Paper 3 Minister for Health and Social Services and Deputy Minister for Social Services

Paper 3

National Assembly for Wales

Children and Young People Committee

Scrutiny of Draft Budget

Purpose

To provide an evidence paper on the budgets and priorities of the Health and, Social Services Main Expenditure Group (MEG) within the remit of the Children and Young People Committee (CYP).

Introduction

The Draft Budget was published on the 8 October 2013. This paper provides information for the Children and Young People Committee (CYP) on the future budget proposals for 2014-15 and 2015-16.

Children’s and young person’s expenditure occurs across a range of budgets.

There are two specific Actions made up of three BELs within the Health and Social Services (HSS) MEG that cover Children’s Services these are:

Action: Children’s Social Services (CSS)

Grants in Support of Child and Family Services.
Services for Children

Action: CAFCASS CYMRU Programmes

CAFCASS Cymru.

Budget Overview – Changes since Final Budget 2012

The table below shows the budgets for these two Actions/BELs as at Draft Budget. Details of individual transfers at Action level are shown in Annex A to this paper.

Revenue	2014-15	2015-16
Children’s Social Services Grants in Support of Child & Family Services- Baseline No Change Services for Children – Baseline No Change	£m 4.5 - 5.8	£m 4.5 - 5.8
Total Children’s Social Services Action	10.3	10.3
CAFCASS Cymru Programmes CAFCASS Cymru – Baseline No Change	10.2	10.2
Total CAFCASS Cymru Programmes Action	10.2	10.2
Total Budget	20.5	20.5

In addition to this, Local Authorities receive funding in their revenue settlement to deliver on their children and family services.

NHS service provision in relation to children, children’s medical conditions and general health of children are funded primarily through the annual revenue allocations to Health Boards. It is for Health Boards to determine the use of this funding across all their areas of responsibility to meet the health needs of their local population.

Areas of Interest as detailed in the Letter form the Committee Chair

Health Spend

As my predecessor explained to the Committee during the scrutiny of the 2012-13 Draft Budget, it is for Local Health Boards to determine the amount of their discretionary funding they should spend on services for children and young people. They will make that judgement based on the detailed needs of their local population, and it would be in appropriate for the Welsh Government to set a budget that Boards must spend on services for children and young people. This expenditure is met from Local Health Board revenue allocations, funded from the Delivery of Core NHS Services Action.

My predecessor wrote to the former chair of this Committee in December 2012 providing information on the identified NHS expenditure on services for children and young people. In the letter, she stated that spending on these services in 2010-11 was £208 million, an increase of 3% on 2009-10. In reviewing the equivalent expenditure for 2011-12, the most recent year for which information is available, it was noted that the 2010-11 total omitted to include expenditure on community paediatric medical services. The revised total for 2010-11 is therefore £225 million. The equivalent expenditure total for £2011-12 is £215 million, a reduction of £10 million on the previous year’s total.

This expenditure analysis reflects the outturn of treatment decisions taken across the NHS on a daily basis, and it is therefore not possible to point to any single factor causing this reduction. The 2012-13 expenditure analysis will be available later in the autumn which will provide further trend analysis, and this will be brought to the Committee’s attention when it becomes available.

Social Services Spend

The Children’s Social Services Action has £10.3m allocated to it for 2014-15. The main areas of spend within the Action are:

Family Fund Trust - £2.6m
Looked after Children Transition Grant - £0.6m
Children & Families Organisation Grant - £1.3m
Integrated Family Support Services - £4.5m
Safeguarding - £0.7m

Much of the Department’s work impacts directly on the outcomes for children and young people and this is particularly relevant in policy areas relating to Looked after Children, Adoption, Fostering and Safeguarding.

However, our social services policy, set out in Sustainable Social Services, is to consider children and young people in the context of their families and communities. This means that many of our interventions, such as Integrated Family Support Service (IFSS) provide services within this policy context. Therefore there are budget areas within other Actions which will influence the social care and support of children but they cannot be split out to separately identify those elements relating to children.

Transfer of Functions

The restructuring of the portfolios across the Welsh Government meant responsibility for Children and Young People moved to the Minister for Communities and Tackling Poverty. This incorporated a number of key policy and funding areas including Flying Start, Families First, Childcare, Play, Children’s Rights and the Children’s Commissioner.

Almost all of these budgets were clearly demarcated and moved across the portfolios without any concern. The only area to require further discussion was the Children and Families Organisational Grant scheme which has budget provision within both MEGs. Arrangements have been put in place to ensure synergy across the newly created schemes. The social services budget has not been impacted by the transfer across portfolios and remains unchanged.

The delivery of outcomes for children and young people within social services is not solely dependent on the investment within the HSS budget. Significant dependencies lie across portfolios, including Communities and Tackling

Poverty and Local Government, through the Revenue Support Grant.

Programme for Government Commitments

Designed to Smile

Our ‘Designed to Smile’ programme will see a continued investment of £3.7m in2014-15. This funding is within the recurrent ring fenced dental allocation in the Delivery of Core NHS Services Action. The programme is operating in deprived areas across the whole of Wales. The programme currently involves 1,211 nurseries and schools across Wales. In total, 78,350 children participate in the daily brushing programme (43.2% of all children from nursery to Year 2 in Wales). The 2011/12 dental survey of 5 year old children shows a 6% decrease in the proportion of children with experience of dental decay in Wales (47.6% in 2007/08 falling to 41.4%). Dental disease levels in children are improving in Wales across all social groups. There is no evidence of widening inequalities. This is in contrast with previous surveys when improved decay levels were associated with widening inequality.

Childhood Obesity

The All Wales Obesity Pathway sets out a tiered approach for the prevention and treatment of obesity, from community-based prevention and early intervention to specialist medical and surgical services.

To support the Pathway a number of national initiatives are in place to encourage and support children and young people to eat a healthy balanced diet and be more physical active. This includes programmes such as:

· Change4Life with a budget of £0.3m in 2014-15.

Also within the total core allocation of £80.4m to Public Health Wales are the following programmes for which no specific budget is available. PHW funding is not ring-fenced, allowing the organisation flexibility to allocate resources according to need

· Children’s Weight Management Referral Programme

· National Breastfeeding Programme

Improved Health Outcomes

We are committed to tackling inequities in health in Wales and recognise the serious impact of inequities on children and young people. This has been set out in Together for Health and in Fairer Health Outcomes for All (FHOFA), Wales’s national strategic action plan to reduce inequities in health.

There is no stand-alone budget for the implementation of FHOFA. Instead implementation is mainstreamed across different programmes and budgets, particular those addressing the determinants of health, and is also taken forward in ways other than through direct funding, such as through the provision of guidance.

Inequalities in health are monitored and reported on by the Welsh Government and Public Health Wales who are also developing a new set of indicators for FHOFA. Individual programmes also undergo evaluation. For example, as part of the evaluation of Fresh Start Wales, we will be publishing later in the year a report on public attitudes to smoking in cars. This, along with studies on primary and secondary school aged children’s exposure to second-hand smoking in cars, will be used to assess the success of the Fresh Start Wales campaign.

Social Services

In terms of Social Services, the budget and other resources have been fully re-orientated to deliver our Programme for Government commitments. This means that the current budget reflects the cost of delivering the Programme for Government.

Our policy, set out in Sustainable Social Services, is to consider children and young people in the context of their families and communities. This means that many of our interventions, such as the Integrated Family Support Service (IFSS), provide services within this framework.

The delivery of social services Programme for Government commitments is monitored through the strategic five-year approach, the Sustainable Social Services Programme. This cross-cutting Programme and Project Management approach incorporates all of our Programme for Government commitments and a monthly report is provided to the Deputy Minister and Minister regarding progress. Alongside this approach, an annual report on the outcomes associated with the Programme for Government is produced for the Department.

Some of the Welsh Government’s specific commitments in social services that impact directly on children and their families are delivered with dedicated funding through the MEG. This includes £5.6m within the Services for Children Action which provides specific budgetary support for PfG commitments in the areas of a National Adoption Service, Safeguarding and Integrated Family Support Services.

Equality Impact Assessments

In setting the budgets for 2014-15, consideration of equality impacts has been given to all of the protected groups in Wales throughout and has assisted in our decision making process. Through its internal business planning process the Department for Health & Social Services ensures that our priorities – as set out in the Programme for Government– can be delivered effectively and within budget.

The link between spend and the outcomes associated with our PfG commitments is reported upon annually through the Programme for Government Annual Report each spring.

Provision for Legislation

Social Services and Well-being (Wales) Bill is currently undergoing scrutiny by the National Assembly for Wales. As set out in the Regulatory Impact Assessment, the system wide impact of the Bill is expected to be cost neutral over the long term and when taking into consideration anticipated benefits. However, some areas of one off transitional costs have been identified and these include training, dissemination of information and costs to the Welsh Government of implementing the changes. £2.1m has been provided to support the transformation costs associated with Sustainable Social Services, which will include support to enable local and regional delivery of the transition arrangements.

National Adoption Service

In 2013-14 provision of:

£0.050 m has been provided to the Association of Directors of Social Services Cymru (ADSSC) to procure resource to facilitate a project looking into the governance arrangements and business modelling of the National Adoption Service.

£0.070m has been awarded from the Social Services for Children budget for the development of a National Standardised Performance Framework for the National Adoption Service.

An additional £0.100 m has been identified within the Social Services for Children Action to undertake a procurement exercise for the development of a National Adoption Register for Wales..

This level of spend will be maintained in 2014-15.

UK legislation in the HSS portfolio area

DHSS Policy Officials monitor UK legislation and are engaged with Whitehall colleagues on the 6 UK Bills before Parliament, 3 UK Draft Bills, and 16 Private Member Bills that are considered to have possible policy implications for Health and Social Services in Wales – these include:

the Care Bill,
Children and Families Bill,
Prisons (Drug Testing) Bill and
Bills relating to driving under the influence of drink or drugs.

Until the final Bill provisions affecting Wales are known it is not possible to identify firm financial implications. The key aim of Policy Officials is to ensure that Wales and the Welsh Ministers are not adversely affected by any UK legislation and that opportunities for any legislation for Wales are taken.

Implementation of the recommendations arising from the Family Justice Review are taking place through both legislative reform and operational practice. The Plenary debate on the legislative consent motion on the Children and Families Bill on 16 April 2013 confirmed there were no anticipated financial implications for the Welsh Government associated with the provisions.

In respect of operational practice, including local authority and CAFCASS Cymru responsibilities, the Deputy Minister for Social Services has established the Family Justice Network which brings together key players within the family justice system to deliver improvement of services and outcomes for children and families in Wales, and complements the Family Justice Board for England and Wales.

This includes continued scrutiny of any additional resource implications arising from the reform programme.

Preventative Spending

Together for Health, the 5 year vision for the NHS in Wales, set out a renewed focus on children having a good start in life – ‘the NHS will play its full part in supporting a good start in life, the vital basis for lifelong good health, from action before birth through to supporting healthy schools and school nurse initiatives’. This built on Our Healthy Future, Wales’ public health strategic framework, which recognised that the foundations of good health are laid during pregnancy and infancy and built upon in the school-age years.

In line with this strategic approach, we have established a comprehensive set of interlocking initiatives aimed at promoting and protecting children and young people’s health and wellbeing. These initiatives are subject to constant refinement and retuning as needs, opportunities and behaviour change. This is evidenced by the review of health improvement programmes conducted by Public Health Wales which included initiatives targeted at children and young people, such as the Welsh Network of Healthy School Schemes.

Our children and young people’s initiatives also contribute to broader Welsh Government agendas, in particular on tackling poverty (including action to reduce teenage pregnancy) and targeting the early years (including breast feeding and immunisation programmes).

Public Health Wales core allocation in 2014-15 will be £80.5m from which to deliver a range of public health services that cover health improvement and protection, public health intelligence and research, and national population screening programmes.

In addition to the work being led by Public Health Wales, there is a wide range of local action addressing children and young people’s health under the leadership of Directors of Public Health and their partners.

Some limited examples of retuning existing and new initiatives to improve children and young people’s health and wellbeing include:

Screening programmes are important public health initiatives as they allow for the early detection and treatment of potential health problems. Key highlights for children and young people include:

• In June 2013 parents of newborns were offered screening for Sickle Cell Disorders for the first time as part of the Newborn Bloodspot Screening programme.

• The newborn hearing screening programme continues to achieve an excellent level of service. At the end of 2012/13, 99.6% eligible babies entered the programme and 100% completed it.

Breastfeeding rates have risen in Wales since 2005 from 67% to 71% in 2010. Increases in prevalence were also seen with the proportion of mothers exclusively breast feeding, though much improvement is still needed in continuing to breast feed with rates of 17% at 6 weeks. The National Breastfeeding Programme is addressing these rates with a programme of activities which incorporate work within the NHS, communities, schools and the voluntary sector.

Measles – The recent outbreak in Wales has refocused attention on this issue. There has been a significant reversal of the lower than optimal immunisation levels of recent years. The simple, cost effective intervention of immunisation protects children and adults from a number of significant illnesses, including protection for those in the community who cannot be immunised. For example, the level should be that at least 95 per cent of children receive two doses of the MMR vaccine. The latest figures for Wales indicate that the annual uptake of all routine immunisations in one-year-old children exceeded the 95 per cent target in all locals authorities in Wales and there were similar successes in older groups.

Healthy Schools and Colleges - The Welsh Network of Healthy School Schemes (WNHSS) supports schools to consider a whole school approach to 7 health topics.

Indicators for the WNHSS National Quality Award (NQA), in which schools are independently assessed after 9 years involvement, were issued in 2010. Currently nearly 3% of schools across Wales have achieved the NQA award. There is a national target to have 10% of all maintained schools in Wales achieving an NQA award by 2015, rising to 20% by 2020.

A Task and Finish Group is currently finalising criteria for Healthy Further Education and Higher Education. It is expected that this will be launched in summer 2014.

Fresh Start Wales - The Fresh Start campaign to tackle smoking and exposure to second-hand smoke in cars by children was launched in February 2012 and is scheduled to run until March 2014. Children are particularly vulnerable to the effects of second-hand smoke and are more likely to develop long term conditions such as asthma at an early age which will affect them for the rest of their lives. Since its launch, there has been extensive promotional activity across Wales and over 29,000 Fresh Start packs, to help smokers protect themselves and their families from second-hand smoke and to support them to give up smoking, have been distributed.

The Tobacco Control Action Plan was launched in February 2012 as a development of existing Welsh Government policies. This includes building on our programme of measures to discourage young people from starting to smoke. Funding of £1.0m has been made available in 2014-15.

Teenage pregnancy – The teenage conceptions rate is continuing to decline and was 40.1 per thousand girls aged 15-17 in 2009. Action to further this reduction is being supported by the Empower to Choose project which was introduced by Public Health Wales in April 2012. The project consists of awareness and raising and education of Long Acting Reversible Contraception (LARC) and an audit of contraceptive advice given to pregnant teenagers.

The Integrated Family Support Services (IFSS) is a statutory scheme to help some of the most vulnerable children and families in Wales. Services focus on families where parents have particular and challenging problems that affect the welfare of their children. IFSS teams started work on 1st September 2010 and by 2014 will operate across Wales. We have made significant financial and other investment in building capacity and skills not just those of the IFSS teams themselves, but training professionals and others across their partnership in key techniques. These techniques help the professionals to better engage families and to embrace the ethos of working with the families strengths to empower them to effect changes in their lives. In 2013-14, when IFSS is fully rolled out, over £4.5m will be made available to local authorities (who must agree expenditure with their LHB partners). Funding profiles will be agreed through the regional statutory IFSS Boards, to support a minimum of 10 statutory IFS teams across Wales. This funding level is scheduled to be maintained for the 2014-15 and 2015-16 and is contained within the Children’s Social Services Action.

The Social Services Directorate also provides significant support to children and family organisations in the voluntary sector in Wales. Through the Family Fund Trust and Children and Families Organisation Grant we contribute over £3.9 million directly to the third sector. These grants support both projects and capacity within the sector, often directly aiding the most vulnerable children and their families. For example:

· The Family Fund Trust, which receives annual funding of £2.6m contained within the Children’s Social Services Action, provides grants and information in relation to children's care including holidays, transport, household equipment and driving lessons to families of severely disabled children up to the age of 18.

· The Children and Family Organisation Grant (£1.3m within the Children’s Social Services Action) supports a variety of organisations and initiatives. Examples include money to Voices from Care providing support to Looked after Children and care leavers, and the Fostering Network who support and advise those who act as foster carers across Wales.

Additionally through the implementation of the Autistic Spectrum Disorder Strategic Action Plan, (£1.9 million within the Adult and Older People Action) is provided to support both children and adults with autism in Wales. This includes funding for small regional projects delivered at the community level and support for adults with Aspergers Syndrome.

Additionally, the Welsh Government is committed to maintaining its work to safeguard and protect the most vulnerable in society. Our safeguarding budget of £0.7m which is contained within the Children’s Social Services Action supports a variety of initiatives to strengthen arrangements across Wales, in areas such as neglect, child trafficking, child sexual exploitation and child death reviews. It is also supporting our work to put in place a new National Safeguarding Board and new regional arrangements for Local Safeguarding Children’s Boards. This budget has been maintained for 2014-15 and this work will continue to be extended as we seek to provide an equivalent framework for adult protection, including the implementation of adult practice reviews.

Child and Adolescent Mental Health Services (CAMHS)

Mental health accounts for the largest single area of health expenditure in Wales at approximately 12% of the NHS budget. Our continued commitment to mental health is demonstrated by ring-fenced funding (the minimum LHBs should spend on mental health services) which has increased year-on-year from £387.5 million in 2008-09 to £577 million in 2012-13 and just under £587 million in 2013-14.

CAMHS total spend, published in the annual NHS programme budget expenditure analysis, totalled £51.4 million in 2011-2012 [latest published data].

Forensic CAMHS £0.5m

Multidisciplinary teams targeted towards young people deemed to pose a high risk, who have histories of violent behaviour, but who are based in the community. The teams work closely with families and carers and provide a quick response service. They work closely with other specialist service providers and Youth Offending Teams.

Extending the Age range to 18 - £0.7m

Additional staff have been recruited and LHB CAMH Services now provide services up to the age of 18 years. Welsh Government continues to consolidate and monitor the impact of work to achieve the requirements of section 31 of the Mental Health Act 1983 for age appropriate accommodation and age appropriate in-patient accommodation for young people under 18 within adult mental health facilities.

Learning Disability £0.5m

Studies have identified that there is a higher rate of diagnosable mental disorder in children with learning disabilities, establishing this as 35-40%. It has further been established that whilst more than 50% of children with severe learning disabilities have significant mental health problems, only a small percentage receive services.

Fostering good working relationships between CAMHS services and Learning Disabilities services is a key issue in Together for Mental Health in terms of building an individual’s resilience.

Consultant Nurses £0.7m

Two nurses located in Betsi Cadwaladr and Aneurin Bevan LHBs since 2004 (though working strategically across LHBs) delivers and evaluates the care, support and educational needs of children and adolescents suffering from mental health disorders. The post holders provide direct engagement with children, adolescents and their families, as well strategic development of Specialist CAMHS, including service developments, nursing education and R&D activity; and operational management of Specialist CAMH nursing services.

Primary Mental Health Workers £0.3m

Part 1 of the Mental Health (Wales) Measure reasserts the responsibility of health and social care to work in partnership to provide Primary Mental Health Workers (PMHWs) within CAMHS as part of core services.

Advisor in Child and Adolescent Psychiatry to the CMO £0.05m

A Service Level Agreement for the time (4 sessions per week) to act as the CMO Adviser in Child and Adolescent Psychiatry providing professional support and clinical advice to the policy division and others across Welsh Government as appropriate.

Parc Prison In-reach £0.050m

Young Offenders Institute Parc has places for 64 young men, aged 15 to 17 years old. Until 2009, If a young person had an identified/established CAMHS need whilst in Parc, they would have been sent to a secure juvenile unit in England to be assessed, but concerns about the health needs of those in Parc remained. To ensure appropriate clinical care was available, in 2009 it was agreed to provide forensic CAMHS in-reach service into the juvenile unit at Parc. Funding provides the salary of a specialist mental health nurse at Parc to work with the Tier 1 and 2 healthcare staff based there.

Attention deficit hyperactivity disorder (ADHD) Background

ADHD is treated within mainstream mental health services in common with other conditions with treatment provided on the basis of clinical need of the individual.

The diagnosis and treatment of ADHD is guided by NICE guidelines, and, as with all NICE guidelines, the responsibility for delivery lies with the Health Boards. The guidelines recommend medication is the treatment of choice for the majority of cases. CAMHS services are aware of the needs of this particular group and the Royal College of Psychiatrists identifies ADHD as being within the remit of specialist CAMHS. CAMHS services also have strong working relationships with schools and others to enable problems to be highlighted and addressed at an early stage.

By identifying and tackling issues early further problems developing later in life can be preventable. Together for Mental Health emphasises the need for services to work together and to strengthen the links between CAMHS and adult services so that young people transfer seamlessly and continue to receive the help and support they need.

Social Services

The Social Services programme portfolio encompasses a range of activities that incorporate both preventative and non preventative intervention.

Many specific preventative initiatives carried out within the sector are funded through the Revenue Support Grant to local authorities, or specific grants such as Invest to Save or Supporting People. The Department supports and leads these developments through its leadership and programme approaches, but does not directly fund them.

One key area that can be considered as preventative spending is the Integrated Family Support Service. In 2014-15, £4.5m will be provided from the Children’s Social Services Action to local authorities, who will agree funding profiles through the regional statutory IFSS Boards to support a minimum of 10 statutory IFSS teams across Wales.

Children and Young people’s budget statement

For the reasons explained at the beginning of this paper, it is not possible to provide a budget statement for the health and social services expenditure on children and young people.

Children's Rights

CAFCASS Cymru has a vital role in supporting children and families in Family Court proceedings. We advise the courts on the best course of action on what we consider to be in the best interests of individual children.

The child’s future welfare is at the heart of every decision made and every

action taken by CAFCASS Cymru. Our purpose is to safeguard the child and

ensure their voice is heard within proceedings, particularly during this period

of significant reform within the Family Justice System

Children’s Rights Impact assessment for 2014-15

The work of the Health and Social Services Department is underpinned by the United Nations Convention on the Rights of the Child (UNCRC) and our duty to have regard to the rights of the child have been factored in to the overall departmental budget planning process.

At the individual policy and programme level, for example, our ‘Designed to Smile’ initiative considered the oral health status and future dental needs of children in Wales. In relation to legislation, the Children’s Rights Impact assessment completed for the Human Transplantation (Wales) Bill recognises that it will be important for children to be provided with information at the right time so they can understand that at the age of 18 the new soft opt-out system will apply to them. These are just a few examples of how the Department’s policy interventions take account of our responsibilities to have due regard to the UNCRC and we will continue to ensure that we strengthen our arrangements to support this.

ANNEX A to CYP Committee Paper – Scrutiny of Draft Budget

1. Children’s Social Services

This funds a range of programmes and policy developments to support vulnerable children, including Integrated Family Support Services and work on safeguarding and protection. There is no change to this Action.

2. CAFCASS Cymru Programmes

CAFCASS Cymru is a child – focused social work organisation, which provides expert social work advice to family proceedings courts, the County Courts and the High Court. Funding here supports the organisation’s core duties, as well as obligations under the Children & Adoption Act 2006 including the provision of contact centres and contact activities. There is no change to this Action.