Public Audit and Post-legislative Scrutiny Committee

Meeting date: Thursday, September 27, 2018

Official Report 735KB pdf

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“Children and young people’s mental health”

The next item on our agenda is consideration of the Audit Scotland report, “Children and young people’s mental health”. I welcome our witnesses from Audit Scotland: Caroline Gardner, the Auditor General; Claire Sweeney, audit director, performance and best value; and Leigh Johnston, senior manager, performance and best value. I invite the Auditor General to make a brief opening statement.

Thank you, convener. This report looks at children and young people’s mental health services across Scotland.

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.

The Scottish Government’s mental health strategy focuses on early intervention, but in practice this is limited. The current system is geared towards specialist care and responding to crisis, rather than identifying young people with issues and helping them at an early stage. Access to early intervention services such as school counselling varies across Scotland.

The system is also complex and fragmented, making it difficult for children and young people to get the support they need when they need it. Accessing the right services needs to be easier for children and young people, their parents and carers and the professionals who work with them.

We found examples of good practice and projects aimed at improving services. The challenge is how to sustain improvements in the longer term, especially when projects rely on short-term funding.

Data on spending, performance and outcomes is limited. We do not know with any accuracy how much is spent on mental health services for children and young people, or what impact that spending has. The information that we have indicates that it is a small proportion of overall mental health spending.

Without a clearer picture of what Is happening across all four tiers of the system, it will be hard to make the improvements that are needed. That will require the Scottish Government, national health service boards, councils, integration authorities and voluntary organisations to work together with children and young people to bring about a step change in how support is provided.

As always, my colleagues and I will do our best to answer the committee’s questions.

Thank you. We have many questions. Colin Beattie will start.

Auditor General, one thing that jumps out in this report and which you touched on in your opening remarks is the issue of data. I cannot remember how many times you have raised that issue in reports. Without data, we do not know if we are getting the correct outcomes or if the money is being spent in the right place. Data is fundamental. Have those responsible for providing data services responded to the recommendations in your report about data?

I am pleased to say that, on the publication of the report, the Government accepted the findings and our recommendations, which is an important step. The chair of the task force that was commissioned by the Government, which is reporting jointly to the Government and the Convention of Scottish Local Authorities, has made that one of her early priorities, as set out in her first report, which was published a couple of weeks ago. There is an acceptance of the need. The hard work that is required now is to collect that data and make good use of it.

We have seen many reports with comments on a lack of data. Looking across the public sector, is there an improvement overall?

We see pockets of improvement. Overall, we still do not have the data that we need, particularly in developing policy areas, such as those relating to the provision of more early intervention and preventative services. In health and social care more generally, what is happening in community services and primary care is that we tend to be very good at collecting lots of data in the more traditional services, such as hospitals, compared with the more flexible services, which are often the preventative services. Lack of the data that would let people involved in those services plan and track progress over time is one of the blockages to making a reality of the Government’s outcomes approach.

Would it be correct to say that the majority of data disconnects come about when local councils are collecting data on one side, Government is collecting on the other side, and somehow they do not come together?

That does not help, but I do not think that it is the whole story. There are certainly gaps in social care and gaps in the way health services and social care work together, but there are also important gaps in what we know about community health services and primary health services.

I vaguely remember that the Government put together some sort of task force on data several years ago. Am I wrong about that?

That does not ring a bell. We have seen lots of initiatives around things such as the integration of health and social care and the wellbeing of young people more generally through the early years commitments, but I think that that is a question for Government rather than us.

One of the big questions is that of financial reporting, with regard to how much is being spent on this issue. It is hard to understand why that information is not available, at least on a local basis. Is it simply that the information is not being harvested nationally but is being reported locally?

In exhibit 9, we try to pull together the available information on spending on these services across Scotland. The numbers are so variable as to not be credible. Claire Sweeney can talk you through some of the reasons we have found for that.

We had a hard time getting a clear picture about how the resources were being used. We could see, to a certain degree, how much was being spent in health, but that data was very limited. In the report, we have presented as much information as we could gather nationally, but it is not good. There are key gaps in how the information is collected locally and in how it is reported nationally and publicly. We have highlighted some of the key areas in exhibit 9. There are inconsistencies in the ways in which organisations work out how much is spent, what is included and what is excluded. In some areas of Scotland, the information on how much is spent on community services does not feature. The information is by no means comprehensive but we have given you as much as we were able to collect, with those heavy caveats that there are some significant gaps.

In paragraph 50, you say:

“the CAMHS workforce increased by 11 per cent between 31 March 2014 and 31 March 2018”.

That is a fairly big increase. How does that feed into the results? It is not clear from your report that there is a direct correlation between the increase in the headcount and the outcomes.

You are right; it is not clear. There are a couple of reasons for that. One reason involves our finding that the number of referrals increased by 22 per cent over a five-year period so, although there has been an increase in the workforce, the level of demand has also been increasing, and doing so more quickly. 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. We do not know enough about that. Dame Denise Coia, the chair of the task force, is very keen to fill that gap.

Surely the local councils, which are mainly concerned with CAMHS, must have some deep data on outcomes; they must have something to justify the increase in headcount and so on.

It is not quite right to say that it is the councils that are mainly responsible for CAMHS. Again, Claire Sweeney can talk you through that.

What we saw overall was a lack of clarity about how the whole system worked. We were looking for connections between different services but we saw a siloed approach in some areas. We would see particular specialities focused on certain needs of children, and also very broad services trying to support children in a range of different ways, through local authorities, charities and the private sector.

All those things are good initiatives that try to support children, but we are clear that the matter can be addressed only by a range of different organisations working together more effectively. 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. There needs to be a much clearer sense of what interventions work and where the money should be targeted, and there must be monitoring of what difference any of it makes to children.

Throughout the report we have stories from the children and young people we spoke to when we were carrying out the work. They told us how frustrating it was to repeat their stories to different professionals and to be unclear about what services they could access when they needed help. The same points were raised by their families. We see that there are problems across the system rather than just in particular parts of it.

Who should be doing the assessment of the outcomes?

Anybody who is providing services and support for children should be thinking about what difference their service is making and what impact it is having on children locally.

As the Auditor General said, we can see data on waiting times. That data does not tell a great story but it gives us a picture of what is happening. There is a gap with regard to measuring outcomes, which is to say, the differences that services make.

In the report, we highlight the fact that measuring outcomes is not seen as a priority in all areas of Scotland. The integration authorities have a key role to play in that area, improving the line of sight and the priority that is given to services across Scotland. From the evidence that we saw, measuring outcomes is not a priority everywhere.

Again, you highlight a concern, saying that each individual organisation involved should be assessing its own outcomes, but as you can appreciate, everybody might apply different criteria, so we could end up with data that is not of much use anyway, even if there was somebody who was bringing it all together. Who might bring it together?

The issue links clearly to the national performance framework. It is difficult and challenging across the whole public sector to get good information on outcomes. The services need to be locally responsive to needs and differences, and there needs to be variety—we recognise that to be true—but there still needs to be something that brings the information together. We would ask some simple questions. How do you know that the millions that are being spent on these services are making a difference, and how do you tell that that is happening locally? At the moment, we do not see that thread throughout the way in which everybody is working. We see a system that is under significant pressure, we see a lot of effort going into harnessing the views of children and young people and we see a policy priority around the mental health of children and young people, but we do not see that being translated on the ground.

During our fieldwork, we saw examples of measuring outcomes locally. What we are trying to say is that, at a national level, we have no idea of the outcomes that are being achieved, so we have no idea about where to direct funding and what to spend it on.

The Scottish Government is working on developing a number of quality indicators for mental health across six different quality dimensions. However, the issue there is that we understand that boards will choose which ones they want to measure, and that will make benchmarking very difficult.

Can I follow up on that point, in terms of the sharing of learning? It is a slightly different point from the data and the financial aspects. On page 21 of your report, you talk about NHS Ayrshire and Arran. It seems to have continued to improve performance to meet the 18-week standard consistently throughout the period. How did that happen? What is it doing that is significantly better than some of those that you reference on page 19, and how is that learning either being shared or going to be shared, either as a result of this report or in general?

09:15  

NHS Ayrshire and Arran is taking a whole-systems approach. It is working towards multiagency collaboration, for example seconding teaching staff to the CAMHS service, and vice versa—CAMHS staff sitting within schools. 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.

We have to be cautious. NHS Ayrshire and Arran is now struggling with how to maintain the pilot initiatives with short-term funding. Another thing to acknowledge is that different areas have different needs and challenges. 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. Good practice will be shared in relation to various things that are going on. For example, I was at a conference yesterday and representatives of the youth commission on mental health services were also there. I know that the commission will make a number of recommendations and share ideas and good practice, and the task force will hopefully progress that work of sharing good practice.

I am sure that we will come back to the nature of funding.

Might I press you on a local issue? On page 19, you talk about NHS Grampian and NHS Tayside, which are of particular concern to me in my representative capacity. NHS Grampian seems to have a 21-week wait time for first appointments and NHS Tayside an 18-week wait time, which are significant waiting periods. Presumably this is happening when someone has an identified need and should get into the system as quickly as possible. What are NHS Grampian and NHS Tayside doing to address those wait times and/or learn from the likes of NHS Ayrshire and Arran how to improve that performance?

Towards the end of our report we refer to some good work that is going on in Grampian.

We have to be cautious about the waiting time figures. As Claire Sweeney has said, we have outlined the data that was available, but 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. The differences are also to do with workforce capacity and issues with the way that data is collected and monitored. We also found there were issues around the referral process—the referral criteria changing—and that, therefore, the number of young people that were seen fluctuated over a period.

Auditor General, you bring a lot of performance audit reports to the committee and they cover a wide range of services and projects. Some of them are good—and later in today’s agenda we will look at one that is good—some are bad, and some are downright damning. Where would you place the report in that spectrum?

The report highlights a problem. We know that dealing with mental health problems early in their lives is difficult for children and young people, and distressing for them and their families.

The evidence shows that it can make a difference to how well they thrive for the rest of their lives. If they get the help and support they need early, a relatively minor problem can be nipped in the bud and they can get back into full-time education, and continue to build relationships, their confidence and their ability to flourish as people.

If they do not get that help and support early on, they can get into a cycle of depression and anxiety, doing less well at school and being less likely to fulfil their potential once they leave school. That is why the report is so important and why the failings that we have identified, and which the Government has accepted, matter.

The team doing the work heard stories of young people and their difficulties in getting some of the help that they needed, often for quite small reasons, such as teachers not knowing what help was available or how to refer them, and referrals being made that did not meet the referral criteria for the service that they were being sent to. Those things should have been quite straightforward to fix and yet they had an impact on young people’s lives. That is why the problem matters to us.

So the team identified exceptional problems that went beyond the usual difficulties that we find when public bodies work together, or problems with outcomes or data. The problems were greater than the team was used to dealing with.

It was a combination of lots of the young people who we are talking about finding it difficult to access what ought to be relatively straightforward interventions in practice. Some of the pathways are described in the report. Leigh Johnston, do you want to talk about that?

There were several barriers. One was the lack of early intervention and prevention services. Referrals to the CAMHS specialist service are increasing greatly. Because the data are not there, we do not have the evidence to understand what the demand for the lower-level services is, but we imagine that some young people could be helped with better services in place at the tier one and tier two levels, so they might not need the specialist services. We suggest in the report that the four-tier approach to the service delivery might no longer be fit for purpose and that we need to look at how we might provide a more person-centred service to save children and young people from bouncing between the different tiers. We need to make sure that the lower-level services are there to prevent people from being referred to CAMHS or their condition deteriorating further.

Is it fair to say that the report could be summarised as saying that we cannot go on like this, and that something has to change?

We say in the report that a step change is required. The Government and the chair of the task force recognise that. The challenge is to make a reality of the required changes.

On that challenge, the report also says:

“It is not clear how the Scottish Government’s mental health strategy will improve outcomes for children and young people.”

Why do you feel that to be the case?

There are 40 actions in the strategy, 15 of which relate to children and young people. We found that a lot of the actions within the strategy were focused on trying to understand how the system works and the challenges it faces rather than outlining action that was going to be taken and the outcomes that the Government wanted to achieve. The Government has said that it will develop a framework that will measure progress and outcomes, but there is no timescale for that work.

The Government delivered the progress report against the strategy a couple of days ago and things are happening. However, the report focuses on things such as the youth commission and the task force, which will look at the challenges and figure out what is going on and what needs to change. That is why we feel it is not clear how the strategy will improve outcomes.

Since the report that we are considering today was published, a couple of things have happened. One is the annual report on the strategy; the other is the programme for government, which made some announcements about counsellors in schools and additional funding. Even with those iterations, is the strategy still inadequate to meet the challenges identified in the report?

We need to see the outcomes and recommendations of the task force and the youth commission. In our report, we say that we would like to see the task force consider the recommendations that we have made in our report.

Funding for more school nurses and school counsellors will start to make a difference but, as we say in our report, it is also necessary to look at the way in which organisations work together and for them to work in a more joined-up and collaborative way.

You say the plan to do those things still needs to be demonstrated.

Yes, that is local and national bodies working together to take that forward.

I want to focus on demand. The most worrying aspect of this is that nobody seems to have a handle on the level of demand and, more importantly, not just the numbers but what is behind the numbers—what kinds of services people need.

Historically, as you have said, there has been a lack of sufficient data—qualitative and quantitative—on demand. How quickly do you think that gap can be satisfactorily rectified?

In the report, we mention a case study in Grampian where some mapping was carried out to understand the levels of demand and need, and then start to think about what the services to respond to them should look like. The message is that it can be done.

There is another issue that we have not touched on so far. We saw a lot of committed professionals who want to get this right. There is a lot of frustration within the system.

The report also highlights that some groups of children and young people are more affected than others. That is well known and a lot of research around that is available. We would like to see that more clearly recognised and targeted.

Exhibit 1 in the report sets out in much more detail information about those children in Scotland who are more likely to have a mental health problem, such as children who are looked after in the care system, and children who are living in the more deprived areas of Scotland. We did not see enough activity to target those children and to help give them the support they need. There is more to do, but it can be done. The case study in the report shows how it can happen.

I presume that there is a close link between children with adverse childhood experiences and children with mental health problems.

Absolutely.

Filling the data gap on a permanent basis is a slightly longer-term exercise, by the time we set up IT systems and so on, and we know the problems that are associated with IT systems. Should the Grampian mapping exercise not be replicated throughout the country?

It should. What happened in Grampian reminds me of what we have said on a number of occasions about genuinely transforming care for older people. If you are going to do that, you need to know what need and demand look like. A relatively small number of people require the most intensive support and, in this case, you start in schools, early learning centres and nurseries to identify the children who appear to have challenging behaviour or whose parents are struggling for a range of reasons, and you build that up from localities to the health board level, and gradually build up a national picture. Doing that helps you to not treat the data collection as a separate thing. As you are identifying those children, you are starting to understand what help can be provided in a nursery or a school and which children need to be referred to specialist services. Local intervention is always the best place to start.

The data that is available is historical. It seems to me that it is a fast-changing world in terms of the requirements for children’s mental health. Take an issue such as autism: we are much better at identifying autism early on—I am not saying we are perfect, far from it, but identifying children who are showing signs of possible autism is a lot better than it was even 10 years ago. Is anyone looking at the changes in the nature of child and adolescent mental health?

I will kick off. I am sure that colleagues will want to add to what I say.

First, you are right that we do not know what is causing the increase in demand. There are two broad theories. One theory is that life is more stressful for children and young people with things like social media playing a part. Another theory is that the reduction in stigma and greater awareness of mental health problems is making it easier for young people to come forward. Nobody knows how far those the things are the case and what else might be happening.

I was encouraged to see the proposal in Dame Denise Coia’s preliminary report. She suggested moving away from the current four-tier approach that aims to cover everybody to something that focuses first on children who have relatively mild levels of need and can be helped in school, secondly on people who need specialist services, then on children who have neurological problems such as autism, attention deficit hyperactivity disorder or Asperger’s syndrome, and finally, on children who are at risk because of deprivation and adverse childhood experiences. Without second-guessing Dame Denise Coia’s expertise, that approach is likely to give a way of understanding what is happening that is better than treating all mental health problems as though they were the same.

09:30  

It would also give us a better understanding of the resources and expertise that need to be put in place, and when and where.

Absolutely.

In the report, we mention the THRIVE—timely, helpful, respectful, innovative, values-based and efficient—model, which has been used in some areas in England. That model looks at different kinds of support that children and young people need and starts to map the resources that might be required.

One of the reasons that the Grampian example is attractive is that it gets away from a siloed approach, where specialists in a condition treat children with that condition. There is sometimes a lack of connection between them and general practice, schools, education and so on. In Grampian, it was good to sense a whole system coming together to start to think about shared responsibility for children in the local area. We would like to see more of that.

The Government has announced an average 6 per cent per annum increase in mental health resources over the next few years. I presume that that additional money should be focused first of all on developing something like THRIVE throughout Scotland so that we see better use of resources—more targeted and earlier intervention, and all the other good things that we have been discussing—and also that the resources go to where they would be most effective.

We say in the report that it is really important to understand the levels of need and what makes a difference before you start to think about how you spend the resource. That is absolutely critical and it can only be done with the children and young people involved, as well as the folk who are providing the good services locally. There is a need to understand it all.

Is that not one of the key issues? The section in the report on resourcing says lots of good stuff about money being put into various things. The committee is hearing, however, that no one has worked out where the most effective interventions are and at which of the four stages interventions should be made. Is there not also an issue about what I think you call non-recurrent funding and how third sector organisations are able to budget and say they will be able to deliver the service effectively in future? Could you tell us something about that?

You have just summed up the end of the key messages of the report where we say that transformation will only happen if there is a clearer view of what works, a plan for how the system needs to change, and a move away from relying on short-term and isolated initiatives. It is easy to say that and much harder to do it. Claire Sweeney, would you like to pick up what that might mean in practice?

We saw examples of voluntary sector initiatives and projects being introduced because there was a pot of money, but it was not clear whether the initiative had worked, whether it would be mainstreamed, and what had been the shared learning around it. If it had not worked, where was the decision making to say that it was not going to be continued and for good reason? Although we saw a lot of commitment to the overall idea of supporting children’s mental health services, and we saw some resource against it, we did not get the sense of a system learning together and working as one coherent whole. There are messages in the report from children and young people about the system feeling fragmented and we saw that through the way in which money is counted and performance is measured, and the current focus on short-term initiatives.

Sticking with the demand issue that Alex Neil was talking about, can you tell us more about the benefits of early intervention and prevention, or the early stages of the four? What do you see as the positive outcomes that those measures can bring?

Moving on specifically to the matter of the resources that Claire Sweeney was talking about, is the solution as obvious as saying that extra investment at tier one and tier two reduces demand on tier three and tier four, such that those who do require stages three and four get a better service and the money is better allocated?

The idea that focus on prevention and early intervention is a good thing that will have a positive effect on reducing demand has long been held in the health and social care services; people will be less likely to get into a crisis situation.

We were careful about our language around that issue. We say in the report that the service is focused on crisis and specialist need. We are not saying that that is a bad thing—of course there will always be children who need that kind of support—but we are saying that it is not a good thing if it operates to the exclusion of prevention and early intervention. A shift is needed. There needs to be a clearer picture of what works and a greater commitment to early intervention and prevention, which people know makes a difference.

We also think that one of the factors underlying the increasing number of referrals to specialist mental health services and the increasing number of rejected referrals, is that people could be well supported by lower-level services closer to their homes and schools but because no specialist service is available locally, they are being referred up the chain to more intensive services that are not the best ones for them, and they are then rejected and left clogging up the system. The system is therefore under more pressure, the young people are not getting the help they need, and we are not breaking out of the cycle because we do not yet have the school counsellors and trained teachers who can spot a problem early and know who to refer it to, and a system that can respond in the best way for an individual child’s needs.

I am going to press you, Auditor General. We are going to come back to the rejected referrals in two seconds. First, would you mind developing the point about access to early intervention? Having written this report, what do you see as the key barriers to the early intervention that Claire Sweeney is saying is vital?

There are a number of things and the team knows more about them than I do. Briefly, however, there is something about having the services available in the first place, making sure that people such as teachers and GPs, who are in contact with young people every day, have some training in that general level of mental health and know what services are available, and making sure the system works smoothly so that it is easy to make a referral once, with the right information for that referral to be assessed and picked up by the right service. It comes back to looking at the system as a whole rather than having separate bits of it working in isolation.

I echo what Claire Sweeney said. We should give due credit to the professionals who are working hard to deliver the services. We are asking questions about the system, and I will move on to ask some questions about rejected referrals.

The key facts section of the report states that there has been a

“24 per cent ... Increase in the number of referrals rejected ... since 2013/14”.

Further on, in paragraph 25, you give some reasons why that has occurred, which include:

“the ... young person does not meet the criteria for treatment”,

“a lack of tier one and two services for children ... experiencing less severe mental health problems”

and

“the referral does not contain enough information.”

First, you say that national data is not being collected on reasons for rejection. Are you aware of local data being collected? Secondly, is there any evidence to show that the NHS boards that are under the most pressure, perhaps because of the number of referrals that they receive or their level of service provision, apply the criteria for rejection more strictly than NHS boards that are under less pressure? Please do not feel that you have to be careful with your language.

We found throughout our fieldwork that there are local examples of the collection of data. However, at the national level, we have no idea what the trend is for rejected referrals, or what the reasons are for them. It comes back to the lack of data. The Scottish Association for Mental Health recently published a report, which was commissioned by the Government, on rejected referrals and what happened to young people after their referrals were rejected, and it makes a number of recommendations. To understand the matter better, however, we need to come back to the matter of data.

Was that the answer to my first question or my second question?

Sorry. Will you repeat your second question?

Are there hotspots in health boards that are under more pressure because they get more referrals or have fewer services available? Do they reject more people because they know that they cannot treat them, for whatever reason?

Again, we simply do not know that because we do not understand the reasons behind the rejected referrals. The information is not collected at a national level.

In our report, we outline why we think that some referrals do not meet the criteria. We heard that there are children and young people who would have benefited from lower-level early intervention and prevention services but, because they are not available locally, the young people are being referred up to CAMHS, and then they are rejected. Rejections can also be due to referrals not including enough information.

Yesterday, I presented the findings from the report at a conference, and I met an academic from the University of the Highlands and Islands. About four years ago, she looked at the reasons for rejections, and she found that there were a range of reasons. Children and young people with behavioural issues were more likely to be rejected, and referrals from teachers were more likely to be rejected. However, that was a small-scale study. We need to understand what is going on at the national level, and that comes back to the collection of data.

Out of interest, did that academic give any reasons why teachers’ referrals might be rejected?

She hypothesised that it was perhaps because of the language that they were using, because they were not clinicians. Knowing the language to use would perhaps make referrals more successful. However, she did not know the absolute reason.

Auditor General, do you have anything to add?

No.

I have a supplementary question. You talked about local strategies and what might be failing around data collection and the provision of services, which leads to inappropriate referrals. I do not want to lose sight of paragraph 70 of the report, which says that local mental health and wellbeing strategies focus on adults. Is the problem that, at the local level, there just is not a strategy for children and young people’s mental health services? The problem is not that the strategy does not gather data or that it is not working very well. There just is no strategy for children and young people. The strategy is for adults.

We certainly got a sense of the level of priority that children and young people’s services have in certain areas. There is potentially a link to our message on waiting times. We say in the report that the waiting times have been a focus. That is not to say that we should not be concerned and know more about how long children are waiting to get services, but we have already highlighted the problems with the data that make it hard to answer some of the previous questions.

Our sense is that children and young people’s services need to be a greater priority. There are lots of good and committed people working in the system and there is some clear evidence about where the problems are, but there is a lack of pulling together to make sure that those needs are responded to and that the money is there to make that happen. We definitely see this an issue on which a number of organisations need to work together very closely, including the Scottish Government and COSLA.

That is surely a massive disconnect between stated national priorities and local priorities on the ground, is it not?

We say in the report that we absolutely see a commitment in terms of policy on the issue. It is very clear that people recognise the policy as important in Scotland. What we did not see, however, was that translating into practice in all areas, and that is why some of the recommendations speak to that point.

There is a related point that I do not want us to lose sight of. It is further up that page, in paragraph 68. A lot of the policy focus has been on the importance of integration authorities in getting oversight of what is happening for children and young people as a whole, but we found that only 11 of the 31 integration authorities across Scotland have responsibility for both children’s mental health services and social work mental health services. They are the ones who are best placed to do that. The other 20 will clearly find it more difficult.

I will ask a few more questions. Going back to rejected referrals, which Bill Bowman asked about, I note that some reasons are given on page 18 as to why referrals are rejected. What I heard from your earlier answers is that there is no data. The report gives three reasons why referrals are rejected:

“the child or young person does not meet the criteria for treatment”,

“lack of tier one and two services”

and

“the referral does not contain enough information.”

That is qualified later, at paragraph 28, which mentions

“the level of detail provided by the referrer.”

For clarity, is there any data on how many of the rejections fall into each of those categories?

09:45  

No. As we say at the beginning of paragraph 26,

“National data on reasons for referral and rejection is not collected”,

which makes it very difficult to be clear about that. As Leigh Johnston said, the Government commissioned some work from the Scottish Association for Mental Health to examine what has happened, and it published its report recently, but that has been a specific clinical audit rather than routine data collection, which we think is important.

I agree with you.

Going back to the point about the referrer, I note that a lack of services points us towards funding and supply, but the other two reasons for rejection seem to me to relate to the competence of the referrer. I do not use that term in a pejorative sense; it is just about their ability and whether they have the guidelines to do it. Somebody has identified a need and said, “I have a young person here who needs help”, but because of—again, I do not say this pejoratively—a failing on the part of the referrer, that young person is unable to access the help. That is hugely concerning. Is that a fair summary? What is being done?

As we outline in our report, 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.

We outline some good practice in NHS Highland, where there is a primary mental health worker who undertakes a triage service. The young person goes to their GP and the primary mental health worker is there and can assess them and offer, almost, a step up or down. If they do not think that a referral to specialist services would be appropriate, they will step the young person down, and vice versa. If they think that the young person requires more specialist help, they will step them up.

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.

On that exact point, you mention in your report a revised role for school nurses. Are there sufficient school nurses such that, if there is that change in role, it will make a significant contribution to early intervention? Alternatively, is it the case that it is a good thing to do but, ultimately, early intervention will not be significantly impacted?

As we say in our report, mental health and wellbeing is a priority for school nurses, but they have indicated that they require a bit more training and help in that area. It was announced in the programme for government that a significant number of school nurses will be brought on board. We will wait to see the impact of that.

Finally, I want to press you on the data-sharing aspects. At page 23, you say that multi-agency working together is going to be crucial and that the

“Young people ... found it very frustrating”

having to repeat their histories and challenges

“to multiple professionals.”

What is the issue with data sharing? Is it about IT, for example? Is it the data-sharing regulations? What is going on and what can be done to fix it?

We have been looking at the issue in the round as part of our work on the integration of health and social care services, and the Auditor General will bring a report on the issue to the committee later in the year. Some of the issues that we saw in our piece of work were about the quality of records. For example, some areas are using paper-based records, which by definition makes it difficult to share information. There are a range of factors.

Earlier in the report, we talk about the need for trust in relationships, and that goes for the professionals who work in the system just as much as it does for the children and young people who need the support. We see information and data sharing as just one part of that. Use of paper records does not help, but we need to understand how the system is working together and what information everybody needs to know.

Over the past few years, there have been developments in some parts of the health system to try to move that issue on. An example is the sharing of emergency care summaries for people who are going into accident and emergency services. It can be done. Work can be done to improve the way that information is shared across the system in order to make care better. However, we saw that there is a long way to go for the services that we have been discussing.

As colleagues have no further questions, I thank our witnesses for their evidence, which has been very useful.

I will suspend the meeting for five minutes to allow for a change of witnesses.

09:51 Meeting suspended.  

09:54 On resuming—