National Assembly for Wales

Children, Young People and Education Committee

 

CAM 29

 

Inquiry into Child and Adolescent Mental Health Services (CAMHS)

Evidence from : Children’s Commissioner for Wales

 

1.      The availability of early intervention services for children and adolescents with mental health problems

Mental health and mental illness can profoundly impact on the ability of children and young people to reach their full potential and may, as a consequence, result in the lack of enjoyment of their rights, as set out within the UNCRC.

 

Early intervention can be the key to the prevention of more serious mental health issues developing in children and adolescents reducing long term costs and improving individual life chances.  The Mental (Health) Wales Measure provided for the establishment of local primary mental health support services by local authorities and local health boards operating either within or alongside GP practices across Wales.  However, anecdotal evidence from key CAMHS stakeholders suggests that the Measure does not allow for the most appropriate application for children and young people.  The service model currently available to service planners only allows for referrals via GPs and therefore does not reflect the fact these professionals are often not the first point of contact for children and young people.  As a result we are aware that in one LHB area, services have been redesigned to ensure that children, young people, and their families are seen as early as possible by practitioners with appropriate skills within primary care.  This in turn ensures sufficient regard for children and young people within their structure of service provision. 

 

It should not be forgotten that many other services contribute to promoting mental health and emotional wellbeing including education, social services, youth work, play and recreation, community development, transport, environment, housing, and youth justice.  I am concerned that the scale and breadth of the cuts to local authority budgets is having and will continue to have a significant impact on the very preventative services that could provide the support and early intervention to children and young people that could help prevent their descent into more serious illness.

 

Cuts are likely to impact significantly upon those families and groups of children who are most vulnerable and at greatest risk of developing mental health problems; those living in poverty, those who are eligible for social care and support, and those living in rural areas.  The costs of travel and access to scarce services will impact particularly those who are living in poverty and

 

 

rural areas.  I am also concerned that children and young people are likely to have less access to the Tier 1 advice and support that can be provided by non CAMHS professionals.

In order to better understand the impact of the cuts that are being made I will be writing to all local authorities asking them how they are making decisions in relation to cuts to budgets and whether they are completing child`s rights as well as equality impact assessments to inform the decisions they are making.

 

School based counselling – I welcomed the School Standards and Organisation (Wales) Act 2013 that placed school based counselling on a statutory basis.  Providing counselling services in respect of health, emotional and social needs to secondary school pupils between 11-19 years and for pupils in their final year of primary school, is an important early intervention service. Early indications are that participation in counselling was associated with large reductions in psychological distress; with levels of improvement that, on average, were somewhat greater than those found in previous evaluations of UK school-based counselling. Significant numbers of young people have accessed those services throughout Wales. However, I have been made aware through individuals who have contacted my advice and support team that the implementation of school based counselling in some schools can dissuade some individuals from accessing the service e.g. being taken out of lessons for counselling sessions which identifies the individual concerned as someone who is accessing what is supposed to be a confidential service.  It is important to design services that will meet the needs of those who will benefit from accessing them and to involve children and young people in the design, feedback and evaluation of services.  

 

2.      Access to community specialist CAMHS at tier 2 and above for children and adolescents with mental health problems, including access to psychological therapies

Issues in relation to CAMHS have consistently been raised with my office through our Advice and Support team.  We have assessed the contact made from children, young people, parents/carers and professionals (amongst others) and as a result, we have distinguished many continued barriers children and young people face across Wales in accessing CAMHS services. 

The most consistent concerns relate to access issues; waiting times and delays in the assessment process; high thresholds and availability of provision, and access to information on provision.  This list is not exhaustive but reflects the issues that are most prominent amongst those making contact with the team.

Cases received by our Advice and Support team between April 2012 and January 2014 in relation to CAMHS have reflected the experiences of children and young people where referral processes have been unclear and thresholds have been high affecting access to services; the quality of provision has been questioned; and a lack of joined-up approach between CAMHS, education and social services has impacted on the ability of children and young people to access their rights.

 

We have identified that there is particular cause for concern in relation to three major areas of mental health provision.  These are detailed separately below and include a brief summary of the emerging concerns.

·         Access to psychological therapies

Children and young people accessing a medically driven service model where access to psychological therapies, including the provision of counselling, has not necessarily been made available to them in conjunction with the prescription of medication.  Access to psychological therapy should be made available to children and young people at the earliest point of need, and service provision should not reflect a crisis management approach whereby the individual must meet a high threshold in order to gain the necessary support they need.

·         Autistic Spectrum Disorder

Children and young people being caught up in unclear assessment protocols and availability of ASD treatment and support.  CAMHS contribution to the assessment and treatment processes are unclear and children and young people are experiencing lengthy waiting times as a result of demand upon services and unclear referral pathways.

·         CAMHS provision in youth justice settings

Young people in contact with the youth justice system continue to experience barriers to accessing CAMHS provision as a result of often unclear and complex commissioning arrangements; lack of joined up services; and an understanding of information sharing expectations and integrated assessment processes. Concerns exist with regard to CAMHS both in the secure estate and in the community.  There is a lack of consistency across Wales which impacts negatively on the opportunities for young people in contact with the youth justice system to enjoy the same rights to support for their emotional wellbeing and mental health as other young people.

Mental and emotional wellbeing are significant factors in the lives of children and young people and it is their right to access timely interventions to ensure that their mental health and wellbeing can be secured and problems do not deteriorate.  The planning and provision of support for the emotional and mental wellbeing of children and young people must be driven by the needs of those children and not led by the demands of systems and services.

 

3.      The extent to which CAMHS are embedded within broader health and social care services

CAMHS services do not always appear to be operating effectively within broader health and social care services although this can vary across local health boards and local authorities.

I await with interest to see how the work of the new National Health Partnership Board impacts upon the implementation of the “Together for Mental Health and Wellbeing in Wales” delivery plan. It is encouraging that the Board, led by Welsh Government brings together representatives from the statutory, third and independent sectors, service users and carers.  It is important that the Board does not become just another talking shop and that the board is effective at holding to account local health boards and local authorities via performance management arrangements and that this leads to better outcomes for children and young people.

Together for Mental Health also aims to ensure that multi agency partnership arrangements are established on LHB footprints.  The arrangements were to be in place by January 2013 and an annual report was to be produced and sent to the National Partnership board by January 2014.  We are aware that local mental health partnership arrangements are in place in all LHB areas and that Welsh Government requested sight of each annual report in October 2013.  It is important that these reports are effectively scrutinised to ensure that outcomes for children and young people with mental health problems improve and the reports are able to effectively identify best practice and issues requiring further attention.

 

CAMHS will only become fully embedded if national outcomes across health, social services and other key partners are aligned.  As I stated in my response to the Social Services (Wales) Bill the usefulness of a national outcomes and standards framework as a means of securing implementation and holding services to account should be informed by the lessons learnt through the process for delivery of the NSF for Children Young People and Maternity Services. The fact that duties to scrutinise delivery on the standards was left to those responsible for the delivery has arguably had an impact in relation to weak implementation of NSF standards. Frameworks should not only be aligned but able to demonstrate quality assurance; reflect the lived experiences of service users; and are not only a quantitative data exercise.

 

I welcome the fact that the Minister for Health and Social Services is considering work to scope a specific NHS Delivery Plan for Children and Young People to complement the suite of health service delivery plans that have been developed over the last 18 months. It is important that CAMHS are an integral part of this work.

 

4.      Whether CAMHS is given sufficient priority within broader mental health and social care services, including the allocation of resources to CAMHS

I am concerned about the level of funding for CAMHS in Wales.  Whilst I have received anecdotal evidence of the impact of insufficient funding on the availability and quality of CAMHS services for children and young people, statistics produced by Welsh Government evidence the concern further.  From a comparison of NHS expenditure programme budgets over the two financial years (2010-11 and 2011-12) we understand that Welsh government report that “the largest single programme budget category was spending on mental health problems which amounted to 11.9 per cent of the total”.  Whilst this is a key point made in both publications, upon further analysis of the breakdown of expenditure, both documents conclude that the percentage share of the total expenditure on mental health problems for CAMHS until 2011-12 (which is stated as 1% ) has consistently remained at 0.8% since 2006- 2007.

 

Considering that early identification and investment in prevention and protection has been recognised and prioritised by the Welsh Government we are concerned that this level of investment in CAMHS does not reflect this commitment.  CAMHS has for too long been described by many as the “Cinderella service” and will never address the needs of children and young people who have early signs of mental health problems if we do not sufficiently invest in it. 

 

There have also been delays from the local health boards in relation to making decisions about reviewing the arrangements for the three specialist CAMHS planning networks.  I am aware that a review of the networks commenced early in 2012 for the purpose of outlining proposals to restructure the way in which CAMHS in Wales was both planned and delivered.  In view of the delay in making a final decision I am currently organising an evidence exchange between lead professionals for CAMHS across Wales and myself in order to distinguish the current status of the reconfiguration proposals, identifying current levels of service delivery and assessing the impact that recent developments are having on the rights of children and young people across Wales.

 

5.      Whether there is sufficient regional variation in access to CAMHS across Wales

I recognise that in a small country that difficult decisions have to be made in respect of the allocation of resources, and the provision of specialist services and that sometimes this means that specialist services may not be available in all communities.

 

However I think that in general far more could be done to involve children and young people and their families in discussions about service provision and the development of services within their health board area.  I am concerned to ensure that the voice of the service user is

sufficiently taken into account in the planning and delivery of services within a rights based practice approach.

 

 

6.      The effectiveness of the arrangements for children and young people with mental health problems who need emergency services

The “Child and Adolescent Mental Health Services :Follow up review of safety issues” report published by Healthcare Inspectorate Wales and the Wales Audit office (December 2013) clearly indicates that there is a lack of comprehensive community services which has contributed to young people in crisis being admitted to adult mental health or paediatric wards.  My Advice and Support team have had such cases being brought to the attention of the office.  Children, young people and their parents have been frustrated by inpatient units either determining that their unit is not appropriate for the presenting need or the unit is full and there is a waiting list for admission.

 

It is not acceptable that young people are still routinely being admitted to adult mental health wards.

 

7.      The extent to which the current provision of CAMHS is promoting safeguarding , children`s rights and the engagement of children and young people

In November 2009, Healthcare Inspectorate Wales (HIW), the Wales Audit Office, Estyn, and the Care and Social Services Inspectorate (CSSIW) Inspectorate published a hard hitting joint review of CAMHS.  The November 2009 joint report identified a number of safety concerns that arose from practices largely within the NHS.  In December 2013 Healthcare Inspectorate Wales and the Wales Audit Office published “The Child and Adolescent Mental Health Services: Follow up Review of Safety issues”.  I am extremely concerned that this review concluded that

 “  ….. children and young people continue to be put at risk due to inappropriate admissions to adult mental health wards, problems with sharing information and acting upon safeguarding duties, and unsafe discharge practices”. 

 

This findings of this report suggests to me that despite the proliferation of strategies and governance arrangements and mental health partnerships and annual reports, children and young people are still being badly let down by a system that is slow to change and which is clearly not compliant with a number of articles of the UNCRC.  CAMHS needs to provide a more holistic service for children and young people and move from what appears to be a model that focuses upon assessment, diagnoses, and a clinical approach, to one that meets the needs of children and young people in an outcomes based approach.

I appreciate that change can be difficult, complex and time consuming but it is not acceptable that the very clear safeguarding concerns highlighted in 2009 are still present four years later in 2013.

 

8.      Other issues

Rights based approach to mental health services

I am concerned that the loss of a distinct and separate national strategy for children and young people and its replacement with an all age strategy “Together for Mental health:  A strategy for Mental Health and Wellbeing in Wales” could potentially dilute regard to the intentions of the UNCRC.  I welcome the fact that the strategy includes the seven core aims for children and young people in Wales under the UNCRC within its approach.  However I am still not convinced that this can provide stronger direction in relation to a rights based approach to mental health services for children and young people than would have been provided in a separate and distinct strategy.

 

Whilst it is clear that mechanisms have been in put in place to ensure that there is a focus on the age specific elements of the new strategy – a CAMHS Delivery Assurance Group (CAMHS DAG) reporting to the newly established Mental Health Partnership Board (NPB) on progress and any emerging issues, it remains to be seen whether these arrangements materially change service delivery and the experiences of children and young people with mental health problems.  Services, practice and culture must be child centred and focused.

 

 

Keith Towler

Children’s Commissioner for Wales

 

27th February 2014