Public Petitions Committee

Meeting date: Thursday, December 7, 2017

Official Report 541KB pdf

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Continued Petition

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Mental Health Treatment (Consent) (PE1627)

Welcome to the 22nd meeting in 2017 of the Public Petitions Committee. I remind members and others in the room to switch phones and other devices to silent.

Agenda item 1 is evidence on a continued petition. PE1627, on consent for mental health treatment for people under 18 years of age, was lodged by Annette McKenzie.

Members will recall that we previously reflected on the evidence that the committee received in relation to the petition. That evidence highlighted the importance of young people’s right to confidentiality and, therefore, did not support any change in terms of young people being able to consent to their own treatment. However, recognising the issues of confidentiality and consent, the committee agreed to invite oral evidence from charities with expertise in youth mental health services, to explore the wider support that is available to people under 18 years of age who experience and seek treatment for mental ill health.

I am grateful that we are able to explore some of those issues with Graeme Henderson, director of services and development at Penumbra; Carolyn Lochhead, public affairs manager at the Scottish Association for Mental Health; and Amy Woodhouse, head of policy, projects and participation at Children in Scotland. I am grateful that you are all here.

In order to make the most of our time, we will move straight to questions. Following the petitioner’s evidence, the committee felt strongly that there is an issue here. If the issue is not on the question of confidentiality and sharing information, it may be on what we can do to keep our young people safe. We hope that you can help us consider some of that.

What are your views on current support services for young people with mental ill health?

Thank you for the opportunity to talk to you this morning.

I recognise the sad reason why we are here. It is right that we explore the issue and what can be done to prevent unnecessary deaths.

There are about 1 million children in Scotland. It is estimated that about 10 per cent of them will have a diagnosable mental health problem—if you can do the maths, that equates to about 100,000 children. That is not an insignificant number; we are talking about a large number of children and young people. Those children have a diagnosable problem—they do not just have low moods or stress with school or life.

We have statistics on child and adolescent mental health services and staffing numbers and waiting times. They show a bit of a gap. There are about 1,000 members of staff in the CAMHS workforce—one to every 100 young people with a diagnosable mental health problem. About 4,000 referrals go to CAMHS every quarter—4,000 referrals but 100,000 children. The CAMHS workforce has a very small role within the overall support provision for children and young people with mental health problems. We need to talk about the response to that and whether that is the whole picture.

Given that three representatives from the voluntary sector are here, we would say that that is not the whole picture and that statutory CAMHS are only part of the story and the overall service provision for children and young people with mental health problems. The voluntary sector has a huge role to play. I particularly acknowledge the role of youth work. As you may be aware, Children in Scotland is a membership organisation from the children’s sector. We have about 500 members across Scotland, many of whom provide support to those 100,000 children, and many more.

The voluntary sector is strapped for cash and its services are short term, but it is providing a vital role—as part of that picture of support—not just in helping those with mental health problems, but in prevention. That work is vital if we are going to address the significant problem of young people’s mental health in Scotland.

I absolutely agree with Amy Woodhouse. There are another couple of points to be made on CAMHS.

Amy Woodhouse is absolutely right in the statistics that she cites. It is important to remember that we have targets and statistics only for the upper levels of CAMHS. CAMHS are intended to be a four-tier system, starting with universal services—schools, general practitioners and health visitors—and moving up to more specialist services. We have data only on referrals to tiers 3 and 4—the more intensive sectors. People are waiting longer than they should be in those sectors. Only about 80 per cent of children and young people are seen within the 18-week target—a target that we feel is too long.

One in five young people is rejected from CAMHS for one reason or another. We are grateful that the Scottish Government has recently asked us to look into that. There is a lot to look into and we hope to discover what is going on and make some recommendations to improve the situation.

Amy Woodhouse is right that it cannot all be about clinical and national health services. We are particularly keen to see the provision of support in schools. Most children—not all, but most—are in school, so it makes sense to provide support there. We would like to see the provision of counselling for all children of secondary school age. That would go a long way towards providing support to children where they are and when they need it, rather than their having to go through what can be a tricky and complicated referral process. About a quarter of a million children in Scotland have no access to school-based counselling. Fourteen local authorities have no on-site provision of school-based counselling—only 40 per cent of secondary schools have that provision. The Scottish Government is looking at that issue and we think that it is urgent.

Elsewhere is the United Kingdom, there is a guarantee of school-based counselling—particularly in Wales, which has quite an advanced system. Good evidence is coming out that school-based counselling makes a difference. Scotland should be no different; Scotland’s children deserve no less than those in the rest of the UK. We would like to see action on that.

Do you have a view on the case that prompted the petition? The young woman was out of school, but in work, and was under 18. I presume that some support can be provided by pastoral care staff. How does the model work for young people who are not in school, but are under 18?

You raise a really important point. CAMHS are defined differently across different NHS boards. In some areas, services are provided up to the age of 18. In other areas, that is only the case if children are in full-time education—otherwise services are provided only up to the age of 16. There is a problem with children falling through those gaps.

We want CAMHS to be extended up to the age of 25 for those who are already in the system, because the transition can be very difficult and, to be honest, is not always well managed. We have also heard from young people—via the Scottish Youth Parliament, which has done some excellent work on the issue—who feel that people of that age do not really fit into either child or adult services. In the longer term, we need a specialist service for the 16 to 25 age group, so that people do not keep falling through the gaps.

I will move away from CAMHS and turn to the services that the third sector can provide. Since 1994, Penumbra has provided open-access youth services, including work in schools, for those with mental health issues. For example, we worked in all 19 secondary schools in Fife, for a cost of about £200,000 per year—about £10,000 per school. To give you an example of the issues that were raised by young people—we were working with those from secondary 4, 5 and 6, typically—in one term, 120 young people expressed suicidal thoughts. That service was closed by the council because of cuts. It is now provided by another organisation, but on a much smaller scale.

We are currently working with primary 3 and 4 pupils on body confidence, because that is an issue that affects people at that age and later and has a massive impact on mental health and wellbeing.

We have a number of open-access youth projects, which were originally funded by the choose life programme, which started around 2005. However, as Amy Woodhouse said, the cuts to, and pressures on, council budgets are having an impact on those services.

Do GPs have all the necessary training to support people with mental health issues generally? More specifically, do GPs have the necessary training to make appropriate decisions when prescribing mental health drugs to under-18s, to ensure that those around the young people are informed of the possible side effects of medication? How confident are you that GPs are well enough equipped to deal with prescribing drugs to young people?

There are two points to be made. First, you are right to highlight the role of GPs. Most people say that they would go to their GP for help with their mental health, so GPs have an absolutely central role.

A few years ago, we did some research with GPs. GPs told us that they wanted to know more about mental health. They did not always feel that they had enough information; I think that just over half of GPs were aware of the Scottish intercollegiate guidelines network guidance that exists on non-pharmaceutical approaches to depression. We would like to see an increase in that awareness. There is an issue with GPs receiving more training and support on mental health issues and, indeed, guidance on confidentiality and when they can break it. In our response to the petition, we said that there is currently the ability to break confidentiality when a young person is potentially in danger. We are not sure that that is widely understood.

Secondly, we want to see evidence-based treatment and support for children and young people. In many cases, that can be a referral to a psychological service, or another service. However, medication has a role to play. I worry sometimes about the impression that we give if we talk about mental health medication in a different way from how we talk about medication in other areas. Many people find medication helpful in their support, and we should be careful not to stigmatise people who are prescribed medication. That said, GPs need more support and training in mental health treatment and understanding the range of what is available.

I go back to what you said about confidentiality. As I understand it, individual GPs have discretion as to whether they inform parents or a close family member. To your knowledge, does that happen a lot? Do GPs often go down that road?

I have heard of that happening. I have never seen any figures that would indicate what scale that is on.

There are no statistics.

Not that I have seen.

There are a couple of issues. One is on confidence in talking about mental health. From my previous experience of working at the Mental Health Foundation Scotland—prior to my current post—with the Royal College of General Practitioners, GPs themselves identified that area as one in which they lacked training. Across the board, there is definitely a need for more training. GPs recognise that and would support opportunities for such training.

Then, there is the issue of confidence in talking to children and young people. Again, more could be done in that area. Some practices have specific GPs who focus on that issue. Young people are encouraged to make appointments with that GP. Things can be done about private spaces and signposting information; that is really important.

The links worker role that exists in some GP practices is primarily for adults, but there is probably a lot of scope to extend that model to include children and young people. GPs would then know what options are available in their local areas so that more social prescribing can be done.

The royal college also talks a lot about the amount of time that GPs have with patients. Can you really have a complex detailed conversation about mental health in 10 minutes? No. Young people are probably not aware of their right to ask for a double appointment, but even in 20 minutes you will not be able to cover everything. However, it could help if young people were aware of that and knew what they were entitled to.

It is also about how we talk to young people about GP services, how their rights can be met and how to get the most out of those services. In addition to what Carolyn Lochhead said, there is quite a lot there.

09:15  

Given that we all have mental health, it should be mandatory for GPs to have training on mental health treatment. Yesterday, at the biannual forum on the mental health strategy, several GPs from the Royal College of General Practitioners and accident and emergency consultants mentioned that they had not had mental health training since they did their university training. They were in their 50s, so it was a long time since they had had that training.

GPs are not aware of other options so, in struggling to come up with a solution, they might revert to medication as the only answer, which it clearly is not—there are other options for people.

Following on from Rona Mackay’s questioning, will you clarify whether the current guidelines that are in place for GPs to support young people presenting with mental ill health are fit for purpose and being adhered to in practice?

A mix of SIGN and National Institute for Health and Care Excellence guidelines exist for medical staff in general. There is a SIGN guideline on non-pharmaceutical approaches to depression, but it is not specific to children and young people, and there is NICE guidance for children and young people that relates to depression and social anxiety. There are no further NICE or SIGN guidelines that relate specifically to mental ill health in children and young people, which is possibly an area that we should look at. You have had evidence from the General Medical Council about its guidelines, which I am less familiar with.

We hear from GPs that they would like to know more about mental health and how to support children and young people, in particular, but there is not a lot of evidence about how strictly the guidelines are adhered to.

As a children’s rights organisation, we always advocate asking children and young people what would help them and what would make services more accessible for them.

In the spirit of things from the past that are still relevant, I point you to the work of the Paul Hamlyn Foundation, which a few years ago had a five-year £5 million programme that looked at how GPs should support young people aged 16 to 25. It produced a series of guides on how practice could be improved that were written from the perspective of the young people and included what they felt would be helpful. The guides cover having conversations about, for example, knowing what the side effects of, the alternatives to and the benefits of medication are. They back up what the GMC says in its guidance and provide a bit of assurance that we are covering the information that children and young people need to make informed decisions.

If this is all based on young people having the capacity to make decisions about their care and treatment, we all have a duty to ensure that they are given the information that they need in a form that is clear and understandable to them. It must go beyond the technical side of medications to how we have conversations with children and young people about what the medications mean for them and their lives.

I mentioned earlier some of the services that we provide, and one of the services that we worked with in Glasgow was a peer-mentoring service for S3 to S6 pupils. It was a project that trained S5 and S6 pupils to be peer mentors to S3 and S4 pupils, because young people tell us that they get a lot of information from their peers. Whatever the issue might be, they talk to their peers before they talk to anyone else, which is why peer mentoring and supporting young people to become peers would be a helpful way forward. As we all know, GPs have little time to talk to people and, as Amy Woodhouse said, even a 20-minute session would not provide adequate time to talk through some mental health issues.

What is your view of the links worker programme? To what extent are general practices in Scotland currently participating in that programme?

Penumbra has just started a links worker project up in Moray, where there are six workers across 13 GP practices. The project has been going for about a year and the evidence that is coming back from it is that the bulk of the issues that are being referred to links workers from GPs are social issues, mainly around housing, poverty and family relationships. Mental health probably makes up about 20 per cent of the referrals that are coming through.

We also have a wellbeing centre in Moray, which takes referrals from the links workers as well as having a walk-in facility. I know that there are other links worker programmes around the country, but that is what we have in Moray.

We also provide links work services, particularly in North Lanarkshire. We were very involved with the initial pilot that was led by the Health and Social Care Alliance Scotland and the deep-end GPs, which you are probably aware of.

There is a lot of benefit in the model, not least because it begins to address some of the issues that Amy Woodhouse raised about the time that is available with GPs. The job of the links worker is to be embedded in the local community and to have that sense of what is available locally—the strengths and assets that people can benefit from.

Mental health, in the broadest sense, tends to be one of the big issues that are raised. It can be a specific mental health problem, but it can also be an issue such as bereavement or it can be related to debt or unemployment. The model offers the opportunity to explore issues and look for what will help the person at the time. It allows them to lead the conversation, so it is very much about identifying their goals and helping them to link in to what is available.

We see more and more GPs starting to engage with that model and, indeed, more integration joint boards beginning to commission such models. It has a lot of potential to ensure that people can access the services that exist.

I do not have much to add to that apart from the point that you need the services to exist in order for the links model approach to work. That requires a strong community sector that provides support to young people and adults where they live.

There are slightly different models that involve a self-help support approach—with life coaching and a little bit of talking therapy as well—and there might be a bit more scope for young people to explore those models.

It adds considerably to what the practice can offer when the GPs know what is available within their communities. The time that it takes to find that out is not readily available at the moment, so the links model is invaluable where it exists.

I declare an interest in that I managed services that provided mental health support up to tiers 3 and 4.

As you are aware, it has been widely reported that there has been a significant increase in the rate of antidepressant prescribing to under-18s in recent years. The Scottish Government’s explanation for that is that the number of young people seeking help has gone up. Do you agree with that explanation, or do you think that other factors, such as access to other therapies, should be considered?

We have definitely seen an increase, over the years, in the number of young people seeking help for mental health issues. We have figures that demonstrate that the rate is going up.

There is some evidence that the prevalence of emotional issues in young people is going up, particularly among young girls, who are experiencing increasing emotional issues. Trying to unpick how much of that is due to the fact that society is more open about mental health and how much of it is due to a genuine increase in the number of incidents is difficult, and I will not pretend that I have the answers.

We want to make sure that, when young people take what is often a very difficult and brave step of seeking help, they get a correct, evidence-based response. That comes back to the issues that we have discussed already. It is about making sure that GPs and others whom they speak to have the confidence, the awareness and the tools at their disposal to make a good decision about where to refer someone or what to prescribe them, if that is appropriate.

An issue that we have not touched on so far is people’s confidence in having conversations about mental health with children and young people. We recently surveyed staff working in schools and got more than 3,000 responses, with about two-thirds of teachers saying that they did not feel that they had had enough training in mental health to do their job properly. We worry about the level of confidence and the knowledge of mental health in children and young people generally, as well as about ensuring that the services are in place.

The CAMHS statistics show that, at the end of each quarter, more people are waiting to start treatment in CAMHS than started treatment during that quarter. That suggests that demand is outstripping the services that are currently available.

I agree with Carolyn Lochhead about the concern for teenage girls. We know from longitudinal evidence from the health behaviour in school-age children study that something happens when girls in Scotland hit their teenage years. Their mental health deteriorates quite significantly, and we do not fully understand whether that is to do with increased pressures in society. Social media has been cited as bearing a lot of responsibility for that, and I am sure that it is a factor, but schools clearly have a role to play. We know that relationships across the board and teenage girls having a trusted relationship in their life can be important protective factors.

The statistics do not surprise me, but that does not mean that they are accurate. It is not easy to know what the correct rate of antidepressant prescribing should be. I remember when there was a health improvement, efficiency, access and treatment target for reducing antidepressant prescribing, which was felt to be a good thing, but we did not really know what the right rate should be. I guess that it is the same for children and young people. We should recognise that a prescription for antidepressants probably is the right thing for some children and young people, but are we doing enough to prevent that stage from being reached? If it gets to the stage at which a young person needs a prescription for antidpressants, we have left it too late. We need to focus on what we can do to prevent their mental health from getting to that point.

That is not easy, but we have a role to play. The early years are important in building resilience and good attachments—we know that and have evidence for it. If we are going to follow up on what should be done, we should put more into the early years and into parental support, as that would make a difference. As children get older, they need to be made aware of mental health issues so that they can understand their own mental health. That is absolutely key as well. They need to know the things that are likely to make their mood deteriorate or that will help to boost them and keep them well. Having a trusted adult is vital, and we know that it can be the protective factor that makes all the difference, so how can we ensure that they have that relationship?

On the rise in the disclosure of mental health problems by young people, it is worth thinking a bit differently about what people disclose. Often, they disclose not mental health problems but distress of some kind.

One of the things that we discussed yesterday at the mental health biannual forum is that people who present to GPs or to accident and emergency units and disclose distress, unhappiness or whatever it might be often do not get to the point of having a diagnosed mental health problem, so they do not enter the mental health system. That means that they are unable to access other services, so they go away without a solution to whatever their distress is. It is therefore important that the distress brief intervention pilots that are running gather that information in relation to mental health, not just in relation to general distress.

09:30  

I looked very hard at what the GMC and other contributors to our inquiry said, and two things stood out for me. One was the statement by the GMC that doctors

“should only prescribe medicines if they have adequate knowledge of the patient’s health and are satisfied that they serve the patient’s needs”.

What amount of time would you say that doctors need to spend with a young person before they can “adequately” make that decision?

The second thing was the GMC’s very clear statement in its letter that

“doctors should disclose information if this is necessary to protect the young person from risk of death or serious harm”.

We all recognise that from the safeguarding procedures that are part of the mandatory training for most third sector organisations, which has to be regularly updated. What I did not get from the statement was whether GPs are required to undertake that mandatory training on a regular basis and, if so, whether training on the information-sharing regulations that most of us are bound by, recognise and would explain to a young person is undertaken regularly.

What is your understanding of those two things and your response to the GMC’s comments?

It is difficult to say what amount of time is needed. I suppose that it depends on how well the GP already knows the young person. We could look back to the golden era when everybody knew their family practitioner and had built up a relationship with them, although there were issues with that as well. If a GP knows the young person too well and knows their family, would they feel able to talk about mental health or something that would be potentially stigmatising? The point, though, is that 10 minutes would probably not be enough for an issue as sensitive as that.

In my previous role, I did a lot of work around long-term conditions and mental health. When I talked to people who went to their GP practice with multiple conditions, they told me that the mental health condition was always left until last. It was almost as though, as they were leaving through the door, they would say, “Oh, and another thing, doctor—”. That is because it is not easy for people to talk about how they are struggling and having difficulties with a stranger who is acting in a professional role and has more power than them.

I do not know what the answer is other than more time, doctors making efforts within their practices to become inclusive and welcoming to children and young people, so that the practices feel like safe spaces, or having other professionals such as nurses, links workers or even youth workers based within practices who can have those conversations. Some practices have clinics for young adolescents and hold drop-ins at which they can talk about sexual health and other issues. It would be helpful to extend those and ensure that they also cover mental health.

On the duty to share information, I do not know about the technicalities of practice in Scotland, so I would probably be overstepping the mark by going into that. We have good suicide intervention training in Scotland, through ASIST—applied suicide intervention skills training—and STORM, which is skills-based training on risk management. There were great pressures to ensure that a high proportion of the workforce was trained through those packages. It would be interesting to see what proportion of primary care staff—GPs, in particular—have had specific training through those standardised packages. I am sure that there are ways of finding that out, but I do not know the answer.

We mentioned the training packages at the forum yesterday, including the mental health first aid training through ASIST and STORM. There was originally a Scottish Government target that 50 per cent of front-line staff should receive that training, and it appears that that target was reached—I think that the figure of 52 per cent was reached. Now that that target has been reached, we need it to be 100 per cent.

Are you saying that the Government stopped having a target?

There is no target now—it was achieved. It appears that that box has been ticked. However, it is my view that 100 per cent of front-line practitioners should have training in mental health first aid through ASIST and STORM.

We may be able to pursue that.

Carolyn Lochhead mentioned the Scottish Youth Parliament. Its members favour an increased focus on social prescribing opportunities such as peer-to-peer support—which was mentioned by Graeme Henderson—talking to youth workers, information centres and counselling as alternatives to or to complement medical interventions. Can you expand on the views that you have articulated about those alternatives? Are you aware of any good practice that has not been mentioned this morning?

The Scottish Youth Parliament has done some excellent work on mental health in recent years. Its report “Our generation’s epidemic” was one of the factors that pushed SAMH towards campaigning specifically on children’s and young people’s mental health. The Scottish Youth Parliament has done a great job of highlighting the problems and potential solutions.

We absolutely agree that social prescribing, links work and all the approaches that you have mentioned should be developed and made more available so that they are available to people when they are the best option. I am a little wary of presenting them as alternatives to medication because I do not want to suggest that medication is always a bad thing. There is an evidence base for medication, as we have said. People should be given the right treatment and should not be made to feel stigmatised for it, but a wide range of approaches should be made more available. In particular, I would highlight the need for counselling to be available in schools.

There are some good examples of peer work, with young people supporting each other. As long as the young people who are doing the supporting are themselves properly supported and trained, that can be helpful. I absolutely support the suggestions that the Scottish Youth Parliament has made.

Again, it is probably worth asking young people themselves about what helps them, and digital spaces are important in that regard. We must recognise that young people get a lot of peer support online. We talk a lot about the risks that are associated with social media, but it also offers great opportunities. For example, someone who lives on a croft in a remote part of Scotland and does not have the opportunity to go to a youth centre in their local community will find online space invaluable for connecting with others who have had similar experiences to theirs and for getting vital peer support.

We have a responsibility to tool ourselves up with knowledge about the places where young people are going to find support so that we can encourage them to go to the places that are good and supportive and can steer them away from the ones that are risky and damaging—which certainly exist in relation to self-harm and suicide, for example. Most young people live their lives equally online and offline in a seamless manner, and mental health professionals and people in the public sector—like probably everybody else—are not necessarily fully equipped to understand how young people use online spaces. The option of seeking support online should be one that people who are involved in social prescribing have in mind. It can certainly be a great resource, and I know that it has saved people’s lives.

I can give an example of that. Our Fife service set up a closed, managed Facebook group that the young people requested, and those young people used it to support each other. It was managed by Penumbra workers to ensure that there was no inappropriate behaviour.

Earlier, I mentioned work that we are doing with primary 3 and primary 4 schoolchildren on body confidence, which is a huge issue for young people. A lot of the pressure around it comes from social media, so there is a need to educate people and to focus on body confidence and not negative body images, which is the prevailing approach in the general media.

I am pleased to hear the Scottish Youth Parliament being praised for its work so far on this issue. A couple of weeks ago, I was involved in a question time at a high school in my constituency, and the issue that we are discussing was the one that was of most concern to the high school pupils.

I want to skip on to the Scottish Government’s 10-year mental health strategy, which was introduced earlier this year, and the issue of CAMHS, which has already been mentioned. I believe that, as part of the mental health strategy, the CAHMS budget was to increase by £15 million—I do not have the figure in front of me, but I think that it was £15 million. I probably know the answer to this, but is that enough to support school-based counselling services? Are you surprised that the provision of such services was not already included in the mental health strategy?

As well as a general lack of resources, there is a lack of outcomes and targets in the strategy, and there is a specific issue with the lack of resources directed at children and young people. In both the previous and present strategies, the focus has been on NHS and medical interventions, not on non-medical, upstream interventions with younger people. We wait until people are diagnosed with an illness before we put in support. Whether the figure is £15 million or £100 million, it is still not adequate, because much more of the resource should be directed at children and young people. I think that we spend about £1 billion on mental health; at yesterday’s forum, there was a call for 50 per cent of that money to be spent on children and young people. That would be a good place to start.

So early intervention is the key.

We know that most mental health problems start in adolescence and that, if they are not treated early, they will continue on into adult life and will have hugely debilitating effects on the rest of many people’s lives. They will be responsible for the health inequalities that people with mental health problems experience and which result in their dying younger.

There is an imperative to address the issue, not just because children and young people have a right to good mental health here and now but to prevent them from incurring extra costs—emotionally, socially and financially—in their adult lives. Therefore, a very strong case could be made for putting a much higher proportion of the overall budget towards children and young people. You will not get any complaints from us about that.

It is worth bearing in mind that other parts of the Government are partly funding mental health responses. I mentioned youth work, and it is also worth being aware of the pupil equity fund, which provides funding to address the poverty-related attainment gap. It can fund literacy, numeracy and health and wellbeing activities, and many schools are choosing to use their money to invest in school-based counselling and mental health support for pupils. In that way, they are contributing to the response to the issue.

Whether that is right or wrong, though, is open to debate. Whose responsibility should it be to fund such work? Should it all lie with the Government’s mental health unit or should it be spread across Government? There is an argument that says that mental health is everybody’s business, so it is education’s business and communities’ business—it is probably also fisheries’ business in one way or another. If all parts of Government made a contribution, we might have a better chance of reaching the total that we need to enable us to respond effectively.

I have a caveat to Amy Woodhouse’s point about mental health being everyone’s business: if it becomes everyone’s business, it becomes nobody’s business. At yesterday’s forum, we spoke about doing a mental health impact assessment across all policy areas of the Scottish Government. Equality impact assessments and environmental impact assessments are routinely done, but mental health impact assessments are not. If they were, every Government department would have an idea of what the impact of policy on people’s mental health and wellbeing would be.

09:45  

There are some other points to be made about the issue of school-based counselling that you raised. We know that the strategy contains a very welcome commitment to reviewing school-based counselling, and we know that children in Northern Ireland and Wales already have a guaranteed right to that, as they do in England, to a lesser extent. It seems fairly clear to us that there is no reason why Scotland’s children should not have that right, and we would like that to be acted on quickly.

We have also previously called for the CAMHS budget to be doubled. Someone asked whether that would be enough; the answer is no, but it would be a good start.

Although the mental health strategy contains good actions relating to children and young people’s mental health, there are some things worth looking at. This week, a green paper on children and young people’s mental health was published at Westminster; it builds on the existing £1.4 billion of additional money that has been made available for children and young people’s mental health, and it commits to recruiting 1,700 more therapists and supervisors and ensuring that an additional 70,000 children and young people obtain support from mental health services.

I do not want to overemphasise what is happening, because some of that is being rolled out quite slowly and only in certain areas of the country, but it is still worth looking at what is happening in other areas of the country and asking whether we are doing enough and whether we can learn from other areas. Is there more that we can do?

Going back to the petition, I have to say that a question has been in my mind since hearing the evidence. When a person’s mental health deteriorates to a point at which medication is required, should we not ask about that person’s competence to manage their own medication?

Is that a question about capacity?

The petition obviously concerns a tragic and extreme case. In cases where medication is required, we are passing to the patient the competence and ability to manage their own medication, but should the GP be doing that if the patient’s mental health has deteriorated to a point at which they need medication?

As a representative of a children’s organisation, I probably have to think about that from the perspective of the rights of the child. In that respect, several rights are relevant. As we talked about earlier, there is the right to have a say about matters that affect you in your life. Children and young people are individual citizens in and of their own right and if they have the ability to make decisions, particularly at the age of 16, they should be able to do so, especially as they have many other rights to exercise and decisions to make, such as how to vote, whether to get married and so on. Decisions about their care, in principle, are also fundamentally important.

One of the articles that are relevant here is article 3, which says that adults should do what is best for you. Are we doing enough to ensure that? I recognise that young people are vulnerable, because of their mental health, and they need all the support that they can get to make those decisions. There might be a role for advocacy to ensure that those young people have an adult, perhaps at one remove from the mental health practitioner or the GP, who can talk through the options with them and come up with a plan so that they are not just making the decision by themselves. I recognise that it could be a difficult decision, particularly if you are being offered medication or nothing. That is Hobson’s choice for many young people, especially when they consider the side-effects that might be associated with the medication.

I am reluctant to talk about all this. The implications of your question are that someone with a mental health problem does not have the capacity to make decisions about their care. I fundamentally disagree with that: everybody who has mental health problems deserves support from professionals to help them to make such decisions and work through the process in a rights-based way. They are entitled to have choices that will help them with their care and treatment.

I suppose that the petitioner’s point is that, had she known that the tablets had been prescribed to her daughter—even if she did not agree with the treatment, or she was concerned about her daughter taking the tablets—she would have known to look out for and to understand the side effects and support her in managing her medication. This was not a case of a hostile person denying a young person their rights; rather, it was a case of a person who, had they been provided with more information, could have provided the support that clearly was not available in the system, because what was available in the system was medicine. Linked to that, I wonder whether, if a person does not have that guarantee—in other words, if there is no supportive person who can help manage their medication—there should be a limit on how many tablets they are prescribed at a time.

I would be extremely concerned if we were to go down the road of assuming that a young person with a mental health problem lacks capacity—

With respect, I did not say that—

I understand that—I am responding to Mr Whittle’s question.

It is not that they lack capacity, but distress and anxiety has brought them to that position. We have all known people who have been in such circumstances. If I have broken my leg, and it causes me distress, I do not expect someone to tell me to just get on with it. Non-medical supports will be put in place, and there will be an understanding that I will need support, because I might be in shock or whatever.

The question of how someone feels when they finally get to a doctor should be recognised. I am assuming that that is the case, because I have spoken to GPs and they tell me that it is not simply a question of handing over tablets and telling the patient that they are confident that they can deal with the matter themselves. Is there an issue of GP practices being under phenomenal pressure? They can prescribe, because they are allowed to do so, but they do not have the time to do the other things. Should there be in place a hierarchy of interventions by the GP before they get to the point of prescribing tablets?

Absolutely, and the point that I was about to go on to make relates to points that we have made before on the importance of reviewing prescriptions when they are written to make sure that people are not simply given a prescription and left for a long time. They should be reviewed quickly; indeed, prescriptions should not be made unless they are in line with evidence-based guidelines.

In the earlier question—the one to which I was responding—it was suggested that there might be a question mark over the ability of a young person who has got to the point of being prescribed medication for the treatment of mental health to manage that medication. I would have great concerns about making a blanket assumption that those young people would not have the capacity to manage their own medication. It is really important for GPs to be aware of the guidance on whether they should prescribe—and, if so, how much they should prescribe—and at what point they ought to breach confidentiality. When I read the petitioner’s evidence, those were the questions that were going through my mind.

We have mentioned the Scottish Youth Parliament’s excellent work. In its evidence, it expressed concern about whether young people, if they did not consider that their confidentiality would be respected, would come forward for help at all. That is a genuine point. We must also recognise that not everybody has supportive parents who want to, or who will, understand the issues, and not everybody has supportive parents who will help them manage their medication, if they are put in that position. We need to look at every case individually, but we must also ensure that the guidance for GPs—and other professionals—on managing such cases is well known and followed.

I want to clarify my position. I was not suggesting for one second that there be a blanket policy saying that young people do not have capacity in such situations, but surely a question about their ability to manage the medication must be in a GP’s head when handing it over.

I have a question on the same topic, which takes us back to a much earlier question about GPs’ training and competence. There seems to be no standard framework for GPs. The situation is not like prescribing someone a course of antibiotics and telling them to come back if they do not feel better. Surely a GP must know that if a young person is at the point where they must go to a doctor and receive medication, their treatment must be followed through; they cannot just be given a load of tablets to deal with. Surely in the GP’s mind, that must not be the correct way of treating the situation. What are your views in a professional capacity of a doctor handing out tablets to someone who clearly has mental health issues?

In our original submission, we reviewed some of the guidance for GPs. I am very wary of talking about an individual case when I do not have all the facts, but it is important to ask whether the guidelines were followed. For example, was consideration given to whether to involve the parents or breach the child’s confidentiality? Doctors can do that—they have the right and, I would say, a duty to do so. Were the guidelines followed on what and how much to prescribe? These really important guidelines should be well understood and followed, and I am not sure that they always are.

An additional question that it would be useful for doctors to ask young people is whether there is an adult in their life whom they trust enough to talk to about this. What do we do with looked-after children? What do we do with young people who are taking on a caring role? What do we do with children who do not have a positive relationship with their parents? We can ask them whether there is somebody else in their life. Do they have, say, an auntie or a granny? Is there an adult who can support them through this, and can we tell them about it? We can share information if we have young people’s consent; the first thing to do is find out whether doctors are asking that question. I do not know whether they are.

What we are dealing with here is the difference between a mental health consultation—which, for a young person, would probably last an hour—and a 10-minute GP appointment. I am sure that I read in the previous papers for this petition that the petitioner’s daughter declined psychological support. Am I correct in saying that, convener?

I think that there was some suggestion of that, but I do not think that we will want to second-guess what was decided in an individual consultation. The question that we are asking is how we build on that. In some circumstances, people repel all boarders at first but can be persuaded or encouraged later.

The NICE guidelines are very clear about the process that GPs and others should follow when prescribing medicines. In the case of antidepressants, the guidelines indicate that a person should be seen within a week of the prescription being issued and encouraged to do other things. It goes back to the whole business of training and updating, because we seem to have a gap there in the treatment of young people.

I wholly support young people having the right to confidentiality and the right to make decisions. They should be able to see a GP without feeling that whatever they say will be passed on to all and sundry. However, the safeguarding requirements with regard to information sharing should be paramount. Things such as the NICE guidelines are there for a specific reason and are the result of consideration of the evidence base.

When we discuss guidelines for treating young people and make decisions and come up with strategies, is adequate attention paid to the evidence base? When young people ask for help—particularly in the context of mental health—do we need a much more robust response? I am talking about a bit more than just having a guideline that may or may not have been read or thought about recently. There has been a huge increase in the number of young people who are seeking such help. As Amy Woodhouse indicated earlier, we do not entirely understand why, but perhaps we are not responding adequately. What do you think should be done?

10:00  

I guess that the GMC would be the best place to find out whether there is adequate adherence to the evidence base and the guidelines, and whether complaints have been made in general practice. I cannot illuminate the issue, because I do not have that information.

On the question of a more robust response, I whole-heartedly agree that we need to do more to ensure that support is available across the whole of the tiered-model approach, which has been around for quite a long time. There is low-level prevention and awareness-raising work in schools and community settings, which—as you will know from your service—can be ramped up or down as required, depending on the needs of the children and young people. At the moment, we have specialist services, which are small and overstretched, and with CAMHS, we have some awareness raising happening at the lower level but very little in the middle. There is a real gap there and that should be our focus. It is a gap that primary care often fills, but primary care does not seem to offer much for children and young people at the moment, other than medication.

I should mention that Audit Scotland is currently doing an audit of child and adolescent mental health services, which is due to report in September, and that will be invaluable evidence. It is a challenge, but Audit Scotland is looking across the whole tiered approach. I do not know to what extent it will get into the community-based stuff, but that will give us a picture of what mental health services for children and young people look like in Scotland. At the moment, we do not really have that picture. The audit will show us where the gaps are, and we will be able to use it to advocate for change. I urge members to look out for that report when it comes, if you are not already aware of it.

It is frustrating that we already have good, well-written, evidence-based guidelines but that they are not always adhered to and people are not always aware of them. As Amy Woodhouse says, the GMC is the place to look for factual information on awareness and adherence. There is a question for the GMC and the royal colleges about how we increase that awareness and ensure that people are working to the guidelines. There is an issue about not just the guidelines but the support that is available. When you recognise that a young person is in need of some kind of help, do you know what is available? Is there enough available?

In the coming months, as part of the audit that I mentioned, I hope to look at the threshold and the criteria for CAMHS. What a particular service provides can vary across the country, as can the threshold that someone has to meet to qualify for it. It sounds to me as though, in some areas, a young person would have to be really quite unwell to get access to CAMHS. Is that the right approach? If it is, what else are we making available for those people who clearly need some help but might not meet that rather high threshold?

Specifically in relation to GPs who prescribe psychotropic medication, it might be possible to have a guideline that tells them not just to prescribe medication but to do something else—whether that is providing access to a supportive adult, arranging a nurse follow-up in less than a month or referral to another service, such as a talking therapy.

Michelle Ballantyne mentioned the safeguarding requirements. As a service provider, all our staff are contractually required to adhere to safeguarding rules, but I am not sure whether the same applies in other areas.

It might be worth clarifying that the NICE guidance on depression in children and young people says that they should be offered a psychological therapy as well as an antidepressant. That is another point to note in relation to the awareness of guidance.

My mother’s generation were routinely offered antidepressants, but the world has moved on and said that there should be a presumption against that. Perhaps what we should be exploring further is the possibility of taking further steps to dispel stigma. If people need medication they should get it, but the inappropriate use of medication is a historic fact. People did not really address the questions around mental health; they simply said, “We’ll give you a tablet and you can deal with it.” As a result, a whole load of people got tablets when it was perhaps not appropriate.

I was concerned by a response from the Scottish Government on the increased prescribing of drugs—I am not sure whether it was in relation to this petition or a later one—that said that it was good, because it meant that more people were coming forward. It might mean that because they are under pressure, GPs are prescribing to people who are coming forward with mental health issues. We might want to explore that.

I will let other folk in to suggest how we should take forward the petition. It has been a very useful session. We have explored a range of challenges for anybody who works with young people who have mental health issues.

I have been told anecdotally that young people have to refer themselves to CAMHS, whereas if they go to a GP and something is physically wrong with them, they are referred to a consultant. We might want to explore that. The issue of there no longer being a target for training is also something that we might want to highlight.

We have already discussed the possibility of inviting the Minister for Mental Health to the committee, and I think that we should agree to do that.

Absolutely.

Is there anything else? We can check back in the Official Report of our meetings for other things that have come up that it might be worth pursuing. We got a response from the GMC, but there might be things that we want to remind ourselves of ahead of any meeting with the minister.

I would like us to go back to the GMC to ask about safeguarding training and adherence to guidelines. Its response was very full, and it is quite clear that all those things are there in line with its expectations, but there is a difference between them being there and them being done.

There is an enormous amount of pressure on GPs at the moment, and most of them are not paediatric specialists. Dealing with the mental health of young people is a big piece of specialised work that they have probably had minimal experience of, and I would like to know what requirements there are and what percentage of GPs—if the GMC has that information—are doing their safeguarding training and their updating on mental health.

I do not know whether that is something that the royal colleges would be more aware of—there is a distinction between them and the GMC. Of course, you might know more about it than I do, but we might want to check where we would get that information.

Following on from that point, I would be interested to find out about access to continuous professional development generally across the health service. It might be available, but do staff have the time capacity to access it? As has been said, some people might be 30 or 40 years into being a GP, and mental health services have moved on dramatically in that time.

CPD is compulsory for registration, but obviously people are not necessarily going to cover every subject. The question is what, if any, mandatory CPD there is.

There is also the balance between GPs who are unaware of what the training is and those who are under such phenomenal pressure that they are simply managing the process. I had the privilege of meeting the GPs at a practice in my area, who made the point that they are so under the cosh in terms of appointments that they do not necessarily have the time for CPD.

There is also the issue of the provision of link workers in deep-end GP practices. That is only a small part of the provision, but it might be something that we can look at further.

Do we agree to invite the Minister for Mental Health to explore the issues that are highlighted in the petition? We recognise that the petition has arisen from very difficult, tragic circumstances and that although the solution that it offers on confidentiality might not be the answer, it highlights a number of other issues that we would want to look at so that we can protect our young people and keep them safe.

Is it an issue for health and social care partnerships as well? Should they issue guidelines, or do more than that, in their local areas? If a young person is prescribed treatment, should it be a requirement that they are signposted to local counselling? I do not know whether that is within our remit.

When we invite the minister to come to the committee, perhaps we should ask what role she sees local health and social care partnerships having.

I think that it all comes back to safeguarding. Information sharing has been a huge element of discussion over the past few years. The safeguarding guidelines that are produced by every local government and NHS area are underpinned by the question about when to share information. Information should be shared when there is reason to believe that the young person’s life might be in danger or that they might be endangering somebody else.

That decision making is crucial, because the right to independent and confidential access is paramount, but the safeguarding procedure overlays that. That is the point at which the decision is made about whether it is necessary to tell somebody about what is going on with that person. For me, that is the crux of the problem in the petitioner’s case and in many of the cases that relate to it.

It is important to remember that we could be talking about 16-year-olds, and 16 is very young.

Safeguarding applies to vulnerable adults as well, so it would count either way.

The issue is how visible the situation is to somebody. If a person is in total crisis, you could spot that, but if somebody is quite calm when they present and says that they are suffering a bit from stress or that they feel anxious—

But that is also about training, because the ASIST training teaches you that truly suicidal people are extremely calm; they are not het up. It is a question of being able to spot and understand what is going on.

There is loads for us to explore with the Minister for Mental Health on the whole question of how we address support for young people and ensure that they get the appropriate support and treatment if it is deemed necessary.

I thank the panel for being here—we found the session very useful. We look forward to further consideration of the petition. I suspend the meeting briefly to allow the witnesses to leave the table.

10:11 Meeting suspended.  

10:14 On resuming—