Cynulliad Cenedlaethol Cymru The National Assembly for Wales Y Pwyllgor Plant, Pobl Ifanc ac Addysg The Children, Young People and Education Committee
Dydd Iau, 17 Gorffennaf 2014 Thursday, 17 July 2014
Cynnwys Contents Cyflwyniad, Ymddiheuriadau a Dirprwyon Introductions, Apologies and Substitutions Ymchwiliad i Wasanaethau Iechyd Meddwl Plant a'r Glasoed—Sesiwn Dystiolaeth 5 Inquiry into Child and Adolescent Mental Health Services—Evidence Session 5 Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o’r Cyfarfod Motion under Standing Order 17.42 to Resolve to Exclude the Public from the Meeting....
Cofnodir y trafodion hyn yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. These proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included.
Aelodau’r pwyllgor yn bresennol Committee members in attendance
Keith Davies	Llafur Labour
Suzy Davies	Ceidwadwyr Cymreig Welsh Conservatives
Bethan Jenkins	Plaid Cymru The Party of Wales
Ann Jones	Llafur (Cadeirydd y Pwyllgor) Labour (Chair of the Committee)
Lynne Neagle	Llafur Labour
David Rees	Llafur Labour
Aled Roberts	Democratiaid Rhyddfrydol Cymru Welsh Liberal Democrats
Simon Thomas	Plaid Cymru The Party of Wales
Eraill yn bresennol Others in attendance
Mark Drakeford	Aelod Cynulliad, Llafur (y Gweinidog Iechyd a Gwasanaethau Cymdeithasol) Assembly Member, Labour (Minister for Health and Social Servcies)
Jo Jordan	Cyfarwyddwr Gwasanaethau Corfforaethol a Phartneriaethau, Llywodraeth Cymru Director of Corporate Services and Partnerships, Welsh Government
Dr Sarah Watkins	Uwch-swyddog Meddygol, Llywodraeth Cymru Senior Medical Officer, Welsh Government
Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol National Assembly for Wales officials in attendance
Steve Davies	Cynghorydd Cyfreithiol Legal Adviser
Sarah Bartlett	Dirprwy Glerc Deputy Clerk
Sian Thomas	Y Gwasanaeth Ymchwil Research Service
Marc Wyn Jones	Clerc Clerk
Dechreuodd y cyfarfod am 09:01. The meeting began at 09:01.
Cyflwyniad, Ymddiheuriadau a Dirprwyon Introductions, Apologies and Substitutions
[1] Ann Jones: Good morning, everybody. Welcome to the Children, Young People and Education Committee. It is the last meeting of the term, but I will still do the housekeeping rules; perhaps, next term, we might dispense with them, as we all know them. If you have your mobile phone on, can you switch it off? While it does not affect the broadcasting or the translation, it probably will irritate me, and I will start a charity box—it will be £10 into a charity box. So, it is just out of courtesy to other people. We do not expect a fire alarm. If there is an alarm, we will take our instructions from the ushers. We operate bilingually, as you know. Channel 0 is for amplification of the floor language. Channel 1 is for the translation from Welsh to English. We have apologies from Angela Burns. Angela is on long-term sick leave, and we hope that she is making good use of this nice weather that we are having. We send her our best wishes, and I am sure that she will be back soon.
09:02
Ymchwiliad i Wasanaethau Iechyd Meddwl Plant a'r Glasoed—Sesiwn Dystiolaeth 5 Inquiry into Child and Adolescent Mental Health Services—Evidence Session 5
[2] Ann Jones: I do not know whether anyone wants to declare any interests that they did not declare when we first started looking at this. I see that no-one does. Okay.
[3] We are joined in the gallery by some of the young people some of us met when we were out and about doing our research. After this session with the Minister, we are going to have 10 minutes with them, during the break. It is great to see them all coming in; that is really good.
[4] Our public session today is with the Minister for Health and Social Services, Mark Drakeford. Mark, we are very grateful to you for coming; I know that you are short on time. Do you want to introduce your officials? Then, if it is okay with you, we have four areas of questioning that we want to go through in three quarters of an hour. So, we are going to try to move it along.
[5] The Minister for Health and Social Services (Mark Drakeford): Fine; thank you, Ann. I am joined by Dr Sarah Watkins, who is the professional lead on mental health services in the Welsh Government, including child and adolescent mental health services, and Jo Jordan, who is a senior policy official on that side of my department.
[6] Ann Jones: Thanks for your evidence, and thanks for coming in. As I say, we have four areas to cover, and we are going to talk about access to CAMHS, resources for CAMHS, Welsh Government oversight of CAMHS, and then structure and delivery of the CAMHS service. Those are the four areas, and I am going to try to get through as many of the questions as possible—Members have quite a lot from when we took our groupings. The first set, then, on access, is from Simon and Keith.
[7] Simon Thomas: Rwy’n barod i ddechrau. Bore da.		Simon Thomas: I am ready to start. Good morning.
[8] Mark Drakeford: Bore da.		Mark Drakeford: Good morning.
[9] Simon Thomas: Wrth inni gasglu tystiolaeth yn yr ymchwiliad hwn, y math o beth a oedd yn cael ei ddweud wrthym yn gyffredin iawn oedd bod ceisiadau ar gyfer gwasanaeth CAMHS yn cael eu gwrthod heb eglurhad, a bod hyd yn oed gyfeiriadau gan feddygon teulu i wasanaeth CAMHS yn cael eu gwrthod. Roedd sôn mai dim ond pobl broffesiynol ymhlith rhieni a oedd yn gwybod y drefn, ac mai dim ond rhieni a chanddynt gefndir meddygol eu hunain a oedd yn gallu llywio drwy’r system a chael y gefnogaeth angenrheidiol i’w plant. Roedd rhestrau aros ar gyfer cefnogaeth arbenigol CAMHS yn 19 mis mewn un ardal ac yn 16 mis mewn ardal arall. Felly, i ddechrau, a yw’r dystiolaeth rydym wedi ei chael fel pwyllgor yn dystiolaeth rydych yn ei chydnabod fel rhywbeth sy’n digwydd yn y system ar hyn o bryd?		Simon Thomas: As we collected evidence in this inquiry, the type of thing that was said to us generally was that requests for CAMHS were refused without explanation, and that even referrals by GPs to CAMHS were refused. There was talk that it was only professional people among parents who knew what was going on, and that only parents with a medical background were able to navigate the system and obtain appropriate support for their children. Waiting times for specialist CAMHS support was 19 months in one area and 16 months in another. Therefore, to begin with, is the evidence that we have received as a committee evidence that you recognise as something that is seen in the system at present?
[10] Mark Drakeford: I recognise the evidence in some ways, but what I want to say in general in response to Simon’s question is that I do not believe that we will get a sensible approach to specialist child and adolescent mental health services if we focus just on whether supply is sufficient to meet the demand. We have to look at the nature of the demand as well. There has been a 100% increase in referrals to the system over a four-year period. I cannot imagine that anyone would think that the amount of mental ill health among young people in Wales has doubled since the year before the last Assembly election. Derek Wanless told us a decade ago that, in the health field, if you think that the answer is always to go on ratcheting up supply to meet demand, you will never reach a point where the system is in balance. So, it is very important that CAMHS see the right sort of young people. It is a specialist service, not a generalist service. I worry about the fact that, with the number of people being referred into it and the waiting times that then result from that, there are young people who really do need a CAMHS service, people with the early onset of psychosis, very severe depression, or an eating disorder problem that is escalating, who may not be seen in a timely fashion because all sorts of other people who are not proper candidates for CAMHS but who need a different sort of service are there waiting to be seen in front of them. So, dealing with the nature of demand is very important in this field.
[11] Simon Thomas: Mae awgrym yn eich ateb nad yw gwasanaethau gofal cynradd yn cydnabod yr angen am gymorth a chefnogaeth gynnar ymysg pobl ifanc gyda phroblemau iechyd meddwl. I droi’r cwestiwn ar ei ben, gallech ddadlau bod y cynnydd yn nifer y cyfeiriadau at CAMHS yn arbennig yn ffrwyth llwyddiant, o fath—hynny yw, ein bod yn fwy parod i gydnabod problemau iechyd meddwl ymysg plant a bod Mesur Iechyd Meddwl (Cymru) 2010 wedi bod yn llwyddiannus o ran codi ymwybyddiaeth o’r materion hyn. Fodd bynnag, mae’n dal i fod yn wir, o’r holl rai yng Nghymru sy’n aros mwy na 18 wythnos am driniaeth iechyd meddwl, mai plant yw’r cyfan, bron. Felly, mae dal i fod problem yn y gwasanaeth hwn.		Simon Thomas: There is a suggestion in your answer that primary care services do not recognise the need for help and support at an early stage among young people with mental health problems. To turn the question on its head, you could argue that the increase in the number of referrals to CAMHS especially is a sign of success, really—that is, that we are more ready to recognise mental health problems among children and that the Mental Health (Wales) Measure 2010 has been successful in raising awareness of these issues. However, it is still true that, of all of those in Wales waiting more than 18 weeks for mental health treatment, almost all are children. Therefore, there is still a problem with this service.
[12] Mark Drakeford: Rwy’n cydnabod bod problem yn hynny o beth, ond mae mwy o blant yn cael eu gweld o fewn yr amseroedd targed nag unrhyw gyfnod arall ers i ni gael CAMHS.		Mark Drakeford: I recognise that there is a problem in that regard, but more children are being seen within the target times than at any other time since we have had CAMHS.
[13] Simon Thomas: Rwy’n derbyn hynny, ond mae dal—		Simon Thomas: I accept that, but there is still—
[14] Mark Drakeford: Wrth gwrs, oherwydd bod mwy o bobl yn dod drwy’r drws. Mae’n bosibl dadlau, fel y mae Simon Thomas wedi ei wneud, bod hynny’n rhan o lwyddiant y gwasanaeth oherwydd bod mwy o bobl yn gwybod am y gwasanaeth ac yn fodlon ei ddefnyddio. Mae un pwynt yr hoffwn ei wneud.		Mark Drakeford: Of course, because more people are coming through the door. It is possible to argue, as Simon Thomas has done, that that is part of the success of the service because more people know about the service and are willing to use it. There is one point that I would like to make.
[15] The CAMHS end of the service is the specialist clinical end of the service. It is not intended, nor was it ever intended, to be the whole of the answer to young people who are experiencing difficulties as they are growing up and whose mental wellbeing needs to be attended to. I am, as I have said many times on the floor of the Chamber, always anxious that drawing a young person into a specialist mental health service labels them in a way that lives with them for a very long time during their lives. We are by no means at a point where such a label does not have costs with it in terms of stigma and other impacts on young people’s lives, so we should always be attending carefully to that border line to make sure that those people who need a CAMHS service get it and that those young people whose needs can be better attended to by the more universal and general services get the help that they need there. It is not an argument about not getting help; it is about making sure that you get the help in the right way and in the right part of the system. There is certainly more that we can and need to do to make sure that those people who come across young people in those circumstances feel that they are equipped and skilled enough to be able to respond to them and do not feel, ‘Here is something that I am not sure what to do with. I know what I will do: I will refer them on to somebody else. I have discharged my responsibilities by passing that child elsewhere.’
[16] Simon Thomas: I know that you have made that point previously, Minister, but I have to return to the core evidence that we were finding, which is whether your explanation is correct or not. For the young person concerned, they feel cast adrift, uncertain of where they have been referred and uncertain of where they are going to get the help. Again, the inference in your response to what we have examined at the specialist end of things is that the non-specialist, generic GP, and other community services, are not effective and efficient enough at early intervention. Early intervention was the key concept in the mental health Measure and how that was moved along, and that does not seem to be working either, if we, in turn, are seeing this massive increase in referrals to CAMHS, which, as you say, is not due, we assume, to that 100% increase in mental health problems among young people in adolescence.
[17] Mark Drakeford: I have one specific point and then one general point on that. Where we have evidence of the mental health Measure in relation to young people, what we find is that young people are receiving a service in primary care as a result of the Measure in greater proportions than the proportion of young people in the population. We do not collect that information routinely, but in the Aneurin Bevan health board, where they have collected the material, they found that over 7,000 people were being seen in primary care as a result of the Measure, with more than 1,500 of those being children—people aged under 18. So, more than 21% of all of those people seen within primary care as a result of the Measure were children or young people. Take it as fact that babes in arms and toddlers do not use CAMHS, then about 12% to 14% of the population using mental health services are of the CAMHS age, yet 21% of all referrals into the primary care side of the mental health Measure were for that age range. So, I do not think that the evidence, when you look at what we really know, is there to say that the Measure is not being effective with young people.
[18] I do agree with the general point that Simon Thomas is making, in that one of the reasons why we get this volume of referrals to CAMHS, and a high proportion of those then rejected by CAMHS as not being suitable for what they can provide, is because we need to strengthen the ability and the confidence of a wider range of lower-tier professionals to respond to the needs of those young people.
[19] Keith Davies: Ar yr un trywydd, roedd Simon yn dweud yn gynharach, ac mae’r ffigur sydd gennym yn y fan hon yn dangos, bod 2,400 yn aros i gael apwyntiad. Rydym wedi clywed gan bobl broffesiynol nad oes pwynt gwneud hyn o gwbl, weithiau, yn eu profiad nhw. Wrth edrych ar y tabl sydd gennym yn y fan hon, ac rydych wedi sôn am fwrdd iechyd Aneurin Bevan, mae’n dweud bod 648 yn aros i gael apwyntiad, ond wrth edrych ar y tabl ar fwrdd iechyd Hywel Dda, dim ond saith sy’n aros. Os ydych yn clymu’r ddau gyda’i gilydd, a yw’r bobl broffesiynol wedi penderfynu nad oes pwynt gwneud hynny gan nad ydynt yn cael apwyntiad?		Keith Davies: Along the same lines, Simon said earlier, and the figure that we have here shows, that 2,400 people are waiting for an appointment. We have heard from professional people that, sometimes, there is no point making referrals at all in their experience. Looking at the table that we have here, and you mentioned Aneurin Bevan health board, it says that 648 are waiting for an appointment, but looking at the table on Hywel Dda health board, only seven people are waiting. If you take those together, have the professional people decided that there is no point doing it because they are not getting an appointment?
[20] Mark Drakeford:  Of all of the things that I read in the evidence that has been put to you, I found that point very difficult to recognise or understand. If you have a service to which the referrals have doubled in a four-year period, and then argue that people are not bothering to make referrals—the two things cannot both be true. The actual evidence, rather than the opinions that people have put to you, is that people are referring to CAMHS like they have never referred before. So, the idea that people are thinking that it is not worth bothering is simply not borne out by the practice of people on the ground.
[21] Keith is absolutely right to point to the fact that things are different in different parts of Wales. In Hywel Dda health board, no-one waits for more than 18 weeks. In Betsi Cadwaladr health board, far too many young people wait for more than 18 weeks.
09:15
[22] We have instituted a national CAMHS improvement plan that we will put money into through the Welsh Government in securing fresh professional leadership for the plan, because what we see here are different professional practices in different parts of Wales. Not every service has been brought up to date in the way that we would like it. There has been very considerable improvement in Aneurin Bevan—the health board to which Keith referred—because of some extra investment of a relatively modest £80,000 that that board has made. The investment has not just tried to turn the handle faster on the service that it provides; it has been to remodel the service so that it is sure that it is dealing with the young people who really need the service, to strengthen other parts of the system to respond to other young people’s needs, and to change the pattern of the professional workforce so that you have more people available to see young people. I think that it has succeeded in reducing those over-18-week waits quite quickly.
[23] Ann Jones: We will now move on to the resources. I now turn to Lynne.
[24] Lynne Neagle: We have taken quite a lot of evidence that CAMHS feel under significant pressure. My questions are about the resources available for CAMHS. Minister, do you think that local health boards are spending the correct proportion of their money for mental health on CAMHS? We understand that less than 7% of the funding is spent on children and young people, whereas you have highlighted the much higher percentage of children and young people who are actually getting the service.
[25] Mark Drakeford: I do think that it is a more complex question than simply looking at the proportion within the population and then saying, ‘If you’re 20% of the population, you should get 20% of the spend’, because the nature of mental ill health is different in different parts of the population. Let us assume, for a moment, that there are four adults for every one child, yet in terms of admission into in-patient care, 100 adults have in-patient mental health treatment for every one child that does. So, that is a completely different pattern. The weight of expenditure in mental health services comes when you have to have in-patient treatment and when you have people who have very severe and long-lasting mental health conditions, which need resourcing in a way that the nature of children services does not. I am not saying that the split is right; I am not saying that 7% is the right figure, but I am saying that it is not quite as simple as saying, ‘Twenty per cent of the population are children, so how come 20% of mental health money isn’t spent on them?’ The nature of the service that they need, and the nature of the experience that they have means that the expenditure is not required in quite the same way. It is for local health boards to make those decisions. I know, because I have read some of the evidence that you have had, that the question of the mental health ring fence has been raised with you. You know that we have brought forward our review of the mental health ring fence, and I know that you raised the question with me in a letter from the Chair about whether the CAMHS part of that would be included in the review. I can confirm today that we have decided that it will be.
[26] Lynne Neagle: Thank you, Minister. I think that that is a very positive step. Sixteen and 17-year-olds were included within CAMHS in 2012. Have you expected LHBs to increase the amount that they spend on CAMHS since that change?
[27] Mark Drakeford: That is absolutely right that the views of the Children’s Commissioner for Wales and others led to that change. It was partly, certainly, inspired by concerns over transition and the fear that 16 and 17-year-olds, in particular, were falling between the two stools—neither children nor adults. They were always part of the spend of local health boards. These were not new people; they were receiving a service. Whether the spend is allocated on one side of the ledger or the other, I think that you could say that you would expect that. It is a distinction without a difference, in a way, because the money was being spent whether it was entered in one column or the other.
[28] Lynne Neagle: You referred to the impact of the Measure on children and young people. Have you made any assessment of whether the money that the Welsh Government allocated for the implementation of the Measure has been appropriately targeted at children and young people?
[29] Mark Drakeford: Well, Chair, you will know that the Measure operates in both primary and secondary care. I have said something already about primary care services. What I am told—and maybe Dr Watkins will want to add a bit to this—is that where the Measure has had its greatest impact in relation to children has been in the provision of a care and treatment plan for young people in secondary care. The previous practice was that adults—although not in sufficient numbers—by and large probably did have a care and treatment plan set out for them, but it was not the normal practice in relation to children and adolescents. It was a conversation between the child, the family and the service, without anything being set out. Now, 94% of all children receiving secondary mental health services have an agreed, worked out care and treatment plan. So, from our monitoring of the Measure, I think that we can see it having a real impact at secondary care level. We have not, as I said, done an across-Wales analysis of young people using primary mental health services as a result of the Measure. However, where we do have solid evidence, it is that they are receiving a service there in considerable numbers.
[30] Dr Watkins: Yes, and, when we undertook the review, we asked the LHBs and voluntary sector bodies to make sure that all ages undertook a service users’ satisfaction survey. We did not want children to be excluded from that. That was an interim review of the Measure. There is a full one that we will be completing by December 2016, because obviously it is critical that we do evaluate the Measure and how it is working for all sorts of people. Certainly, that is not to say that there may not be some changes that may be required, because it was new, it was groundbreaking, it was the first in the world. So, that review will take on board comments from children and young people. For example, some of the wording in the care and treatment plan may not be entirely appropriate for children. Certainly, psychology colleagues have said that the term ‘relapse signature’, if you do not have a diagnosis, is inappropriate, and they are probably right. So, there will be changes, but, broadly speaking, children should be accessing more services, because £3.5 million is a lot more money, and we think that it does help children and young people and their families to have a written care and treatment plan that shows you who to contact in a crisis and what the name of your key worker is. Service users, over and over again, tell us that that is what they want.
[31] Lynne Neagle: Okay, thank you. Just finally on staffing, the committee understands that, in Wales, we have less than 50% of the recommended number of CAMHS medical staff that the Royal College of Psychiatrists’ guidance recommends. Do you have any comment on that?
[32] Mark Drakeford: Chair, one of the things that I think I have learnt very strongly in the time that I have been Minister for health is that if you ask any royal college what needs to be done to improve the service, it is a bit like asking Assembly Members whether they think there should be more Assembly Members. Ask the Royal College of Psychiatrists, ‘What is the answer to problems in psychiatry?’ and the answer is, ‘More psychiatrists’, and that is true of any royal college at any time I have asked the question. There is no doubt at all that its ratios are aspirational. We do not know of any service anywhere that is meeting the guidelines that the royal college sets out. What we do know is that we have a better proportion of staff to need in Wales than they have across the border and that there was a 24% increase in staff within CAMHS during the last Assembly term. That is not to say that we would not like to strengthen the service. It is certainly not to say that there are not some recruitment hotspots. In another place, some of us have talked about eating disorder services and the struggle there can be sometimes to get psychiatrists who have a special interest in eating disorders among young people. We have talked elsewhere about consultant staff being able to offer a service through the medium of the Welsh language. I am not arguing at all that there is not more that we can do and that there are not some real issues where we have to find other ways of trying to make sure that young people get the service they need. However, to set the royal college standard as though this was something that was within anybody’s immediate grasp would not be true of Wales and would not be true of anywhere else either.
[33] Ann Jones: Simon, it is your question next, briefly.
[34] Simon Thomas: You mentioned one of the questions that I was going to ask you and that was about Welsh language provision. That, clearly, is still a difficulty in Wales. However, is there not a geographical aspect to this as well? Certainly, in the north Wales parts of my region, this is far worse than in other parts of my region. There is an issue here, is there not?
[35] Mark Drakeford: There certainly is an issue. There are geographical dimensions as well as professional expertise issues. We have been having a lot of conversations recently within Welsh Government and then with the profession about innovative ways in which we can provide services not just to young people, but in the mental health field more generally, in those parts of Wales where we do not have everything that we need. Yet, in Hywel Dda, nobody waits more than 18 weeks. So, it is not as simple as mapping geography onto the problem and saying that it is all in one part of Wales. As I have said previously when talking to some Members here, it is a combination of some telehealth—using people where we have them to talk to people remotely—and it is partly about using the wider range of staff that we have in the mental health team to be able to maximise the contribution they can make where they are available and others as may not be.
[36] Ann Jones: We turn now to the Government’s oversight of CAMHS. It is Aled first and then Suzy.
[37] Aled Roberts: Rwyf eisiau gofyn ichi a ydych yn fodlon bod trosolwg y Llywodraeth yn ddigonol. Rydym wedi cael tystiolaeth, er enghraifft, nad yw’r Llywodraeth yn cynnwys data o’r byrddau iechyd unigol ynglŷn â sut mae’r bwrdd iechyd unigol hwnnw’n gweithredu yn erbyn y targedau blynyddol o dan y fframwaith gweithredu. Felly, a ydych chi’n fodlon bod gennych ddigon o wybodaeth ganolog ar hyn o bryd?		Aled Roberts: I want to ask you whether you are satisfied that the Welsh Government’s overview is sufficient. We have had evidence, for example, that the Government does not include data from individual health boards on how that individual health board is operating against the annual targets under the implementation framework. Therefore, are you satisfied that you have enough central information at the moment?
[38] Mark Drakeford: Diolch am y cwestiwn. Rwy’n mynd i droi at Jo Jordan i esbonio’r system gyffredinol sydd gennym yn y maes hwn. Yr un peth rwyf wedi’i wneud yn yr amser rwyf wedi bod yn Weinidog dros iechyd yw sefydlu system lle rwy’n cyfarfod bob chwarter gydag is-gadeiryddion y byrddau iechyd, oherwydd gyda nhw y mae’r cyfrifoldeb yn y maes iechyd meddwl. Felly, rwy’n cwrdd â nhw; mae yn nyddiadur bob un ohonom. Bob tro rydym wedi siarad am CAMHS, rwyf wedi codi nifer o bethau gyda nhw ac maen nhw’n bwydo yn ôl i mi. Maen nhw’n ysgrifennu yn ôl am beth maen nhw’n ei wneud ac rydym yn siarad eto am y pwyntiau yr ydym wedi’u codi yn y cyfarfod nesaf. Felly, rwy’n teimlo fy mod i, fel Gweinidog, yn cael mwy o gyfle i gael effaith ar y system. Rwy’n trio codi proffil yr is-gadeiryddion o ran y cyfrifoldebau sydd ganddynt, yn enwedig yn y maes iechyd meddwl. Rwy’n meddwl bod hynny’n dechrau gweithio, ond y tu ôl i’r system honno mae lot o bethau eraill yr ydym yn eu gwneud fel Llywodraeth. Gall Jo Jordan esbonio’n fras beth yr ydym yn ei wneud.		Mark Drakeford: Thank you for the question. I am going to turn to Jo Jordan to explain the general system that we have in this area. The one thing that I have done in the time that I have been the Minister for health is that I have established a system where I meet every quarter with the vice-chairs of the LHBs, because they have the responsibility in the mental health area. So, I meet them; it is in everyone’s diary. Every time that we have discussed CAMHS, I have raised a number of issues with them and they feed back to me. They write to me about what they are doing and we speak again about the points that we raised at the next meeting. So, I feel that I, as a Minister, have more of an opportunity to have an impact on the system. I am trying to raise the profile of the vice-chairs in terms of the responsibilities that they have, particularly in the area of mental health. I think that that is starting to work, but behind that system there are a lot of other things that we are doing as a Government. Jo Jordan can explain generally what we are doing.
[39] Ms Jordan: I think that in the evidence that you have received there was some discussion over an old annual operational framework target, and they do change over time. The focus also changes. It might be true that our focus regarding what we collect in terms of what we now call our tier 1 priorities has changed in respect of CAMHS, because our focus over the last year or so has been the implementation of the Measure. That was one of the key targets that we were expecting LHBs to meet in relation to mental health and CAMHS—to ensure that we were reaching the 94% of young people receiving the care and treatment plan. That is probably what LHBs are seeing as our key focus. However, that is not to say that we, at Welsh Government, are not keeping a very close eye in terms of what is happening to waiting lists et cetera.
09:30
[40] We collect information on performance at four weeks, 10 weeks and 18 weeks, and that performance by LHB. So, we have been keeping a close eye on that. We have known that, particularly over the last 12 months, the number of people on the waiting list has been increasing. That is when the really big increase has been. That has been the time that we have been very closely working with LHBs to say to them, ‘How are you going to deal with this? This is not an acceptable position’. In fact, you could probably say that CAMHS at the moment in Welsh Government, and over the last 12 to 18 months, has had a much closer focus and attention than previously. As part of that, there is the work we have done to ensure that the in-patient facilities that we have in Wales are used more appropriately, more effectively and that occupancy rates are nearer to what you would be expecting, so that fewer young people need to be sent across the border and we are using our in-patient facilities. The monitoring that the Welsh Government has been doing on that, and the work with local health boards in that area, has seen some real improvements.
[41] Aled Roberts: Ond os yw eich monitro mor effeithiol—. Rydych wedi sôn eich bod yn edrych ar y gwasanaethau mewnol a’r gwelyau o fewn y gwasanaethau mewnol hynny.  Rhyw ddwy neu dair blynedd yn ôl fe wnaeth Llywodraeth Cymru roi arian ychwanegol er mwyn cynyddu nifer y gwelyau, yn arbennig yn y gogledd. Hyd nes inni dderbyn tystiolaeth, nid oedd yn amlwg fod y Llywodraeth na WHSSC yn ymwybodol o’r ffaith na fu unrhyw gynnydd a bod y bwrdd iechyd wedi defnyddio’r arian a gafodd gan y Llywodraeth at ddibenion eraill.		Aled Roberts: However, if your monitoring is so effective—. You mentioned that you are looking at internal services and the beds within those internal services. Around two or three years ago, the Welsh Government gave additional funding in order to increase the number of beds, in particular in north Wales. Until we received evidence, it was not clear that the Government or WHSSC was aware of the fact that no progress had been made and that the health board had used the money it received from the Government for other purposes.
[42] Ms Jordan: That is the point I was making. It is a result of the work we have been doing, particularly over the last 12 months, with health boards that has shown us that the occupancy rates are lower than we would expect in the Welsh in-patient units. We have been asking questions about why this is the case, and why we are not making better use of them. We can see quite an improvement in the occupancy rates in the Welsh units. The impact of that, we hope, will be fewer children being sent across the border. For the first quarter of this year, the number of out-of-area replacement referrals was just three. We are anxious to watch that that trend continues for the rest of the year. It does not happen that, today, you make a decision that you are going to increase an occupancy rate and it happens within a week or a month. You have to staff the unit up, et cetera; you have to get the appropriate referral in. It takes time to work through.
[43] Aled Roberts: Ond a oedd Llywodraeth Cymru wedi cytuno na fyddai Betsi Cadwaladr yn cynyddu nifer y gwelyau o fewn yr uned yn Abergele? Neu a oedd hwnnw’n benderfyniad a gafodd ei gymryd gan y bwrdd iechyd lleol, heb unrhyw fath o drosolwg gan y Llywodraeth? Dyna beth rydym eisiau ei wybod yma. A yw’r byrddau iechyd yn derbyn arian oddi wrth y Llywodraeth, ac ar ôl hynny mater iddyn nhw yw sut maen nhw’n gwario’r arian hwnnw?		Aled Roberts: Had the Welsh Government agreed that Betsi Cadwaladr would not increase the number of beds within the unit in Abergele? Or was that a decision taken by the local health board, without any overview by the Government? That is what we want to know here. Do the health boards receive funding from the Government, and after that it is a matter for them as to how they spend that money?
[44] Ann Jones: That is quite a specific case to Betsi; I wonder whether we can follow that up with—.
[45] Aled Roberts: It is a general point on how much, if there is extra money coming in—. Minister, we welcome the fact that you have mentioned this morning a national CAMHS improvement plan, and you have mentioned that there is money, but will that money be controlled centrally or just devolved down to the health boards? How will that work, given that previously there have been significant amounts of money given to health boards, and it has been not used it for the purpose that it was given?
[46] Mark Drakeford: In an era when money is in such short supply, where we are able to find some extra money, like the £250,000 we found last year for eating disorder services, I am very keen that, from a Welsh Government perspective, we track that money so that we know that it is being spent on the things we want the money to be spent on. The money that we will put into the improvement plan will certainly be tracked in that way.
[47] Dr Watkins: We demand actuals. Certainly, for the money for revenue funding, when we get it and it is in my budget, then we insist, because money is very tight, that we actually see the staff in employment before we release the money. It is very challenging, but we have to do that. We did that with the adult eating disorder hub and spokes. We certainly did not give them the £250,000 until we were assured that they were spending it on the staff that we had stipulated.
[48] Ann Jones: Can we have a specific note on Betsi, because I have some issues around the Abergele unit as well? We can then look at the specifics, but we are trying to keep to a general overview today, although I know that we have mentioned various issues. So, if we could have a note and we will write to you with what we specifically want out of that.
[49] Aled Roberts: Mae gennyf un—		Aled Roberts: I have one—
[50] Ann Jones: Very quickly, because Suzy has to come in as well.
[51] Suzy Davies: This is not related to my question—
[52] Ann Jones: Okay.
[53] Aled Roberts: Mae eich tystiolaeth hefyd yn dweud bod gwelliant wedi bod o ran CAMHS a’r awdit rydych chi’n ei wneud ohonynt. Felly, ar ba sail ydych chi’n dweud hynny o ran eich tystiolaeth chi? Pa fesuriadau sydd wedi dangos bod gwelliant o ran y gwasanaeth? Yn gyffredinol, rwy’n meddwl mai’r awgrym rydym ni’n ei gael gan bobl sy’n ymwneud â’r gwasanaeth yw bod y gwelliant hwnnw—. Rwy’n derbyn yr hyn rydych chi’n ei ddweud am y cynnydd yn y galw, ond mae rhan o’r dystiolaeth oddi wrth bobl ifanc a phlant sy’n defnyddio’r gwasanaeth yn eithaf damniol, i ddweud y gwir, o ran yr eirfa y maen nhw’n ei defnyddio.		Aled Roberts: Your evidence also says that an improvement has been made in terms of CAMHS and the audit that you are conducting of CAMHS. Therefore, on what basis do you say that in terms of your evidence? What indicators have shown that there has been an improvement in the services? Generally, the suggestion that we hear from people who use the service is that that progress—. I accept what you have said relating to the increase in demand, but part of the evidence from young people and children who use this service is quite damning, to tell you the truth, in terms of the vocabulary that they use.
[54] Mark Drakeford: There is always likely to be a tension, it seems to me, Chair, between the specific views of individuals and, sometimes, the general picture. Aled asks how we can know that the service has improved; here are just three ways: here is a service that employs more professional staff than ever before, which sees more young people than it has ever seen in its history, and that uses its most specialist services—the two in-patient units that we have in Wales—more effectively than it ever has before. At the start of this Assembly, the occupation rate of those units was 57%, and last year it was 71%. That is, I hope, as a result of us sending fewer young people across the border and providing services for more young people closer to home in Wales. From those three things, I think the general picture is clear. For specific individual young people, I understand that the system will often not seem to be responding in the way that they would hope to their own particular set of circumstances.
[55] Ann Jones: We move to Suzy, very briefly.
[56] Suzy Davies: What those three measures do not tell us, though, is whether the improved system, if you want to call it an improved system, is acting in a way—. What I am coming to is that those three indicators do not tell us whether people’s mental health has improved or whether the management of their chronic conditions has improved; are they getting the right help and are they benefiting from it? It is not just a question of throwing money at it. They have to be getting the right and appropriate help. Do you have anything that can say that x number of people have said that they are better as a result of the interventions?
[57] Mark Drakeford: I will probably ask somebody to answer—
[58] Suzy Davies: I know that it is a complicated question.
[59] Mark Drakeford: I absolutely endorse the question in the way that Suzy Davies put it. We spend a lot of our time looking at inputs and outputs, how much we are spending and how much activity there is. We know that we have to, in measuring success, move on from that to think about outcomes. Is all of that activity making a difference in the lives of young people? We have outcome measures, which we are now using. Sarah will tell you more.
[60] Dr Watkins: Again, we feel that we are being quite innovative in this in Wales, in that one of the things that was said in ‘Together for Mental Health’ was that we would develop a core data set but, within that, we would have outcomes from a service-user perspective, which is very innovative. Other people are looking at that across the UK. We have piloted it and we are about to send it out to the LHBs with a view to implementing a comprehensive assessment system across Wales. You are right; it is not easy. It is about quality, what we know and things like the Mental Health (Wales) Measure 2010. It is embedded now, but we need to improve the quality of what people get. It is absolutely the same for CAMHS services. We need to be able to answer that question robustly. We hope that our new core data set will answer not just the numbers, but also something about quality.
[61] Suzy Davies: When do you roughly expect to evaluate whether that pilot project has been successful?
[62] Dr Watkins: The pilot project has been successful, so it is now going to be rolled out into every LHB, starting next month. We have detailed different sets of questions—I have even brought one, which I can show you—which are specific to children and young people for CAMHS because, obviously, the outcomes are going to be different if you are in a service for people with dementia and those sorts of conditions, rather than in CAMHS. So, we have to get this right. It will be a work in progress, but it is something that we take very seriously. ‘You are right,’ is the answer—we need quality—
[63] Suzy Davies: I wonder if we could have a note on the evaluation of the pilot scheme. It is probably out there, but I have not seen it.
[64] Ms Jordan: We work very closely with service user groups and the voluntary sector in terms of developing these outcome measures. They are not professional-led. We have worked with the voluntary sector.
[65] Suzy Davies: That is encouraging. Has Aled finished on his question?
[66] Ann Jones: Come in very briefly, Aled, because I also want to come to Bethan’s question.
[67] Aled Roberts: Erbyn pryd fydd pob bwrdd iechyd yn gweithredu hynny?		Aled Roberts: By when will every health board be operating that?
[68] Dr Watkins: We are expecting them to start implementing it now and it should be fully up and operational by December. That is the plan.
[69] Ann Jones: Suzy, it is your question.
[70] Suzy Davies: I want to take you back to what I think was Lynne’s point about how much money is spent on CAMHS, which is not the issue in and of itself, but we are talking about a ring-fenced budget for mental health. You have explained that the high-end need and the high-end spending are primarily in adult services, so what I wanted to ask was this: I appreciate that there has been a massive increase in referrals from primary into specialist CAMHS, many of which have been turned down. Some of those will be because they are inappropriate referrals, effectively, but would you recognise that there might be a risk that some of those slightly borderline referrals do not pass because there are financial pressures? It is the equivalent of nobody is going to statement a child if they then have to pay for the results of the statement. Is there a chance that that could be happening?
[71] Mark Drakeford: It would be impossible to deny, would it not, that the system is under pressure? The system is under financial pressure, as all public services are. I would be very disappointed if I thought that a child was being denied a service because the affordability issue had determined that decision. These are all professional judgments in the end, and they should be made on the basis of clinical need. We have succeeded in the Welsh Government, despite all the pressures that there are in the system, to maintain our spend on mental health. We know that there are reductions in local authority spend on mental health services, which are causing some extra pressures in the system, but we are not in the position that they are across our border, where 77% of all clinical commissioning groups in England have frozen or reduced their spending on children’s mental health services this year, and where one major city authority has reduced its local authority spending by 94% on CAMHS.
[72] When the system is under pressure and when the headlines are always dominated by demands for the latest drug and the latest bits of equipment, and never by mental health, you have to work very hard to defend mental health budgets. I think that we are very lucky in Wales to have a third sector that is actively ensuring that that does not happen and a very committed workforce as well. However, I could not possibly answer the question by saying, ‘Oh no, money’s no problem and never enters the calculation’.
[73] Suzy Davies: May I follow that up then with this question: perhaps it is slightly early days, because the Measure has not been in place for that long, but do you have any data collected on people who have required deeper mental health intervention who had a primary referral, were turned down and then reappeared in the system with far more serious problems? I know that prevention is difficult to measure, but if you are looking at cost, then obviously people needing specialist CAMHS when that might have been headed off at the pass, that is costing more.
[74] Mark Drakeford: That is a really important question. I suspect that we probably do not have those data immediately, but I think that Sarah Watkins said earlier that in our major review of the Measure, partly as a result of this inquiry and the evidence that you have had, we are going to put an extra focus on the way that children have been treated within the Measure, and we will take that question in as part of that.
[75] Suzy Davies: Thank you for that.
[76] Ann Jones: You may come in very briefly, Lynne, because I want to—
[77] Lynne Neagle: I just want to ask if the Minister could let us have a note on the local government funding pressures that impact on CAMHS in Wales.
[78] Mark Drakeford: Yes, we will do our best and send you a note.
09:45
[79] Ann Jones: I wanted to move on to the structure and delivery of CAMHS because I think that that is quite—. Sorry, Minister, I know, but if we can just—. I will ask Bethan to move on to this.
[80] Bethan Jenkins: I think it is important that we ask some of these questions, although I appreciate the time constraint. With regard to the clinical-based model, young people whom I have talked to have said—I will reference eating disorders because that is what I know—that they might have good treatment as in-patients, but, when they go back into the community, they feel that they do not get the support that they need, because it is a nine-to-five service or the service is not there. A lot of the young people have been asking whether it can be amended so that it is more flexible, in line with what they want and when they need it, really. So, I would just ask for a comment on that.
[81] Dr Watkins: We have new community intensive treatment teams being rolled out across Wales. All of the new ones are planned to be extended hours, so they will work a little bit later and they will be available at weekends. Certainly, with the money last year—it is quite difficult to spend money very quickly, because of recruitment and things—every CAMHS service in Wales had extra training for nurses in particular for eating disorders. So, they used that money quite practically and quickly to improve standards. In CAMHS particularly, every profession is likely to meet people with eating disorders, and therefore they need the competencies and the confidence to be able to address that in a therapeutic and helpful way, so that young people—as we have always said, and this was part of the vision for the money originally—do not go out, but, when they do go out, they have the right support so that they do not get worse again. So, it is keeping people within Wales.
[82] Bethan Jenkins: It was also about attending—. I think that what I am trying to say is that, in terms of the clinical model, quite often these are vulnerable people, and if they cancel an appointment it is seen as the end of the situation for them. I suppose it is about being flexible, again, and understanding why that has been cancelled and how they can go about dealing with it in a more appropriate way.
[83] Dr Watkins: We have stopped that. As that was an issue that the WAO raised, the delivery unit audited that and will be re-auditing it. So, in terms of the did-not-attend policy, we are insisting that services make sure that they examine why somebody has not attended, because it is critical that we do not discharge people just because they have not turned up. Services are being expected to audit that, and to make sure that they are also reaching out more.
[84] Bethan Jenkins: Quickly, on emergency and out-of-hours services, we visited Bridgend recently, and they said that they were going to be creating, I think, two emergency beds there, because they were recognising that people were going to adult services or going to A&E and not being seen appropriately or—not being misdiagnosed, but their illness was being misinterpreted. Many of the young people that we talked to also said that. Do you have a comment on that particular issue?
[85] Dr Watkins: We are looking at inappropriate admissions guidance quite closely. We know that we have to get it right for young people. It is possible that a 17 and a half year old who needs an admission has the capacity and is able to make a choice as to where they feel would be the better place. So, broadly speaking, we need to be sure that young people are placed on children’s wards whenever possible and appropriate, and we recognise and count those instances where it is inappropriate. We also need to be sure that older children are allowed to express their right in law to be able to say where they want to be. If they are on an adult ward, we still say that a CAMHS consultant must be involved as well and that there must be the safeguards, such as the two emergency beds that you mentioned, wherever you are in Wales, to say that staff have been police-checked, and that all of those safeguards are in place.
[86] Bethan Jenkins: Well, I hope that we can see progress on that. My final question relates to what Simon touched on earlier in terms of access to talking therapies. It has been noted by Cardiff and Vale University Local Health Board that access to psychological therapies in CAMHS is extremely limited and does not comply with NICE guidelines for common conditions. So, I guess that what we are trying to say is that, if we can get that right in terms of psychological services, we will inevitably see fewer people needing to seek CAMHS. That may be where the problem lies at the moment, in that people are seeking CAMHS because they are not getting that basic access to therapies.
[87] Mark Drakeford: There is no dispute that we are not yet able to provide psychological therapies on the scale that we would like to see in Wales. The report that the Welsh Government commissioned that was published last year demonstrated that. We were able to find some money last year; we found £635,000 this year for investment in psychological therapies. It has to be on the basis not that we are going to be able to employ a huge new cadre of people, but that we use the people who are already in place and give them the skills and the abilities they need to be able to deliver psychological therapies. We are very clear that a proper proportion of that money needs to be provided in the CAMHS side of mental health, as well as in other areas of demand.
[88] Ann Jones: Thank you, Minister. Sorry, we are five minutes late and I know that you are on a very tight schedule. It was a tall order to try to talk about everything, because there is a lot more.
[89] Bethan Jenkins: I have not mentioned everything, but if we could write to—
[90] Ann Jones: There are several things, if we could write to you about them. We have asked for several notes, but, if we could write to you again, because this is part of an ongoing inquiry and we are moving a stage at a time—.
[91] Mark Drakeford: Of course.
[92] Ann Jones: Thank you, and thank you for you attendance this morning.
09:51
Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o’r Cyfarfod Motion under Standing Order 17.42 to Resolve to Exclude the Public from the Meeting
[93] Ann Jones: I move that
the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).
[94] If the committee is agreeable, we will move into private session. I see that you are.
Derbyniwyd y cynnig. Motion agreed.
Daeth rhan gyhoeddus y cyfarfod i ben am 09:51. The public part of the meeting ended at 09:51.