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Services for children and young people with emotional and mental health needs 24 November This report has been prepared jointly by the Wales Audit Office and the Healthcare Inspectorate Wales (HIW),
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Services for children and young people with emotional and mental health needs 24 November 2009 This report has been prepared jointly by the Wales Audit Office and the Healthcare Inspectorate Wales (HIW), supported by Estyn and the Care and Social Services Inspectorate Wales (CSSIW), and is presented to the National Assembly under the Government of Wales Acts 1998 and Further information on the roles of the Wales Audit Office, Healthcare Inspectorate Wales (HIW), Estyn and the Care and Social Services Inspectorate Wales (CSSIW) is given in Appendix 4 of this report. Auditor General for Wales 2009, Crown Copyright 2009 You may reuse this publication (not including logos) free of charge in any format or medium. You must reuse it accurately and not in a misleading context. The material must be acknowledged as Auditor General for Wales and Crown copyright and you must give the title of this publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned before reuse. Any enquiries regarding reuse of this publication should be sent to The images used throughout this report have been selected from material produced by children and young people who took part in group work sessions as part of the consultation undertaken as part of this review. Contents Foreword 6 Summary and recommendations 7 About our review 8 Main conclusions 9 Recommendations 14 Service provision 16 Part 1 Services that focus on prevention, early intervention and supporting those with less severe problems 17 Availability of services 17 Nature and quality of services 20 In conclusion 29 Part 2 Specialist community services 30 Availability of services 30 Nature and quality of services 42 In conclusion 52 Part 3 Inpatient and residential services 53 Availability of services 53 Nature and quality of services 55 In conclusion 60 Barriers to improvement 61 Part 4 Implementing policy 62 Policy guidance 62 Planning and commissioning services 66 CAMHS coverage in key local strategies and plans 71 In conclusion 72 Part 5 Weaknesses with the approach to service development 73 Taking account of the views of children and young people 73 4 Joint working between the health, local authority and voluntary sectors 74 Funding arrangements 75 The management and control of specialist services, such as forensic mental health and inpatient services 77 Sharing good practice and service evaluation 78 In conclusion 79 Part 6 The CAMHS workforce 80 Staffing levels and expertise 80 Capacity and skills to support services and service improvement 81 Recruitment 81 Supervision and support 82 Training and skills development 82 Workforce planning 83 In conclusion 83 Part 7 Performance management 84 Performance management information 84 Performance against targets 85 Managing performance 86 In conclusion 88 Appendices 89 Appendix 1 Who provides specialist (CAMHS) 89 Appendix 2 How the review was undertaken 93 Appendix 3 National Service Framework flagged actions for CAMHS 98 Appendix 4 Audit and Inspection bodies involved in the review 99 Appendix 5 Glossary 101 Appendix 6 References 107 Appendix 7 Acknowledgements 108 5 Foreword In One Wales, A progressive agenda for the government of Wales, the Assembly Government placed a new priority on providing for mental health, including child and adolescent mental health services. This report, on services for children and young people with emotional and mental health problems, is intended to support the Assembly Government, NHS bodies and local authorities in delivering against this priority. The review arose because of concerns raised during related audit and inspection work, and from issues raised by a wide range of stakeholders. Children and young people with emotional and mental health problems often have complex and wide ranging needs that require a co-ordinated response from different professionals and services in the fields of health, social care and education. As a result, it was appropriate for us, as the audit and inspection bodies covering these sectors in Wales, to work together in delivering this report. This is the first time that all four of our organisations have been involved in a major service review. In undertaking the review we sought to answer the question Are services adequately meeting the mental health needs of children and young people? We have concluded that despite some improvements in recent years, services are still failing many children and young people, reflecting a number of key barriers to improvement. A key part of our review has been to gather the views and experiences of children, young people and their parents or carers. These feature throughout our report. Our thanks go to Barnardos Cymru for undertaking the consultation exercise on our behalf, and most importantly to all those who shared their experiences of services. The challenges faced by the Assembly Government and those providing services in meeting the needs of children and young people with emotional and mental health problems are considerable. Given the scale of the task ahead, our organisations will over the coming years continue to monitor the progress made across Wales in developing comprehensive, effective and safe services. Jeremy Colman Auditor General for Wales Peter Higson Chief Executive, Healthcare Inspectorate Wales Bill Maxwell Chief Inspector, Estyn Jonathan Corbett Acting Chief Inspector, Care and Social Services Inspectorate Wales 6 Summary and recommendations 1 Mental health is one of the Assembly Government s key health priorities. Most recently, the Assembly Government in the One Wales document placed a new priority on providing for mental health, including Children and Adolescent Mental Health Services (CAMHS) i. 2 Accurate figures on the number of children and young people at risk of or experiencing mental health problems are not available. However, the Assembly Government estimates ii that: more than 40 per cent of young people have recognisable risk factors; between 30 per cent and 40 per cent may at some time experience a mental health problem; and up to 25 per cent may experience a more severe or persistent mental health disorder. 3 In September 2001, the Assembly Government published its CAMHS Strategy, Everybody s Business, which set out a 10-year programme to establish comprehensive, high quality services across Wales. This multiagency strategy has been further developed through various Welsh Health Circulars, and the 2005 National Service Framework (NSF) for children, young people and maternity services. 4 Everybody s Business identified a number of concerns about CAMHS provision at that time. These included: the distribution of services owing more to historical patterns and local advocacy for service development than it did to assessed needs; education and social services not playing their full parts in planning or delivering mental health services; first-line staff groups working with children and young people having little capability to deal with mental health problems due to a widespread lack of training and uncertainties about roles; children s services provided by a range of organisations, such as social services departments, educational psychology and special education services, community and hospital paediatricians, child and adolescent psychiatry services, and child clinical psychology services, being valued but under enormous pressure; 7 specialist CAMHS being in danger of being swamped by rising levels of demand with many services having long waiting lists and waiting times; the distribution, role and volume of more specialised services needing to be rethought, with the capacity of specialised services such as day care and inpatient services being too small, and psychiatric inpatient services lacking the most appropriate focus; and good practice being disseminated, but slowly, incompletely and not systematically. 5 To address these shortfalls Everybody s Business set a series of high level objectives for services, including: improving the mental health of children and young people, and providing effective and timely interventions for those presenting with mental health problems; making services available across Wales on the basis of need; building child protection measures into all services, to provide safeguards for children and young people wherever and whenever they are cared for or treated; promoting a multiagency, multi-disciplinary approach and integrated service provision; involving parents and carers in a meaningful way in planning and commissioning services; and establishing child-centred services which take into account the views of the young people and families using them. 6 The 2001 strategy set broad priorities for action. These included the development of the range, scope and diversity of services; increasing the volume of local services; and improving the capacity of services, particularly within the fields of training and staff development, prevention, early intervention and the provision of services for people with the most serious problems. The priorities were supported by detailed actions to be taken by the Assembly Government, service commissioners and providers. The NSF for Children, Young People and Maternity Services built upon the strategy and set out 22 targets relating to CAMHS. About our review 7 The review set out to establish whether services are adequately meeting the mental health needs of children and young people in Wales. Healthcare Inspectorate Wales (HIW) and the Wales Audit Office jointly undertook the review, supported by Estyn and the Care and Social Services Inspectorate Wales (CSSIW). The review arose from concerns Box 1 - Terminology used in the report In this report, the term child and adolescent mental health services refers to all services that impinge on the psychological well-being and mental health of children and young people. Some of these services are specialist in nature, but many of them do not specifically provide mental health services. We use the term CAMHS to refer to the full range of services provided by all sectors and professionals, and the term specialist CAMHS to refer to those services provided by specifically trained health and social care professionals such as psychiatrists, psychologists, and mental health nurses. Appendix 1 shows which NHS organisations in Wales provide specialist CAMHS. The terms emotional health, emotional well-being and mental health are used interchangeably throughout this report to refer to a broad range of issues, ranging from relatively common emotional or behavioural difficulties through to more severe and persistent mental health disorders. Use of the term parent in this report includes all natural parents and any person who, although not a natural parent, has parental responsibility for a child or young person or has care of a child or young person. We undertook our fieldwork prior to the creation in October 2009 of the new NHS bodies, and as a result, evidence was collected from the former Local Health Boards (LHBs) and NHS trusts. Throughout this report, we use the term LHBs or NHS trusts to refer to the former organisations and health boards to refer to the new bodies. 8 raised about CAMHS during related work undertaken by these audit and inspection bodies, and from issues raised by a wide range of stakeholders. 8 We drew on evidence from a variety of sources over the period 2007 to We gathered the views of children, young people, and their parents through a consultation exercise undertaken on our behalf by Barnardos Cymru. We also gathered evidence from service commissioners, and statutory and voluntary sector providers. Appendix 2 provides more details of how we undertook the review. Main conclusions 9 Our overall conclusion is that despite some improvements in recent years, services are still failing many children and young people, reflecting a number of key barriers to improvement. Service provision Services that focus on prevention, early intervention and those with less severe problems Comprehensive services are still not in place despite some important developments in services that focus on prevention, early intervention and supporting those with less severe problems. 10 Parenting and family intervention services have been developed through various funding streams, including those overseen by children and young people s partnerships. There is widespread support for these services from professionals and parents. 11 School-based counselling services have been expanded and the Assembly Government has committed to making these services available to all school pupils. However, developing these services for children on the fringes of, or excluded from, school, for those in transition from primary to secondary school, and outside of school hours will be challenging. 12 Services targeted on children and young people at risk of developing mental health problems and early intervention services for those who subsequently develop problems are underdeveloped in many parts of Wales. 13 The extent to which staff who work on a day-to-day basis with children provide active support to children and young people with emotional or mental health problems varies too much. We found this variation to be the case across a broad range of staff including school nurses, community and inpatient pediatricians, social services, schools staff and educational welfare services. 14 Progress has been made in introducing primary mental health workers in many areas. They provide support to a wide array of professionals who work with children and young people, such as GPs, school nurses, schools staff and social workers. Many non-specialist staff told us that they valued the support provided by primary mental health workers and reported that, as a result, they were more confident in identifying and managing emotional and mental health problems in their early stages. However, the role of these workers varies, and the provision of consultation and advice from specialist CAMHS to other professional staff can be inadequate. Also, meeting the target number of primary mental health workers will be challenging. 15 Educational psychology services provide support in educational settings with all aspects of children and young people s learning, behaviour, and social and emotional development. However, we found that the input from educational psychologists to meeting the needs of children and young people with a mental health problem varied, and that closer co-ordination with specialist CAMHS would be beneficial in many parts of Wales. 9 Specialist community services Some specialist services in the community are not provided within Wales and there are unacceptable variations in the availability and quality of those services that are provided. 16 Unlike in other parts of the UK, there are no specialist mental health services in the community for children under five years of age. Further, although a lower age limit for specialist CAMHS teams is often set at five years, this can be as high as 11 years and, as a result, younger children can lack specialist CAMHS support. 17 There is too much variation across Wales in eligibility criteria and referral arrangements for specialist CAMHS teams, and the referral process is often unclear. There is evidence that waiting times for initial assessment and intervention by specialist CAMHS have reduced since 2008, in response to a waiting times target. However, we do have concerns about the interpretation of, and the measurement of performance against, this target, and there is a risk that the benefits implied by the reported improvements in waiting times are not fully delivered in practice. There is also a risk that the waiting time target could have some adverse consequences on other aspects of care and support. 18 Access to specialist CAMHS in the community for some children and young people depends on where in Wales they live. This includes access by children and young people with a learning disability; aged 16 to 18 years; placed from out of area; with unstable home and family circumstances; with a substance misuse problem; and with a diagnosis of conduct disorder. Overall, access is too variable across Wales and some children are not receiving the specialist CAMHS support they need. 19 Community intensive therapy and treatment services have been established in some parts of Wales, but in others, children and young people can only access intensive support from inpatient settings. As a result, children and young people in similar circumstances are supported in the community in some areas, but in others, they are being admitted to an inpatient unit. 20 There has been slow progress in establishing comprehensive services for children and young people with mental health problems who are at a high risk of offending. Despite funding being available, it has taken considerable time to put in place a Forensic Assessment and Consultation service. There are also shortfalls in the specialist mental health services provided in the two units housing young offenders in Wales, although action is in hand to address these. 21 The availability of day care and eating disorder services is particularly patchy and bears little relationship to the local need for such services. There is also inconsistency in the availability of advocacy services; although a pilot national advocacy and advice service is in place, significant local improvements are needed if the Assembly Government s aims for universal and integrated advocacy are to be met. 22 Specialist CAMHS teams in many parts of Wales are struggling to provide services in a way that meets the specific needs of children and young people. The location, environment, and opening times of services are frequently not child or family friendly. 23 Children and young people who miss appointments are, as a consequence, discharged by specialist CAMHS teams in many areas, and a lack of routine follow-up of missed appointments can put children at risk. In some parts of Wales professionals in different organisations are not appropriately sharing information on individual cases, putting children and young people at further risk and undermining child protection arrangements. 10 24 In many parts of Wales, children and young people are not receiving holistic care based on meeting their often wide-ranging needs. A multiagency and multi-professional response to meeting the individual needs of children and young people is rare. Many children and young people are inadequately involved in planning their care, and do not always feel that professionals listen to their views. Overall, there is a lack of information for children and young people on their rights and what they should expect from CAMHS. 25 There are inadequate arrangements to ensure a smooth and effective transition from CAMHS to adult mental health services in many parts of Wales, increasing the risk that young people disengage from services. Specialist inpatient and residential services There are important weaknesses with specialist inpatient and residential services. 26 A new inpatient unit opened in North Wales in July In South Wales, the unit was temporarily relocated in December 2007, with a new unit planned for However, there are a number of issues with inpatient services, the resolution of which will require more than investment in new facilities. 27 The development of a new unit in North Wales will address some of the existing limitations in inpatient services there. Unlike the former unit, the new facility is able to accept emergency admissions and those detained under the Mental Health Act, and to provide care for acutely disturbed children and young people. 28 Following the opening of the new inpatient units, the total number of inpatient beds routinely in use has increased in North Wales. However, bed numbers in South Wales are lower than originally planned an
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