficult for them to hand over young people, from a safeguarding perspective, if you're accountable for that young person's care. So, we really need to be able to get over some of the information-sharing issues on a broad and more universal scale and then also to be able to really understand that accountability and how we make sure that we are case holding those young people appropriately. 

What's the relationship like generally between education services and health services where it comes to managing a specific child or young person's case, if you like? Is there a dovetail between the services that are being provided and the communication between the two services, so that everything fits together for the child or young person? What happens with that?


Shall I pick up some of that? Going back to your first question, I think there's a lot of work to be done in linking up the education sector with health around the lower level needs of the child—so, tier 0 or tier 1, whichever we want to call it, really. In Gwent, there's heavy involvement now in a multidisciplinary approach with the £1.4 million investment in a joint health, social care and education initiative around bringing together all of the professionals. We're leading that through our primary care mental health team because they are closer to the schooling groups and the cluster of schools, and they can then draw in the specialist CAMHS knowledge as and when it's required. But I think the majority of cases that they will tend to deal with or tend to work through in a joined-up way will be around the coping mechanisms and emotional intelligence and all of those well-being issues.

We're also working with a cluster of schools in Newport, which is a completely separate project, around bringing the professionals together, because I think one of the things that we've seen through the implementation of the integrated assessment programme is the lack of a dovetail, if you like, around getting that very clear referral and clear understanding of the child's need, which I think has moved forward massively in the last 12 months, but I think there's still a long way to go in really driving that ownership across all of the public sector bodies to make sure that everybody understands what the child needs, and secondly what the treatment plan or what the next steps in the care are. That's where we've got to go next. We've established a process of integrated assessment, and now how do we deliver integrated treatment plans that really are tailored to the individual child's needs? That's the next challenge for us.

I think some of the challenges are the number of schools, the engagement of different schools. In Cardiff, what we've been trying to look at—and Melanie mentioned it earlier around Families First and working with Families First—is to try to move towards a school cluster model that effectively is putting an identified named worker in each school cluster, which I think is similar to what you're describing, in order that you can have an early conversation and avoid the, 'Must have a referral. Must go to the GP.' So, it's the same principle really and, I think, if there's an area for development, that is without a doubt where we need to go to make that system work and support young people where they need to be, really, rather than getting a referral into a clinic appointment or whatever. It's about supporting them where they need the support—in their communities. 

I'd agree with that. I think what we're all looking at—this next phase, if you like—is developing that seamlessness, because the children and the young people, and their parents as well, need to have a very clear route through. We talk about low-level children. That's the area we do need to get into, because actually that's the preventative area. We do want to develop that area with our school colleagues, with local authorities as well. That's where we can make the biggest impact for the future, because we do want to be looking at—. Clearly, we had major issues in terms of the waiting times for some very complex children and young people with mental health issues, and, as we've been able to progress in that arena there, we're all very focused now on the preventative agenda, because what we want to do is to prevent more children and young people ever getting to a stage where they need that complex service. But we have to develop the seamlessness between all the agencies, and certainly between education and health. It's absolutely key. I think the bridge provided there is with the school nursing service, and it's how we support them, because, again, they need a constantly increasing level of knowledge and development themselves to be able to respond to what is a changing picture. We've done a lot of work around the mental health aspects and the mental well-being. We know that we've got emerging and challenging issues now, around emotional well-being and also behavioural aspects. And if we can help to support children to have a greater level of self-esteem and more confidence themselves, they move forward as young people, then, in a more confident way, and we avert some of those risks around a developing mental health condition, which can actually then follow them through life.


Just a final point on this one, one of the things that the clinical directors have been working on on a national level is the development of specialist CAMHS referral criteria. I think when people usually hear about referral criteria, then they expect that hard gatekeeping follows with that sometimes, and, actually, having seen some of the detail that the clinical directors have been developing and then how that's translating into local working, it's much less a signposting kind of model and much more an enhanced referral kind of model. So, what those referral criteria are trying to do is to make sure that there is good shared understanding across the professional system about the range of services that has now been developed. So, we do have an integrated autism service that is now developing at pace in each of the health boards. We have neurodevelopmental services that are at a scale that we haven't had previously. We've got psychological therapies investment that's gone into our specialist CAMHS service. Our teams need to be very aware of each other when they're dealing with complex patients that are coming to us for referral, so I think that's a good intervention and one that should help with us connecting not just within the health system, but connecting out into the wider public service system as well.

Just before we move on, then, and I bring Mark in, you referred to the referral criteria that are being developed by the clinical directors, but we heard earlier that the GPs haven't had any involvement in that, which does raise questions as to how much of a whole-system approach that is. Have you got any comment on that?

I think, probably, just to say that I think that is a responsibility not just at national level, but at the local level as well. So, I'm pretty sure, in terms of the implementation that's now happening—because it's not complete work—that GPs are being involved. I know for certain that, in Cwm Taf, our GPs have been involved in those conversations, that they've been involved in framing the forms that we're going to use to express those criteria, and, indeed, it's been through our local medical committee. So, we have had oversight from the GP body, officially and formally, if you like. I think that pattern is being followed in other places. So, it might just be a phasing issue, in that it's still work that's ongoing, but of course we'll take that feedback back as well and think about how we make sure that there's a national line on it.

You raised, I think, in the written evidence from Cwm Taf to us, about the national referral criteria to specialist CAMHS and how those were being developed. Is that what you've been talking about just now, with reference to your clinical director? To what degree is this something you're driving in Cwm Taf, or to what extent is it a national initiative, and how are those two knitted together? 

It's a national initiative. So, our clinical directors across Wales with responsibility for specialist CAMHS have been meeting collectively. I think it's quite a self-aware kind of project, in that they realise that we'd had some issues with referral generally and that we needed to be driving more multidisciplinary team working off the back of referrals. So, they've had a proper, I think, professional reflection that has led to that national debate and, now, a national piece of work. The bit that we're in the middle of at the moment is then translating that guidance into local adoption. So, the kind of pattern we would then go through is that we would go into our local medical committee, and we go into our specialist CAMHS senior management team meetings, and we promulgate. And there will be probably some differences from health board to health board about exactly how those referral criteria are applied, but there will be a common core.

Yes. I mean, the GPs we've just had from the royal college of GPs didn't seem to be aware of this initiative from that perspective, and you've referred to knitting in the LMC into that. I sort of understood the LMC had more of a shop-steward-type trade union role for GPs. Is that the appropriate body to be dealing with, rather than the RCGP, in developing this pathway?


Well, it sounds like we've got more work to do with the college, so we'll have to take that in hand. I think that, certainly for introduction of new referral criteria, the LMC is absolutely the right place to go for that conversation, and it is a conversation that probably usually takes a couple of iterations to get absolutely right. But then, of course, you don't stop in the formal environment because what we all have now across all of our health boards are established clusters with often cluster leads in place, locality clinical directors who are resourced from within core health budgets but who are representing the GP voice in the organisation, working on integrated pathways. So, it's the follow-on work that goes through those kinds of individuals and out into the wider body of our GPs, where we'll be concentrating not just on the mechanism but the culture that we need to have in place to do this work properly.

And how much difference would you expect to see—and I don't know whether others want to contribute as well—across different health boards in terms of what the referral process is and, for instance, what the acceptance rate may be for referrals to CAMHS? Would we expect that to be consistent across Wales or different depending on the health board approach?

So, I would expect the criteria to be the same. Some of how you get into it—the technical mechanisms for making the referral or whether you've got a single point of access, how you take those referrals in—might vary. What is then appropriate for specialist CAMHS, as for the referral criteria, I would expect that to be the same because that's been developed nationally by the clinical directors.

Just to come back on it, if you look at the overall referral figures at the moment—. So, I can speak for the operational element that I cover for ABMU, Cardiff and Vale and Cwm Taf. Current referral rates or acceptance rates are 59 per cent for ABMU, 59 per cent for Cardiff and Vale, 79 per cent for Cwm Taf. Now, I think the referral criteria might bring those numbers down to a degree, but actually I think what it will improve is a more structured referral on to other services. So, bearing in mind that we've got new services developing and growing, like neurodevelopmental services, like the integrated autism service, forensic elements, psychological therapies and so on, I'd want us to be referring on to those in a very structured way. And if you spoke to the clinical directors, what they would say is that they would anticipate doing much more multidisciplinary team working across those services as a result of a more structured referral pathway. 

So, for example, I've got the December figures for Cardiff and Vale. The December figures were 62 per cent acceptance rate into specialist CAMHS. However, most of those young people were referred into other services, so either primary mental health or the emotional well-being service, through a multidisciplinary meeting to determine the most appropriate place for that young person. It was only 13 per cent that there wasn't actually a service for, and that's about some of the gaps that we talked about earlier and some of the behavioural aspects et cetera that don't fall into the mental health and emotional well-being services that we currently provide.

Melanie, you're Cardiff and Vale, and, John, you're employed by Cwm Taf but you are also, I think, able to speak to some degree for Cardiff and Vale and ABMU just now. Can you just clarify how you're working across health boards in that way?

So, Cwm Taf is operationally responsible for Cardiff and Vale, Cwm Taf and ABMU specialist CAMHS and also for the tier 4 service that's run out of Tŷ Llidiard. So, you have either side of me my commissioners for the operational service. So, actually what you've just heard from us is good consistency. So, the aggregate data from the last year is 59 per cent for the accepted referral. So, we've got a monthly variation a little bit up to 62 per cent in the data that Mel's given you.

We had written evidence from Powys in reference to referral rates continuing to rise and this causing various issues or problems for them. Is that something that's consistent? Can we just clarify what the current state of demand is and whether we're still in a situation of significantly and continually rising referral rates?

It's probably not at the volumes over the last two years that it has been over previous years. I'll give you the data straight off the bat. So, ABMU accepted 1,541 referrals over the last year, from 2,612 presentations. That's a 9 per cent volume increase for ABMU. So, that's significant. Cardiff and Vale accepted 1,200 of 2,034, and that was a 1 per cent increase in overall aggregate demand. For Cwm Taf—interesting figures for us. So, we had 1,723 referred in. We accepted 79 per cent, 1,361, but that's 9 per cent down on the previous year.

I think the story within that, if you were to look at what types of patients are presenting, it's undoubted that there's a level of acuity and complexity that's increasing. We tend to see that surfacing through, actually, the tier 4 service, where we are seeing, I think, more demand for complex placements that require maybe an in-patient stay, certainly some kind of quite significant multidisciplinary team working between local authorities, health boards and the specialist CAMHS service thereafter. So, whilst numbers overall, you could say, look fairly static, if you blend them across the overall position there's a lot of challenge within that. Nick, I don't know whether you just want to reflect on your numbers at all.


Yes, we're seeing a similar pattern where, in overall terms, the numbers are slightly rising, but I think it's the acuity of a certain number of the cases where we're seeing the biggest challenge for ourselves. So, the urgent assessment numbers are going up quite rapidly. Our acceptance of referrals overall is about the same. It's about 50 per cent, and that's been consistent now for 12 months or so. But in urgent assessments we've seen a big increase, and the number of young people then assessed in the system, again, has gone up in overall terms. But referral numbers are not massively increasing and are not causing undue concern in that way. It's the levels of intervention that are required, either at specialist CAMHS or urgent and emergency levels, and what we did, as we spoke about earlier, at that low level with patients who are not accepted by CAMHS—what treatment pathway we can then put them on—is quite key I think.

So, I think that we are seeing a steady increase in primary mental health referrals for children and young people, much more consistently than in CAMHS. We were getting, on average, between 70 and 80 a month, and it's been up over 100 for the last three months, in each month, and that can be quite peaky. So, quite a lot of that is driven by activity and media activity and things like that. So, you might see a couple of steady months, but then you might see a peak up to 120 or 130, and then it drops down. We're talking about relatively small specialist teams, so that makes that profile quite hard to manage.

Thank you. I want to move on now to waiting times. Can I appeal for witnesses to be as concise as possible in their answers, because we've got a lot to get through, please? Julie.

I wanted to ask you about the 28-day target. I just wondered: what are the challenges of meeting that 28-day target?

Shall I kick off with that one? It's been very challenging, I think. Last year, we delivered 100 per cent on the 28-day target across all three health board areas that are within the network that Cwm Taf serves, but we drove a lot of medical activity. So, we had huge numbers of medical follow-ups coming into the next year, and I think I would accept that, as the lead for the service, I probably drove the performance management too hard in a system that wasn't yet mature enough to really deliver that performance level sustainably. So, what we've done this year—and this was always part of the plan—is we've introduced a choice and partnership approach, which is a completely different model of delivering CAMHS services. It's therapeutically led. It generally means that the first appointment has a wraparound with different types of clinicians in the room, not just a consultant lead, and it will be with the family. The conversation, really, there is about the appropriateness of the specialist CAMHS to deliver the outcome that the patient wants. So, it's very much a patient-directed approach to the service. 

So, we've implemented that now, from the beginning of last year, in Cwm Taf, and then, from mid year, in Cardiff and Vale and ABMU. What that has done is start to change the case load that we're holding quite significantly, because it just doesn't fall, therefore, onto the shoulders of the medics; it's a blended approach that is getting different inputs from the professions. We've brought about 50 different types of professionals into the system over the last two years, with the new funding available, which allows us to do the family therapy kind of work.


I suppose I'm surprised that it's only now that that's been brought in, because it seemed such an obvious thing to do that it's surprising to me that that hasn't been done earlier.

I think that's a fair challenge. But I think if you look at the pattern of mental health service delivery across all domains over the last 10 years, there's been a general movement away from medicalised models towards something that is more blended and therapeutic, less dependent upon pharmacological intervention, and I think CAPA has developed within the body of both the medical and nursing bodies within CAMHS and is now seen as the standard. And we're implementing that as quickly as we can. It runs in four quarterly cycles, so you adjust the job plans of your teams on a quarterly cycle, according to the need of the patients.

As it stands at the moment, as I said earlier, we've got about 600 patients on our waiting list, 300 of those patients are over 28 days across the three areas of the network, but we're confident that we're tracking in to deliver the 80 per cent target at the year end. We might have a couple of challenging areas in that, but the important thing about achieving CAPA is it allows you to balance your system, rather than having a large number of medical follow-ups in the system. So, we feel that, having achieved 100 per cent last year, we'll achieve 80 per cent this year without then finding ourselves with a very difficult follow-up challenge in the new year. So, we hope that we'll stabilise our performance at around the 80 per cent target. 

If you were to look at Nick's model—and Nick can speak for himself, of course—I think we see a model of sustained CAPA actually helping the target to be delivered on an ongoing basis. So, those, I think, are my reflections on performance.

We introduced the CAPA model 18-plus months ago. We had 639 patients at that point who were outside of what would've been the waiting list target, and it took us probably 12 months in order to see and put those patients on a treatment plan. As a result, we've now achieved the 80 per cent standard for the 28 days for probably the last nine out of the last 12 months, and I think the December figure, which I'm not sure has been fully reported yet, is that 88 per cent of patients are seen within 28 days. So, we are confident, now, that we've got a sustainable system, based on the CAPA model, which will continue to deliver the national target of 80 per cent of patients being seen within 28 days.

I think we had the challenge early on and we've invested a lot of time and effort in managing that waiting list and putting in additional resource. We used quite a lot of the additional resources that came into CAMHS to recruit and resource additional staff, so that we could get ourselves on an even keel in terms of the delivery of that. So, yes, it was challenging, but I think we're now consistently delivering a service in a timely way for children and young people across Gwent.

And how confident are you about the accuracy of the statistics for the CAMHS waiting times?

I'm extremely confident of mine, and we manage our patients on an individual basis, and that is reflected in an assessment that is done on a monthly basis, looking at all of those patients, not only on the four-week waiting list, but also on the 26-week waiting list for neurodevelopmental, so we know exactly where they are in the pathway and how many weeks they've waited. There are no hidden backlogs or waiting lists. We're absolutely confident. My briefing for today from my team in AB—literally, I know every patient's time of wait, and that is managed on a weekly basis by the team in the health board.

Because there has been some concern, as you know, about the accuracy of the statistics.

There has been—absolutely. I think we saw, probably two years ago or slightly less, patients waiting over two years to get into the system, and they were becoming hidden in the system. I think we're clear now what we've got. We measure our primary care mental health target, both in young people as well as adults, because, given the volume of adults, the waiting list for children can become hidden. We recognised that about six or eight months ago, and put a piece of work in where we looked—I think it was in Caerphilly, we had 230 children in the primary care service who hadn't been seen in four weeks. They have all now been seen; there's a plan for all of them. So, I think there have been some concerns, but I'm absolutely confident, over the last six to eight months, that these are accurate figures and they accurately reflect the issues. There will always be the odd child or young person who waits longer than that. That may be because of certain individual difficulties, it may be their ability to access an appointment. So, you will always get some outside, but I am confident that we know who they are and that their care is being managed.


Nick's trumped me now, because I was going to say 'very confident' and he said 'extremely', but I'm very confident. Over the last couple of years, we've all heard the feedback that we had to be sharper around this. The Cwm Taf system that serves ABMU and Cardiff and Vale, as well as Cwm Taf, has migrated onto the Myrddin system over the last 18 months. We are now able to pull click data on a daily basis that shows every single appointment booked, every single patient, the profiles for the rest of the year, their waiting list challenge and so on and so forth. We've also had a number of audit activities to make sure that that migration has been done properly. So, I think we can say very confidently that our data's good.

I'd just pick up on the same point that Nick was making: because our system is a little bit less mature, we're working through the primary care element of our work at the moment, but we have, if you like, exposed those lists, despite the fact that they haven't been driven by a national target, and we've got waiting list initiative activities ongoing in ABMU, Cardiff and Vale and Cwm Taf at the moment to make sure that we've dealt with that underlying issue, if you like, that could, down the line, have an impact on our specialist CAMHS service. So, we feel it's very transparent and the data is well collected.

I think from the ABMU perspective, we obviously receive information that provides reports that break things down very carefully for us into individual areas and treatment areas. But what we also do is we triangulate that information ourselves, because we know that we have areas where we have hotter spots for children accessing services, and in other areas we have perhaps lower numbers of children who are trying to access services. So, as a commissioned service, we received the information from Cwm Taf, but we also triangulate information from our own intelligence within the health board. For example, last week, our quality and safety committee at the health board was receiving a report on the CAMHS services that are provided for ABMU. So, I would say it's very high on all our agendas, so that we are confident that we are managing the children in the most appropriate way, and that, similarly, we are developing the services to meet a changing need, a changing demand, because one of the things we haven't talked about is some of the issues that result in children having emotional concerns, and they can be around things like social media. There are so many aspects now that impact on their health and well-being, and it's how we respond early enough to actually address those needs.

I'm going to go now to out-of-hours and crisis support. Llyr.

Thank you, Chair. I'm just wondering whether you can confirm that there is now a 24-hour, seven-day-a-week crisis CAMHS service in each of your health board areas.

I think we can say that, actually, we haven't got that service at the moment. So, services, in general terms, are five days, 9 a.m. to 9.30 p.m., and that gives us a degree of coverage. We have been looking at wider coverage models, so we already have an on-call rota that works out of hours, and that's a two-level on-call, with clinical support, so it is there to be called upon. We've been looking at a seven-day model in ABMU, and we have run that through a degree of time. It's been difficult to resource, frankly, in terms of workforce availability, so we're just having a bit of a stock take on that at the moment. But we are thinking about how we might build a business case that would take us to a seven-day service. But we were just reflecting on this earlier, actually, that it's about having an appropriate service for the level of demand that is in the system. So, we as executives would always know if there's a crisis moment over the course of a weekend, and whether there are emergency services that need to be pulled in to support a patient. Those events are not regular. We do find that the service coverage that we have at the moment does mean that, most of the time, we're able to do what we need to do through our crisis service, or through the community intervention teams that have been a feature of our work over the last couple of years as well. So, I think it's an issue we're alive to, and we do need to think about what's the next business case for developing the service further. 


So, how far away, do you think, is that, potentially, in terms of realising that aspiration, depending on the business case being accepted and everything? You know, you're thinking about it. Are you—? How far away are you from presenting something?

I think we work very strongly in integrated medium-term planning cycles now, so there is a strong annual cycle for us. I don't think we will catch this round of IMTP for putting a major business case forward for changing our crisis services. Remembering that these are quite new services, we're still learning about them, we're still developing them, and we've got a bit of notable practice that we've just been trying out, I think it would be a business case for the next IMTP cycle. So, earliest introduction would be 2019-20.

Okay. So, you recognise therefore—because we've had evidence from people saying that they are concerned about the availability of out-of-hours services, with children inappropriately ending up on adult wards or paediatrics, and other issues around being discharged without follow-up support, and lack of in-patient beds for emergencies. These are all things that you recognise, but you're doing what you can to manage that.

I wouldn't minimise the issue. Certainly, I can think of several occasions over the last two years where we've been called upon as executives to be involved in significant multidisciplinary team discussions to properly place a patient. But actually I'm not sure that the crisis service was the service that was most important in terms of placing those patients. There might be an immediate response that's required, and in general terms we're able to deliver an immediate response. It's what happens, I think, the next day and the following couple of weeks when you're trying to stabilise a patient with multidisciplinary team working. What you're usually looking for in those kinds of cases is some type of placement where you've got a safe and secure environment, whether that's Tŷ Llidiard or a local authority care placement of some kind, and then you're looking for peripatetic services, often the community intensive treatment team, to go out and support that individual in an appropriate way.

So, I think our services now have to be quite flexible to wrap around those individuals. I can think of four incidents over the last two years where we've had to do really intensive work around individuals as a result of an initial crisis presentation that's been out of hours. There'll be ongoing work all the time, but I do feel that we've got to be very proportionate, learn from the pilot activity that we've been doing and make sure that, if we're bidding for serious new moneys to come into CAMHS, we're judicious about that.

Thank you. Hefin. Brief questions, please, and brief answers.

Okay. Some of the evidence we've received has said that local primary mental health support services are still quite adult-oriented, and staff sometimes don't have the skills to undertake age-appropriate assessments. Do you think that's the case, and what would you do to address that?

Can I just speak from a Cardiff and Vale point of view? Our local primary mental health service for under-18s is entirely resourced through a children's—it's actually sat within a children's directorate, and all those workers have come through a children's route. So, I know there are differences across the area, but, for us, it's very much a children-focused under-18 service.

I think, as I expressed earlier, we've invested quite a lot of moneys into the local primary health service for children and young people. We invested £156,000 of the CAMHS moneys into that service in the last 12 months and have increased our number of clinicians from six to 11, who are CAMHS-based, into the local primary care mental health service. So, I think there was a recognition that, yes, your point was probably correct, it was adult-orientated. In recognising that, we've sought to use the additional moneys and resource that we've had to put additional services in for children that were specific for children, rather than multi-disciplinary.  


That's been done over the last six to eight months. 

And, similarly, in ABMU, I spoke earlier about the Western Bay regional approach, and they have a target, obviously, around the CAMHS services now and how we do ensure that it is child-focused, and that the practitioners who are working within the service have the appropriate skills and expertise to actually address the needs of the child.

And how are you ensuring that there is the rapid and early intervention that was intended under the Mental Health (Wales) Measure 2010? 

I think, in terms of the Measure, we all track our performance on the mental health Measure on a very regular basis. It has board scrutiny, so we will lay out all the performance domains of the mental health Measure every month in our executive boards, and at health board level. And, in that, we'll break down the various elements of the mental health Measure that show part 1 assessment, part 1 treatment and part 2 care treatment planning. And then, underneath that, we'll show the CAMHS performance, which is a contributory element of the mental health Measure's overall achievement. So, we are completely transparent and visible about our performance on that front. 

And then, for the primary care element, or the local primary mental health support services element, I think we've all acknowledged that we've had challenges around that performance over recent years, and that we've had to put catch-up activities in—waiting list initiatives, that sort of thing—very recently to get our performance to where it needs to be. Obviously, everyone is in a slightly different position on that front. But I think there's a recognition that we need to continue working at that. The conversations we were having earlier about more investment into tier 0, tier 1, is absolutely the place that we need to focus on as we go forward into the next cycle, and I'd put that ahead of other investments that we'd need to look out for CAMHS.    

So, I think, from Cwm Taf, that just 8 per cent of the overall mental health budget was going into CAMHS. I wonder: do we have any equivalent figures for other health boards represented here?

Our CAMHS spend is £4.1 million, which is up £1 million on the previous year, and if you compare that as a—. Because it's run separately from our mental health service, it would represent around 8 per cent to 8.5 per cent of the core service mental health budget. 

So, we spend in total about £6.4 million on the broadest definition of CAMHS, including emotional well-being, et cetera, and the highly specialised services, and it's around 7.6 per cent of our overall mental health budget. 

And in ABMU we spend about £4.5 million—just over £4.5 million—and that's about 6.2 per cent of the mental health budget. 

I think it's just worth adding that I think we're grateful for the investment that has come into the CAMHS service over the last three years. It has in some terms taken us from a place where we've been regarded, I think, as a cinderella service to something that now is approaching levels of resourcing that are allowing us to get into the other services that we need to put in place to protect specialist CAMHS and make sure it does what only it can do. If you look at the overall Welsh data, it's £45 million going into CAMHS against £310 million for adult mental health. The network with the Cwm Taf service has gone from about £9 million up to now about £12 million, so that's been a significant improvement for us. So, I think it's just worth stating that we've had good support over the last three years to build the base. 

But that £45 million out of £355 million—we're looking at 12.5 per cent, 13 per cent there, which is an awful lot higher than the figures that we've been given for each health board, and the other figures we've got from elsewhere are in the same range. So, I wonder whether John or anyone else might take a lead on this, but could you perhaps assist us in getting consistent local health board numbers that compare to that Wales-wide number—12.5 per cent, 13 per cent—that is a lot higher than what we're being quoted for the individual health boards. Why is that? 

I'd be happy to write to you with a reconciliation on that. 


Thank you. Final questions from Julie then, please.

Yes. Thank you very much, Chair. I wanted to ask about in-patient provision. And, first of all, how many young people do you have to place out of area?

A fair question. At the moment, it's relatively small numbers compared to where we have been in the past. So, we'd be on an average of three or four out-of-area placements per month. In the past, that would have been in double figures, but since we've had the investment in Tŷ Llidiard, which is the 15-bed in-patient unit—

—and it also has the five intensive beds as well—we've seen out-of-area placements come down very significantly, and I think we could give a very strong picture that those out-of-area placements that we now do make are not about bed capacity. They're almost exclusively for reasons of secure environments or appropriate care being delivered. 

But shortage of particular type of beds that we don't have here. 

It's about secure environment provision, often for highly complex patients that we're just not able to serve within that environment appropriately. 

We've had four out-of-area placements over the last 12 months for similar reasons to what John has described. I think one of the things that we've implemented as part of our emergency response team is to have a designated CAMHS bed based at our Ysbyty Ystrad Fawr unit as a holding option, so, if there is a patient that needs a particular placement, usually to Bridgend, then, rather than send them out of area, we will hold them in this designated bed until an appropriate bed becomes available, and we've seen that reduce the number of out-of-area placements on the back of that. 

So, these figures of three or four, what was it before? What was the average before?

Before, we were in double figures on a monthly basis, before the unit came into being. There's a demand pattern that runs through the year, so, over the last three years, it's a very clear pattern that we're underutilised from April through to September, and then, from September through to the end of the year, we'll tend to have high levels of utilisation. And, so, for that reason, there have been questions previously about did we need to utilise the beds in a different way during the first half of the year, maybe look at different types of provision around eating disorders, or whatever else. That's normalised a little bit this year. We thought, over the first couple of years, it was that the CIT teams were beginning to be very successful at driving discharge and getting peripatetic support in the communities, so that was taking pressure off the system, and therefore freeing beds within the in-patient environment. As I say, the last six months, we've seen quite a consistent pattern of being usually about 13 beds—we usually have a couple available—but utilisation feels more balanced now, and maybe, again, this is about maturity of the system, the CIT teams, and the in-patient facility coming into balance. But, certainly, we aren't having classic bedblocking kind of problems on a regular basis. That would be a very rare event for us. 

Yes, I was going to ask you about the effect of the CIT teams on in-patient provision. So, you have definitely seen an effect.

We've seen occupancy drop quite considerably across the bed base, and, therefore, that allows us to have that flexibility of use. I don't think there's particular bedblocking now in the system on the back of the introduction of those sorts of services. 

Thank you very much. Well, we've come to the end of our time. Can I thank you all very much for attending? We will write to you with some questions that we weren't able to cover, if that's okay, and you will be sent a transcript to check for accuracy in due course. Thank you very much. The committee will now break until 11:10. Back promptly, please.

Gohiriwyd y cyfarfod rhwng 11:04 ac 11:12.

The meeting adjourned between 11:04 and 11:12.

4. Ymchwiliad i Iechyd Emosiynol ac Iechyd Meddwl Plant a Phobl Ifanc - Sesiwn dystiolaeth 19
4. Inquiry into the Emotional and Mental Health of Children and Young People - Evidence session 19

Welcome back everyone to our next evidence session. I'm very pleased to welcome our panel, in particular Warren Lloyd, who is consultant psychiatrist and associate medical director and clinical director for mental health at Hywel Dda; Liz Carroll, who is director of mental health and learning disabilities at Hywel Dda; Peter Gore-Rees, who is a consultant child and adolescent psychiatrist and clinical director for CAMHS at Betsi Cadwaladr; Alberto Salmoiraghi, who is a consultant psychiatrist and medical director at Betsi Cadwaladr; and Rhiannon Jones, who is the interim director for community and mental health services at Powys teaching board. So, thank you very much, all of you, for attending. If you're happy, we'll go straight into questions—we've got a lot of ground to cover. I've got Llyr first.

Thank you, Chair. Bore da. I'm just wondering if you could tell us what the main changes are from Together for Children and Young People since it was started about three years ago, and where you think the main challenges still remain.