1
Introduction
1.1.1
Public Health Wales welcomes the opportunity to respond to the
Consultation on the emotional and mental health of children and
young people.
1.1.2
Public Health Wales has stated as one of seven Strategic priorities
that we will ‘Work across sectors to improve the future
health and well-being of our children. In our current Strategic
Plan 2017-2020, Public Health Wales has sought to place equal
emphasis on both mental and physical health in the delivery of our
priorities, as it is understood that health, well-being and a
reduction in health inequalities can only be achieved by focusing
on both physical and mental well-being. Our work to develop our new
10 Year Strategy has already highlighted that greater prominence
must be given to mental health and wellbeing across the life
course. The Mental Health/Learning Disability improvement team in
Public Health Wales 1000Lives has prioritised and supported the
improvement of Specialist CAMHS at both national and locality
levels.
1.1.3
Public Health Wales contributes to the ten year mental health
strategy, ‘Together for Mental Health’ through
actions under a number of our priorities. Public Health Wales
actively supports the Together for Children and Young People
Programme, with representation at the Programme Board and the
Project Group and specialist input to two of the workstreams (the
Resilience and Early Intervention Workstream and the
Neurodevelopmental Workstream).
1.1.4
In support of the Together for Children and Young People Programme,
Public Health Wales has undertaken a Child and Adolescent Mental
Health Needs Assessment (available at
http://www.goodpractice.wales/SharedFiles/Download.aspx?pageid=185&mid=326&fileid=329
).
1.1.5
Public Health Wales seeks to improve population mental health
through the promotion of mental wellbeing and prevention of mental
health problems at the population level, focussing on the universal
approaches that reach children and young people through the home
and educational settings.
2
Specialist CAMHS
2.1
The extent to which new (and/or reconfigured) services are helping
to reduce waiting times in specialist CAMHS. Whether the
improvements in waiting times Welsh Government expected from CAMHS
have been met.
2.1.1
Whilst CAMHS has participated in national benchmarking of service
utilisation and capacity, there remains an absence of nationally
agreed standards for quality and performance measurement and
monitoring, with the exception of ‘waiting times’.
Various measures and data metrics are used, but there remains a
lack of nationally agreed data definitions to ensure robust
comparison between services across health boards and localities in
order to better interpret and understand differences between them
on the ‘timely’ provision of assessment, diagnostic and
treatment services. Public Health Wales is working with Welsh
Government on a standardised set of data metrics/measures for
national monitoring, including performance and quality standards.
It is planned that these be integrated within the forthcoming Wales
Community Care Informatics Solution (WCCIS, the joint HB and Local
Authority Information Technology system being developed by NWIS).
When this IT system is in place in all local services they will be
able to demonstrate systematically whether new (and/or
reconfigured) CAMHS services are delivering improvements in waiting
times on other quality and performance measures.
2.2
What the data tells us about the variations in practice (equity of
access) across Wales.
2.2.1
In light of the challenges presented by current data metrics
assessment of variation across Wales is difficult. More robust and
reliable data is available from the two improvement programmes that
the team currently support, (i) for Neurodevelopmental Services and
(ii) early intervention psychosis services. Both demonstrate the
variation in practice (and therefore inequity of access) across
Wales that is generally more widely reflective of CAMHS provision
across Wales.
2.2.2
The Together for Children and Young People programme national work
stream for Neurodevelopment (ND) Services for children and young
people covers all ND conditions (including Autism Spectrum Disorder
(ASD), attention deficit
hyperactivity disorder (ADHD) andTic Disorders) and links to the All Wales Group for
Learning (Intellectual) Disability service improvement.
2.2.3
Provisional audits of new ND services in 2016 and 2017 reveal
variations in practice (and equity of access) across Wales. The new
ND service teams funded since 2015 have inherited historic waiting
lists for specialist assessment and diagnosis from pre-existing
services, with some having inherited waiting times well over three
years - from receipt of a referral to first face to face
consultation (diagnostic assessment) meeting.
2.2.4
Referrals in 2017 range from 200 to almost 900 people per annum and
waiting lists from 100 to 600 people – adjusted rates per
100,000 local Heath Board population. This significant variance in
the demand for, and provision of ND services across Wales, reflects
the different historic patterns of service development in many
localities and a level of ‘unmet’ need which is more
readily identified now that the new ND services are establishing a
single point of local access under an all-Wales ND pathway.
2.2.5
The establishment of a new service, and publicising its
availability, focuses previously ‘unmet’ need to
present at the front door/access point of the service. The ND
National Steering Group (NSG) is working to reduce such variance.
The focus has been on access for assessment and diagnosis. The NSG
is now working on access to evidence based service
interventions.
2.2.6
The 2010 ‘intelligent target’ for First Episode
Psychosis (FEP) services aimed to implement evidence based services
for young adults with an emerging psychosis and to reduce the
Duration of Untreated Psychosis (DUP). At that time only two Health
Boards provided bespoke FEP or Early Intervention Psychosis
services (ABUHB and HDUHB). Only more recently have all
health boards begun to develop bespoke FEP services, largely in
response to the 2015 allocation of new funding for Early
Intervention in Psychosis by the Welsh Government. There is
currently a significant variation in service capacity and provision
across the health boards.
2.3
The extent to which changes have addressed the over-referral of
children and young people to CAMHS.
2.3.1
The concept of ‘over-referral’ to CAMHS is a function
of the availability of alternative early intervention services;
population need and effective referral management systems.
These take time to develop and implement. In addition making
comparisons requires robust and consistent data which enables
comparisons to be made between different service models.
2.4
Referrals and access to CAMHS by individual Health Board, including
the restrictions and thresholds imposed by CAMHS
2.4.1
Public Health Wales does not have an evidenced based view on this
due to the absence of reliable nationally standardised data.
Anecdotal data and national service improvement work indicates that
families, education, social services and GP’s etc, all
routinely report experience of boundaries and restrictions in
timely access to CAMHS, and also the newly developing
Neurodevelopmental services. The establishment of routine Patient
Reported Experience Measures (PREMS) and their equivalent for
families and professional referrals will be able to evidence
change. The use of a range of outcome measures, including Patient
Reported Outcome Measures (PROMS) must be part of routine practice
and data collection. A set of routine outcome measures/tools was
agreed by CAMHS in 2015-16 and will be implemented as integral to
the roll out of the WCCIS.
2.5
Whether the changes have helped to improve specialist CAMHS’
ability to respond out of hours and at times of crisis; whether out
of hours care is working effectively, and specifically looking at
the needs of those children and young people who present and are
assessed at hospital A&E departments.
2.5.1
Public Health Wales does not have an evidenced based view on this
due to the absence of reliable nationally standardised data.
Anecdotal data and national service improvement work
indicates that the expansion of Community Intensive treatment teams
has improved the out of hours service and decreased the use of out
of area beds. It is anticipated the Welsh Governments 2015 funding
to expand Liaison Psychiatry services will improve assessment and
response at Accident and Emergency departments. The Public Health
Wales 1000Lives Improvement team is establishing a national
Community of Practice for the new Liaison Psychiatry services in
November 2017.
2.6
Whether there is sufficient in-patient capacity in Wales.
2.6.1
Public Health Wales inputs to and supports the delivery of the
review of Tier 4 CAMHS services, perinatal mental health services
and eating disorder services led by WHISC. Further work will
be required to enable this question to be fully addressed.
3
Funding
3.1.1
Health Boards will be best placed to advise and comment on how
funding has been utilised to support the goals and objectives of
the Together for Children and Young People Programme.
3.1.2
Public Health Wales is aware that considerable developmental work
has been undertaken by Health Boards across Wales to improve their
understanding of the issues in their individual health board
localities and to begin to utilise the available information to
inform improvement action.
3.1.3
There is general recognition that mental health services have not
always received sufficient recognition when funding decisions are
being made. We would also reflect that to date the emphasis
on funding allocation has been in improving specialist CAMHS when
the greatest gains are likely to be made by strengthening universal
prevention and early intervention services and improving the
capacity of the whole system to respond to the needs and concerns
identified by children, young people and their families.
4
Transition to Adult Services
4.1
How well planned and managed transitions to adult mental health
services are.
4.1.1
Public Health Wales supports and endorses the recent national
guidance and standards for improving Transitions from CAMHS which
has been developed under the T4CYP programme. Evidence of its
impact has yet to be developed.
5
Links with Education (emotional intelligence and healthy coping
mechanisms):The work being done to ensure children and young people
are more resilient and better able to tackle poor mental well-being
when it occurs including:
5.1
The development of the Health and Wellbeing Area of Learning and
Experience as part of the new curriculum.
5.1.1
Universal approaches such as the introduction of a new curriculum
in all schools are essential if improvements in population outcomes
are required. Building the foundations for good mental health and
wellbeing for all children and young people should be the starting
point for any strategic programme to improve mental health
outcomes. It is never too early to promote positive mental
wellbeing. A focus on improving infant mental health and supporting
the development of secure parent – child attachment provides
an opportunity to improve mental health across the
lifecourse. In addition to a focus on parenting and infant
mental health and wellbeing; schools are well placed to support the
development of mental health and wellbeing in school aged children
and young people.
5.1.2
Public Health Wales has been working to support the Welsh
Government’s curriculum reform programme. The approach
being taken by the Health and Wellbeing Area of Learning and
Experience is encouraging. The work by the pioneer schools to
date has demonstrated an excellent understanding of the role that
schools can play in developing healthy and confident
individuals. There is much work still to do in shaping the
detail of the curriculum but the work to date is in our view
consistent with the evidence base and priorities in this
area. Public Health Wales will continue to support the AoLE
as it continues its work.
5.1.3
In addition Public Health Wales has been reviewing and
strengthening the criteria of the Wales Network of Healthy Schools
Scheme (WNHSS) in respect of emotional and mental health. The WNHSS
provides a platform for progressing action at school level in
respect of health and wellbeing, including building resilience and
emotional wellbeing and developing healthy personal relationships.
A school which achieves the National Quality Award will be
providing an environment; curriculum and support services which
will support young people’s health and emotional
development. This whole school approach is consistent with
the international evidence base and best practice. The
involvement of almost 100% of schools in Wales in the scheme means
that we have an excellent platform on which to build; complementing
the work of the curriculum reform programme.
5.1.4
A selection of those delivering the WNHSS have been involved in the
WISE study a Randomised Controlled Trial with DECIPHER at Cardiff
and Bristol Universities to examine the mental health of staff and
pupils in secondary schools.
5.1.5
Public Health Wales hosts the ACEs Hub and has collaboratively
developed and is supporting a feasibility study to consider what
taking an ACE-informed whole school approach in schools in Wales
would involve. Public Health Wales is of the opinion that an
ACE-informed approach must be strongly underpinned by existing
initiatives within schools.
5.1.6
One of the challenges currently is to bring together at a strategic
level programmes of work relating to young people and mental health
and wellbeing across policy areas. There has been a
commitment to joint working to date; however strengthening the
cross government and cross programme working in this area would be
beneficial.
5.2
Children’s access to school nurses and the role schools
nurses can play in building resilience and supporting emotional
wellbeing.
5.2.1
There are a number of professionals who can contribute to this
important agenda and support schools in meeting the mental health
and wellbeing needs of their pupils.
5.2.2
The availability of school nurses in Wales has been subject to
review and development in recent years but we believe there is much
still to do. School nurses should be the first point of
contact for schools in assessing the needs of individual pupils and
signposting to the most appropriate support and help.
Currently, there is variable practice across Wales in this area
largely determined by the demands on school nursing from
immunisation and safeguarding activities. While these areas
are of course important priorities in themselves there would be
value in reflecting on the role of the school nurse in the
future.
5.2.3
When we talked with children and young people few were aware of the
school nurse and had any contact with them. It was clear that
there was a lack of knowledge and understanding in many schools of
the school nurse as a source of advice and support to pupils.
5.2.4
It is essential that the School Nursing workforce is skilled and
confident to address the issues of greatest concern to children and
young people and this would include mental health.
5.2.5
We would not expect to see school nurses contributing directly to
curriculum activity in this area as this would not represent best
use of their skills and expertise.
5.3
The extent to which health, education and social care services are
working together.
5.3.1
It is noted that there are considerable challenges presented in
co-ordinating the activity of health professionals/ bodies working
to improve the mental wellbeing of children and young people, those
working on educational reform and action on pupil well-being and
the ACE’s agenda. Public Health Wales recognises these
challenges and is playing a key role in strengthening the
integration of these issues and the closer working of professionals
across the system.
5.3.2
Public Health Wales will be supporting the new CAMHS in School
Liaison Services recently announced by the Cabinet Secretary; this
will be a further vehicle through which more effective joint
working can be established.
5.4
The take up and current provision of lower level support and early
intervention services, for example, school counselling
services.
5.4.1
Public Health Wales considered the role of school counselling
services as part of the Needs Assessment undertaken for the T4CYP
Programme. It was clear that school counselling services have
the potential to support pupils in relation to their emotional and
mental health but that inconsistency in data collection and
reporting meant that it was difficult to assess the true impact of
these services across Wales as a whole.
5.4.2
It would also be beneficial if General Practitioners were more
aware of the availability of these services and could support young
people to access them where they identify that less specialist
support is required.