Health and Sport Committee

Meeting date: Tuesday, November 15, 2016

Official Report 497KB pdf

---

Mental Health

Good morning, everyone, and welcome to the 11th meeting in session 5 of the Health and Sport Committee.

I ask everyone in the room to ensure that their mobile phones are on silent. It is acceptable to use them for social media purposes, but please do not take photographs or film proceedings.

Agenda item 1 is an evidence session on mental health. We will focus on children and adolescent mental health services.

I welcome to the committee Lorna Wiggin, chief operating officer, NHS Tayside; Tracey Gillies, medical director, NHS Forth Valley; Jackie Irvine, children and families committee, Social Work Scotland; and Barry Syme, chair of the Association of Scottish Principal Educational Psychologists and principal educational psychologist, Glasgow psychological service.

We will move straight to questions, as we have less than an hour for the session.

Good morning, panel. Thank you very much for coming to see us today.

Everyone in this room is aware that the mental health strategy expired at the end of last year and that we are still awaiting a new one. Given that, as we learned during the summer, some children in parts of the country are waiting as long as two years for treatment by CAMHS and that CAMHS in-patient beds are sometimes rendered unavailable because staff are not there to service them, will panel members reflect on what they hope will be in the next mental health strategy? I ask that they focus on CAMHS and whether it should have its own strategy that underpins the overall mental health strategy.

In our submission, we make the point that looking at CAMHS in isolation will not solve the problem. We need to look at the continuum, from the lower-level tier 1 to tier 2 services through to the tier 3 and tier 4 services. We know, because it happened often in the past and is possibly still happening, that children are referred to CAMHS when there could be other services that they could get earlier in their journey of mental wellbeing. We know that that creates a bottleneck into CAMHS. The mental health strategy needs to look across that variety of provision and make those connections helpfully.

It might be helpful for me to say something about NHS Forth Valley’s waiting times, because they were particularly low in the recent NHS Scotland Information Services Division reported figures. I assure the committee that we have taken the matter extremely seriously and have put a lot of time and effort into working with CAMHS. I am very pleased that the number of children who were seen within our 18-week referral-to-treatment waiting time has increased from 74 per cent in September to 87 per cent in October. There has been a significant turnaround in the waiting times.

Alex Cole-Hamilton might have been referring to our very low waiting times in June. Those low waiting times were influenced partly by our ensuring that children who have been waiting a very long time are seen. Obviously, having those children come through the service has a negative impact on the overall RTT time that is reported, but it is still important that children are seen and prioritised appropriately.

Looking at the whole-life continuum, I would like to see much more emphasis on how care pathways are provided from birth right through to adulthood; on building up tier 1, to support the resilience not only of families but of individual young people and children; and on continuing to develop tier 3 and tier 4, to ensure that we can provide as comprehensive a service as possible for the young people and children who need that level of service.

It is imperative that we work across agencies and with the voluntary sector, the third sector, families and young people to get that right, and I would like to think that there will be an emphasis on that in the next strategy.

10:15  

On my question about the lack of availability of tier 4 beds, in the summer, we put in a freedom of information request, and the numbers that came back on kids who were referred to tier 4 beds but were turned away because the beds were not available—not because they were full, but because there were no staff to man them—were quite astonishing. Would you like there to be further investment, particularly given that we have no tier 4 beds north of Dundee? That is a natural gap in our provision in Scotland.

Currently, we have all 12 beds open in our facility, which serves the north. The issue is not always just to do with staff; it can be to do with the young people who are in the unit at the particular point in time and our clinical and multidisciplinary team’s risk assessment of what it is safe for the facility to look after.

I would like more emphasis to be put on keeping children and young people out of in-patient facilities. We can do that—we have seen good, intensive support-at-home models emerging. For example, we have a programme called MacX, which puts in very intensive multi-agency and multidisciplinary support to keep children in their family home and in education.

It is a combination of both things. It is not just about the beds; it is also about putting all the infrastructure into the community services.

But is there a gap? I accept what you have said, which certainly chimes with a lot of what we have heard about giving people care in the community, which is absolutely laudable. However, are all the needs being met? If people are referred to tier 4 beds and are turned away, are they getting the support at home that you have described?

Some of them will; some will need admission, so obviously we would seek a bed elsewhere for them that was suitable for their needs.

Through work that we have done in our eating disorder pathway and the more intensive family behaviour and cognitive support that we have put in, our admissions have gone down. It is not simply a matter of keeping on putting more beds into the system; it is a matter of considering what support the individual child or young person requires. Obviously, there should be intervention at an early stage if possible, as that stops deterioration. However, if the in-patient option is required, we must be sure that it is the right one.

I honestly have not seen any data from a whole-system risk assessment that would tell us how many beds would be the right number.

On the point about trying to keep children and young people supported in the community, from my experience in greater Glasgow and Clyde, I think that managing a person’s transition from being an in-patient to going out to the community is probably also an issue. My team has done a piece of work on that. I am responsible for children’s social work services and health services, and I have a responsibility for community CAMHS. We have ensured that we have transition guidance, as young people can sometimes get stuck as in-patients, and there will be a level of anxiety in the family and among the professionals around them about their coming back into the community.

There are advantages and disadvantages. Obviously, a short stay is preferable, but we have some very complex cases that mean that people will stay in longer.

We have probably all experienced variations in availability across the country. At one point, our 12-bed unit was full, but I understand that we currently have vacancies. However, that is very difficult to anticipate.

Similarly, I am not aware of any whole-system look at indicative needs for in-patient beds.

Many submissions have highlighted the increasing number of referrals to CAMHS. Some people thought that that reflected growing need and were concerned about the number of rejected referrals.

Last week, we heard from the Scottish Association for Mental Health, which called for a wider review of how people are referred. It also wanted to understand better what is happening at tier 1.

Jackie Irvine said that some young people are referred to CAMHS when they could be referred to other services.

The latest ISD figures show that 18.7 per cent of referrals were rejected in 2015-16, and West Lothian Council, for example, has called for an urgent review because it is concerned that some children and young people are missing out on help that they may urgently need.

I cannot comment specifically on the position in West Lothian, but we recognise that some children who are referred to tier 3 of CAMHS could be dealt with appropriately at tier 1 or 2, for example through school counselling. There is a demand that is not being addressed as early as it could be. We have worked in partnership across the country to build tier 2 services, but they are funded in a variety of ways. Some of the funding comes from councils, some from health boards and some from council education services, and some will be in the third sector. The variation across Scotland probably reflects the variation in what sits around CAMHS. I know what is in my area and I have heard from colleagues about what is in their areas, but some areas will be short of such support.

Even at tier 1, there is a need to support the development and confidence of staff who work with children in communities, whether in nurseries, primary schools or secondary schools, so that they do not become overly anxious and are able to deal with the children. At times, we are managing professional anxieties around children, and that does not help the children and certainly does not help to provide things when they need them, there and then, and for as long as they need them. Some children might be escalated to CAMHS when they could have been managed and helped to recover within tier 1.

Quite often, children have adverse experiences in family relationships. We are seeing a slight growth in functional family therapy in CAMHS tiers 1 and 2, but it is variable throughout the country and quite costly. In West Dunbartonshire and Glasgow, we have invested in functional family therapy for children aged 11 upwards, but the feeling is that signs of difficulty in children’s behaviour start to appear much earlier than that, from the transition from nursery into primary 1. Difficulties can appear even earlier, but they are certainly evident in the early primary years.

There is a package of options. Sometimes we try to fit the child into the services that we have as opposed to asking what service the child needs, if it is not available.

In last week’s evidence session, the view was expressed that better training for teachers and so on would enable them to help young people instead of feeling that they had to refer them on because they did not have the capacity themselves. How is a rejected referral experienced by a young person? Do they go along to a tier 3 or 4 service?

I can tell you what happens in NHS Tayside. A referral could come through various routes—from a teacher, a general practitioner or a school nurse—and is considered by a disciplinary team against all the information that they have available to them. If they require more information, they will seek it. Once they have considered the referral, they decide whether it fits into tier 3 and the young person requires to be seen by a specialist or whether there is an alternative that they should access.

The referrer will always be contacted, which allows them to say why they are not suitable to deal with the issue, and they will be told what other options are available and signposted to other services that might be appropriate. They are also given some information and advice tools that might be beneficial. It is not a matter of the young person having to come along and then being told that there is no need for them to be there.

I do not know whether practice is similar elsewhere.

Jackie Irvine indicated agreement.

That matches our experience. We have done a lot of work with GPs and other primary healthcare services on our referral criteria to ensure that they are well understood and agreed by all. We provide information if a referral does not progress following a multidisciplinary discussion such as Lorna Wiggin has described. We also have an advice-only email referral service and a professional-to-professional advice line. There are ways in which people can discuss referrals or receive further information about services.

Is that your experience as a practitioner, Barry?

It depends on how people get into CAMHS. In Glasgow and other authorities, we try to follow getting it right for every child, with a multi-agency meeting. We are trying to push for referrals—I hate the word “referral” because it implies that we are putting the matter somewhere else. However, we would see ownership remaining within the school establishment and that a referral to CAMHS should go through that multi-agency group, whether it is called a joint support team or a joint assessment team. The advantage of that is having people around the table from social work, health and education giving advice about the appropriateness of the referral. We know that the majority of referrals come through GPs, but there is a piece of work to be done with them about how they link GIRFEC into their practice so that the most appropriate referrals go to CAMHS.

If that is not deemed appropriate, the question is what other supports are there? There are lots of supports around, but getting them is often a postcode lottery. Even in a large city such as Glasgow, certain parts of the city will have certain resources but others will not, and it is about having local knowledge. In Glasgow, we have 28 joint support teams and we are working towards using the GIRFEC model so that referrals go through the joint support team. That will mean that the most appropriate referrals will go to CAMHS, but it also means that if a referral is not going to CAMHS, or if one comes back from CAMHS—or if there is a lack of other support available—it should go back to the joint support team.

Another issue is the quality of the referral when it gets to CAMHS. If it has the most pertinent information, that quickly gives CAMHS a much clearer idea of whether it is an appropriate referral for which they have to provide assistance. In West Dunbartonshire, we had a pilot involving GPs and education colleagues in sharing information around GIRFEC, which was widely reported to Government ministers. One of the outcomes very early doors was our finding that, quite often, schools knew the child and the family much better than the GP did, because they would know the parents and the siblings and have that background knowledge.

Therefore, we moved towards encouraging educational psychology services, when they think that a referral is required, to convey that to the GP. It is not that educational psychologists are not allowed to make referrals, so we are encouraging them to say to GPs, “We could do the referral. We agree with what you and mum are saying; we think that a referral is required, too. If you have not done the referral yet, we could complete it.” As everyone around the table has said, if a referral does not seem appropriate, there is a response to the referrer on why that is so, but we are encouraging people to have telephone conversations about referrals in the first instance. If that does not happen, there should be a telephone conversation when the referral is not accepted.

I want to move on from what we have been saying about referrals and expand the discussion a bit. At last week’s committee meeting, some of the panel, and some of the written evidence, talked about different referral criteria for different services and the need for national guidance on referrals. I am interested in the panel’s views on that.

There is definitely variation across health boards in the referral criteria and even in the tiers at which patients will be seen. It would be advantageous to have some national guidance that would at least allow a young person, child or family member to understand what type of service will be provided and how that will be done. There is no doubt that there is variation at the moment.

Does anyone else want to comment?

I agree with Lorna Wiggin that there is variation, even across neighbouring authorities and health boards—we find that in Glasgow. My particular area in the south of the city borders three other areas, and the variation between them causes problems for parents. I had an example of that a couple of weeks ago when a parent was told that their child required an educational assessment by an educational psychologist. That was then the parent’s expectation and we were contacted because the case was in our geographical area, but our threshold is different. There is a piece of work to be done on that situation.

Would differences in referral criteria explain why there is such a variation in the rate of referrals to your services that are accepted? Are you getting lots of inappropriate referrals sent to you that do not meet the criteria? If so, that would seem to me to be quite a waste of your time and that of healthcare professionals. It would also set up expectations by families and young people about the service that they will receive, which then turns out to be inappropriate for them.

10:30  

Some of the variation is more in the availability of what other support is available. I suppose that I would look at it more from a health perspective, although what my colleagues have said is appropriate. We are seeing quite a lot of pressure on primary care resources, and a lot of GPs are working as locums in different areas. The fragmentation of primary care services and the difficulties with GP recruitment that we are all experiencing sometimes mean that people are less aware of what is available locally, particularly with third sector or local authority services, which might be called different things. There is a need for better signposting to make people aware of what is available.

We have not really touched on some of the administration processes that sit behind all the services. When referrals are not received electronically, sometimes they just do not contain enough demographic information or all the pieces of information that would be useful. That can lead to a request for more information and for the referral to be sent again. The referral might not necessarily be inappropriate; perhaps it just did not have all the right information to start with. Those cases are counted in the ISD numbers. It is important to separate out the cases that are administratively incomplete from those that do not meet the referral criteria.

What are the health boards doing to address the issues that you are picking up?

We have put in place a way to ensure that we receive as much information as possible electronically and we work with our local authority and third sector colleagues to provide electronic information about what support services are available, which can be kept up to date and passed on to the young people. There is also a push system, with an advice sheet that goes back out to referrers at the point of referral to let them know what other support is available.

We use the information and the data that we get to create a dashboard for the service and for clinicians, which lets them look at themes. If we see that there is a particular issue in a school or a cluster of GP practices, we can go back in and do further education and try to understand why the issues are arising. There is a mixture of trying to ensure that the information is easily accessible, trying to ensure that people are up to date on what is available—because things change—and ensuring that, if there is an issue, we identify it quickly and try to do something about it.

You might have addressed this and I have not picked up on it, but what happens after a referral is rejected?

In Tayside, the referrer is contacted and told why the child or young person has not met the criteria and what other services would be more appropriate. There is signposting to any other support, information or advice or any tools that might be helpful for the individual. There is always contact with the referrer, whoever they are—it is not always a GP; it could be a school nurse, teacher or whatever.

Is that then tracked?

No. Once the person is referred back, they are discharged from the service at that point.

So they are referred back and then there is no follow-up to see whether the action that was suggested was successful. We do not know whether the rejections result in people coming back through the system.

No—we would monitor that.

How do you monitor it?

For readmissions, everybody has a community health index number, so—

I am not necessarily talking about readmission. How do you monitor—

If someone is re-referred to out-patients or—

No. How do you monitor what happens after a referral has been rejected?

If the referral was from a named person, such as an education professional or health visitor, or from a lead professional, which is predominantly those in social work services, they would maintain responsibility for the child. Barry Syme mentioned that the word “referral” feels a bit like talking about something being moved from one place to another. That is why, in GIRFEC terminology, we have moved to talking about requests for assistance.

The originating referrer, if you want to put it that way, or the lead professional or named person would maintain responsibility for the child and that case. Obviously, the lead professional or named person might do a variety of things. They might go back to CAMHS and have further dialogue about why the request was not accepted, but they would certainly go back to the team around the child to look at what other service could be put in place for the child. That is obviously more difficult if there are fewer alternatives, but from our knowledge and the growing implementation of GIRFEC it is certainly helping to keep an eye on that child and to make sure that they do not just drop off the plate.

Do you collect data on that? Is there a standard reporting system?

No. Nationally we are not in a position to do that because there are different information systems across social work services, education authorities and health authorities.

Do you therefore know how many referrals have been rejected and then come back?

No. I can honestly tell you that I do not have that information. However, from the point of view of being head of children’s health and care, I would know if we had an issue in my area.

Would any of the witnesses be able to know that?

No.

We have heard about the transition from child and adolescent services up to adult services, and last week we heard that there are different cut-off points in different parts of the country—some relate to full-time education, some are 16 and some are 18. We also heard from the representatives of the Scottish Youth Parliament and SAMH that they would prefer there to be a bespoke service for children between the ages of 16 and 24 that would see them through vital periods of transition in their lives so that any damaging consequences from their having been severely ill are limited. For example, if somebody has had to come out of education because of their illness, they will still have a team that can support them to get back into education even though they might be 17 and a half. Would you support that? Do you have any thoughts about that particular variation in the service?

Our services go up to age 18. It is difficult to make one size fit all. I agree that some individuals would benefit from a clearly staged, gradual transition and the holistic team approach being maintained for a longer period. Equally, some people at the age of 16, 17 or 18 clearly wish to mark that they feel ready to move to adult services and would prefer to be managed in adult services. Maybe we should be making those opportunities more available when they are appropriate.

If young people are telling us that that would the best pathway of care for them, we should be listening. We need to look at what we have currently and the steps that we would need to take for those who would benefit from such an approach. Some young people will definitively opt to move to adult services; that might be because, having experienced a young person’s unit in which the age group can be quite young, they feel that that is not the right place for them. You are right to say that there is an age at which they fit in neither one nor the other, and we need to find what the pathway looks like for each individual.

Clare Haughey mentioned that last week. We were talking about referrals at the other end of the age scale, where there used to be a cut-off age of 65. Perhaps specifying a number is not useful and it would be more useful to base services on an individual’s needs. That is what you guys are saying.

It might just be me who does not understand how the other thing that I want to ask about works, so please excuse me. How does educational psychology fit in with CAMHS? How do the services work together? I imagine that somebody who has autism spectrum disorder or attention deficit hyperactivity disorder is more likely to need a lead professional who is an educational psychologist rather than a psychiatrist, whereas some people will need a psychiatrist to be their lead professional. How do the two systems work together to provide care?

In the past 20 years, the role of the educational psychologist who works in mental health has certainly increased. Last year, ASPEP undertook an audit of all 32 services in Scotland and we did event sampling for a week to look at how much time we spent on mental health. It came out that 29 per cent of our time was spent on mental health work, which ranged from direct work with young people and children to advice and so on.

Across Scotland, services will vary, depending on their size. It is a question of capacity—there are places with two psychologists and places with 40 psychologists. We are talking about economy of scale. At the most recent count, there were about 20 different interventions in mental health that educational psychology offers, including cognitive behavioural therapy, eye movement desensitisation and reprocessing, and video interactive guidance.

We have developed a skill set, and we need to identify how we fit in with the tier model. It has taken a long time for educational psychologists to get their heads round the working of the tier model. We are now trying to target our interventions at a tiered level. We are focusing on tier 1 and tier 2, because that is where we know that the gap is. In fact, we are taking an even broader outlook; we are looking at tier zero, which is about promoting universal resilience. As educational psychologists, we are pretty good at that.

We target our interventions and focus on evidence-based interventions at tier 1 and tier 2. A prime example is safeTALK. My authority really pushes safeTALK, which is suicide awareness training. Every establishment has a member of staff who is safeTALK trained, and we are now rolling out safeTALK to S5 and S6 pupils. That is being done by educational psychology alongside health and social work services.

You mentioned autism spectrum disorder and asked how we work with CAMHS. The diagnosis would come either from the Scottish centre for autism or from the local CAMHS team, depending on the set-up, but that is just the diagnosis. That is fine as a medical diagnosis, but the issue is what to do with that diagnosis. We are working with CAMHS on what the implications of that are and what a child in that position needs help with. The child will have to go to school and be educated, so consideration needs to be given to his sensory issues. If he cannot cope with loud noises or with the dinner hall, we need to think about how we can we make environmental changes to his curriculum so that he can go to his local school. That is where the partnership working comes in.

The situation is improving, although there is further work to be done. Discussion is on-going in greater Glasgow and Clyde CAMHS, particularly in clinical psychology, about how we can formalise that in a better way so that we know exactly what we are doing.

Much of our focus has been on CAMHS. When we look at CAMHS, are we capturing that activity?

I do not think that we are; it is an untapped resource. All educational psychologists are Health and Care Professions Council registered, so we have to conform to those guidelines. We have the skills, because there are similarities between the training for educational psychology and the training for clinical psychology. We must distinguish between clinical psychology and CAMHS, which are two separate things.

I do not think that that activity is being captured. It is a resource that could be used more widely.

I want to explore how you measure the performance of the system as a whole. There is a target in place for the waiting time at tier 3, which seems to be the main indicator that is used. Is that the right thing to measure? Should other things be measured as well? Are there unintended consequences of using that indicator to measure performance?

From Social Work Scotland’s point of view, nationally there is a view—which I concur with—that measuring just the waiting times as a hard outcome is of fairly limited use, although it does give an indication of when people are not getting a service. I am aware that many health boards, including Greater Glasgow and Clyde NHS Board, have moved to the choice and partnership approach—CAPA—model, which allows them to look more at general outcomes for the family and the child. Collating that information on a local area or a health board basis can be difficult, but we are looking more at outcomes to do with reintegration back into education and communities. A CAMHS service on its own would be a bit limited in its ability to assess whether that approach was working or was right.

The other aspect comes back to the transition back into education and communities. Even if a child has not been in an in-patient bed, it is a case of helping the professionals around that child to continue to provide support and to understand what has made a difference.

There is a real issue for communication. That is why the partnership approach is providing a more holistic approach: it is not a case of starting CAMHS, ending CAMHS and then getting back to life. It is a case of starting CAMHS and educating other people about what needs to happen for that young person.

Practice is variable rather than consistent across areas. There are teams within CAMHS in West Dunbartonshire, such as the young people in mind service; in other areas, they work with carers, such as foster carers, residential carers or families, to help them to understand the behaviour that might be exhibited by their young person so that they can understand the premise and therefore how to respond better. That also provides good outcomes.

10:45  

Do you measure that?

We measure it on an individual child basis, and that is the difficulty that we have with any outcome approach. We have been discussing that with colleagues in the Care Inspectorate. Aggregating from one child up to the population is very difficult.

Why is it difficult? You measure whether the outcome, if you want to call it that, for that child was successful and then you aggregate all those individuals.

I suppose that it is because the question whether the outcome is right is subjective. The best person to give the view on that would be the child and parent, whereas the professional might say, “Yes, we’ve achieved an outcome.”

We measure population information in relation to numbers of referrals, the number of children who are looked after and the number of children who are referred to the Scottish Children’s Reporter Administration. Measuring whether outcomes are improving for children who present with very different circumstances is different. We measure that individually, but aggregating it is more challenging, particularly nationally.

We do not have good systems, as the committee heard earlier. Health, social work and education have different systems. Doing that work takes a lot of effort and hours. That takes away from the time available to provide services, so there is a balance.

Access to services is important, but it is only one indicator. We would all agree that some more qualitative outcomes should also be measured, both for children and families, and for how we are using the resource, so that we can understand the variation better and know whether it is right. Sometimes the variation is right, but sometimes it is not.

The question was about performance measurement of the system. You are telling me that it is difficult to measure the performance of the system so we do not do it.

No; we measure. We have a whole dashboard of different measures that are agreed with our clinicians and multidisciplinary teams.

The headline number is the waiting time target at tier 3. The question was what other measures we should use, and whether there are unintended consequences of having the primary measure as the waiting time target at tier 3.

I cannot answer that question.

From an education perspective, we monitor not by looking at waiting times but by looking at outcomes and how they are tracked over time. As a number of other services do, if we are doing a direct piece of work, we use standardised assessments or core measures before and after. To some extent that is a pretty dumb way of doing it, and the better way is to specify from the outset what is being looked for.

The fundamental point about referral to CAMHS is what is wanted from that referral or piece of work. If a piece of work comes to educational psychologists, the first thing we ask is what the referrer wants us to do. Then we do it, or not, and measure the outcome to ask whether all agree with the intended goal and the result.

The outcome also has to be measured over time. You could do a piece of video interactive guidance or parenting work with a family, and the parents could say that they are a lot happier. The case is then effectively discharged and inactivated. Down the line, however, is that child still in mainstream education? That is what we need to be better at, and we are starting to do that in education.

Are you doing that?

Yes, we are. We are starting to measure, certainly. That is being driven by Education Scotland as part of its inspection process. We are slightly smaller: it would be more difficult to do that nationally across CAMHS.

Is that a better headline measure than the waiting time target at tier 3?

I think that it is. Ultimately, if you are going to keep on forcing that waiting time target, that is where you will put your money.

Yes. That is what I am trying to get to. The problem that you have is, if people are saying that the waiting time target is not a good target, what can you put in its place? I am not hearing about anything that is measurable—or rather, I am hearing something from Barry Syme. You are right in saying that what you measure gets done. If you are not measuring the right thing, it will not get done. I am a bit disappointed that people are not saying what they want to measure. It all sounds a bit vague, to be fair.

That was a statement rather than a question. Tom Arthur is next.

I have a quick question for Jackie Irvine. When the convener asked what happens when CAMHS referrals are rejected, you said that the data that is required to answer that question is not available nationally. Is more data sharing between services needed?

I meant that how a rejection is dealt with probably varies somewhat across the country. I can speak only about my health board area, although I am here to speak on behalf of Social Work Scotland. The mental health strategy might want to reinforce the management of that process and the information that goes back.

I think that it is standard for information always to go back to the referrer about the reason for the rejection and about what other service might be preferable or more appropriate for the child. I am not quite sure exactly what you want me to answer.

Given the range of services, is data sharing between services seamless enough?

I do not think so; there is still work to do on that. We involved GPs in our pilot, which went well locally, but we are still looking to roll that out from one area of our patch to the next. West Dunbartonshire is very small.

Data sharing happens only with consent. If families are presenting to their GP or to a school with difficulties, it is much easier for the pastoral care teacher, for example, to speak to the GP and do the referral on their behalf or with them. GPs are always notified of whether a child has been accepted into CAMHS, even if they are not the referrers. It helps them to have that up-to-date information.

There is the general communication issue about what people are experiencing in a local area depending on the demand at the time. We need to make sure that the information is communicated to all services so that they can address issues in a solution-focused way. We do that through our community planning partnership children’s services strategy work, which we make sure focuses on children’s mental health and wellbeing. The work is reported up to the community planning partnership. If we were having significant difficulties in managing or accessing services, we would report those difficulties up. The difficulties could be to do with resource, a spike in demand or a lack of appropriate services at lower levels.

Would any other panel members like to comment on the data-sharing issue? It seems that data sharing in some areas might be insufficient. Is the lack of data sharing potentially a barrier to better outcomes for service users?

In general, we all have data-sharing agreements and protocols that specify what we can share, the levels of consent and the information that goes back. Having the principles and protocols set out is different from having systems that speak to each other easily on a daily basis—that is probably where the need is greater.

The issue is not just that education services as a whole have a different system from social work as a whole. In social work, there are different information systems across the 32 local authorities for client-held records. Those systems do not speak to each other. In health services, there are different levels of recording for client-held information. It is not just three systems that lack connectivity—there are variations in those systems. That is why addressing the issue is so complex.

The teams that work with children share information and work well together, but the information technology systems do not enable that information sharing to work seamlessly and smoothly in real time. We are embarking on using a product that will enable our social work, health and other colleagues to see on a single system all the information that it is appropriate for them to see about a child or young person. That product is being rolled out.

The information sharing is there. Any child who comes before us will have a single plan to support them that has been developed by the voluntary sector in a multidisciplinary and multi-agency way. With a paper-based system, however, an individual who goes into a family will not always have access to all the information at that time. We are working on a solution to enable that to happen and to ensure that the information is there when it is needed.

If we had more time, I would get you to explain functional family therapy, but I can probably guess what it is.

In its submission, Social Work Scotland talks about the need for a “much more holistic approach” and “early intervention” and says:

“the best way to deal with mental ill health is through a social model”.

I do not disagree with a word of that; indeed, I totally endorse it. After all, much of this is about poverty, inequality, poor housing, poor environment and the rest of it.

In a previous inquiry into looked-after children in which I was involved, a number of people talked about the need for social workers—or what previously were called social work assistants or, as some called them, the home makers from years ago—to go in, do fairly basic work with families, get them into a routine and deal with systems of behaviour, boundaries and all that kind of stuff. That is desperately needed, but how can it be done in the current climate when local government budgets are under such pressure? Following on from that, do you have the human resources—the people on the ground—to deliver not only that but the range of other services that are involved in CAHMS?

Your question is obviously very sensitive. We still have a model of what we would call home helpers or family support assistants, but that is a precarious service to keep afloat in the current financial climate. As someone who is responsible for social work services in my area, I can say that we have to make some difficult decisions.

Which area is that?

West Dunbartonshire. The situation there is no different from that anywhere else in the country.

How many people are delivering the service on the ground in West Dunbartonshire?

About 48 to 50 social workers who are qualified in fieldwork are out in the communities.

In the inquiry that we had, social workers told us that, given the pressures that they are under, that element of their work has largely gone and they do not do much of it these days.

The 21st century social work review recognised that professionals should be doing what they are trained to do, as in any profession, and that there was a need for social work assistants or family support workers to do more of the hands-on work that you talked about—setting boundaries, helping people to get into a routine and to understand what children need to keep them healthy and well behaved, and managing families’ stress and chaos at times. I am sure that, if a study were to be carried out, it would find that staff have been lost in those areas, and that leaves social workers possibly having to do a wider range of tasks, because they have not had that earlier support.

Families find such workers—we would call them paraprofessionals—much less stigmatising. Instead of a social worker coming to their door, they have people who can take them out into the community and do things with them, such as getting them used to shopping. Because our area is very small, the people in the community know the social workers, and there is a huge stigma in that respect. Our health visiting service has young family support workers who are, helpfully, funded by education services, as are the outreach workers that we have from nurseries. They work really well with lower-level families where the concern is not with immediate risk but with helping families who are struggling with poverty or other difficulties.

I suppose that the level varies, and we are experiencing many more complex cases. I should say that that observation is anecdotal and relates to what I have seen in West Dunbartonshire; it is not made on behalf of Social Work Scotland.

11:00  

What do the other witnesses think about resourcing? Across the field, how many workers short are we? Is there an oversupply in anyone’s area?

Are you talking about staff who work in child and adolescent mental health services or the type of workers that you referred to earlier?

I am thinking of child and adolescent mental health services, but the aspects are associated.

We have seen a significant increase in the number of staff as a result of our investment in and redesign of the service. That work was done partly to address the waiting times issue that has been highlighted and partly to ensure that we have good provision not only at tiers 1 and 2 but at the tier zero level that Barry Syme mentioned, which I think comes back to your question about the community support that is available. We are just about to finalise the recruitment of extra nursing staff, which will leave us where we were at establishment.

The position is the same for Tayside. At the start of 2015, we invested in nursing, psychology, professional leadership from medicine and nursing, further work on enhancing the support that is available at tier 1 to do education and training, and support for families.

Our biggest issue is recruiting to consultant psychiatrist posts. We have 2.7 whole-time-equivalent vacancies in out-patients and a 0.5 vacancy in in-patients, and the shortage of individuals to take up those posts has been quite a long-standing issue. That has given rise to challenges with regard to the resources that are available.

Moreover, NHS Tayside has only one university output to recruit from. We recruit very small numbers from elsewhere, so we really rely on the students who are trained by the University of Dundee and Abertay University, and that can sometimes restrict the number of registered mental health nurses who are available. However, we have managed to recruit some additional staff.

I do not know whether that helps.

So we have a panel of people who are saying that they do not need additional resources. That is a first.

I am sorry—I am not saying that. As far as additional investment is concerned, it is recognised that referral rates are increasing. Last year, we took a big look at our demand to ensure that we had the right resources, hence the investment that we have just embarked on. There will be another round to look again at the issue in the knowledge that our referral rates have gone up, in order to understand why that has happened, what the issue is and what areas we need to think about for the future. I am not saying that we have reached a position where we do not need more investment in CAHMS.

We know that our hard-to-reach populations probably do not seek services, and I am sure that children and young people are no different from the rest of society. I am therefore not complacent, and I do not think that we will not need further investment.

Before I bring in Miles Briggs, I should say that the submissions that I have been reading refer to looked-after children—particularly those who are in residential care. I will not comment on that, but we should put on record the concerns that have been expressed about that group of young people.

My question is about disparities in the referral system. To what extent does your experience show that potential referrals are more successful if they come from a GP rather than from a named person or a school?

Given that we are holding you captive for a wee bit longer this morning, do you want to identify any priorities and important issues that, from your experience, should be included in the next mental health strategy?

I highlight the disparities in referral data. I cannot with confidence say that one group refers better or more appropriately than other groups, but I certainly know that what has helped locally—colleagues have mentioned this—is education work with GPs and referrers to make clear to them what we can achieve in CAHMS or what social workers are looking for in that respect. What also helps is being clear about the other services that are available prior to tier 3 to ensure that people get referrals in early.

That is the gist of my response, although I should point out that, as we have mentioned, the specific criteria for getting into CAHMS might vary. We want to eradicate that variation, because the criteria need to be standard across Scotland to ensure that families and professionals understand and are talking about the same thing.

As for the mental health strategy, I go back to my earlier point that I—and certainly Social Work Scotland—want an emphasis on tiers 1 and 2. If those services are not there, some children will be escalated into CAHMS inappropriately, or they might have to wait so long that they do not get the service that they need when and for the length of time that they need it. That sort of thing is variable, and the variability comes down to funding. As we have discussed, such services are funded by the voluntary sector, and some CPPs put in money in various ways, but we are picking up a significant gap there.

Aside from asking for extra money for CAHMS—notwithstanding the fact that demand for CAHMS has gone up, particularly in relation to autism spectrum disorder and ADHD, the assessments and diagnoses of which take some time and a lot of work—I want an emphasis on ensuring that every CPP has a view about what it has on the pathway all the way from what my colleague has helpfully termed tier zero, so that people understand how children are routed into the appropriate service at the appropriate point. In the main, we identify children quite early, but it is not unknown for a child to reach secondary school and to be struggling with a lot of the transition by mid-secondary school. That is when their mental health rapidly deteriorates.

We need to strike a balance because, as we have discussed, if we focus on only one area, such as waiting times for CAHMS, we will miss out on doing a lot of the preventative work that we could be doing to keep children and young people from needing such services and, indeed, adult mental health services in the future. We need to take what could almost be called a spend-to-save approach.

We will have to stop there. We could say a lot more on the issue, and I am sure that we will do so in the future.

I thank the panel very much, and I suspend briefly for a changeover of witnesses.

11:07 Meeting suspended.  

11:11 On resuming—