Friday 3 August 2018

Lynne Neagle AM

Chair

Children, Young People and Education Committee

National Assembly for Wales

Cardiff Bay

CF99 1NA

Dear Ms Neagle,

The emotional and mental health of children and young people

I am writing with regard to the recent report on the emotional and mental health of children and young people, as well as the Welsh Government’s response.

Thank you for the opportunity to give evidence to the Committee, both orally and in writing. The subject is an extremely important one and it’s vital we get this right.

‘Mind over matter’ raised some very important issues and RCGP Wales believe it made many constructive suggestions to improve the services Wales offers its children and young people.

I noted your reaction to the Welsh Government’s response and RCGP Wales shares concerns about the rejection of certain recommendations. I am aware that you have asked the Welsh Government to reassess their approach on the other side of recess. This is a call RCGP Wales agrees with.

We are writing in the first place to express our support for the need for more action, and additionally to provide some thoughts on the report and the Welsh Government’s response.

I hope the information in this letter can support the work of the Committee. Annex 1 contains analysis of the Welsh Government’s reaction to some of the recommendations. Annex 2 contains a briefing on the Committee report.

Yours sincerely,

Dr Jane Fenton-May

Vice-Chair, Royal College of General Practitioners Wales.

Annex 1 – RCGP Wales analysis of the Welsh Government response to ‘Mind over matter’

The information below picks out the recommendations particularly affecting GPs where we have concerns about the Welsh Government’s response.

Recommendations 3, 4, 5 and 6 all focused on developing services in schools. In each case, the Welsh Government’s response was to ‘accept in principle’.

We share widespread concern about the frequent use of ‘accept in principle’ as a response to recommendations. It is common across different inquiries and government departments. It risks obscuring the issue and discouraging engagement.

The Welsh Government’s rationale for accepting recommendations in principle was often because it believes that work is already in place. We have some concerns about this approach; if the current approach was working then the report would not have made the concerning findings it did. The Committee’s report expressed serious doubts about the current state of affairs, which was informed by expertise from across the sector. If the Welsh Government is unwilling to accept recommendations it should at least do more to outline how it will improve current services. This is particularly true for recommendations 3, 4, 5 and 6 and also has wider relevance.

In its response to recommendation 3, the Welsh Government seems unwilling to recommend a national approach. In response to recommendation 4, it says it is unable to endorse a specific programme. In ‘A Healthier Wales’ the Welsh Government talks about the need for stronger national leadership, and providing stronger direction to decision making. This was in response to the Parliamentary Review of Health and Social Care highlighting the OECD’s call for a ‘stronger central guiding hand’ to play a more prescriptive role. We believe these principles should still apply, a cross-departmental approach cannot lead to inconsistency in approach. If the Welsh Government is unwilling to follow the recommendations to the letter, we believe it should consider alternatives approaches to showing more central leadership.

GPs have a vital role in the emotional and mental health of children and young people, but we acknowledge there are difficulties in engaging with that particular group. In many cases school based services are more appropriate and we strongly encourage their development. ‘Accept in principle’ cannot mean business as usual.

Recommendation 9 - WG make available the management and data tracking progress in relation to LPMHSS waiting times for assessment and interventions for cyp since the commencement of the provisions of the MHMeasure 2010.

Welsh Government response – ‘reject’

This has been rejected on the basis that figures relating to age of referrals have not been available. This seems difficult to understand. It is important that data is collected efficiently by LPMHSS, including waiting times for different treatments as well as assessment, and that account it made of different groups to ensure there is no discrimination by age or other factors (such as language).

The criteria for data collection must be set nationally so that there is clear comparison between LHBs, rather than LHBs being able to choose which data is publicly available. What may still be hidden by the referral data is that locally the lack of appropriate services means that referrals are not made, so gaps in data also need to be explained to ensure services can be developed in a timely fashion. GPs need to know there are services available via LPMHSS for patients who have problems, providing support before problems escalate to requiring more advanced services.

This preventative approach is consistent with Welsh Government objectives, most recently restated in ‘A Healthier Wales’.

Recommendation 11 - WG ensure:

1. consistent pathways for all sCAMHS services based on the national referral criteria once agreed, are implemented by all health boards (and related agencies where relevant) within six months of this report’s publication.

2. Each pathway is accompanied by defined standards against which all health boards can be measured and benchmarked consistently

3. Information is made publicly available so that health boards and WG can be held to account for performance in a transparent and well-informed way.

Welsh Government response – 11.1 accept, 11.2 accept, 11.3 reject

11.3 has been rejected on the basis that it is up to LHBs to determine what information they publish. Unless there are minimum standards and similar data collections, then comparisons between LHBs to identify the gaps in delivery will be difficult. The Welsh Government has said it ‘would expect’ this information to be in the public domain – either through the local Partnership Board or other route – we believe a stronger commitment to ensure the data is available is necessary.

Recommendation 15 - WG, within six months of this report’s publication, in relation to crisis and out of hours care:

1. Work with police forces to scope the proposed all-Wales triage model which would see mental health practitioners situated in police control rooms to provide advice when cyp (and other age groups, if appropriate) present in crisis

2. Outline how resources could be directed towards enabling crisis teams in all health boards to provide training and cascade expertise to other frontline services, particularly colleagues in A&E, in border areas (to improve cross border relations with those centres most often accessed by Welsh domiciled patients), and in schools (to normalise conversations about suicide and selfharm in particular).

3. Ensure that follow-up support is being provided by health boards after discharge, provide information on how health boards monitor this provision and commit to making this information publicly available to ensure transparency and accountability

4. Ensure all health boards are adhering to the requirement to hold designated beds that could be staffed adequately for under 18s in crisis, indicating how this will be monitored and reported in future and what steps will be taken if such beds are not available

5. Implement with pace and in a uniform way across health boards the single point of access approach to specialist services, to ensure timely and appropriate access to support, urgent or otherwise

6. Reflecting on the results of the review of crisis care, outline what more needs to be done to deliver a safe and cost-effective 24/7 crisis care service in all areas, how that will be done and by when.

Welsh Government response – 15.1 accept, 15.2 reject, 15.3 reject, 15.4 accept, 15.5 accept, 15.6 reject

We are concerned about the rejections in this group of recommendations. Access to services for children and young people with mental health crises is patchy across Wales. If they are seen it is equally important they are adequately supported by follow up services after discharge. Unless these are monitored and the result made available, there will continue to be gaps in service and inequity in provision.

Crisis services need to be available across Wales on a 24/7 basis. We acknowledge concerns about cost effectiveness, but maintain that children and young people suffering from acute severe mental health need to be managed by specialist CAMHS psychiatrists. They should not be treated by other health professionals who do not have the specialist knowledge and training. In emergencies, specialist CAHMS psychiatrists (if distant from the patient) should be able to provide advice to other health professionals to enable suitable transfer to safe care. Many drugs used for mental health problems are not advised for children and adolescents, and GPs are not trained in managing these complex problems or to prescribe psychiatric drugs for this age group.

Recommendation 19 - WG in light of the importance of the transition period in retaining engagement with support services and the heightened vulnerabilities of young people as they enter adulthood, require health boards and LAs to report to them on a six monthly basis: 1. Steps taken to ensure implementation of the transition guidance 2. Assessment of their level of adherence to the guidance 3. The challenges they encounter when seeking to deliver smooth transitions and how they are mitigating those risks

Welsh Government response – ‘reject’

We are sad to learn that there will be further delays in ensuring transition services and processes are implemented. For some young people there are not complementary adult mental health services. It is inappropriate if GPs are expected to take over their management as they are unlikely to have the necessary specialist skills. It risks treatment and support stopping as young people reach adulthood, potentially preventing them entering employment or further education and disadvantaging their future prospects. We have been involved in discussions about transition and the development of pathways under the Together for Children and Young People Programme and we are concerned that there continues to be poor progress in implementation.

Annex 2 - The emotional and mental health of children and young people – RCGP Wales briefing

(Note – this was a briefing issued to Welsh Assembly Members in July 2018)

· It is vital that GPs have services available to refer patients in a timely fashion. The current picture is one of delays and a lack of available services. In this context, RCGP Wales is particularly supportive of recommendations 11 and 20.

· We acknowledge there can be difficulties for a GP in engaging with children and young people in this area. In many cases services in schools are more appropriate and we would encourage the development of these. We support recommendations 3, 4, 5 and 6.

· We have raised issues around the transition from child to adult services, and we support recommendation 19 of the report.

RCGP Wales welcomes the debate on the emotional and mental health of children and young people. The College submitted written and oral evidence to the Committee’s inquiry.

A GPs role in the emotional and mental health of children and young people

· At the frontline of the NHS, we recognise the important role GPs can have in this area. The report recognized that joint working between professionals from across sectors is important.

· We recognise there can be difficulties in engaging with children and young people on emotional and mental health:

o Children may be unlikely to present to a GP by themselves, for example if they are unfamiliar with the system.

o If they are brought by a parent or parents, it may be difficult to discuss the relevant information with extra people in the room.

o Short appointments – with 10 minutes being the norm and workload pressures making it difficult to expand them on a regular basis – can make it difficult to build trust and obtain the necessary information.

· In this context, school services may be more appropriate and the development of them is essential.

· The report highlighted a variation in individual experiences of seeking mental health support from GPs for children and young people. It called for more training to be available for everyone working with children and young people. RCGP Wales believes there is a role for more training and there would be appetite for it from some GPs. We also note that we remain a generalist profession, covering an extremely broad range of areas.

· In many cases it would be inappropriate for a generalist professional to be the sole practitioner managing these patients. A GP cannot be expected to work outside of their competency. Often a GP’s main role is to provide support and reassurance; the crucial thing in these situations is ensuring there are services to be able to refer onto.

Referral

· GPs report inconsistent services being available to them to refer patients in a timely fashion.

· The report made recommendations for improvements to community and specialist services, and for urgent attention to be given to services available in the community via primary care. RCGP Wales fully supports this. It is particularly worrying that the report states there has been a regression in primary care services over recent years.

· There is a particular problem around a lack of talking and psychological therapies. If a GP feels a patient is not accepted by CAMHS or too young for anti-depressants, but there are no talking therapies available, then their options are extremely limited.

· When patients are referred to CAMHS lengthy waiting times are common. The report outlined the current CAMHS target of 80% of patients receiving an appointment with 28 days, stating it has been missed every month since March 2017. This leaves a patient without much needed support, potentially worsening their problems, bringing them back to the GP, who can only try to do what they have already done.

· Some GPs report that there is a delay in rejection from CAMHS. If CAMHS deems a patient does not meet their criteria – perhaps recommending to primary mental health – this needs to be communicated to a GP immediately. Otherwise a patient is left without support and without someone trying to obtain support for them as they believe it is in order. Processes need to be made more efficient.

· RCGP Wales is particularly supportive of recommendations 11 and 20 of the report. Recommendation 11 calls for consistent pathways for all specialist CAMHS services. Recommendation 20 calls for a national action plan for the delivery of psychological therapies for children and young people.

Transition between child and adult services

· In our written and oral evidence, RCGP Wales raised concerns about the transition between child and adult services.

· Some child services have no clear adult equivalent. Older teenagers may not engage with either paediatric or adult services.

· One case study from the report highlighted difficulties in this area very well:

· We support recommendation 19 in the report calling for greater engagement with the transition period.