Cynulliad Cenedlaethol Cymru

Y Pwyllgor Plant, Pobl Ifanc ac Addysg

Gwaith dilynol ar yr adroddiad Cadernid Meddwl

MOM: 29

Ymateb gan:  Coleg Brenhinol Pediatreg ac Iechyd Plant



National Assembly for Wales
Children, Young People and Education Committee

Follow-up on the Mind over Matter report

MOM: 29

Response from:  Royal College of Paediatrics and Child Health (RCPCH)



About the RCPCH

The RCPCH works to transform child health through knowledge, innovation and expertise. We have over 500 members in Wales, 14,000 across the UK and over 17,000 worldwide. The RCPCH is responsible for training and examining paediatricians. We also advocate on behalf of members, represent their views and draw upon their expertise to inform policy development and the maintenance of professional standards.

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.


RCPCH comment: We have seen increased investment with recruitment and enhanced services but it is less clear that the new services are part of a wider whole system approach.

RCPCH member feedback suggests that the role of Primary mental health in the wider plan for intervention and support to CYP requires consideration as does basic process as there are opportunities for increased efficacy which would require both local operational and national strategic consideration.

A member provided the following example to illustrate this:

The “refer “on structure can interfere with a more holistic or efficient approach - clarification as to whether this is a national concern would be helpful as in some localities (possibly all)  if a paediatrician identifies that an assessment /intervention in primary mental health could be beneficial to a child that they have seen they cannot access this service - they contact the GP who then contacts PMH - is there an opportunity to further improve this system?


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.


RCPCH Comment: It is helpful to have defined pathways, referral criteria and standards for CAMHS services, however this may have a tendency to increase pressure on the ‘missing middle’: as specialist CAMHS services become more defined, more children who do need support may not meet the criteria for CAMHS services and therefore require alternative support or services.


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.


RCPCH Comment: We are aware that recruitment is happening and there is work in progress on these issues. We hope that the next phase of Together 4 Children and Young People will make further progress on these issues. We welcome the continued funding and hope that the next phase will increase and improve integration to deliver a whole system approach, with the Whole School Approach agenda forming part of this, alongside health services, Regional Partnership Boards and local services.


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.


RCPCH comment:

We welcome the progress made to date on Neurodevelopment and recognise the output from the first phase of the T4CYP workstream notably with regard to national pathways, guidance, data collection and clinical toolkits.

This work alongside proposed input from the NHS Delivery Unit will assist in the process of defining the data for publication and increasing validity and transparency - this is however work in progress and effort must be sustained to achieve this by 2021

The greater concern expressed by college members is the pressure on families and professionals resulting from demand for both assessment and intervention in relation to ND. We have previously highlighted concerns around demand and capacity in relation to ND services in the context of Welsh Government proposals for a Code of Practice on Autism Services – you can see our full response here.

National guidance has provided a framework to develop and improve services however this advice now needs to be implemented and the mechanism to achieve this needs to be shared with the stakeholders and linked to resource and support. Clinicians are concerned that financial pressures could prevent this change occurring. An example highlighted by a member is a freeze on administrative staff recruitment in some health boards - colleagues have lived experience of the impact this has on a service’s capacity to apply a prudent or efficient process. This is all the more critical when we know that there is a workforce deficit with the skilled clinicians - we need to use their time very prudently.

There is therefore good work happening at a strategic level, the key issue remains around capacity and demand and effective delivery.


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.


RCPCH Comment: The Welsh Government has set up a programme of work looking at transitions (or handovers) from paediatric to adult services and paediatricians did take part in meetings of a Board set up by the Welsh Government as part of that project. We note that the Welsh Government is currently consulting on guidance for healthcare services, dealing with children and young people as they move to adults’ services. We will give this consultation our consideration and respond in due course.


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.


RCPCH Comment: We are currently working on the latest workforce census and hope to have a report looking at the picture in Wales late in 2020, which we will share with this Committee. The latest census will include an expanded section on Community Paediatrics, which will be highly relevant to the work around Mind Over Matter.

We are in regular contact with Welsh Government officials who have given assurances that they will encourage health boards to respond. We recently ran a survey on emergency paediatric care and are pleased to report that we got a 100% response rate from Wales (we are currently analysing results to publish in due course).


Further comments:

The Committee may wish to note the following two reports, which illustrate some of the challenges faced by community paediatricians relevant to this work:


·         Community paediatric workforce - short report (2017)


·         Workforce census: Focus on vulnerable children and families paediatric workforce (2020)