Health and Sport Committee

Meeting date: Tuesday, November 8, 2016

Official Report 600KB pdf

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Mental Health

The third item on our agenda is the first evidence session in our mental health inquiry. In this session, we will look at child and adolescent mental health services. I welcome to the committee Rachel Stewart, who is the senior public affairs officer at the Scottish Association for Mental Health; Sophie Pilgrim, who is the director of Kindred Advocacy and a representative of the Scottish children’s services coalition; and Michael Gowan, who is a member of the Scottish Youth Parliament.

Before I invite questions from my colleagues, could one or all of you—it would probably be better if one of you did it, given the time constraints—explain tiered intervention in child and adolescent mental health services?

I can do that. Child and adolescent mental health services are set up in four tiers; tier 1 is for the least severe problems and tier 4 is for the most severe. Tier 1 is identification level, which is when a child would first seek help from universal services—a teacher, a general practitioner or someone else in universal services. It is the first port of call. Tier 2 is community-based CAMH specialist services, which involve primary mental health workers. Tier 3 is a bit more specialist and is where the access target—according to which children and young people should be seen within 18 weeks of referral to CAMHS support—starts to be applied. Tier 3 involves support for children with more severe, complex and persistent conditions. Tier 4 is specialist in-patient CAMHS, when young people need to be treated in hospital for a time.

My limited experience of the issue when I was a teacher was that because of resource pressures quite significant pressure was put on support for learning staff and the like not to put children on individual education plans or to make referrals. Is that your experience? Have you found anecdotal evidence of that?

We have found anecdotal evidence of the existence of a mixed picture across Scotland. Some places have quite good links between education and CAMHS in the health service, but there are other places where young people whom we surveyed and spoke to say that their guidance teacher did not know about CAMHS, and where the line of communication and the awareness link do not seem to be as good as they could be.

11:15  

As to whether universal services are being told not to refer young people because of resource pressures, we would need a bit more evaluation of what is happening across the board to enable us to say whether that is the case. That is why SAMH has been calling for a wider review of the whole CAMH service and the four-tier system. The information that we have is about the access point, which is at tier 3, and onwards, but we do not know how many young people are seeking help before that point and being turned away or told that they might grow out of what they are experiencing and should just rest easy because it will pass.

We have been calling for a wider review so that we can explore the situation. As we are on the cusp of a new 10-year mental health strategy and a new 10-year child and adolescent health strategy, we think that consideration should be given to placing wider focus on the access points and on how well professionals are equipped to deal with people who ask for help.

Has statistical analysis been carried out of how many young people are at each of the tiers? Over time, have the numbers gone down or up, or are they fairly consistent?

The number of young people being referred to tier 3 services has been going up. There has also been a rise in the number of young people who, having been referred to tier 3 CAMH services, have not been deemed unwell enough to require that level of support. However, there has been no statistical analysis of the number of young people who seek support at tier 1—the universal level—or tier 2. Those numbers are not measured in the same way because there is no target attached to access points in those earlier stages of CAMHS support.

That is very helpful. Thank you.

Good morning, panel. It is well known by the parliamentarians and the stakeholders at today’s meeting that, in addressing the significant difficulty that we have with delay in the CAMHS set-up, we are not in any way belittling the work of CAMHS workers.

The problem can be measured in a number of ways. For example, we do not have any tier 4 beds north of Dundee, and those that are ostensibly available are not always available because there are no staff to man them. In some parts of the country, children have to wait for up to two years—a considerable part of their young lives—for an initial appointment. In my constituency, I had a situation in which a child was struggling at school. An educational psychologist referred her to CAMHS in the belief that she might have undiagnosed autistic spectrum disorder. She was seen for initial triage comparatively quickly—within a couple of months. The family received the devastating news that their daughter was on the autistic spectrum, but she had to wait another year for a formal diagnosis. In that time, she missed out on any state support that she would have been afforded if she had had a diagnosis.

I invite the panel to reflect on that situation. What do you think needs to change? Is money or investment needed, or do we need a change in policy direction? Are all those things required?

I am director of an organisation that supports about 1,000 families every year. A very high proportion of the children have neurodevelopmental—mainly autistic spectrum—disorders.

Regarding the situation that Alex Cole-Hamilton talked about, our experience is that schools often do not recognise quite clear signs of autistic spectrum disorder early on, and children get picked up only when things start to go wrong. As he said, the problem then is that there can be an extremely long time before formal diagnosis.

Looking after a child with autism is completely different from looking after a child without autism. There is a huge range of autistic spectrum disorder, but there are certain things that people with autism have in common, one of which is a need for structure. They probably also have a need for a less stimulating environment. Until a diagnosis is obtained, it is not possible to put in place the necessary support.

In working with children who have a very high level of additional support needs, one of the issues that we see is that there is, as Alex-Cole Hamilton mentioned, a lack of the high-level tier 4 services. In Scotland, we have no in-patient services for children with learning disability, no specialist in-patient services for children with autism and no forensic in-patient services. The Scottish Government and Mental Welfare Commission for Scotland are about to publish a report, which will recommend the provision of central belt in-patient care for those children.

Currently, the impact of children who have extreme needs is that other services are distorted. There are children who experience high levels of distress and community services are drawn into emergencies, which take up their time. Anyone who is in regular contact with CAMHS psychiatrists knows that they are unable to get on with their regular duties because their time is taken up by emergency acute care of children who need short periods in hospital. That is a big issue. We need the top level of support for children so that we can free up time for CAMHS to diagnose more quickly.

I congratulate the Scottish Youth Parliament on its survey and its report, “Our generation’s epidemic: Young people’s awareness and experience of mental health information, support, and services”, which is helpful in its consideration of what is a huge problem for our country.

I am interested in early intervention and prevention. We get a lot of mixed messages about what improvements are needed and how the Scottish Government’s new strategy should be shaped. What interventions or additional information for young people would make the most difference? How should such approaches be rolled out?

Thanks for the plug.

A key issue that was identified, which links to what the convener said, is that resources in schools are stretched too thinly. For example, one respondent to our survey said;

“Teachers are really stretched too thin, and there aren’t enough resources.”

Another said:

“25 students in one class is way too many for a class to be able to give one-to-one support. It should be like 10 or 15.”

Young people asked how front-line practitioners could be expected to detect problems and manage them.

Training is another issue. How many teachers in more rural areas, for example, can do continuous professional development when there are staff-retention problems and schools cannot afford to let staff out often for CPD?

Only 24 per cent of the young people who responded to our survey said that they would be comfortable talking to a teacher. If only one in four pupils in a classroom is willing to talk to the person whom they see every day, that is a barrier to getting potentially quite vulnerable and underconfident young people to open up about problems, so that they can be caught early. We perhaps need to look at how we build bridges between young people and front-line practitioners.

I endorse everything that Michael Gowan said. There have been pilot projects in which mental health and wellbeing have been promoted in schools. The “See me” pilots have had an impact on the whole school, in that young people have felt much more able to ask for help, and teachers who have been through Scottish mental health first aid have been able to respond much more appropriately. Teachers often feel very stressed, and teaching has a high sickness absence rate, so such training might help to protect teachers, too.

Other pilots, for example in Peebles high school, have linked with third sector organisations in the community including the Samaritans and Penumbra to raise awareness. That has made it easier to signpost young people to support.

Health and wellbeing is one of the three crucial elements in curriculum for excellence, but children and young people have been telling us that, in relation to mental health, the only thing that they ever hear about is how to deal with exam stress, and not how to be less stressed in general. If health and wellbeing were to be included in inspection of schools and there was more curriculum guidance about mental health, that would set a good tone.

Michael Gowan’s point about continuing professional development and rural challenges was very well made. One of my colleagues in SAMH does an hour a term on mental health for some of the teacher training colleges. That is not really enough for the fourth-year students, so more such training could be considered.

There are a lot of positive developments in how we support children who are on the autistic spectrum. Those developments can make a huge difference at virtually no cost, through spreading ideas about intensive behavioural support for families. We have two services in Scotland, both in NHS Lothian, that provide positive behavioural support to families. That is also being promoted within adult care for people with learning disability and autism. That can mean that we prevent the much higher cost of in-patient care.

Thank you to the panel for coming along this morning. I am sure that we are going to find out some really valuable information from you.

I was interested in a point that Sophie Pilgrim made about in-patient beds and the development of in-patient services. The focus of health at the moment is on developing community services as opposed to reprovisioning and in-patient services. I am aware that there is already a children’s in-patient unit in the Royal hospital for children in Glasgow. Do you have any comment to make on use of the beds there? Has it been considered that some bed time there might be used for more specialist areas of child and adolescent mental health services?

Provision at that hospital has a very good reputation, but it is to support children who are under 12 years old. It is predominantly in the teenage years that children and young people experience mental health issues. At present we have across Scotland three in-patient units for adolescents. The problem is that provision is not suited to children with learning disability or autism.

When we are talking about children, what age are we talking about? I am maybe confusing children with adolescents.

We do not have provision that is specific to learning disability and autism for any child or young person under the age of 18. The Royal hospital for children in Glasgow has some expertise in that area. According to records, over the past five years about 85 children—that is probably an underestimate—have either had to be accommodated in adult wards or sent down south. It is not the case that they are being treated in the community: they are in-patients but they are very inappropriately treated and as a result end up being in hospital for a long time at great cost.

We have seen examples of children or young people in the three generic young people’s units whose mental health has deteriorated dramatically. If they are transferred to a unit that is appropriate and has appropriate autism understanding and environment, they begin a process of recovery literally within days. Children who are sent down south can—after a very long time—be returned to the community support services, but sending them south to provision is really detrimental to their health and comes at great cost.

Just for clarification so that I have got it right in my own head, are you talking about adolescents, as opposed to children, when you are talking about children with specific disorders and illnesses?

I am talking about children over 12. There is very little incidence of extreme need for in-patient care in the under-12s. At present we have national provision in Glasgow, which has a very high level of expertise and is well regarded.

You are saying that sometimes adolescents are admitted but the environment is not suitable, so is the problem the level of training of current in-patient staff in the adolescent mental health units?

11:30  

That is right. There is a difference between provision that is suited to children with autism and provision for children who have severe mental health issues who require in-patient care—for example, children who are bipolar, who have eating disorders or who have extreme anxiety and depression and who self-harm. Those children require the three services that we have in Scotland. However, for children with autism, we need a very highly structured environment, and we need specialist psychiatrists and CAHMS teams.

We have a very high level of specialist knowledge in Scotland. An advantage of the proposed service would be that the expertise, experience and support of the professionals would be disseminated to the health board and the community CAHMS teams, which would mean that we would be trying to prevent as much as possible the need for in-patient care. Obviously, in-patient care is very distressing and it is the last thing that we want, but we need it for all sectors of the community. At present, we have in-patient care for all sectors of the community apart from for children with learning disability. The Scottish Government has cited that as discrimination against those children.

To be absolutely clear, we currently have no in-patient provision for children and adolescents between 12 and 18 with learning disabilities who require that level of care.

Another way of putting it is that we have no secure in-patient psychiatric care for children. The children who require secure care are those with such extreme challenging behaviour that they are an extreme danger to themselves or to the public. That is a very small group of children. We need to be able to say that in Scotland we can care for any child and that no child needs to be sent away because their psychiatric needs are such that they cannot be cared for here. That group includes children with a forensic background of psychiatric need, children who have extreme challenging behaviour generally because they have autism, and children who have impaired understanding so that they have learning disabilities. It is for that very small extreme group.

Thank you—that is helpful.

I want to pick up on Clare Haughey’s point. Yesterday, I visited the Edinburgh crisis centre, which is run by Penumbra. It can take referrals only of people who are over 18, yet it could be quite an appropriate service for those between 16 and 18, and it has capacity for that. Does the panel agree that it might be appropriate to think about those who are over 16 rather than those who are over 18? With younger young people—or children—would it be more appropriate to have an intensive home nurse service to provide support so that those young people are not taken out of their homes and communities?

In short, issues around self-harm in young people are not well catered for. We know from the Scottish health survey that there have been higher rates of detection of self-harm recently, especially among young women. We are calling for professionals who interact with young people, such as GPs, teachers and youth workers, to receive training so that they can respond appropriately if they discover that a young person is trying to cope with their mental health problems by self-harming, or if a young person approaches them to say that. Given the sensitivities of that and how unwell that young person might be, it has to be done in a certain way, which is why we call for training.

We know that the onset of mental health problems in adolescence tends to be at around 14. We can see from the research that young people’s self-esteem and confidence often take a dip from 14 or 15 onwards, so having much earlier access to treatment and support would be appropriate and desirable.

There should absolutely be an at-home nurse service where that is possible. The Mental Welfare Commission for Scotland published its young person monitoring report a few weeks ago. That report showed that there has been a decrease in the number of young people who have been held and supported on adult wards in the past year from 207 to 135. That is still too high a number for those very unwell young people, but the MWCS attributed some of the decrease to an increase in the number of beds in Dundee and the more wraparound, multidisciplinary support in the community. That is to be welcomed and it would be good to see more of it.

Children need in-patient care for acute treatment partly because, in some circumstances, their behaviour is extreme. For example, the other siblings might be at risk. Sometimes the children do not sleep, they are violent or their behaviour is extremely antisocial. The family breaks down under those circumstances because it is intolerable. In addition to the extremity of behaviour, it is also sometimes necessary to take the young person out of that environment and into a clinical environment so that they can be assessed. Generally, it takes three months to assess what disorders are going on so that they can be treated appropriately.

One of the points that came out of our research is that many young people and adolescents think that a transition service between the age of 16 or 18 up to about 24 would be beneficial. Therefore, rather than simply lowering the bar to 16, it might be worth creating a bespoke service in the NHS that focuses on tailoring treatment for them during that transition period and then trying to get third sector interfaces working with IJBs so that there is a linked-up approach where that is merited.

For clarification, does Sophie Pilgrim believe that young people with neurodevelopmental disorders are best diagnosed and treated within the framework that exists in CAMHS or is she looking for something else?

They have to be, really, because it has to be done within a consistent framework. It is a medical diagnosis. The problem is people not identifying disorders when the signs are evident and the fact that, as others have said, when young people are referred, diagnosis takes a long time.

Several studies have indicated that adolescent girls in Scotland particularly suffer from poor mental health. I ask Michael Gowan and Rachel Stewart why that might be the case and what we are doing to tackle it.

Part of our research was about how some young girls felt that they were not taken seriously about poor mental health. If a young girl says that she feels depressed, the response might be, “Are you on your period? Do you need a tampon?” There is a social structure that needs to be addressed somehow, but practitioners also need to take young girls and adolescents more seriously so that they can intervene early, rather than poor mental health being suppressed because the girl feels that nobody will take her seriously until self-harm and more severe issues come out.

Some of the research on the health behaviour of school-age children was done through the child and adolescent health research unit at the University of St Andrews. It looked at the mental wellbeing and emotional resilience of young people, and at the rates of depression among them. If we look across the board, we see that girls and boys tend to be fairly even at the age of 13. At 15, boys still seem to be quite level—I am using my hands, which will not be very helpful for the official reporters—but there is a drop in the mental wellbeing of girls. There is a general drop, but there is a sharper drop for young women.

The researchers have posited that this is due to exam pressure—young women seem to feel more distressed about the pressure of exams. Social media and body image certainly have an impact on their mental health and wellbeing as well. It is hard to tell, because we know that there are protective factors around peer issues and positive feelings about school. Whenever there are negative feelings about school and the feeling that, “I must pass these exams or my life will be finished,” that is not helpful.

To make things better, we need to teach young people how to cope and how to become more resilient and more able to face what life throws at them, rather than just saying, “Here’s how to cope with exam pressure.” It needs to be more about how to deal with everything and then the exam pressure may not seem as bad.

A lot of the written submissions focus on rejected referrals. There seem to be different views about why referrals might be rejected. Some organisations suggest that they might be rejected to avoid an increase in waiting times. Others suggest that they might be rejected because they were inappropriate in the first place and could have been picked up at tier 1 or tier 2. Do we need to review how we refer?

We need a wider review of how we refer and what is happening at tier 1. When GPs or teachers are approached by a young person about their mental health, we would hope that they are equipped enough to recognise that the young person in front of them needs some support for their mental health, and needs it fast.

Without a review, it is hard to tell whether referrals are rejected because they are inappropriate or because people do not want to increase the waiting lists and waiting time gaming is going on, as we simply do not know how many young people are coming forward at a tier 1 stage asking for support. As Michael Gowan said, young women may be getting an inappropriate response at tier 1 such as, “You’re a teenager—you’ll grow out of it,” “It’s puberty,” or “It’s your period.” It might be that people are seeing CAMHS as something that only begins at tier 3. Universal services need to be able to cope with the mental health of children and young people as it is presented to them.

Another point that came up in our research was about how resources such as school counsellors may be very stretched. Our report includes the following comments from respondents:

“‘You have to be put on a list and wait months to see the school psychologist - not good.’

‘My school counsellor has a waiting list of 170 people.’

‘Counselling sessions are … infrequent.’”

When you have those issues inside a school, the school feels that it cannot cope with the young person and it naturally wants to refer the young person onwards. The school might have the resources, but the capacity is not there because the resources are too stretched.

As for meeting waiting time targets, some practitioners have told me since the research came out that they have had reports of young people basically being handed information pamphlets at their first meeting and then sent on their way as a way of dodging that first waiting time target.

I am not convinced that it should all be focused on waiting times. That might be part of it but there are other ways to get round that if you do not want to flag it up in the system. It may be more about the fact that tier 3 does not have enough community psychiatric nurses to support young people and tier 1 does not have the training or it does not have the resources to support the staff who do have the training, and they are kind of bouncing off each other.

The other challenge is that the waiting time target is only a snapshot of the access point into CAMHS. We do not know what happens after a young person goes into CAMHS; we do not know how long they wait between appointments; we do not know what community support they are receiving; and we do not know whether, at the end, once they turn 18, they feel that they have made a recovery or they are moving into adult services. If they move into adult services, we do not know what impact that move is having on their mental health.

The picture that we have is patchy and not quite good enough, from our point of view. The young people we have spoken to have not been terribly happy about their experiences, whether they are within the CAMHS system, having been assessed as requiring more intense support, or whether they are among the 6,000 a year whose referrals are being rejected and who are then left with nowhere to go. Their GP or someone has said that they need additional support and the specialist support service has told them that they do not, so they are in no man’s land. Everyone has mental health and those young people are not being serviced.

11:45  

I want to ask you specifically about the age of eligibility for CAMHS. We had a bit of discussion about whether people should be able to access adult services at the age of 16. My experience of working in psychiatry is that I had concerns about people coming into adult services at the age of 16 when they were still vulnerable—some young people are vulnerable right up to their late teens or early 20s—and an adult psychiatric hospital was probably not the most appropriate place for them to be cared for.

When I worked in psychiatry, decisions were made—in the Highlands and Islands, at least—on the basis of whether someone was still in full-time education, and that was how the judgment was made about whether they qualified for CAMHS or adult services. The difficulty that I had with that was that I saw many people who had such severe illnesses that they had to come out of education. They needed to go back into education but, because they were in adult services, they did not have access to the specialist support to get back into education. Mental illness at any age is hard enough, but having mental illness at a time when it disrupts your potential to fulfil your educational ability can have a devastating impact on the rest of your life. What do the witnesses think?

On your point about using adult services at the age of 16, young people have very clearly said that they need their own service, rather than having to go up to adult services that are inappropriate. Some CAMHS units are trying to provide a bridging service, because there are issues when people turn 18 and the waiting time for being seen by a CPN suddenly triples. At that age, young people are moving away from school, their friends have left for university and they are expected to either get a job or go to university, or they end up in the benefits system, which can be quite stressful. It is not about putting young people into an adult service; it is about creating a more bespoke service for the issues that they are likely to face during that transitional period.

SAMH has called for a review of the age at which people can access CAMHS. If young people are vulnerable and they need additional support, stopping CAMHS support at 16—as it is for some health boards; for others, it is stopped at 18—is not appropriate and they should continue to receive specialist support until they are 25. We know that brain development continues until they are 25 so the idea follows that fact, as well as the Children and Young People (Scotland) Act 2014, which looked at how vulnerable people should receive support beyond their 18th birthday.

You are right about the NHS boards—for young people who are not in full-time education there is a cut-off point at about age 16 in places such as Dumfries and Galloway, Lanarkshire, Shetland, Tayside, and Ayrshire and Arran. The NHS has said that it wants CAMHS to be provided to 18-year-olds and those health boards are working hard to achieve that. That also has an implication for the pool of young people who would be going forward ineligible for CAMHS support.

I spoke to a young woman on Friday who has been receiving support from SAMH since she was referred to CAMHS at the age of 16. She is now 20, so she has been in children’s services for two years and in adult services for two years. She said that, when she hit 18, that was the end and it was like dropping off a cliff. She had built up a relationship with her CAMHS nurse over two years and she felt that she had been making some progress. She had had a very difficult time when she was 17 and she was detained in a mixed adult ward—which was a terrifying experience for her—but she had nevertheless made some progress. When she hit 18, that was it and she was into adult services. There was no transition from children’s to adult services and there was no discussion with her. She knew that it was coming, but it was not made clear to her what it would mean for her support.

The approach taken by adult services was totally different from that taken by children’s services, so she felt that everything that she had been doing with her clinicians for two years beforehand had been a bit of a waste of time. She was very angry about the way she had been treated, because she felt that there was no continuity or logic in the situation. She had just been suddenly abandoned to adult services, and she did not have the kind of support that she felt that she needed. She is still a vulnerable young woman—she is only 20.

From that point of view, we think that there needs to be an extension and a much more specialised service for young adults. If mental health problems develop at that stage and young people can receive consistent levels of support, as they are developing into adulthood, they are much more likely to make a recovery. Jessica told me that she took a step back when she went into adult services. She felt very challenged by the new system and it set her back. If she had had more of a transition and a joined-up approach, she might have been able to accept things and could have been a bit further on than she is now.

There is also a fairly harsh effect on young people who are waiting to go into the system. If your mental illness is not diagnosed until you are, say, 16 or 17, and then you are told that you are on a waiting list, then at the end of the waiting list you go on to an adult waiting list, which is completely new and has completely different times, and you have to wait on that before receiving an adult service, that can give you a powerful feeling of not being wanted or a feeling that nobody is taking you seriously. One young person said:

“I’m on a waiting list for CAMHS, and have been told I’m waiting for them to hire a new psychiatrist! They’ve told me I’ll be waiting around 8 - 10 months. I’m nearly 18, so I bet I just get passed on again.”

Young people are feeling that the system is dealing with them as a number to be passed on, and you can imagine the sort of effect that that will have on the mental health of someone who is already at tier 3 and how much more difficult it will make their road to recovery. That is something to be aware of. Those who are affected are not just people in the system but people who are waiting to get into the system.

I am aware that NHS Greater Glasgow and Clyde changed the transition from adult mental health services to older adult mental health services, so that it is now much more needs led. There is no longer a cut-off whereby when someone turns 65, their care is automatically transferred. I am not sure whether that is happening across the country, but it is interesting that some health boards have acknowledged that, at that end of our lives, it is not particularly helpful for our care to be transferred to another service.

The committee has said that health inequality is one of our priorities. I do not have a mental health example, so I use the example of dyslexia. In my area, which is one of the most affluent areas, the level of identification of dyslexia is much higher than the level in the poorest areas. Are you finding similar trends with regard to mental health issues? In affluent areas, are diagnoses of autism or attention deficit hyperactivity disorder happening more quickly and at higher rates than in areas of multiple deprivation?

No. We ran our postcodes through the Scottish index of multiple deprivation and found that we are more likely to support families in quintiles 1 and 2, which are areas of higher social deprivation. It is interesting that, for all our projects, the level of support is highest in those areas. It drops off for the middle quintiles, before rising again a bit for quintile 5. We provide our support disproportionately to families in areas of high deprivation.

I know that that goes against what most people believe to be the case, but my experience is that families are desperate to support their children and go to huge lengths to do so. We are missing the fact that parents are a huge resource. However, they come away from treatment and support feeling very belittled and demoralised. One of the reasons why families come to our service a lot is that they feel criticised. They feel that they are being told that their child’s condition is to do with their parenting whereas, if we look at the evidence, we see that, statistically, there will be children with extreme needs across all sectors of the community.

There are definite trends among looked-after children, who have higher rates of poor mental health. There are a variety of trends. Some young women from less-deprived areas seem to feel under more pressure with regard to their mental health during their adolescence than do other demographics, so it is a mixed picture.

What can be done about inappropriate referrals and underreporting or overreporting?

That comes back to education. Children and young people need to be supported from an early age. They need to learn how to look after their mental health, learn how to look for signs of poor mental health and be supported to ask for help at an early stage. Through the Children and Young People (Scotland) Act 2014, there are duties on public services in Scotland to have regard to the United Nations Convention on the Rights of the Child, which is all about services listening to the opinions of children and young people to inform their decisions and ensuring that there is an “ask once, get help fast” approach. A young person does not go to bed on a Monday night and wake up the next day needing tier 3 CAMHS. We need to move backwards and start thinking about how we can help young people at an earlier stage, give them the confidence to ask for help and respond to them appropriately when they do.

One point that came up in our research is that personal, social, health and economic education—PSHE—has been failing young people, in effect. There is a patchwork at best. I do not think that PSHE has been updated since 2008—although please do not quote me on that; certainly, it has been several years since it was updated—it predates curriculum for excellence. If ever an organisation approaches Education Scotland about that, the response is invariably, “It is down to local authorities and individual schools,” so there is a remarkable patchwork in how much support is offered and how much mental health training is available.

One young person said that they had one session on mental health in PSHE in the six years that they were in school and other young people said that it did not show up at all in PSHE, which was about how to write application forms, such as those to get into university. There is not enough in PSHE about how we build young people’s resilience and ensure that they are able to survive outside the school environment, or inside the school environment—how they deal with exam pressure, for instance. I spoke to a local CAMHS worker who said that she gets about twice as many referrals for self-harm, anxiety and stress when it is coming up to exam period because so many young people are crumbling under the pressure that we are putting them under and PSHE in the schools in the area is not as good as we would hope for.

It might be worth the committee’s while linking up with the Education and Skills Committee to consider how we develop PSHE guidance on mental health, how we ensure that there is a universal standard and how we get it inspected in schools so that it is being met and builds young people’s resilience, so that what I describe does not happen as much and, at the very least, young people are able to recognise for themselves when they need to ask for help and are then confident enough to do so.

I said that I would try to keep to time. Does anyone else want to come in briefly?

I have a very quick question. Many of the submissions indicate that demand outstrips the capacity of services, and that is coming across in the evidence. The British Psychological Society states that just 0.46 per cent of the NHS budget is spent on CAMHS. Are our witnesses aware of that? Is it an area that requires greater investment?

12:00  

Yes, 0.46 per cent is spent on CAMHS, and 5.81 per cent of spending is on mental health services, so children really are losing out in terms of the proportion of spend. Where is the early intervention there? Surely we should be investing in children and young people.

A psychiatrist described young people’s development to me as being like a plane taking off. They develop so fast during the adolescent years, when they should be learning the resilience and skills that they need for later life, that if mental health issues take them out of the picture, they will not recapture those skills. I would argue that putting more resources into child and adolescent care would be a really positive investment.

Rachel Stewart and I are both eager for the mike.

One of the things that occurred to me as Sophie Pilgrim was saying that was that Maureen Watt has said that the Government is investing £150 million in mental health over the next five years. That sounds impressive but, when we break it down, it is £30 million a year and there are 32 local authorities, so it is about £900,000 per local authority. There are eight priorities in the strategy, so that is about £115,000 per strategy, which means £115,000 for children and young people, assuming an equal distribution per local authority—and rural areas and the Western Isles will probably not get as much as Glasgow, for example.

I did not know the statistic, but it does not surprise me. We say that mental health has so much, but when we start chipping away and breaking down how much is ring-fenced for youth services, we see that it is not actually very much. We hear the big headline figure, but when we look, we see that it is not so much. How much could we afford for young people with £115,000? It would provide three community psychiatric nurses for tier 3 cases per region, if that.

It is very hard to put a price on how much we should be spending on CAMHS until we fully evaluate the demand for such services. At the moment, it is one of those limitless amounts, because we do not actually know how many young people are seeking help from tier 1 and tier 2 services—measurement starts at the tier 3 end of things.

We know that the Scottish Government has increased investment over the past few years and has earmarked £54 million for CAMHS over the next few years. Some of that has already been set aside for certain spending in relation to workforce development, service delivery and evaluation. We need a wider review, because then we can put a price on what we need to spend.

We very much want some of the funding to be targeted at the early stages. There have been improvements in the volume of staff working in Scotland. We are now at almost 18.2 CAMHS staff per 100,000 of population and the goal is 20 per 100,000. We can increase the workforce and the supply side of things, but until we actually start helping young people to manage their mental health, the demand for services is not going to dry up, and all the supply in the world will not be able to meet the demand. We need a wider review so that we can fully evaluate the need and start supporting young people the first time they ask for help.

Okay, thank you.

I thank the panel very much for their evidence this morning. We will have another session on CAMHS next week, and then a session on adult mental health and a further session with the Minister for Mental Health later in the month.

12:04 Meeting continued in private until 12:36.