At its meeting on 27 September 2018, the Public Audit and Post-legislative Scrutiny Committee took evidence from the Auditor General for Scotland on her joint report with the Accounts Commission on Children and young people’s mental health1 (the Audit Scotland report).
Following the evidence session with the Auditor General, the Committee took further evidence from representatives from North Ayrshire Health and Social Care Partnership, Highland Council, NHS Grampian, Dame Denise Coia, Chair of the joint Scottish Government and COSLA taskforce on children and young people’s mental health (“the taskforce”), the Scottish Government and COSLA officials. Full details of the evidence sessions and the written submissions received can be found on the Committee’s website.2
The Committee heard from Dame Denise Coia on the work of the taskforce, the purpose of which is to “provide recommendations for improvements in provision for children and young people's mental health in Scotland and, in partnership, develop a programme of sustainable reform of services".3 The joint taskforce is working closely with the Youth Commission on Mental Health, with one of its members co-chairing meetings of the joint task force with Dame Denise Coia.4 Subsequent to the Committee’s evidence sessions, the taskforce published its delivery plan. The Committee understands that a more detailed plan will be published in April 2019.
The Committee also received a copy of a report from Barnardo’s on rejected referrals, which it had produced after gathering evidence from practitioners.5
Following the oral evidence sessions, the Committee agreed to produce a report on the key issues that were raised in the Auditor General’s report and the subsequent Committee evidence sessions, which focused specifically on current provision of services. The Committee hopes that this short report will add further weight to the general call for transformative change in the provision of mental health services to children and young people.
There has been wide-ranging public discussion about the significant increase in the number of children and young people experiencing mental health problems and around levels of youth suicide. The Committee recognises that the reasons for the increase in mental health issues among this age group are varied and complex and not yet fully understood. However, it is clear that all children and young people experiencing such problems should be able to access the help and support that they need as quickly as possible.
As a result, it is concerning to the Committee that the Audit Scotland report describes a “complex and fragmented” system of mental health services for children and young people, making it difficult for them and their families and carers to get the support that they need. It is evident from the report and the evidence that the Committee received that the provision and performance of mental health services require urgent and significant improvement.
Therefore, the Committee welcomes the work of the task force being chaired by Dame Denise Coia and, in particular, the undertaking by the taskforce to work with partners to fully implement the recommendations in the Audit Scotland report.
Given the importance of this issue, the Committee intends to follow up the implementation of the Audit Scotland report’s recommendations and the work of the task force.
The Committee considers that comprehensive research into the impact of social media on children and young people’s mental health is required as an essential element of preventive action and early intervention.
The Committee calls on the Scottish Government to commission such research or, if such research has already been commissioned, to provide details.
The role of the Committee is to ensure that public funds are being spent wisely. The absence of basic data in relation to a whole range of factors in relation to the provision of mental health services for children and young people has meant that it is not possible for the Committee to be reassured on this point. In particular, data is absent or underdeveloped on total spend, on the reasons for rejected referrals and, crucially, on outcomes.
In particular, the Committee is concerned by Key message 3 of the Audit Scotland report which states that “Data on mental health services for children is inadequate, with a lack of evidence of what difference existing services are making to children and young people with mental health problems.”
The Committee considers that consistent criteria on the timescale and process for referrals is essential to ensure that children and young people experiencing mental health problems are not disadvantaged because of the area in which they live. The development of consistent criteria would also ensure that comparisons can be drawn across health boards and, where necessary, provide an impetus for improving services.
The high number of referrals to CAMHS which have been rejected is concerning to the Committee and suggests that the overall system for referral to CAMHS needs to be reviewed.
In the absence of national data on the reasons why referrals have been rejected, the Committee was reliant on the evidence provided in the Audit Scotland report and from witnesses, which suggested that the reasons include inadequate referral letters, a lack of tier one or two services and a lack of understanding among referrers about whether a child or young person meets the criteria. This is why a review of the system of referrals is necessary.
The Committee recognises that waiting time targets that are comparable across health boards are a useful measure of performance. However, given that the mental health of a young person or child may deteriorate while waiting for treatment, health boards should ensure that, within that timescale, young people are assessed and treated as quickly as possible and without delay.
The Committee considers further that, while waiting time targets are an important measure of performance, such targets should not be the only measure of success or progress in meeting the needs of children and young people experiencing mental health issues.
The Committee recognises the importance of identifying children and young people at risk of mental health problems at an early stage and providing them with help and support before they reach a crisis situation. The Committee therefore welcomes the taskforce’s workstream which will explore the link between poverty and mental health issues and which will look at other work being undertaken to address poverty and adverse childhood experiences.
The Audit Scotland report and the evidence that the Committee received provided examples of good practice of early intervention around the country. The Committee considers that it is essential that such models are shared across the public sector and adapted by other bodies to their own particular circumstances. The Committee sees a clear role for the Scottish Government in facilitating this and invites the Scottish Government to set out the steps it is taking to address this point.
The Audit Scotland report sets out the scale of mental health issues among young people and children, indicating that by 2017/18 the number of referrals to specialist mental health services for this age group had increased by 22% from 27,271 in 2013/14 to 33,270. It further cites the most recent UK data (from 2004) which estimated that one in ten children and young people aged five to 16 had a clinically diagnosable mental illness.
The Audit Scotland report describes the wide-ranging and long-term impact of mental health on children and young people—
Evidence suggests that mental health problems in childhood and adolescence have a significant impact on physical health, education and on the ability to find and sustain employment. Globally, mental illness is one of the leading causes of years lived with disability, and the life expectancy of people with serious mental health disorders is ten to 20 years lower than the general population.
Audit Scotland. (2018, September 13). Children and young people's mental health. Retrieved from http://www.audit-scotland.gov.uk/uploads/docs/report/2018/nr_180913_mental_health.pdf
Despite these statistics, the Audit Scotland report2 states that the number of specialist CAMHS staff employed by NHS Boards is 1,014 WTE, an increase of only 11% over the same period. In her opening statement to the Committee, the Auditor General described the mental health system for young people and children as “complex and fragmented” and stated that—
Services are under significant pressure. Demand is increasing. Over the past five years, the number of referrals to specialist services has increased by 22 per cent. Children and young people are also waiting longer for treatment, with over a quarter of those who started treatment in the last year waiting more than 18 weeks.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Caroline Gardner (Auditor General for Scotland), contrib. 3, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115500
The report recognises, however, that responsibility for addressing these issues lies with a range of bodies across the public sector. It states that—
It is not possible for one organisation to address all the issues raised in this report. To improve support for children and young people with mental health problems in Scotland, a wide range of organisations, both nationally and locally, need to work together with children and young people.4
There has been wide-ranging public discussion about the significant increase in the number of children and young people experiencing mental health problems and around levels of youth suicide. The Committee recognises that the reasons for the increase in mental health issues among this age group are varied and complex and not yet fully understood. However, it is clear that all children and young people experiencing such problems should be able to access the help and support that they need as quickly as possible.
As a result, it is concerning to the Committee that the Audit Scotland report describes a “complex and fragmented” system of mental health services for children and young people, making it difficult for them and their families and carers to get the support that they need. It is evident from the report and the evidence that the Committee received that the provision and performance of mental health services require urgent and significant improvement.
Therefore, the Committee welcomes the work of the task force being chaired by Dame Denise Coia and, in particular, the undertaking by the taskforce to work with partners to fully implement the recommendations in the Audit Scotland report.
Given the importance of this issue, the Committee intends to follow up the implementation of the Audit Scotland report’s recommendations and the work of the task force.
In her evidence to the Committee, Dame Denise Coia described the scale and changing nature of mental health issues among children and young people. She told the Committee—
problems with mental health for children and young people in Scotland are increasing exponentially. That is not related to the incidence or prevalence of serious mental illness—that is unchanged. The rise is in emotional distress in young people at school, arising from issues around bullying, body image, depression and anxiety.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 16, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131561
The Committee sought to explore the reasons for this increase in incidence of mental health issues and the extent to which the use of social media was having an impact. Dame Denise Coia told the Committee that—
At the moment, we do not have enough research evidence, although there is some research evidence on the impact of social media.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 20, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131565
This view was echoed by COSLA, who indicated in their evidence to the Committee that the impact of social media on young people’s lives was not yet understood.3
However, Dame Denise Coia reinforced the importance of education in helping young people to use social media appropriately, including the pressures that can be associated with its use. She said—
Some schools in Scotland are doing fantastic work to educate young people on how to use social media more responsibly and how to deal with the multiple demands that are made of them. Some of the issues are related to pressures and expectations to do with succeeding in life.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 20, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131565
She agreed, however, that further research into the impact of social media on children and young people’s mental health was required.5
The Committee understands that the taskforce has committed to take into account the way in which digital technology impacts on children and young people’s lives.
However, the Committee considers that comprehensive research into the impact of social media on children and young people’s mental health is required as an essential element of preventive action and early intervention.
The Committee calls on the Scottish Government to commission such research or, if such research has already been commissioned, to provide details.
The absence of research evidence and data was a common theme throughout the Committee’s evidence taking. For example, while Exhibit 9 in the report provides information on the published spending on CAMHS in 2016/17, the report indicates that it is not possible to accurately identify total spending on CAMHS in NHS boards because of poor data. 1
The report suggests that this lack of accurate information on total spend on CAMHS is due to a number of reasons, including inconsistent reporting on spending; the transfers of funds from one board to another and the fact that information in the NHS spending summary is not comprehensive.1
The Auditor General expanded on this point in her evidence. She told the Committee that, in relation to spending on children and young people’s mental health services, “the numbers are so variable as not to be credible".3
On a related point, COSLA subsequently advised the Committee that it does not hold information about the resources that councils provide for direct services or to third sector organisations in respect of mental health services; how that money has been spent and where cuts have been made. i
However, the Auditor General emphasised that the absence of data was not only confined to actual spend on children and young people’s mental health services, but also on the difference that such spend was making. She told the Committee that—
Just as important is that one of the data gaps is about outcomes and about what differences the services are making for children and young people, ideally helping to address their problems early and setting them back to thriving and being able to benefit from their education as they grow up as opposed to getting locked into a cycle of struggling with their mental health in way that limits their potential.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Caroline Gardner, contrib. 17, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115514
While in her evidence to the Committee, Claire Sweeney from Audit Scotland described the difficulties that the auditors had faced in trying to obtain a clear picture of how resources were being used. She said—
We saw gaps and problems throughout the system in terms of how the money is accounted for and, critically, in terms of what difference any of it makes to children. We have made a series of recommendations in the report that those things need to be sharpened.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Claire Sweeney, contrib. 20, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115517
The report noted that the Scottish Government was seeking to address this issue by developing quality indicators for mental health services. These will include measures across six quality dimensions: person-centred, safe, effective, efficient, equitable and timely. However, in her evidence to the Committee, Leigh Johnston from Audit Scotland sounded a note of caution in relation to this development. She said—
The issue there is that we understand that boards will choose which ones they want to measure, and that will make benchmarking very difficult.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Leigh Johnston (Audit Scotland), contrib. 25, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115522
The Audit Scotland report further notes that, in some cases, the lack of relevant and comparable data may be due to the inadequacy of systems. For example, it notes that “not all services and organisations have electronic systems which are fit for purpose so they can improve efficiency, share information and collect data on performance and outcomes.7
The Committee raised this specific issue with witnesses from those bodies responsible for collecting data. In response to the question as to whether their systems were fit for purpose, Dr Lynne Taylor from NHS Grampian responded—
From a Grampian perspective, the simple answer to that is no. We have been raising the issue nationally at leads meetings. The data systems are different across all boards and it is therefore difficult to get minimum data sets on outcome measures, such as patients being seen and when the clock is being stopped.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dr Taylor, contrib. 58, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131603
Dr Taylor added that it would be helpful to have data that is consistent and comparable with other Scottish boards to help plan and develop services.9
Bernadette Cairns from Highland Council agreed with Dr Taylor. She said—
The situation is similar for us. We do not have one system that cuts across the local authority and the NHS, so quite a lot of the data gathering that I do on the effectiveness of the teams that I manage involves reading across different systems. It is a manual comparison rather than a systematised process.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Bernadette Cairns, contrib. 67, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131612
The Committee raised the concerns about data with the Scottish Government and sought clarification as to whether the collection of data, including data on outcomes, would be consistent across the country. Paul Gray, Director-General, Health and Social Care at the Scottish Government responded that—
I am happy to give the committee an undertaking that we want to have comparable data across Scotland
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Paul Gray, contrib. 161, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131706
However, he emphasised that that comparability should focus on outcomes. He said—
I am not going to insist that the way in which we deliver services in Easterhouse should be exactly comparable with the way in which we deliver services in the Black Isle, because that would be foolish.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Paul Gray, contrib. 161, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131706
In her oral evidence to the Committee, Dame Denise Coia confirmed that the joint taskforce would be looking at the issues around data.13
The role of the Committee is to ensure that public funds are being spent wisely. The absence of basic data in relation to a whole range of factors in relation to the provision of mental health services for children and young people has meant that it is not possible for the Committee to be reassured on this point. In particular, data is absent or underdeveloped on total spend, on the reasons for rejected referrals and, crucially, on outcomes.
In particular, the Committee is concerned by Key message 3 of the Audit Scotland report which states that “Data on mental health services for children is inadequate, with a lack of evidence of what difference existing services are making to children and young people with mental health problems.”14
The Committee has regularly criticised the absence or underdevelopment of data in its scrutiny of audit reports. The Committee considers that, in this case, the lack of data, including comparable data, has meant that the Committee has no detail on whether and the extent to which children, young people and their families are receiving the intervention and support that they need, or the impact that such intervention and support has had in cases where it has been accessed.
The Audit Scotland report makes a series of recommendations to the Scottish Government, COSLA, NHS boards, integration authorities and their partners concerning data and, in particular, recommends that these organisations work together to determine what performance and financial data should be collected and reported publicly.
The Committee further notes that the taskforce’s delivery plan identifies data and information as one of four things that need to be corrected to create the right conditions for transformation of the approach to children and young people’s mental health.15
As part of its follow up work on this report, the Committee will be seeking confirmation that the Audit Scotland recommendations on data have been taken forward. In particular, the Committee will wish to see data that confirms that funding designated for mental health services has been spent on that purpose.
Another key theme in the Committee’s evidence taking was the criteria for referring children and young people to specialist mental health services. The Audit Scotland report highlights that such criteria varies across Scotland and in her oral evidence to the Committee, Leigh Johnston from Audit Scotland said—
...the referrals pathway is complicated. The criteria vary across the boards and they are often not easy to follow for young people, for parents and carers or for potential referrers who do not come from a clinical background.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Leigh Johnston, contrib. 82, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115579
The varying approaches taken by different boards is highlighted in Appendix 3 to the Audit Scotland report. This reveals that there are inconsistencies in relation to the age range to which the service applies. For example, in NHS Ayrshire and Arran the age range is 5-18 years old, in NHS Grampian, 0-18 years old, in NHS Shetland 0-16 or up to 18 if in full time education and in NHS Dumfries and Galloway the age range is not specified.2
In terms of dealing with urgent referrals, NHS Highland lists the criteria when referrals are considered urgent, while in NHS Lothian out-of-hours emergencies are advised to contact their GP in the first instance. In NHS Shetland, the process for urgent referrals is not specified. 2
Similarly, the person who may make such referrals varies across Scotland. In certain areas, the referral may be made by a person who knows the child, young person or family/carer. In respect of some boards, the referral person is not specified. In other cases, a referral can be made by a “GP, hospital doctors, school, school nurse, education psychologists or social worker”.2
The Committee considers that consistent criteria on the timescale and process for referrals is essential to ensure that children and young people experiencing mental health problems are not disadvantaged because of the area in which they live. The development of consistent criteria would also ensure that comparisons can be drawn across health boards and, where necessary, provide an impetus for improving services.
The Committee notes that the Audit Scotland report recommends that NHS Boards, councils, integration authorities and their partners work together to ensure there is a clear and measurable process for accessing all levels of service, making sure the referrals criteria and guidance are as clear as possible. The Committee welcomes the joint taskforce’s plans to develop new referral criteria for children and adolescent mental health services.
The Committee will be monitoring these developments as part of its follow up work on the Audit Scotland report.
The Audit Scotland report states that there has been a 24 per cent (1,414) increase in the number of referrals rejected by specialist services since 2013/141 and that in 2017/18 a total of 7,199 referrals had been rejected. However, the Committee noted that because national data on the reasons for referral and rejection is not collected, it was not possible to establish why there had been an increase.2
The report suggested that referrals may be rejected for various reasons including a lack of tier one and two services or because the referral does not contain enough information. The report further suggested that a referral may also be rejected because the child or young person does not meet the criteria for treatment. It noted, however, that—
This can indicate a lack of understanding, clarity, or both, among referrers about whether a child or young person meets the criteria for specialist CAMHS. 2
The reasons for rejected referrals identified in the report were followed up in the Committee’s oral evidence sessions. For example, in her evidence, Leigh Johnston from Audit Scotland, told the Committee—
There are pockets of good practice to try to address some of the referral issues. However, as we also say later in our report, there is a need for more training for non-mental-health specialists such as teachers, school nurses and the like. That might help people to understand the referrals process and what is required in more depth.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Leigh Johnston, contrib. 82, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115579
While Stephen Brown from North Ayrshire Health and Social Care Partnership, told the Committee that—
There has been some discussion around the fact that young people who were potentially struggling have been referred to CAMHS inappropriately. That was perhaps because no one knew what was available locally, so the teacher or the GP decided that, in the absence of anything else, they would refer to CAMHS.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Stephen Brown, contrib. 73, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131618
Stephen Brown continued that, as a consequence, there had been “huge” waiting lists for CAMHS in some places.
Dame Denise Coia appeared to confirm this view. She said—
The vast majority of referrals to CAMHS come from GPs, who have said to us that that happens because they do not have anything else to refer people to.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 32, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131577
Dame Denise Coia added that the issue of referral letters was also important. She indicated that she had met families with rejected referrals and had heard that “people had been rejected because the referral letter did not describe the problem in a way that triggered a response when the CAMHS team read it”.7
The Committee also sought evidence on the impact of those who had not been referred despite suffering from serious mental health issues. For example, during the evidence session on 22 November, the Committee asked the Scottish Government for figures on any incidents of self-harm, attempted suicide or suicide amongst the 7,199 rejected referrals. In its written response8 to the Committee, the Scottish Government referenced the Rejected Referrals Child and Adolescent Mental Health Services (CAMHS): A qualitative and quantitative audit June 2018 report it had commissioned from SAMH and NSS Information Services Division (ISD).9
The correspondence explained that the audit did not break down each rejected referral according to the initial reason for the referral and that it did not provide quantitative detail on whether there were any such incidents following the rejection. However, it went on to state that the audit of seven NHS Boards concluded that 1.4% of all referrals made in those boards during the audit period were due to self-harm and that 0.4% of referrals made were due to suicidal ideation.
The Committee also sought evidence from the Scottish Government on the number of individuals who had lost their lives either through a rejected referral or due to the length of time they were waiting for treatment. The Scottish Government confirmed, in its letter of 22 February,10that this information was not collected centrally. However, it indicated it was currently working with ISD to develop the current datasets gathered from NHS Boards on performance against CAMHS and Psychological Therapies waiting times standards and expected to see substantial improvements in these datasets this year.
The Committee notes, however, that the most recent report from ScotSID (Scottish Suicide Information Database) indicates that between 2011 and 2017 a total of 516 individuals under the age of 25 committed suicide in Scotland. 11
The joint report by SAMH and ISD concluded that—
This report dealt with a subset of those children, young people and their families who are referred to CAMHS but not accepted, so it is not possible to draw conclusions about the entire CAMHS system. However, there are indications that there may be serious problems. 9
The SAMH/ISD report further notes that “In a well-functioning system, there should be no need for rejected referrals.”
The high number of referrals to CAMHS which have been rejected is concerning to the Committee and suggests that the overall system for referral to CAMHS needs to be reviewed.
In the absence of national data on the reasons why referrals have been rejected, the Committee was reliant on the evidence provided in the Audit Scotland report and from witnesses, which suggested that the reasons include inadequate referral letters, a lack of tier one or two services and a lack of understanding among referrers about whether a child or young person meets the criteria. This is why a review of the system of referrals is necessary.
The SAMH/ISD report makes 29 recommendations on rejected referrals covering assessing a referral, rejecting a referral, support for referrers, availability of services and data collection. The Committee notes that the joint taskforce’s delivery plan states that Scottish Ministers have accepted all the recommendations made in the recent reports by SAMH and ISD on the audit of rejected referrals and that the joint taskforce will work with its range of partners to help address these recommendations. 13
The Committee welcomes this commitment and will be reviewing the implementation of the SAMH/ISD recommendations as part of its follow up work on the Audit Scotland report.
Even where a child or young person has been correctly referred to specialist services, however, there was often a gap before they received their first treatment. The Audit Scotland report stated that—
At the end of March 2018, 8,145 children and young people were waiting for treatment, up from 7,116 in March 2014. While children and young people are waiting for treatment, they may receive little or no support or advice.1
The report indicated that between 2013/14 and 2017/18, the average wait for a first treatment appointment increased from seven to 11 weeks and that the waiting time standard of treatment within 18 weeks had not been met nationally since it was introduced in December 2014.
It was noted that a young person’s mental health could deteriorate while they are waiting for treatment. For example, Stephen Brown of North Ayrshire Health and Social Care Partnership told the Committee—
18 weeks is a long time in a young person’s life.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Stephen Brown (North Ayrshire Health and Social Care Partnership), contrib. 47, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131592
The Committee understands that there could be many reasons affecting how long a child or young person waits for treatment including the capacity of the team, the number of children and young people who need urgent treatment and the level of detail provided by the referrer.
The report further noted that there was a significant variation among NHS Boards. For example, the average waiting time in NHS Grampian was 21 weeks, while in NHS Borders area it is 13 weeks and in NHS Highland it is 6 weeks.3
However, in evidence to the Committee, Leigh Johnston from Audit Scotland, advised caution around the waiting time figures. She said—
We know from having looked at the information in more depth that different areas measure waiting times in different ways in terms of what counts as treatment starting. We find that sometimes people go to an assessment and then possibly go onto another waiting list for the treatment that they need.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Leigh Johnston, contrib. 29, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115526
And in her evidence, Dr Taylor from NHS Grampian defended the long waiting time figure associated with her board for that exact reason. She indicated that NHS Grampian ‘stops the clock’ after the child or young person’s second appointment. She explained that—
We class the first appointment as assessment and the second appointment as the start of treatment, but we offer signposting and treatment advice at the first appointment.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dr Taylor, contrib. 49, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131594
Dr Taylor added that the current waiting time from the first appointment to the young person’s choice of treatment is between 6 and 7 weeks.
In any event, witnesses emphasised that waiting time figures did not necessarily indicate a good outcome for the child and young person. In particular, the Audit Scotland report included a quote from an NHS Manager who had said—
Compliance with the [waiting times] target has become a huge focus. It’s been useful in focusing attention on how to do things differently, but once you’ve met the target I would question whether it is actually a good measure of success or progress.6
The Committee recognises that waiting time targets that are comparable across health boards are a useful measure of performance. However, given that the mental health of a young person or child may deteriorate while waiting for treatment, health boards should ensure that, within that timescale, young people are assessed and treated as quickly as possible and without delay.
The Committee considers further that, while waiting time targets are an important measure of performance, such targets should not be the only measure of success or progress in meeting the needs of children and young people experiencing mental health issues.
The Committee welcomes the development of quality indicators by the Scottish Government across six quality dimensions which are: person-centred, safe, effective, efficient, equitable and timely. However, the Committee emphasises that there is a need to ensure that the quality indicators apply to and are comparable across all health boards. It is further essential that measurement against the indicators produces good outcomes.
A key issue explored by the Committee was the resourcing of mental health services for children and young people. In its evidence to the Committee, the Scottish Government referred to the extra £250 million funding that had been announced in the 2018 Programme for Government, to support mental health services over the next 5 years. 1
While the Committee welcomed the £250 million investment, Members noted that, without appropriate data, it would not be possible to know what effect this funding would have on children and young people’s mental health.2
Dame Denise Coia expanded on this issue in her evidence. While she welcomed the cross-party commitment to child and adolescent health, Dame Denise pointed out that children up to the age of 24 are one third of the population of Scotland and the resource had to be targeted at that group of individuals.3 In her evidence to the Committee, she expressed concern that the additional funding would be subsumed into filling the gaps that cuts had already created. She said—
We have to highlight and call out the issue that although everyone is taking cuts, mental health services—particularly child and adolescent mental health services—are, proportionately, taking bigger cuts than everyone else. ... We need to say that there is no use in putting new resource in the front door if it is being frozen at the back door. That is the biggest issue at the moment.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 16, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131561
Dame Denise Coia provided examples of where funding of children and young people’s mental services was not being prioritised. She said—
My other concern is about people freezing posts in child and adolescent services when they might not be freezing posts in other areas; they can do that because the data is more difficult to find.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 22, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131567
She went on to add that—
Until I started going out into communities, I was not aware of how community paediatrics has disappeared and how the acute sector has pulled paediatrics back in to work in that sector to fill the gaps there. That might be appropriate, but we need to be aware that it has happened.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 44, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131589
Dr Taylor from NHS Grampian, also express concerns about staffing for mental health services. She said—
Our staffing had not increased at all between 2013 and 2018. That was partly because money had been taken out of our core CAMHS service by our partners in the council. The core posts in CAMHS had to be filled by the board to address that deficit.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dr Taylor, contrib. 79, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131624
However, she outlined the steps that were being taken to try to address the workforce deficit. She said—
By doing capacity modelling through CAPA, we have been able to clearly demonstrate to the senior leadership team exactly what our gap in staffing is, and we have a very detailed workforce plan. As I indicated, the senior leadership team has committed to giving us £1 million for new posts.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dr Taylor, contrib. 79, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131624
The Committee also sought to explore the extent to which IT was being used to provide remote support to young people in need of urgent support from a mental health specialist.
In her evidence to the Committee, Dr Taylor confirmed that NHS Grampian was using such a tool and commented that the feedback from young people was very positive.9
Dame Denise Coia further confirmed that the taskforce had a workstream looking at the whole concept of the use of IT to deliver services.10
While the Committee welcomes the announcement of an additional £250 million investment, it seeks details from the Scottish Government on how it will ensure that this funding is used to benefit the mental health and wellbeing of young people and children.
The Committee also seeks clarification from the Scottish Government on how it will demonstrate that the additional spend has contributed to improving outcomes for children and young people with mental health issues.
The Committee welcomes the joint taskforce’s intention, as set out in its delivery plan, to “ensure children and young people’s mental health funding is measured consistently, is traceable and its effectiveness can be properly assessed”. 11
It is crucial that CAMHS services are properly resourced. The Committee heard evidence that suggested, however, that the staffing resource in this area had not always been prioritised with posts being frozen or cut.
The Committee notes that the task force has a Specialist Children & Young People’s CAMHS Services Workstream which will be looking at what is the current staffing resource for Specialist CAMHS (professional mix, grades, full time equivalent, funding requirements).
The Committee welcomes this development and will be following up the work of the task force in this area in due course.
The key issue for the Committee was where funding to address children’s and young people’s mental issues should be directed. Both the report and witnesses emphasised the importance of taking preventative action and intervening early, while recognising the challenges that this presented.
For example, Key message 4 of the report states—
Directing funding towards early intervention and prevention while also meeting the need for specialist and acute services is a major challenge. A step change in the way that the public sector in Scotland responds to the mental health needs of children and young people is required, with integration authorities having a major role to play. Transforming services will only be possible with a clearer view of what works, a plan for how the system needs to change and a move away from reliance on short-term and isolated initiatives. 1
The report also acknowledged that it can be difficult to define what constitutes early intervention and prevention and that measuring the impact they have is also challenging as improvements may not be evident in the short term.2
The report concludes3 that additional training and skills are needed to enable those working with children and families to identify mental health problems, intervene early to prevent problems worsening and to refer children and young people to other appropriate services.
In her oral evidence to the Committee, in relation to early intervention, the Auditor General spoke of the importance of making sure that people such as GPs and teachers, who are in contact with young people every day, have some training in mental health and know what services are available.4 She said—
It comes back to looking at the system as a whole rather than having separate bits of it working in isolation.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Caroline Gardner, contrib. 63, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115560
A number of witnesses referred to the work that was being done in Ayrshire in this regard. For example, Stephen Brown from North Ayrshire Health and Social Care Partnership described how “in some pockets of Ayrshire” they were “bringing people together”. He told the Committee—
Alongside police and education colleagues and with some CAMHS resource—we are also utilising the school nursing resource—we are working with families, predominately in high schools, but also feeder primaries, at as early a stage as possible to identify, before they get to crisis, young people who might be struggling a bit.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Stephen Brown, contrib. 54, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131599
Dame Denise Coia also spoke of work being done by schools in Ayrshire. She told the Committee—
They have put in place basic services that involve teachers who have had mental health first-aid training and pupils who are mental health champions. They have a baseline of raising awareness about mental health issues and tackling bullying.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 34, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131579
In her evidence to the Committee, Leigh Johnston from Audit Scotland also referred to the work being undertaken by NHS Ayrshire and Arran and how it is working towards multi-agency collaboration. She explained that—
NHS Ayrshire and Arran is using its data to understand the challenges that it is facing and is piloting different initiatives to address the challenges.
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Leigh Johnston, contrib. 27, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115524
However, she raised a concern that NHS Ayrshire and Arran is now struggling with how to maintain these pilot initiatives with short-term funding. 9
Dr Lynn Taylor from NHS Grampian also emphasised the importance of using new resource to deliver transformational change. In its written submission to the Committee, NHS Grampian had stated that—
It has been estimated that approximately 23% of the workforce capacity is being lost due to travel between CAMHS sites.10
In her oral evidence, Dr Taylor expanded on the steps that were being taken to address this issue. She told the Committee that the board had secured £1 million from the Scottish Government to develop an existing NHS premise with a view to providing a whole-service approach to children and young people based in one location. She said—
That will mean that all the CAMHS staff will coalesce in one building, which will be a fantastic resource that will include an education and resource room, to help us to develop our wellbeing work with our tier 1 and 2 colleagues.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dr Taylor, contrib. 8, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131553
In his evidence to the Committee, Paul Gray, former Scottish Government Director- General, Health and Social Care and NHS Scotland Chief Executive, spoke of an ideal approach being a “no-wrong door approach” which was developed in Canada. He explained—
In other words, wherever a person made contact, there was a means of getting them to the help that they needed. That would be my ideal approach, whereby young people would not need to work out whom they needed to ask.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Paul Gray, contrib. 172, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131717
Donna Bell from the Scottish Government explained that the “whole system” approach the Committee had heard was operating in NHS Ayrshire and Arran was beginning to be replicated elsewhere in Scotland.13
Nonetheless, Leigh Johnston from Audit Scotland emphasised that it was important that authorities adapted good practice models to suit their own needs. She told the Committee—
Other areas could learn from NHS Ayrshire and Arran, but they would need to look at the situation in their own area and decide what pilot initiatives would suit them
Public Audit and Post-legislative Scrutiny Committee 27 September 2018, Leigh Johnston, contrib. 27, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11695&c=2115524
Bernadette Cairns from Highland Council, which is commissioned by NHS Highland to manage the tiers one and two CAMHS service for that area, agreed that a whole-service and whole-systems approach was required. She explained that—
There has been quite a lot of discussion throughout the country about adverse childhood experiences, which also link to poverty. If we do not get this right in the very early years and at school, across the piece, we will do our children a disservice.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Bernadette Cairns, contrib. 89, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131634
The specific link between poverty and mental health was a theme both highlighted in the report and by witnesses. The Audit Scotland report indicates that between 2014-17 it was estimated that almost one in five children were living in relative poverty and that Scottish Government projections estimate that this will rise to 38 per cent by 2030/31.16
The Audit Scotland report states that poverty is a major contributor to mental ill health and that children living in low income households are three times more likely to suffer mental health problems than their more affluent peers16. Specifically, the report explained—
Adverse childhood experiences (ACEs) and trauma are also now recognised as key risk factors for mental ill health. ACEs are stressful events occurring in childhood, such as physical and emotional abuse and neglect. Those living in higher areas of deprivation are at greater risk of experiencing ACEs. 18
While Stephen Brown from the North Ayrshire Health and Social Care Partnership told the Committee that—
From a North Ayrshire perspective, one of the things that I am most ashamed of—I am speaking on behalf of the community planning partnership—is that we have overseen the level of child poverty going up from 29 per cent to almost one in three children living in poverty.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Stephen Brown, contrib. 83, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131628
In her evidence to the Committee, Dame Denise Coia emphasised the importance of tackling poverty as a means of addressing mental health issues. She said—
There are significant child poverty issues in Scotland. I mentioned the strand of at-risk children to tease out that very issue. I want us to focus on that strand as a way of getting us to begin to focus on the prevention agenda and the whole public health agenda.
Public Audit and Post-legislative Scrutiny Committee 22 November 2018, Dame Denise Coia, contrib. 81, http://www.scottish.parliament.uk/parliamentarybusiness/report.aspx?r=11804&c=2131626
The Committee recognises the importance of identifying children and young people at risk of mental health problems at an early stage and providing them with help and support before they reach a crisis situation. The Committee therefore welcomes the taskforce’s workstream which will explore the link between poverty and mental health issues and which will look at other work being undertaken to address poverty and adverse childhood experiences.
The Audit Scotland report and the evidence that the Committee received provided examples of good practice of early intervention around the country. The Committee considers that it is essential that such models are shared across the public sector and adapted by other bodies to their own particular circumstances. The Committee sees a clear role for the Scottish Government in facilitating this and invites the Scottish Government to set out the steps it is taking to address this point.
The Committee recognises the important role that school nurses could play in identifying children at risk of mental health issues and ensuring that they are directed to the necessary support at an early stage. However, in order for this service to be effective it will need to be properly resourced. The Committee notes in this regard the commitment from the Scottish Government to invest £12 million in school counselling services.
The Committee seeks information from the Scottish Government on when it expects its implementation plans for the proposals on additional school nurses and school counselling services to be available.
The Committee intends to review how this funding has been spent as part of its follow up work on the Audit Scotland report.
The Committee recognises that there is much to be done to transform children and young people’s mental health services to ensure that all those who are at risk get the care and support that they need as quickly as possible. The Committee recognises that this transformation will require a commitment across the public sector.
The Committee welcomes the work of the task force and looks forward to the implementation of its delivery plan. As noted above, it intends to follow up the implementation of the Audit Scotland report recommendations.