National Assembly for Wales
Children, Young People and Education Committee

CAM 43

Inquiry into Child and Adolescent Mental Health Services (CAMHS)
Evidence from : Youth Justice Board Cymru

 

The Youth Justice Board (YJB) Cymru, the YJB’s division within Wales welcomes the opportunity to respond to this inquiry.  Our response provides an overview from across Wales and addresses a number of the key issues outlined in the terms of reference.  Specifically, our main focus is on the regional variation in access to CAMHS across Wales. In addition, we viewed it as important to provide contextual information with regard to the young people caught up in the youth justice system; this information is contained within the background paragraphs.  Our response is informed by the following:

·              A Mapping Exercise we undertook in partnership with Welsh Government with regard to mental health liaison and diversion services across all areas in Wales;

·              Our monitoring and oversight of youth justice services; both secure and in the community; and

·              Engagement with stakeholders involved in providing services to young people in the youth justice system.

 

1. Background

1.1. In recent years there have been significant reductions in the number of young people brought into the criminal justice system with many young people being helped through early intervention, prevention and diversion services.  This has, in turn, reduced the number of young people who become subject to court orders and those who receive a custodial sentence.  Consequently, the profile of young people in the system has changed. Those remaining have the most entrenched patterns of offending and often inter-locking complex needs. 

 

1.2. To illustrate this; in 2012, YJB Cymru undertook a profiling exercise of young people with prolific offending histories (25+ offences).  In terms of health needs, the study identified that 18% of the cohort had health conditions that were affecting their daily functioning and around two thirds had difficulty dealing with past events or current circumstances.  These findings have been mirrored by other research undertaken in Wales, notably by Nacro Cymru in 2004.[1]

 

1.3. Additionally, it is well documented that many of the young people youth offending teams (YOTs) work with, who may need a CAMHS service, fall well below the threshold for successful referral. Whilst they may not have a diagnosable disorder, such young people often display problems related to attachment, trauma and bereavement.[2] Their needs often go unmet because of lack of identification of these problems and lack of services to address them. This means that emotional, cognitive and developmental needs are not always appropriately addressed when youth justice interventions are delivered.

2. Key issues identified

Young People in contact with Youth Offending Teams

2.1. Youth Offending Teams (YOTs)[3] are multi-agency partnerships which consist of five statutory key partners;[4] they are responsible for managing young people on statutory court orders.  They are also involved in services which prevent young people entering the criminal justice system.  The ‘Together for Mental Health Strategy’[5] states that YOTs should have available to them:

·              A designated CAMHS Nurse

·              A Mental Health Advisor

 

2.2. There are currently 18 YOTs in Wales; five of these YOTs do not have access to a designated CAMHS nurse.  All of these YOTs are situated within the Cwm Taf Health Board Network.  Of particular concern is the lack of service provision in Cardiff and the Vale of Glamorgan.  We are aware that in these areas 16 and 17 year olds can no longer access CAMHS with referrals now being directed to adult services.  This differential position creates disparities, most notably in ensuring a comprehensive health assessment is undertaken, followed by the support and treatment needed. As noted above, young people in the youth justice system (YJS) often have entrenched patterns of behaviour and wide ranging, interlocking needs.  Liaison and expertise from CAMHS is necessary to enable youth justice practitioners to work effectively with young people. Benefits of these nurses being positioned within the YOT include but are not exclusive to:

·              Preventing cases escalating requiring more specialist intervention;

·              reduces the delays to and inappropriate referrals to CAMHS;

·              they contribute to risk and vulnerability assessments; and

·              they are able to co-work cases with youth justice staff. 

 

Although a Mental Health Advisor is present in most areas, this does not compensate for the absence of a dedicated nurse positioned in the YOT; mainly because these nurses are able to contribute to the day-to-day management of young people, whose circumstances can rapidly change or reach crisis point.

 

2.3. In terms of universal CAMHS provision, this is often inaccessible to young people in the YJS as it is mostly clinic-based, with long referral waiting times.  In some areas the waiting times can be up to 14 weeks for referrals concerning attention deficit hyperactivity disorder (ADHD) and other neuro-developmental disorders.  When fast-track referral processes are not in place, YOTs can be left to understand and address young people’s behaviour and needs without the input of specialist knowledge and expertise.  In addition, cases referred to CAMHS are often closed after two occurrences of non-attendance.  Most young people in the YJS come from disadvantaged backgrounds and have become dis-engaged from many services, as have their parents/carers.  Consequently, the traditional CAMHS model may not be the most effective means of engagement.  Assertive out-reach is often the only way that these young people can be effectively engaged.  However, this approach is not commonplace across Wales. This is the case at all tiers of mental health intervention.  In some areas there is a lack of acknowledgement by CAMHS of the complexity of many YOT prevention cases and what their role should be in addressing needs that fall below the specialist CAMHS threshold.

 

2.4. The general consensus across youth justice services is that CAMHS is an over-stretched resource.  Gaps in service provision consequently mean young people’s needs go unmet.  Notable gaps in provision include;

·              Addressing sexually harmful behaviour;

·              Emotional Health difficulties;

·              Psychology input and access to psychological therapies;

·              Early intervention for psychosis;

·              Forensic services; and

·              Emerging Personality Disorder.

 

2.5. There is also variation across Wales in YOT practitioner understanding of the role of CAMHS and Forensic Adolescent Consultancy and Treatment Service (FACTS) and the thresholds for referrals.  There is a general need for more consistency and better shared understanding of the inclusion and exclusion criteria for CAMH services at all tiers. YOT practitioners also need advice on where to obtain help for young people who have a single diagnosis that might exclude them from CAMHS; eg, Autistic Spectrum Disorder (ASD).

 

2.6. With regard to the FACTS, tension exists specifically in the South Wales area in relation to the unwieldy referral process in place. During the Mapping Exercise we undertook, representatives from FACTS suggested YOT CAMHS nurses should be able to refer directly to the service.  The current arrangements do not allow this; instead young people are re-assessed in CAMHS (sometimes by a Paediatric nurse) and referred into FACTS by a Consultant.  This process is viewed as unnecessary, causing duplication and further delays.

 

2.7. Areas where good practice exists include the arrangements in Powys and also within the Aneurin Bevan Health Board (ABHB).  With regard to ABHB, the main strength is the presence of Clinical Nurse Specialists in all four YOTs, and the willingness of CAMHS to provide advice and support to prevention services, YOT and multi-agency panels irrespective of the level of health need.  When properly supported and advised, prevention services and YOT are able to manage cases more appropriately.  The presence of the CAMHS nurse in the YOT also means that the need for referral and a separate referral process is obviated when specialist CAMHS input is required. 

 

2.8. The YOT in Powys receives support and consultancy from the Mental Health Adviser in ABHB.  Following a Case Learning Review, a Social Communication Assessment Team has also been established in Powys, which brings together educational psychology, CAMHS and School nurses to identify the emerging needs of young people with possible or diagnosed ASD.  This coordinated preventative approach has helped to close some of the previous gaps in provision.  Other areas of good practice include access to emotional health workers which is evident in the Hywel Dda region and where strategic health board personnel are members of YOT Management Boards.  Long-standing difficulties in accessing CAMHS in the Swansea area have been remedied through a nurse being reinstated in the YOT and the YOT having access to a new Clinical Psychiatrist.

 

2.9. With regard to meeting the emotional health needs of young people dealt with by youth justice services in Wales, there is a significant gap in provision with the one exception of the Hywel Dda region.  A high number of young people who are known to youth justice services present with difficulties relating to early childhood development; such as attachment, trauma and bereavement.  These difficulties often present alongside other needs.  The sentences young people serve are often short presenting youth justice practitioners only a short window of opportunity to engage with them and provide them with help and support to lead crime free lives.  Therefore, having access to the specialist knowledge and expertise from CAMHS and FACTS at all Tiers is vital.

 

Young People placed in secure settings in Wales

2.10. The YJB currently has contractual arrangements with two providers of secure accommodation in Wales; Parc under-18 Young Offender’s Institution (YOI) run by G4S and Hillside Secure Children’s Home (SCH) in Neath. These arrangements allow us to place up to 64 young people at Parc and as from the 1^st April, up to 10 young people at Hillside[6].  

 

2.11. While responsibility for health is devolved to the Welsh Government, for the secure estate in Wales some aspects are reserved. This leads to a complex situation with a number of anomalies around the provision of services in both establishments. This means that some areas of health delivery fall outside the Welsh Government’s jurisdiction. For example, in Parc, while primary health care is funded by the YJB and delivered through contractual arrangements by G4S, the Health Board remains responsible for the provision of secondary and tertiary services. In Hillside, the YJB covers the cost of the majority of mental health services through the contractual arrangements we have with Neath Port Talbot local authority. This presents a different picture to that in England where, by the end of this financial year the provision of all healthcare services in secure settings will be the responsibility of NHS England.

 

2.12. In Hillside SCH, to our knowledge there are no issues with regard to the provision of mental health services. The Home has at its disposal a wide range of health expertise and has on-site access to Psychology services and in-reach provided by a Consultant Psychologist. Psychology Services are integrated within the overall service provision and input informs the development of interventions and the direct work undertaken with young people. 

 

2.13. Mental health in-reach provision at Parc YOI was established following a recommendation made in a Report by the Communities and Culture Committee.[7]  The provision of the service is also a requirement set out in the ‘Together for Mental Health Strategy’[8].  Since the provision has been established it has not been free from difficulty.  This has mainly been the result of two main factors; first the complex constitutional context in which it is operating, leading to disagreements over responsibility for commissioning and delivering services; second, the absence of a comprehensive assessment of clinical need to guide and underpin delivery.

 

2.14. The YJB has worked in partnership with Welsh Government to assist G4S and the Health Board to improve service delivery. Difficulties have been experienced due to the differences in perspective between providers in relation to the services which should be in place. This, in turn, has limited progress in establishing the appropriate level and form of service provision needed to ensure the full breadth of care needs can be addressed.

 

2.15. Our concerns about the effectiveness of the service heightened in September, 2013 when we were notified that the in-reach provision had been withdrawn from Parc YOI at short notice. This resulted in the YJB having to temporarily cease placing young people at Parc until we could be assured that the establishment was able to meet young people’s mental health needs. While the Health Board has taken steps to re-configure the service provided, this is frustrated by an absence of information which describes the clinical need of the population placed there and also the ambiguity around responsibility for commissioning and delivering services. We remain concerned about the fragility of the in-reach service and believe that there is a need to establish an up to date Service Level Agreement between Cwm Taf Health Board and G4S informed by a health needs assessment. To assist in this, the YJB has recently commissioned a health needs assessment of the young people in Parc YOI, working alongside the Welsh Government and Public Health Wales. We will make the findings of this assessment available to service providers to help shape the future provision.

 

2.16. Due to there being no secure provision in North Wales, wherever possible we place young people from this region in HMP YOI Hindley, a secure setting in England where service delivery has been adjusted to take account of any distinct cultural and language needs. For Welsh young people in English institutions it is the responsibility of the NHS England to provide for their healthcare needs. We are not aware of any instances where Welsh young people have been denied access to health services or where unaddressed healthcare needs impact on their resettlement back into Wales.

 

Young people requiring Tier 4 services

2.17. For young people in the youth justice system there are currently no in-patient facilities.  Young people who require placement in semi-secure facilities or are in custody and require sectioning under the Mental Health Act have to be transferred to facilities in England.    This then presents a challenge for Welsh services to remain involved.  We are aware that in-patient facilities at Ty Lidiard, Princess of Wales Hospital excludes young people known to youth justice services because they are considered to be forensic cases and thus of too high a risk to be placed. This is certainly not the case, as the vast majority of young people in the youth justice system would fall below this risk threshold, where their mental health issues contribute to rather than define their offending behaviour. We consider closeness to home as a key factor in reducing reoffending so we would encourage young people to be kept in Wales, wherever possible.

 

3. Concluding remarks

3.1. CAMH liaison and diversion services are a vital component in youth justice management and practice.  With regard to YOTs, the most effective model is that to be found in ABHB area where there is designated access to a CAMHS nurse and a Mental Health Adviser. We believe this must be in place; if it is not young people’s needs cannot be appropriately addressed. In relation to the provision of CAMHS and FACTS in secure facilities and access to mental health in-patient facilities this needs immediate attention; except for Hillside the current arrangements are not conducive to the youth justice context.  The YJB is willing to work with the Welsh Government and with health boards across Wales to ensure that there are effective partnerships and pathways in place between youth justice and health services.  This will aid further development and dissemination of effective models of delivery, improve communication and facilitate information sharing.