Cynulliad Cenedlaethol Cymru Y Pwyllgor Plant, Pobl Ifanc ac Addysg Gwaith dilynol ar yr adroddiad Cadernid Meddwl MOM: 23 Ymateb gan: Cymdeithas Llywodraeth Leol Cymru (WLGA), Grŵp Penaethiaid Gwasanaethau Plant Cymru Gyfan, Cymdeithas Cyfarwyddwyr Addysg Cymru (ADEW), Gwasanaeth Mabwysiadu Cenedlaethol (NAS), Grŵp y Prif Swyddogion Ieuenctid (PYOG) ___________________________________

National Assembly for Wales Children, Young People and Education Committee Follow-up on the Mind over Matter report MOM 23 Response from: Welsh Local Government Association (WLGA), the All Wales Heads of Children’s Services (AWHOCS), the Association of Directors of Education in Wales (ADEW), the National Adoption Service (NAS) and the Principal Youth Officers’ Group (PYOG) ______________________________________

Overarching issues
Key recommendation (2018). That the Welsh Government make the emotional and mental well-being and resilience of our children and young people a stated national priority. This status should bring with it a commitment to: · provide adequate and ring-fenced resource for our schools to become community hubs of cross-sector and cross-professional support for emotional resilience and mental well-being. Schools cannot shoulder this responsibility alone - the support of other statutory and third sector agencies, most notably health, is essential; · ensure that emotional and mental health is fully embedded in the new curriculum; · ensure that everyone who cares, volunteers or works with children and young people is trained in emotional and mental health awareness, to tackle issues of stigma, promote good mental health, and enable signposting to support services where necessary. This should include working with professional bodies to embed training in initial qualifications and continuous professional development; and · publish every two years an independent review of progress in this area. This process should involve children and young people throughout. Recommendation A (2019): The key recommendation in our Mind over Matter report called for the emotional well-being and mental health of our children and young people should to be a national priority. Further to this, we recommend that the Together for Children and Young People Programme is extended to help ensure sustainable improvements in access to support services within both primary and secondary care through Child and Adolescent Mental Health Services (CAMHS), as well as supporting the whole-system approach. It is our view that the Together for Children and Young People Programme should be extended to coincide with the end of Together for Mental Health 2012-22, the Welsh Government’s 10 year strategy to improve mental health and well-being.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Whilst we are yet to be convinced that emotional well-being and mental health has become a national priority, it is essential that it does become so, particularly for children and young people. However, whilst there is a long way to go, it is evident there is a clear momentum in this crucial area of work, receiving a higher profile in recent years, particularly in the areas of Health and Education. Though we fully support the principles of the T4CYP programme and are pleased to hear of the programme’s extension, we believe local government services, including education, social services and youth work must be afforded a prominent role. It is essential that these services are involved not only in the workstreams but also at the programme board level in order to ensure that these vital service areas are able to influence and shape the work of the programme.	We know that early help in mental health can prevent symptoms escalating and give children the tools to cope with and manage their condition. More early help, and more general help for mental wellbeing, can reduce the pressure on acute care so that it has the capacity to help the most vulnerable. However, the needs of our most vulnerable children those ‘looked after’ and with high levels of need are yet to be addressed; existing cohorts of these children and young people cannot wait for the early intervention approach to impact. There has to be an ambition to bring services together to form a single, seamless, comprehensive system for addressing mental health needs across all ages as we know that it is at the points of transition between services that care and treatment can break down. We have welcomed the inclusion of the priority area of, “Improving access to support for the emotional and mental health well-being of children and young people” within the latest delivery plan of Together for Mental Health. The principle of partnership working across Government, public and third sectors must underpin Welsh Government’s approach, recognising no single body or sector can transform services and improve the mental health and well-being of our population alone. However, we also feel that greater recognition of the needs of care experienced children and young people needs to be reflected within this ambition.	We have seen some progress in regard to agencies coming together to address this issue but there needs to be much quicker pace in changing attitudes and structures to enable greater collaborative working and more intelligent sharing of resources. There is also an urgent need to better co-ordinate the number of programmes which have developed in recent times – they may all, in their own way, be effective but this is not always evident. Also, some are available to parts of the sector whilst not in other areas/sectors. This is why there is an urgent need to map what is available but also to communicate the efficacy of each and how and where it can be accessed. The impact of T4CYP has yet to be felt at operational level, including children’s services and youth work and the most vulnerable children and young people that they work with – whilst many practitioners and volunteers are aware of the programme, there is little evidence that practice has been influenced by T4CYP – where good practice exists, this unlikely to be as a direct result of T4CYP. The funding of services and provision needs to be carefully considered and local authorities working with key partners need to secure efficient and effective investment and deployment of resources. Whilst the emphasis on schools as providing early alert and developing whole school approaches is welcome, a whole system approach offers greater strengths and guards against a proliferation of approaches across the many different schools in Wales. We believe a new national whole system approach that locates the funding and provision of early intervention and preventative approaches with local authorities, with Regional Partnership Boards providing an avenue to embed joint planning and joint decision making through local arrangements would support this.
The new curriculum
Recommendation 1 (2018). That the Welsh Government publish, within three months of this report’s publication, a route map of how health (led by the Together for Children and Young People Programme) and education (led by the Health and Well-being Area of Learning Experience) will work together to inform the new curriculum. This route map should contain clear milestones and specify the agencies or individuals responsible for delivery.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	Whilst recognising that schools are important for the vast majority of young people, we must also recognise that Education occurs in a huge variety of environments and settings. The health and wellbeing AOLE is at an early stage of development and implementation at school level.	Alongside the previous uncertainty regarding the continuation of T4CYP, whilst accepting its important role, there has been a disproportionate focus on a Whole School Approach. It is important for the whole school approach not to be seen as a silver bullet and to be clearer on how it fits with the Whole System Approach. Considerable work is needed on how health and wellbeing becomes a mainstay of curriculum delivery. This includes work on pedagogy, assessment and progression.	Professional development support for teachers, youth workers and other education professionals/specialists supporting curriculum delivery. Curriculum design and delivery support. Leadership support in securing a health and wellbeing friendly school environment and other child/youth and community settings. Support for schools in evaluating effectiveness of current and proposed provision.
Measurement of well-being in schools
Recommendation 2 (2018). That the Welsh Government prioritise the work of improving measurement of well-being in schools within the inspection framework in order to drive activity and performance. The development of these measures should involve all relevant stakeholders to ensure that they are fit for purpose and do not lead to unintended consequences. Most importantly, children and young people should be involved in the process of preparing these measurements to ensure that they capture correctly the factors that influence their well-being. These measures should be available within six months of this report’s publication, or form part of the report of the independent review of the implications of the educational reform programme in Wales for the future role of Estyn, whichever is the earliest.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	Current measures relate mainly to pupil attendance and exclusion.	We need to develop a more sophisticated and richer suite of measures that inform curriculum and wider provision. Measures may need to be more subjective in nature and based on the lived experiences of children and young people. Measures also need to consider risk and vulnerability of pupils relating to the communities where they live.	WG needs to work with Estyn, ADEW and other key stakeholders to develop an agreed suite of measures. Careful consideration needs to be given to how these measures are used and managed, avoiding or minimising their use as accountability indicators.
Emotional and mental well-being initiatives in schools
Recommendation 3(2018). That the Welsh Government undertake a review of the numerous emotional and mental well-being initiatives underway in Wales’s schools, with a view to recommending a national approach for schools to adopt, based on best practice. The Welsh Government should work with exemplar schools such as Ysgol Pen y Bryn in Colwyn Bay to develop elements of this national approach, including but not limited to mindfulness Recommendation C (2019): Further to Recommendation 3 in our Mind over Matter report, the Welsh Government must ensure the implementation framework for schools is published without delay, by December 2019. This is to ensure that all schools are working to a fundamental set of principles in relation to children and young people’s emotional well-being and mental health and are supported to do this. We want the Welsh Government to be working with schools to implement the guidance and to begin the self-evaluation process. Recommendation 4 (2018). That the Welsh Government, while undertaking the review we call for in recommendation 3, work in the meantime with the Samaritans to develop its Delivering Emotional Awareness and Listening (DEAL) Programme for wider use in schools in Wales. Subject to the results of the DEAL evaluation that is underway, the Welsh Government should fund the extension of the programme to the primary school sector. Recommendation 7 (2018). That the Welsh Government issue interim guidance to health and education services (and other relevant statutory bodies) about the support they should deliver for emotional and mental health in schools. This should specify the support that they should expect from each other as statutory services. This guidance should remain in place, and should be resourced adequately, until the findings of the in-reach pilots are reported to us and others. The guidance should be issued within three months of our report’s publication and reviewed after the in-reach pilots conclude.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	There has been some progress in schools, with far more are using mindfulness and seeing mental health as something they should focus on for their pupils. But still a very long way to go.	The partnerships with health and social care need to be developed much more rapidly.	CAMHS and other mental health staff need to integrate more closely with education colleagues to plan and deliver mental health care at all levels of need.
School counselling
Recommendation 6 (2018). That the Welsh Government assess the quality of the statutory school counselling available, not least how the service copes with increasing demand, tackles stigma and meets the needs of children and young people. This should include consideration of providing counselling support online and outside lessons/school, and for those younger than 11 years old.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Green / Amber	All local authorities provide comprehensive SBCS. Recent funding from WG has allowed us to extend the reach of the service to those younger than 11 years old.	We need to sustain current funding and secure further resources from WG to meet demands within this key service area.	Mainstream additional grant funding into the RSG. Consult with local government and schools on additional demands within the system. It should be noted that this comparatively low cost service saves significant high cost demand further along the ‘needs’ continuum. Investing in this service must be a priority.
School staff
Recommendation 5 (2018).That the Welsh Government commission a mapping exercise of the availability of non-teaching staff in schools to support emotional and mental health and well-being, and the anticipated level of future need. This exercise should provide an outline of how any shortcomings will be addressed. Recommendation 8 (2018). That the Welsh Government pilot the role of “guidance teacher” in Wales, or adopt another model that allocates responsibility for the emotional and mental health of pupils to a lead member of teaching or nonteaching staff. Recommendation B (2019). To ensure that all school staff have a sufficient understanding of children and young people’s emotional and mental health and well-being, the Welsh Government should develop―as a matter of priority―a programme of compulsory training for new and existing school staff.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Improving the mental health and wellbeing of young people is not just a job for CAMHS, it is a task in which all practitioners in contact with children and families have a role to play. However, all require the skills, resources and confidence to effectively support children and families.	It is vital to raise awareness and knowledge of mental health issues in the community, including in schools, to improve outcomes and reduce stigma. Staff training and development is crucial, but so is development and support for foster carers and postadoption support where needed. Youth work also plays a significant and vital role in supporting children and young people and their emotional health and wellbeing and so given the considerable impact of austerity on this section of the workforce and so consideration must be given as to how they can be supported to be able make a greater contribution in schools and/or in communities.	Mapping exercise to be completed along with the identification of resources required to support
Primary health care
Recommendation 9 (2018). That the Welsh Government make available the management data tracking progress in relation to local primary mental health support services (LPMHSS) waiting times for assessment and interventions for children and young people since the commencement of the provisions of the Mental Health (Wales) Measure 2010. Recommendation 10 (2018). That the Welsh Government set out an improvement plan for local primary mental health support services (LPMHSS) for children and young people in Wales. This should provide an assessment of current levels of provision, the anticipated demand for services over the next 5-10 years, and the estimated level of resource needed to join the two. It should also outline how LPMHSS will engage with other statutory and third sector services, and provide the most accessible, appropriate and timely “intermediate” support services to bridge the gap between emotional resilience support on the one hand, and specialist CAMHS on the other. The improvement plan should outline clearly the pathways available for children and young people so that signposting to and between each level of services is clearer and simpler. It should make explicit reference to how LPMHSS should liaise with schools in particular. Recommendation F (2019). Further to Recommendations 9 and 10 in our Mind over Matter report, we expect to receive a copy of the NHS Delivery Unit’s review of Local Primary Mental Health Support Services, as well as the Health Board improvement plans, this summer (2019). Publication of this information will help to provide a better understanding of whether there is enough capacity in the primary care CAMHS
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Despite some very committed work by individuals within health, local authorities continue to face a challenge in sourcing health services to offer sufficient priority to the emotional and mental health needs of children in care and care leavers. This often results in the burden of responsibility being placed on local authority children’s social services.	WG’s response to the Committee identifies their intention that from April 2020 data on LPMHSS waiting times for assessment and interventions for children and young people will be published routinely. If this is the case then by April 2021 we should be able to better monitor progress and have a stronger evidence base to identify any issues around access and waiting times for services. This needs to the help inform our response and how we can ensure that sufficient priority is given to those children and young people who require these services, helping to ensure that there is enough capacity in the system to meet demand.	There has been a long standing disconnect between the access threshold applied by CAMHS and the presenting emotional needs of looked after children and care leavers. The issue of looked after children and care leavers’ rights to an appropriate range of provision to meet their psychological and emotional health needs, when they need it and for as long as they require it, including the transition into adulthood, needs to be urgently addressed on an all-Wales basis.
Care pathway
Recommendation 11 (2018): That the Welsh Government ensure: · consistent pathways for all specialist CAMHS services, based on the national referral criteria once agreed, are implemented by all health boards (and related agencies where relevant) in Wales within six months of this report’s publication; · each pathway is accompanied by defined standards against which all health boards can be measured and benchmarked consistently; and · information is made publicly available so that health boards and the Welsh Government can be held to account for performance in a transparent and well-informed way.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
The ‘missing middle’
Recommendation 12 (2018). That the Welsh Government outline as a matter of urgency, and within three months of this report’s publication, how it intends to address the challenges faced by the group of children and young people who do not meet the threshold for specialist CAMHS but for whom alternative services are not available – the so-called “missing middle”. This should include: · the detailed steps it will take over the next six months to ensure that their needs are met and that relevant agencies are held to account for delivery; and · an account of the consideration given to focusing referral criteria on levels of distress experienced by children and young people (the source of which can be behavioural, social (including attachment-related disorders) and/or medical in nature), rather than on a medically defined, diagnosis basis alone. This should include consideration of replacing the current “pyramid” model of care with the “iceberg” model presented to us in evidence. Recommendation E (2019). We want to see the Welsh Government implement Recommendation 12 in our Mind over Matter report as a matter of urgency, including publishing details of it how it intends to take forward the early help and enhanced support workstream to reduce the ‘missing middle’. We request an update from the Welsh Government on progress by the end of October 2019.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	The importance of and need to have arrangements in place for an early intervention and prevention approach to emotional and mental health services for children who do not meet the threshold for sCAMHS cannot be overstated. The Public Health Wales CAMHS needs assessment identified that the current model of CAMHS may not be appropriate for the current complex service environment, so we need to consider whether the current model is fit for the future. Young people themselves also warn us that we must not medicalise growing up, they highlight the importance of getting appropriate help at the earliest possible opportunity, rather than allowing problems to escalate to crisis point. In adoption this missing middle ground is now being addressed through the TESSA programme with additional investment from WG adding to that brought by the 3^rd sector from Big Lottery funding.  This is seen as a very positive development but it is outside of this programme and with elements of funding that may not be sustainable in the longer term. .	The WG response to the Committee sets out that WG is working closely with T4CYP to address the issue of improving service provision for the ‘Missing Middle’ in order to make assessment and specialist interventions more easily accessible to those who need it. However, the programme board for T4CYP has only just met and the workstreams sitting underneath have yet to be established. There is a need to ensure that this work progresses at pace and that membership includes education, children’s services (including adoption services) and youth work.  A great deal of work has already been accomplished by the early help and enhanced support work-stream but some of it (e.g. the good practice case studies) has not been published. It would be helpful to revisit some of this and ensure that it is made accessible to strategic managers and frontline services. Also, some work had been carried out around ensuring an accessible/common language which, it had been intended, would add clarity to terminology used by a multi-faceted work-force The reality is that sometimes the way that health, education and social care services are provided can make it particularly difficult for vulnerable groups of children such as children looked after to get the help they require to address their health needs. They may have missed school-based interventions through unstable schooling, and increased absence. Those placed outside their local authority area can face problems accessing health services for a variety of reasons. The limited resources of emotional wellbeing / mental health services may mean it is difficult to respond to the unrecognised or undiagnosed mental health needs of looked after children – who may also suffer mental health stigma. Those children and young people in care, on the edge of care or who have been in care are doubly disadvantaged. Not only are they more likely to have health needs but the services they need to help and support them are often harder for them to access. In some circumstances, there remains a cut off line in terms of entitlement due to changes in a child’s legal status, which is not related to their needs Changing to an integrated approach to assessment and provision of care that is less clinic based and more multi-agency in approach is an essential element to any successful future provision.  The development of a national pathway and approaches would go some distance in addressing the differences we experience across Wales. This change would have impact upon the lives of looked after young people in all areas regardless of whether they continue to live in their home local authority and health board area or move elsewhere. To date, the emphasis on the additional funding allocated to children’s mental health services has been towards improving specialist CAMHS within the existing model of provision. However, the greatest gains are more likely to be made by strengthening universal prevention and early intervention services, rethinking how we deliver services for those most in need with presenting behaviours of trauma regardless of diagnosis and improving the capacity of the whole system to respond to the needs and concerns identified by children, young people and their families. Specialist CAMHS should be for the very few children who need a medical model and is an important and vital resource. However, there needs to be far greater collaboration and shared learning between specialist CAMHS and professionals working in earlier intervention and other areas of specialism. Our experience has demonstrated the need to improve access to emotional wellbeing / mental health services at an early stage, thus preventing the need for longer term interventions from CAMHS. There continue to be significant numbers of young people who require psychological support (intensive or remedial intervention) and examples of positive services although there remains very limited provision. ‘The system’ must be able to identify those individuals whose needs are greater and to provide the support they need, both in a timely manner. It is also important that this access and support continues to be available for those children and young people who move on to alternative arrangements so that there is continuity but also support for latent vulnerability that re-emerges at a later stage. In relation to adoption at least 200 adoptive families should have had the TESSA intervention and we should be able to start to measure the difference that is making for those families.	The Early Help and Enhanced Support work-stream needs to meet as a matter of urgency to consider its work programme and present this to the Board for ratification. Thereafter, there need to be regular meetings of relevant members up to and beyond April 2021 (if necessary). Continued funding via WG investment money in adoption to allow AUK to continue their work is crucial to ensuring this service continues to achieve for adoptive families over time.
Neurodevelopmental services
Recommendation 13 (2018). That the Welsh Government develop an immediate recovery plan for neurodevelopmental services in Betsi Cadwaladr University Health Board to address the unacceptably long waiting times faced by over 1000 children and young people. Recommendation I (2019). We recommend the Welsh Government fully implement Recommendation 13 in our Mind over Matter report in relation to neurodevelopmental services. Alongside this, the Welsh Government should: · set out a clear plan of how it will support Health Boards, local authorities and third sector partners to meet the needs of the estimated 40-50 per cent of children and young people who do not the meet the threshold for diagnosis but need some help, to ensure that families are not left feeling unsupported; · routinely publish data  on neurodevelopmental performance so that there is greater transparency and understanding of whether Health Boards are achieving the 26 weeks waiting time standard for assessment; · provide further details of how the Welsh Government intends to monitor the performance of neurodevelopmental services, so that frontloading support into assessment to meet the 26 week waiting time standard for assessment is not  done at the expense of providing interventions following assessment; · publish the findings of the demand and capacity modelling work it is undertaking to ensure effective neurodevelopmental service models are in place across all areas of Wales.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Evidence from the T4CYP programme identifies that whilst progress has been made it is clear that demand on the new services is increasing and some services are reporting an increased length of time for assessment to take place. This is further evidenced from the information received from adoptive parents who contact the AUK helpline who report that the 26 week waiting time is not improving uniformly across Wales for ASD assessments and in some areas has not improved at all.	All families within this group should be able to access assessment within the agreed timescales and be signposted for further intervention where needed.	There needs to be a better understanding of the demand and capacity relating to these services and a need to link the work of the two workstreams under the T4CYP programme (Early Help and Enhanced Support and neurodevelopmental services) to ensure appropriate links are made and there is a broader dialogue regarding a whole system approach. Published information about the service on offer and how to access it would help professionals and parents alike.
Qualitative measures of performance
Recommendation 14. That the Welsh Government prioritise work to ensure qualitative measures of performance are developed to sit alongside existing referral to assessment waiting time data within six months of this report’s publication. This information should be made publicly available so that those responsible can be held to account for service delivery and performance.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Crisis and out-of-hours
Recommendation 15 (2018). That the Welsh Government, within six months of this report’s publication, in relation to crisis and out-of-hours care: · work with Welsh police forces to scope an all-Wales triage model which would see mental health practitioners situated in police control rooms to provide advice when children and young people (and other age groups, if appropriate) present in crisis; · 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 self-harm in particular); · 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; · ensure that all health boards are adhering to the requirement to hold designated beds that could be staffed adequately for unders-18s in crises, indicating how this will be monitored and reported in future, and what steps will be taken if such beds are not available; · 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; and  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 of Wales, how that will be done, and by when. Recommendation G (2019). Further to Recommendation 15 in our Mind over Matter report, we recommend that the Welsh Government undertake an urgent piece of work to better understand how and why children and young people access crisis/out of hours support. Further improvements to crisis and out of hours care for children are needed to help ensure children and young people can access immediate support when they are in distress, at any time. Access to mental health crisis support must be consistent across Wales, which may require Welsh Government investment to support those Health Boards currently unable to extend their services.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Suicide
Recommendation 16 (2018). That the Welsh Government, in relation to suicide specifically, work with expert organisations to: · provide, within three months of this report’s publication, guidance to schools on talking about suicide and self-harm, to dispel the myth that any discussion will lead to “contagion”; · work with expert organisations to prioritise the issuing of guidance to schools where there has been a suicide or suspected suicide; and The Emotional and Mental Health of Children and Young People in Wales · ensure that basic mental health training, including how to talk about suicide, becomes part of initial teacher training and continuous professional development, so that all teachers are equipped to talk about it. Recommendation D (2019). Further to Recommendation 16 in our Mind over Matter report, the Welsh Government must ensure that all schools and local education authorities implement fully the guidance on suicide and self-harm to be introduced in September 2019.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Guidance remains new and needs time to be fully implemented. Self-harm training has been delivered in most, if not all, local authorities.	Guidance should be fully implemented.	LAs need to review implementation and further support schools to embed practice.
In-patient services
Recommendation 17 (2018). That the Welsh Government: · engage as a matter of urgency in addressing the reduced capacity in the north Wales in-patient unit; and · provide in its response to this report an action plan detailing the practical support it is going to give to Betsi Cadwaladr University Health Board to return the unit to its commissioned capacity of 12 beds by summer 2018. Recommendation H (2019). Further to Recommendations 17 and 18 in our Mind over Matter report, we want to see urgent action taken to address the demand pressures for in-patient care throughout Wales. We recommend the Welsh Government : · ensure the capital works at Ty Llidiard are completed by the end of Summer 2019 and that the unit is in a position to accept children and young people at risk of suicide and self-harm; · ensure the staffing issues at Abergele are resolved urgently so that the unit is in a position to accept children and young people at risk of suicide or self harm. · explore with greater urgency options for creating extra in-patient capacity, specifically to cater for children and young people with complex needs who are currently placed outside of Wales; · put in place more effective arrangements for ‘stepping up’ or ‘stepping down’ between different levels of intervention; · provide capital investment to help progress at greater pace some of the opportunities for more integrated commissioning in relation to mental health, welfare and youth justice. · Recommendation 18 (2018). That the Welsh Government use the results of the review of in-patient capacity in Wales as a basis to: · provide as many services as close to home as possible for Welsh domiciled children and young people; · engage in dialogue with NHS England about options for the creation of very specialist in-patient beds that could serve populations both sides of the border; and · explore the viability of using spare in-patient capacity on the NHS estate to provide step-down services for those leaving placements.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	We are aware of continuing issues in relation to in-patient services - judging by parents contacting the Adoption UK helpline for example there is still no suitable inpatient care for young people with complex mental health needs. For example, we are aware of one young woman who has been placed in the secure unit at Hillside as it was the only place available in Wales where she could be kept safe due to the level of mental health needs she was exhibiting. Equally, the findings of the Welsh Government funded Secure Accommodation research strongly evidences a need to improve joint assessment, planning and provision across the organisations.	Proper in patient capacity with a good understanding of the complex mental health needs which arise from early trauma.	Joint commissioning of alternatives to in patient and secure accommodation.
Transitions
Recommendation 19 (2018). That the Welsh Government, 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 local authorities to report to them on a six monthly basis: · the steps they have taken to ensure implementation of the transition guidance; · their assessment of their level of adherence to the guidance; and · details of the challenges they encounter when seeking to deliver smooth transitions and how they are mitigating those risks Recommendation J (2019). Further to Recommendation 19 in our Mind over Matter report, and given the heightened vulnerabilities of young people as they enter adulthood, we recommend that the Welsh Government consider all options for improving transitions, including exploring the extension of CAMHS up to the age of 25, to provide an extended period for young people to move into adult services, rather than immediately transferring to adult mental health services when they turn 18.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	We know that the impact of adverse experiences of children looked after have been shown to have a lifelong effect, making it all the more important to address the well-being of children whilst in care or in the arrangements that those who cease to be looked after move on to. A research paper from the Wales Adoption Cohort Study by Cardiff University, examined the presence of Adverse Childhood Experiences (ACES) in a cohort of 370 children placed for adoption in Wales in 2014/15. This showed that 47% of the cohort had experienced at least 4 Adverse Childhood Experiences (ACES) before they were placed for adoption, compared to 14% in the general population and placing this group of children in the highest risk group for later life difficulties.  Although there is not a comparable study for children who remain looked after, their early and ongoing childhood experiences are likely to be similar and therefore be at a similar or even increased risk of later life difficulties.  These experiences will often manifest themselves at critical transition points in a child’s/young person’s life (e.g. physiological changes, or changes in schooling). It is important the right services are in place at these times to build resilience both for the children/young people and their parents / carers and wider families.	It is recognised that access to support for care leavers can be particularly challenging, as leaving care coincides with a transition from children’s health and wellbeing services such as CAMHS to adult’s services. We need to make sure there are clear pathways in place which identify what happens at key transition points, such as when a child leaves care. There is a need to carefully manage transition from CAMHS to adult mental health services to maintain continuity of relationships and manage different experiences of services. Services need to be joined up at an earlier stage for young people and their families to be informed and aware of adult services. It would be good to see a plan emerging that has the commitment in principle of all partners, or a commitment to scoping such a plan.	Scoping of the issues and services that are integral to considering this
Psychological therapies
Recommendation 20 (2018). That the Welsh Government, in light of the current variation in provision and the crucial role therapeutic interventions have to play, set out a national action plan for the delivery of psychological therapies for children and young people. As a minimum this should include: · an outline of how primary, secondary and specialist services will work together to ensure a range of therapeutic services across the spectrum of need are delivered effectively; · specific plans for developing and maintaining a stream of sufficiently trained (and regulated/registered) therapeutic practitioners; · details of the proposed review of prescribing trends for children and young people with emotional, behavioural and mental health problems, building on previous work undertaken by Professor Ann John and including an assessment of whether other interventions have impacted on these trends, to begin in the next 12-18 months; and · an assessment of the plan’s financial implications and affordability, and how its outcomes will be measured. Recommendation K (2019). The Welsh Government should work proactively with the Health Education and Improvement Wales (HEIW) to ensure the CAMHS workforce is prioritised in the 10 year workforce strategy. We would welcome further information about plans for developing and maintaining a stream of sufficiently trained therapeutic practitioners to deliver interventions to children and young people. Recommendation L (2019): Further to Recommendation 20 in our Mind over Matter report, we recommend the Welsh Government publish the children and young people’s version of Matrics Cymru by December 2019, alongside details of how this will help to ensure a range of therapeutic services across the spectrum of need are delivered effectively to children and young people across Wales.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	The requirement for psychological and psychiatric assessment, intervention and support through the Family Courts and then into placements continues to be an area of unmet need. Local authorities are resorting to filling the gap with expensive and often unsustainable solutions to broker between the demands of the courts and the availability of the health services. The assessments are frequently then repeated when resource does become available in order to revisit recommendations and identify services available locally.  The costs are considerable and unsustainable, for example on one young person’s case in South Wales, the child’s Guardian was recommending a package of therapy and support to care staff that carried a cost of £26,000. Unless we resolve the challenges, we are powerless to withstand such expectations	We know that there are difficulties faced by children services in accessing a service from CAMHS, linked to lack of therapeutic support as well as the lack of ‘adoption awareness’ within the service. The prevention / early intervention ethos of the mental health measure and the T4CYP programme, does not appear to have had an impact on demand for targeted and specialist support for children and young people. There needs to be: · timely access to an adoption aware CAMHS service · access to a range of psychological therapies that help adopted children recover from the result of early trauma or early attachment problems · support in managing children and young people who display challenging behaviours, particularly aggression and violence to adults · adopters having access to consultations with CAMHS; and · improved links between CAMHS and regional adoption services.
Prescribing and medication
Recommendation M (2019). Our view as expressed in Recommendation 20 of our Mind over Matter report, that a national review of prescribing trends for children and young people with emotional, behavioural and mental health problems is needed, remains unchanged. In the absence of such a review, we recommend the Welsh Government provide us with further assurances on this issue by December 2019.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Advocacy
Recommendation 21 (2018). That the Welsh Government, within six months of this report’s publication, commission a review of the current provision of – and need for – advocacy services for children and young people accessing all mental health services, not just those in in-patient settings. This review should be undertaken in consultation with key stakeholders such as the Children’s Commissioner, the National Youth Advocacy Service, commissioned providers of services, and children and young people. Based on the review the Welsh Government should assess the viability of providing an active offer of advocacy to all children and young people accessing mental health services and should publish a full account of its conclusions.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	Local authorities have undertaken a significant amount of work in recent years around the provision of statutory advocacy services for children and young people and in particular around the development and implementation of a national approach to advocacy that has included an active offer. This work has been focussed on those children and young people entitled to an active offer of advocacy from a statutory Independent Professional Advocate (IPA) when they become looked after or become subject of child protection enquiries leading to an Initial Child Protection Conference. Up until now there has been limited discussions on the wider provision of advocacy across health services and how this might link with existing provision.	Assessment completed and work started on establishing national standards for health-related advocacy for all children and young people who require it.	The experience of the development of a national approach around the provision of statutory advocacy services has highlighted the significant additional investment that is required to be able to provide an ‘active offer’. We would support the need to establish national standards for health-related advocacy for all children and young people who require it and monitor health boards’ progress towards commissioning sufficient advocacy, and their promotion of it.
Vulnerable children (including children who are care-experienced, adopted or have experience of the youth justice system)
Recommendation 22 (2018). That the Welsh Government work across agencies to ensure that the emotional and mental health needs of children and young people are assessed on entry to care and on receipt of a referral order within the youth justice system, and routinely thereafter. This will help inform planning of adequate provision of multi-disciplinary support to meet their often-complex needs in a timely and appropriate way. Recommendation 23 (2018). That the Welsh Government, within six months of this report’s publication, undertake a piece of work on the provision of emotional, behavioural and mental health support for looked after and adopted children. This should: · be informed by the activity of the Ministerial Advisory Group on looked after children and the T4CYP Programme’s work; and · consider, in the case of looked after children, the extent to which public bodies are adhering to their responsibilities as corporate parents to provide both the physical and emotional support they need. Recommendation N (2019). The Welsh Government should provide more detail about―and evidence that―the workstreams of the Joint Ministerial Advisory Group on outcomes for children, the whole-school approach programme, and the Together for Children and Young People Programme are linked and working in tandem to ensure that the most vulnerable children and young people are having their emotional and mental health needs assessed and can access support promptly. The Welsh Government should provide a further detailed update to the committee on this, together with timescales for progressing this work. In the meantime, we remain deeply concerned about the provision of emotional well-being and mental health support for care-experienced children.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Red	The step change towards an integrated approach required to meet need and prevent avoidable escalation of risk and need is yet to be achieved. New funding streams are welcome, however the short term nature of these initiatives, the timescale involved in translating new initiatives into services for young people, and the funding value leaves us concerned about the potential to make the scale of change that is warranted. This leads us to be concerned that need will continue to escalate with a continuing impact long into life including poor adult mental health needs substance misuse, prison, and domestic abuse. The whole school approach is positive but overlooks that for those with the most complex needs, reduced timetable, exclusion or delay in allocating school place due to a placement move means that they will continue to be excluded from accessing the services they so greatly need. Many children and young people at greatest need and greatest vulnerability are also not in mainstream school settings e.g. attending Pupil Referral Units, Social, Emotional and Behavioural Schools/Units and those educated at home. We need to ensure that these individuals are able to access the same level of support should they require it. Children and young people have repeatedly voiced their concerns about the paucity of access to services, the inconsistency of provision, the adult focus of the models of intervention and the absence of child friendly environments for those who do receive services.  The Public Health Wales CAMHS Needs Assessment also recognised that children who are looked after or in need are known to be at greater risk of mental health problems. It also identified a lack of connectivity between different policy and service areas working in children’s mental health Children entering the care system have their physical health needs assessed but not their emotional / mental health needs. Every child has suffered emotional trauma – both through their care experience at home and on being removed from parents and placed in care. In relation to YOS some authorities report that the provision of a CAMHS worker in the service does mean that all children known to the YOS can access assessment and support appropriately. However, the YOS children are a very small proportion of the overall Children’s Services population and there is significant need for a more systematic and consistent approach to the children looked after population.	There is a need to continue to strengthen the focus on prevention across the range of services, to build resilience of children, young people and families, reduce reliance on statutory services and facilitate de-escalation from intensive support where appropriate. Importantly, this needs to include health services working with community-based organisations to support children and young people in the development of life skills and refocusing resources towards early, direct interventions that strengthen the resilience and functionality of families and enabling better and timelier access to services All children entering the care system should be provided with a holistic health assessment including identifying their emotional and mental health needs and for any needs identified to be met through the provision of appropriate support at the most appropriate level. This should also identify any likely future needs. We also suggest: · WG departments work together on one integrated approach · There be one integrated approach for all Welsh young people irrespective of their location · A performance measure that captures well-being outcomes rather than waiting times · Specific expectations of LHBs about integrated approaches to preventative and therapeutic support for children at risk and who are looked after or have a plan for adoption · Consideration given to future funding streams, ensuring they are sustainable and able to meet need. To date there appears to have been limited progress made on linking the workstreams of the Joint Ministerial Advisory Group on outcomes for children, the whole-school approach programme, and the Together for Children and Young People Programme to ensure they are working in tandem so that the most vulnerable children and young people are having their emotional and mental health needs assessed and can access support promptly. It is hoped that now that the future of the T4CYP programme has been resolved this will provide an opportunity to better establish these links and ensure these workstreams are aligned and complementary.	We recognise the challenge of needing to address prevention and early intervention as well as fund intensive services but none the less believe that a specific shared and joint approach with a clear health role should be developed for these children and young people. Health Boards and specifically CAMH Services need to fully understand and commit to their corporate parenting responsibilities and ensure they provide an assessment for every child entering the care system in order to formulate a joint multi-disciplinary plan to address any needs identified. A joint commitment to provide appropriate support from the point of entry into care will enable joint planning and joint decision making throughout that child’s journey through care including agreeing the most appropriate placement choices to meet the child’s needs i.e. agreeing any specialist provision that may be required and for some identifying needs and services into alternative substitute family placements. Quicker timescales for assessment and access to packages of support according to need would be beneficial along with a need for clearer signposting, something that has been frequently highlighted by adoptive families and children. Some positive examples of integrated practice have been designed and are delivered across health and social services but a more systematic and integrated approach at a national, strategic, regional and local level, would benefit children and young people. The differences in definitions and understanding together with the continued lack of connectivity lead to additional challenges and a lack of shared ownership in discharging the well-being duty.  There is a compelling and pressing requirement to develop a common language, assessment tools and strategic planning framework. At present, different agencies have varying definitions of the words used in relation to emotional wellbeing / mental health/illness and also of terms such as ‘prevention’ and ‘early intervention’. In turn this can lead to inconsistency in those who meet thresholds for services, including CAMHS and specialist CAHMS, even though presenting needs can often be very similar.
Working with the third sector
Recommendation 24 (2018). That the Welsh Government, within three months of this report, act on the evidence received from the Royal College of Paediatrics and Child Health that it needs to establish an overarching group “with teeth” to manage the joint working that is needed between statutory and third sector organisations in order to deliver effective and timely emotional and mental health support services.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Workforce
Recommendation 25 (2018). That the Welsh Government ensure that all health boards respond promptly and comprehensively to surveys on workforce numbers conducted by the Royal Colleges in Wales. This will help enable the design of services that take into account staffing capacity and respond in an effective and innovative way to any shortages.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Welsh language services
Recommendation 26 (2018). That the Welsh Government ensure the T4CYP Programme undertake a comprehensive piece of work on the current and future availability of Welsh language emotional and mental health support services.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Reporting and data
Recommendation 27 (2018). That the Welsh Government require health boards to report expenditure on emotional and mental health services for children and young people in a uniform way to increase accountability and transparency. This data should include information on all services, not specialist secondary CAMHS services only, and should be broken down by area (e.g. primary, secondary, crisis, therapeutic, third sector etc.) This information should be made publicly available so that those responsible can be held to account in relation to the affordability, relative prioritisation and value for money of the services provided.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Youth work
Recommendation O (2019). The Welsh Government must ensure that within its Draft Budget for 2020-21, and in future financial years, sufficient funding is allocated to youth work in recognition of the vital role it has to play in supporting the emotional well-being and mental health of children and young people.
RAG status	Why have you given this RAG status?	Where, realistically, should we be by April 2021?	What needs to be done to get us there?
Amber	The Youth Service appreciates the recognition which the CYPE Committee has given to the impact of Youth Work on this agenda and in its recommendation to WG to invest in this preventative intervention. The extra £2.5m which came as additional funding via the Youth Support Grant for 2019-20 has assisted the sector to develop some innovative practice, as well as reinforced ongoing efforts. It is also positive to see that this will continue for 2020-21, as indicated in the recent Welsh Government draft budget.	Although capacity continues to be a real challenge, the sector has carried out a lot of work throughout 2019-20 on MH&EW, particularly around running workshops, sharing good practice and engaging with clinical experts at local and national level. MH&EW has also been included as a new standard in the suite following a recent (Summer, 2019) review of the Youth Work National (UK wide) Occupational Standards. However, whilst Youth Work is gaining greater recognition as an effective preventative service, it is perhaps still suffering from a lack of wider understanding of the profession. Whilst Youth Work has a strong tradition built by excellent voluntary and part time staff, the workforce today also includes over 1,000 professional, qualified staff who are registered with and regulated by the Education Workforce Council (EWC) as equal partners in the drive to better improve educational and life outcomes for our young people. It is therefore important that the sector is also represented at strategic level, where decisions are being made, so that this process is carried out in an informed manner, rather than without the input of the profession. There is sufficient time between now and April 2021 for the role of Youth Work to be better articulated and for the sector to be appropriately represented at decision making levels.	Since the onset of austerity, the Youth Service has in many areas been disproportionately affected, a scenario which has been well documented. One of the consequences of this is that, for many local authority Youth Services, core funding has been reduced to levels which have meant that the depth and range of Youth Work available today bears little resemblance to that of even a few years ago. Why this is mentioned is that, in some areas, whilst targeted provision is expanding as a result of such funding, open access services have suffered. The point being made here is not that one directly affects the other but local authorities need the appropriate level of sector knowledge, skills and level of infrastructure to manage and deliver Youth Work grants as effectively as possible. This comes from having sufficient staffing and structures in place which underpin the core Youth Service offer. In some areas, whilst recognising the difficult decisions faced by local authorities in making the most of the reduced funding available, such capacity has become a real challenge. The sector has managed to remain resilient (as recognised by Estyn in their Thematic Review of Youth Support Services, 2019), positive and responsive to the needs young people aged 11-25, however there continues to be a clear need for major investment in youth services in Wales.