input: What did Carol Shillabeer think about the reasons that brought the programme to intersect with the outcomes for children when talking about looked-after children?
  Lynne Neagle AM: Good morning, everyone, and welcome to the Children, Young People and Education committee this morning. We've received apologies for absence from Sian Gwenllian and there is no substitute this morning. Can I ask if Members have got any declarations of interest they'd like to make, please? No? Okay. Thank you. Item 2 this morning, then, is a further session on our follow-up on our'Mind over matter'report. I'm very pleased to welcome Carol Shillabeer, who is chief executive of Powys Teaching Health Board, and who manages the Together for Children and Young People programme. Thank you very much for attending, and thank you for the written update that you provided in advance to the committee. We've got a lot of ground that we want to cover this morning, so if it's okay we'll go straight into questions. If I can just start and ask you if you're satisfied with the progress that's been made since the programme was established in 2015.
  Carol Shillabeer: Thank you very much for that question, Chair. I've got to say'yes', in many regards. So, the key focus of the programme in the early stages was about improving access to specialist child and adolescent mental health services. We developed the windscreen model--or we lifted the windscreen model. Other models that are very similar have been talked about as well, and our big focus was on ensuring that we could make immediate progress around access to specialist CAMHS. It's some years ago now since this committee did the original report, and obviously Healthcare Inspectorate Wales and the Wales Audit Office had done reports in the past, and I think there was a need for a programme that could focus on action. You'll see in the written update that we covered quite a large number of areas, and so therefore had to make a prioritisation. The prioritisation was at the specialist CAMHS end. We have provided the committee with a red, amber or green rating of where we feel that we were, and that was just before submission of the evidence. Overall I would say we have made progress. I recognise you recognise that in your'Mind over matter'report, and that is pleasing. What I would say, though, is that there's a still a lot to be done. Certainly over the last nine months or so, we've seen a real momentum around the whole-school approach work, which we're not actually leading now as a programme, although we facilitated the workshop held in September. But that's got a real momentum, and the absolute priority now is the early help and enhanced support part of the work moving forward, and I'm sure we will come on to that in more detail. But we know there is more community workforce in specialist CAMHS, we know we're seeing children in a shorter time frame, and we know we're accepting more referrals, so our indicators are telling us we are making progress.
  Lynne Neagle AM: Thank you. And you referred to the work on the whole-school approach, which is very welcome, and I recognise that the programme has been involved in driving that as well. But I'm sure you'll also recognise the emphasis that the committee has placed on this being a whole-system approach to children and young people's mental health, and we feel very strongly that if any of the areas get out of balance, then it will jeopardise the progress in other parts of the programme. Are there any particular areas where you feel you haven't made enough progress that you'd like to draw the committee's attention to?
  Carol Shillabeer: This is maybe about what the programme's done, but really around the broader sense as well. I'm going to be very straight and say we should have made more progress on psychological therapies. I'm disappointed that we haven't. I'm assured that we've got capacity in place now and the drive in place to get the Matrics Cymru framework developed for children and young people. I've had discussions with the national psychological therapies committee, who have owned this, and we're working together more on this area. That's not to say for one minute that health boards and local areas haven't been working on psychological therapy service provision and changing the models, but that is an area we should have made, I think, earlier progress on. There's been a general reflection from myself and the Together for Children and Young People programme board over the phase of the programme. I think we started very strongly; I think we probably had a bit of a lull in the middle, if I'm truthful about that--we had a change of personnel, and we really gathered a momentum over the last year or 18 months, and that has helped to push us from a focus on specialist CAMHS into that whole-school approach. But, if I could just agree with your comments about the whole system, it has to be the whole system and that's why the real focus now on early help and enhanced support is critical. If I can just say, in case I don't get a chance to say this later, I was delighted to see the focus on youth work yesterday, because what is clear is for that part, the early help and enhanced support, this isn't just about the NHS and it's not just about education, it's about every part of the system, really, which does make it more complex. But I just wanted to say that I think that youth work has perhaps not have the recognition that it's needed and yesterday was a positive step.
  Lynne Neagle AM: Okay, thank you. We've got some questions now on early help and enhanced support from Janet Finch-Saunders.
  Janet Finch-Saunders AM: Thank you. Good morning. In terms of local primary mental health support services, what is your understanding of the issues leading to some health boards not meeting the Mental Health (Wales) Measure 2010 targets for assessment and therapy for children and young people, and how much of this is due to an increase in demand?
  Carol Shillabeer: Yes, thanks very much. So, it's important to say, I think, at the outset, just by way of reminder, that the target, quite rightly, changed for children and young people. The target changed some years ago for adults, so it was only right that there was an equalisation around children. So, the services were working, a couple of years ago, with significant demand and then a change in the standard. I think you're absolutely right; your question alludes to the fact that some health boards are struggling to maintain the full performance around seeing children, particularly within the 28 days. I would say--. And we've had some discussion about whether the impact of the mental health Measure has actually drawn perhaps some of the workforce, the staff, who would have been working at that earlier stage in local primary mental health, into a bit more of the secondary element, which is why the review being undertaken by the NHS delivery unit into primary care CAMHS is so critical, because, actually, if we don't have--and I believe we don't have--enough capacity in that part of the system, then referrals will move towards the more specialist end of this. So, I think we will have seen, by the evidence submission, that demand has increased, not just in Wales but in the UK, and it has increased significantly. We are doing reasonably well at meeting that demand--so, we have more contacts, more staff, shorter access times, so that is a good news story. We've not got it completely sustained at this stage, and therefore the focus of the delivery unit's primary care CAMHS report is what more can we do in that part of the system to help to see children and young people or provide consultation and liaison to others and support people at that level of intervention.
  Janet Finch-Saunders AM: Thank you. I know, from my own experience as a constituency AM, I have families who tell me that they can't get into the early interventions and eventually things just become so--they end up in the more specialist ones and believe that that's--. And I don't like to put it in resource terms, but it's false economy in terms of the impact on the child and the family, but, obviously, in terms of cost as well. Do you find that that's a common theme across Wales?
  Carol Shillabeer: Yes. I think that the thrust of that is absolutely right. So, we absolutely need to see children and families at the earliest intervention and that's why this is a whole system, not compartmentalised. I think there have been really good attempts in a couple of areas of that greater reach out and that earlier help--hot clinics and those sorts of initiatives that help people not to get in a long queue for specialist CAMHS, but can be supported, often by telephone, at that earlier stage. My sense of where we go next, in terms of, you know, you talk about early help and enhanced support for all the'missing middle', as you referred to it in your report, is to make sure we've got a fully joined-up, multi-agency team approach to that. And I think that will need some resourcing to support that, yet to be fully determined. But yesterday's announcement about youth work, the Government's commitment to primary care, CAMHS, et cetera--that's all going to be very helpful to prevent those young people having to go into specialist CAMHS. And just a final note on that, if I may--at the beginning of the programme, we had a report from Hafal called'Making Sense'and there were 10 key asks, if you like, of the system and the service from young people who had experience of the service. They said,'Please don't medicalise it'--I'm paraphrasing now, of course--'Please don't medicalise it; please focus on supporting teachers and others who can support us at an earlier stage and then, when we really need help, please ensure that it is there at that more specialist level.'That's been a bit of a guiding principle for the programme. So, that reflects the questions that you were asking, really.
  Janet Finch-Saunders AM: Thank you. What are the outcomes of the stakeholder workshop held last week on early help and enhanced support? And how are the actions going to be taken forward and implemented? And also, given that the Together for Children and Young People programme comes to an end in October of this year, who, in your view, is best placed to forward this work stream, and what will be the biggest challenges? It's a bit of a long question, so, break it up however you like.
  Carol Shillabeer: That's absolutely fine.
  Janet Finch-Saunders AM: And what will be the biggest challenges that they will face?
  Carol Shillabeer: Yes, I think that's helpfully laid out in three stages. So, you're absolutely right, there was a highly successful workshop last week really focusing on early help and enhanced support. It brought all of the agencies together, which was--and actually had a bit of a waiting list, apparently, for places. So, there was a lot of demand and a lot of interest in this. In relation to the next steps, there is a planning group reflection in early July, in terms of the outcomes of the workshop or the outputs of the workshop, and there are three commitments that have been made to this stage. One is that we develop those values-led approaches that will bring multiple agencies together to have that common purpose. The second one is to develop the ingredients for successful working in this area, and then, thirdly, to determine or propose priorities and sequencing of next steps. So, that's the next stage of that. I'm pretty sure we'll come on shortly--or hopefully--to the potential of the regional partnership boards. There is some work that we are doing as a programme with the children's commissioner in terms of working more with the regional partnership boards in taking forward this work. So, that will run alongside. But during the summer, then, we will be developing that framework approach, and we will be participating in the Association of Directors of Social Services conference in September, and then a follow-up workshop in October on this matter. On your question of'Well, what happens after the programme?'we are currently working on legacy arrangements for the programme. I'm pretty secure on the specialist CAMHS element. That will move, most likely, to the CAMHS network, which is part of the NHS mental health network. I actually chair the mental health network and that's one part of that. The whole-school approach element is already settled in Government and we've got a connection in to that. The question that's outstanding is where the early help and enhanced support and the neurodevelopmental will go. I am currently in discussions with Welsh Government officials around that. I can be very clear of my own view that there needs to be a confident and clear legacy arrangement for this work. We cannot afford that we've come so far for this not now to proceed. I think there's a huge momentum behind this. I don't see there would be any obstacles--I hope--in getting that commitment translated into a strong approach, as we move forward. So, I'm not in a position to say,'And the legacy arrangements will be--', but I am in a position to say that I'm having those discussions with Welsh Government officials. They know my view that we've got to put something in place that is strong and secure as we move forward, and I believe that they are supportive of that.
  Janet Finch-Saunders AM: Thank you.
  Lynne Neagle AM: Janet, I think those two questions have been touched on, the remaining questions. We are going to discuss in more detail the legacy arrangements, but if I could just ask on psychological therapies: you referred to the fact that you were a bit disappointed with progress in this area, and the area hasn't been directly led on by the Together for Children and Young People programme. Do you think that means now that there is more of a threat to progress in this area, because, you know, we've got different compartmentalising of actions, and this is absolutely key, isn't it, really?
  Carol Shillabeer: Yes. I think there's--. There is some refinement to be done, I think, in making sure the connections are there. So, I think, as we move to programme end, we'll want to be absolutely assured that there are no strands left hanging, so to speak. I am confident--I mentioned the mental health network board that I chair--that we have those strands nailed down, but recognising that the early help and enhanced support and the provision of psychological support is beyond the NHS. So, this will be an area that needs to be very much seen as a key part of that. My own sense is that--. There's been quite a lot of other developments through the life of the programme. So, in the evidence that I've provided, you'll see the First 1000 days, all the adverse childhood experiences work, the Cymru Well Wales partnership, et cetera, et cetera. So, there is a bit of what I would call tidying up of the landscape to be done, and this is the ideal opportunity to do that.
  Lynne Neagle AM: Okay. Thank you. We've got some questions now on specialist CAMHS--if I can just ask about the impact of the specialist CAMHS framework, and how effective you feel that has been in promoting a consistent delivery of care for young people.
  Carol Shillabeer: Thanks very much for that. Without wanting to go back too far in history, I remember coming into this area back in 2014 as I was asked to establish a CAMHS network. My observation was there wasn't really a strong and well-connected clinical community in this area. When we spin forward five years, I can confidently say that there is a strong and well-connected clinical community around specialist CAMHS. The programme has helped; the emphasis and the focus of the programme has helped to bring people together with that more common endeavour to understand, actually, there is a good case for consistency in the main, with local variation. There has been a case for much greater learning between organisations. If I just give you an example--you'll know that the community intensive service teams were put in place in 2015-ish. Some areas have them, but a lot of areas didn't. We do have inconsistency in that, but the consistent part is there is a service now right the way across Wales for more intensive support to children and young people and their families in their own homes, which helps to prevent admissions and then, where there are admissions, helps to support people to be at home. They're all called slightly different things. So, I might have referred in my papers to CITT, CATT, COT and CITE. So, they've all got slightly different names and they've got slightly different opening hours. The key thrust of this is that there is a backbone, if you like, of a consistent approach with that local variation. We have to check. So, things like frameworks for improvement--there is a coming together of the clinicians and the professionals to agree what that framework for improvement is. That then gets implemented, with some local variation. So, I think the process of moving in that way has been extremely helpful. There will be some variation. We want some variation, to some extent, as places try new things and evaluate new things. So, if I just refer to the previous question that I had, and I talked about hot clinics and different ways of reaching out; that's been tried in one area, been evaluated--let's see the spread of that. So, you'll know my view on internet counselling, for example; I feel that is quite a strong offer for children--not necessarily in the specialist end. If that works in one area, why aren't we rolling that out to other areas? So, I think the framework for improvement has provided a vehicle for those clinicians and professionals to come together. It's in a stronger place--a much stronger place--than it was five years ago.
  Lynne Neagle AM: Okay, thank you. You've referred to there being some inconsistencies in terms of crisis care, but are you able to assure the committee that all young people are now getting at least a consistent service, especially in terms of interventions in the instances of young people self-harming. Wherever you live in Wales, is that help there for you now?
  Carol Shillabeer: Well, in your work to produce the'Mind over matter'report, I clearly listened to the views from the police and the recommendations in relation to the police. We've taken that as a further piece of work under the specialist CAMHS umbrella, to truly understand what the experiences of the police are and what some of the root issues may be in relation to that. For example, is it that because the CIT, CAT, COT, CITE--the community intensive service--closes at 10 o'clock in a certain area, that actually it's after that that the network of support isn't as strong, and, if that is the case, what are we going to do about that? There's certainly potential in working more regionally or even working between adults'and children's in terms of the crisis resolution services that work beyond those hours. So, we are taking an extra look at this, because I could not be 100 per cent confident that, throughout the 24-hour period, we've got this fully settled. I continue to hear some stories from the police that they are picking up young people and feeling that they've not got that solid place to go, and we're following those through.
  Lynne Neagle AM: Okay, thank you. We've got some questions now from Hefin David on neurodevelopmental services.
  Hefin David AM: I think, Chair, I should have declared an interest here, as my daughter has been diagnosed with autism and is currently going through the process of receiving neurodevelopmental speech and language support particularly. We're seeing an increase in neurodevelopmental referrals, and that will increase further in the future. Can you give us an explanation as to why this demand is growing and how we're going to meet capacity to deliver and for support for those children?
  Carol Shillabeer: Thank you. They're very big questions in terms of'why'. I'm not sure that anyone really knows why, if I'm honest, although there is a lot of academic research going on. What we do know is that we are starting to see the scale of those referrals coming through. So, in the information provided, I refer to the NHS digital prevalence report in England, which indicates that about 5. 5 per cent of two to four-year-olds have a mental disorder. Now, that sounds a bit shocking when we say that, but that's in the international classification scaling, and, of that, certainly, 2. 5 per cent is around autism. I can just testify, in real life, that demand is absolutely growing. So, if I just take my own health board for a moment, we usually have about 75 referrals per year. Last year we had 300. So, that has felt very difficult to manage. If I can just give you a sense of what we've done so far and then what I think is next, I want to recognise the work of Dr Cath Norton and the steering group that's been established on neurodevelopmental issues under the programme. They had a standing start. They've done a lot of very, very good work. We now have seven teams in place across Wales. We now have a national pathway. We now have a community-of-practice-type environment, and we're really getting into this. Good progress has been made. More people have been seen. More people have been assessed. So, we have made progress. But I've got a long list of considerations that I think respond to your question. One is that most referrals that come through, the clinicians tell me, are seeking support to move through what they perceive to be a gateway for educational support. So, that is often the reason why people come. Now, that is obviously going to be linked to the whole-school approach and how we can support that. Demand is outstripping supply. So, our clinical teams are concerned about how do they keep up. So, if I just take my own example of 300 in the last year, we're looking to try and put some additional capacity in to support seeing those families, but also then to understand what the long-term trajectory is going to be. Because we've put these teams in, because we've got the new pathway, has that opened a gate and we've got a lot of backlog or is that the pattern?
  Hefin David AM: Can I just ask a question there?
  Carol Shillabeer: Yes.
  Hefin David AM: So, with regard to the 75 to 300 increase--in the space of a year was that?
  Carol Shillabeer: In a year, yes.
  Hefin David AM: Did you anticipate that or was that something that just came totally unexpected?
  Carol Shillabeer: I think we anticipated a few more, and just to say that in my--
  Hefin David AM: But not on that scale.
  Carol Shillabeer: No, not on that scale. And in my own health board--I'm just referring to my own, and I'm happy to share the information on this--we already had a service in place. So, it wasn't as if we had nothing in place previously. We had a NICE-compliant service already in place, but we knew we needed to expand that, which we have done, but we didn't anticipate 300. So, this is happening not just across Wales, actually, but across the UK--so, this greater recognition, the desire for families coming forward to access that support and them seeing this as a route, which is really important. What I would also say, and this is part of the bigger picture that we need to consider going forward, is that only about 40 per cent to 50 per cent of those families that come forward have what I would call or the clinicians would call a diagnosis--so, a threshold or whatever term you want to use that takes people through to that educational support. So, we've got a lot of people who are under that threshold, but that's a lot of people who still need help and support. I'm trying to very fairly and, I hope, appropriately represent the very strong views coming from the group--the workstream under the programme. We've got to tackle all of that. It's not going to be good enough for us just to focus our attention on those children and young people and their families who reach a threshold, because there are needs elsewhere as well, and some of that will overlap with the early help and enhanced support. Some of that overlaps with learning disability services. Can I just mention a few more things, as I'm on roll on neurodevelopmental?
  Hefin David AM: It's up to the Chair.
  Lynne Neagle AM: Yes, go on.
  Carol Shillabeer: Is that all right? Sorry, I know it's a very long answer. There is a concern from the neurodevelopmental group to get across that whilst there has been a lot of focus on autism--and we recognise the private Member's Bill--there are other neurodevelopmental presentations and there's a real--. Having the broadest view would be advised by them, and I think they're particularly keen to understand what a future vision and what we call, say, a'perfect world'would look like. That's the piece of work that we're wanting to do now. In terms of giving advice at the end of the programme and into legacy arrangements, about what the big, big things are, we are still needing to tackle.
  Hefin David AM: I mean, I personally took a very personal decision when it came to the Member's Bill on autism you were talking about--and that was the advice I received. You need to look at the wider symptoms that are presented beyond autism and other neurological conditions. So, I'm glad you said that, because it gives me--. Because I didn't vote for that Bill, and I'm glad you said that because it gives me some personal reassurance there. But what I do have concerns about is if the increase wasn't anticipated to the extent that it was and that the Together for Children and Young People programme has a duty to review capacity, after October who's going to make sure that that capacity's reviewed on a strategic basis?
  Carol Shillabeer: So, I should have probably added in that we've got a piece of work under way at the moment--Welsh Government commissioned it--by a person called Patrick Holton, and he is specifically looking at the demands on capacity in relation to neurodevelopmental. I think getting that slightly more independent view of what we think the trends are going to be over the long term will mean we can plan for the long term. We know that money's been put into this and it has had an important impact, but we now need to be planning for the next three, five, 10 and many years beyond that. There is the integrated autism service. I think there are some conversations, when I talk about the landscape being quite busy, about the sense of where this links as we support people through their lives with a neurodevelopmental issue. So, it's not just about a childhood thing; as people move through, we've got to get much better at that long-term planning. So, that piece of work is really important. We will get the report of that over the next couple of months in order for this sort of perfect-world picture that we want to try to describe to be informed by that. It also connects to the early help and enhanced support, because recognising if we just say half of the people who come for an assessment don't meet a threshold for a certain category, that's a lot of people who will need help and support to manage and cope with their condition and their situation.
  Lynne Neagle AM: Okay, thank you. If we can just move on now to in-patient care, and if I can just ask you what the programme has been doing to address some of the challenges and opportunities we face in terms of CAMHS in-patient care, particularly in light of the restrictions that are in place in Abergele and Ty Llidiard.
  Carol Shillabeer: Yes, thank you very much for that question. Again, quite a lot of progress has been made in the early part of the programme around in-patients, and you are very well aware of the challenges over the last year or 18 months in relation to both units. I think, certainly, there is some recovery in the position in north Wales, and the programme did a peer review visit to north Wales, which I think was very helpful. In terms of where the programme has been on this issue, there is some work under way, at quite an advanced stage, around the art of the possible around enhancing the scope of the services. This was quite a tricky thing to start off when you're in a position where, actually, there've been some restrictions, to then ask the service to think about going even further, but we really wanted to see what the art of the possible would be if we could attract the right workforce, get the right environment, et cetera, et cetera--so, that piece of work, the review of the specification about what could be possible. Clearly, we work very closely with Welsh Health Specialised Services Committee as the commissioner, so we don't commission that. We neither performance manage those environments. But, if I can just say, probably the most important part of moving forward now is the longer term work between health and social care in terms of having a much more integrated and joined up approach for children. We believe there would probably be about 100 children who have experienced care in multiple settings. We haven't got that mature approach in terms of these being joined-up teams; we've got social care and we've got healthcare. There is a growing appetite to do something different. There is a meeting with the children's commissioner on 9 July to explore that. I've previously had conversations with the chief inspector of Care Inspectorate Wales, for example, and we have now got, I think, a consensus growing that we need to do something very different for children and young people who are in this sort of need for the future. We also know that there've been some high-profile legal cases as well. So, we've got to move to that step now. It has been largely successful, the work that has taken place over recent years, but not without its key challenges.
  Lynne Neagle AM: Thank you. And, just briefly on the new specification that WHSSC are developing, that will enable admissions at weekends and out of hours. How concerned should we be about that being a challenge, particularly in Abergele, where staffing has been a major issue?
  Carol Shillabeer: Yes. I think we need to be very mindful of ensuring that the right workforce are in place before that gets implemented. The peer review highlighted the challenge of the physical environment, where the unit is, the challenge across north Wales of the workforce. These are issues well known by the health board, by the way, so it wasn't a surprise to them. But that dialogue about how do we ensure that we've got the right workforce, because that unit, potentially, could--you know, it's an isolated unit, and they've been risk-managing. They've been managing the types of young people that they can take bearing in mind the workforce that they've got available, and that's been entirely the right thing to do. But the downside of that is it's not as accessible as we would want.
  Lynne Neagle AM: Okay, thank you. Hefin David has got some questions on workforce now.
  Hefin David AM: Yes. With regard to the increased CAMHS posts that have been made available between 2016 and 2018--a 62 per cent increase in CAMHS posts--we know that there's likely to be labour market demand, high labour market demand, in those instances, so are the vacancy rates higher in Wales than elsewhere, given the increase in those posts to be filled?
  Carol Shillabeer: So, you're absolutely right. There's been quite a lot of investment, and there have been quite a lot of new recruits coming to the service. We had in the early days a situation where we were largely robbing Peter to pay Paul, to be quite frank. So, as new services were being developed, people would move from one part of the system to the other. So, in the early days there was little net gain. That has improved slightly, but we're in a national context, particularly around nursing and around some specialties in medicine, of a national shortage, so this is not a quick fix. We are starting to see a greater diversity of workforce. So, if I can mention psychology assistants, for example, my own health board is employing more psychology assistants as part of a skill mix team, rather than going to where we might have been more traditionally based. We see some of that through the NHS benchmarking, particularly with England. They have more of that. We're perhaps a little bit--
  Hefin David AM: More of what?
  Carol Shillabeer: They have more skill mix in their workforce. We're catching up a bit more on that now.
  Hefin David AM: Just to clarify there, what you're referring to--there are more nursing and medical staff in the Wales system and more psychological staff, experts, in the UK picture. Is that--?
  Carol Shillabeer: In the England picture. So, England had a programme called IAPT, which is about psychological therapies, and had therefore looked at the skill mix. Some of that was--. We've chatted to colleagues in England, trying to learn--we're all trying to make improvements in this area, of course; it's a UK and international issue--what were their experiences of this psychological therapies approach. Because of their vacancies they had to skill mix, and because of the money that they had available--they didn't have as much of a cash injection as perhaps we've been able to secure. So, they skill mixed much earlier; we're skill mixing now. We're using different types of roles, for example. And if I can just make a plea, really, around recognising the input of the third sector--so, it doesn't always have to be an NHS-employed person to work in service provision, direct front-line service provision, and the third sector are offering a significant contribution in a number of areas of our services. And that is one that we will need to cultivate, because, to be quite frank, our recruitment challenges won't be solved overnight. We've recognised that the commissioning numbers for nursing and other professionals have gone up over recent times, but, with the training time, it's not a quick fix.
  Hefin David AM: Does the workforce profile remain different, or are they starting to--?
  Carol Shillabeer: They're starting to come together. There is a--graph 13 in terms of the CAMHS profile. Each year we do the NHS benchmarking, and we can see where we are compared to others, and I would expect over the next year or two that we see a bit more narrowing.
  Hefin David AM: So, if you compare a child in Wales with a child in England in the last two years who's been through this, would they have had a different experience as a result, and different clinical advice as a result, or is there consistency despite the difference in workforce profile?
  Carol Shillabeer: That's quite a big question. Hand on heart, could I tell you I absolutely know the detail of that? No, I couldn't. The practice in this area is guided by National Institute for Health and Care Excellence guidance, so it's pretty much guided. We would expect all of our practitioners to be able to work to NICE guidance. When you skill mix a team, you enable the right referrals to go to the right person, so you wouldn't necessarily have a child or young person with particularly complex needs--well, you would match them to the right practitioner for their needs. So, it does--. And we've seen some of that; if I just make reference to the panel approach in Gwent that's been developed, a multi-agency panel come together, a referral comes in, it's then about matching the right service and the right person to the needs that are being presented. So, we can be much more flexible in relation to that, and we have to be careful to use the right resource for the right person, because, if we've got a resource that is highly specialist, we want them to be dealing with those children and young people.
  Hefin David AM: And one of the things you're able to do--because there's a lot about the labour market you can't control, but one of the things you can control is workforce development and ongoing workforce development. You've mentioned communities of practice. What other things are being done in addition, and how do the communities of practice work might be a good question, but what else is being done in order to upskill and develop and grow the existing workforce that is presented to you?
  Carol Shillabeer: Thank you for that. So, there's a couple of things around--. I think there's a huge focus on staff retention now, not just in Wales but across the UK. So, we've got recruitment but we've got retention. What are the factors that affect retention? Actually, well-being, well-being at work--and you'll know that within'A Healthier Wales'the focus on staff engagement, staff well-being, has been laid out--the ability to work well in teams and the culture of organisations and services, and, then, as you rightly say, training and development and career opportunities. So, the developments over the last few years have brought training opportunities and career development opportunities as well. I think the community of practice--it's something that has become a bit of a standard now across these areas--actually brings people together doing collective audit, doing collective reflection on service improvement, and being very clear about learning from one another. And, if you're a clinician, that gives you a lot of motivation to keep driving forward. So, I think we have the fundamental building blocks in place, but there is more to do around the environment in which our practitioners and our staff operate.
  Hefin David AM: What about the Welsh language in the health board?
  Carol Shillabeer: Thank you very much. There are two elements, if I may, just on that. In your report of last year you highlighted the need to do further work on the use of the Welsh language, and have we got enough Welsh language practitioners where we need them. We are doing that piece of work. I'm pleased to say that, over the last few years, I think all health boards have really stepped up in terms of being able to understand the levels of Welsh speaking amongst employed staff and where their Welsh-speaking communities are. We're particularly looking at it in terms of in-patient CAMHS and community intensive services, because, particularly when people are feeling at their most vulnerable, they would choose the language they wish to choose. So, we know we need to respond to that. So, we will be in a position to, by the end of this programme, provide that position statement on what happens next. I would also say, of course, we've got the Welsh language standards that we are all working on at the moment, and we've got a very clear programme of when we have to be compliant with those standards. So, that element is very high on the priority list.
  Hefin David AM: Okay.
  Lynne Neagle AM: Thank you. Suzy Davies has a question about looked-after children.
  Suzy Davies AM: Yes. Thank you, Chair. Obviously, everything you've been speaking about already, particularly about workforce development, applies to children in care as well, where there's other work also going on in terms of support. Can you give us some indication about how the programme intersects, then, with the outcomes for the children in care work programme?
  Carol Shillabeer: Thanks very much for that. So, we have one of our members of the programme board also sitting on the outcomes for children ministerial group, which is good. So, we've got that cross-link. We also have a director of social services on our programme board and, obviously, they're very clearly linked in to the outcomes for children. I just made reference to, under the question on specialist CAMHS in-patients, the need to bring those services together, and that, really, is the need for much stronger working between the outcomes for children group and the Together for Children and Young People programme and the constituent parts. So, I'm confident that that has been pegged now. We've got a way forward and there is a consensus that we need to do things together on that.
  Suzy Davies AM: Can you just perhaps give us an example of how that then looks on the ground? Because it's great that people are talking together, but how would that affect, I don't know, individual members of the workforce, or, indeed, the children we're talking about?
  Carol Shillabeer: Yes. So, if I just give an example of a unit in south Wales that is a social care unit, we've been having discussions about,'Well, actually, shouldn't you have a psychologist and good access to psychological therapies, et cetera, et cetera, et cetera?'So, we haven't yet got an agreed position on how we're going to do this, but the position is that something needs to be done, and there is an appetite for and an understanding of the case for change, I believe. But what it will mean, I think, in practice, is that you get much more fluid roles moving across sectors, or we could be designing services that are fully integrated. Now, there may be challenges in that, but, you know, let's get them out on the table. So, in terms of this seamless health and social care system for Wales, this is one of the tests of that, I would say: can we, within the next five years, 10 years, really bring that together? That will take quite a lot of work and commitment. On the looked-after children specifically, we have picked that up, particularly following your previous report, looking specifically at the assessment of young people who are care experienced who are in the system. Absolutely, part of the health assessment is emotional health and mental health. We are questioning whether that needs to be a greater part and what the level of support needs to be, particularly because of the backgrounds of children that have led them to be in those circumstances. That's a core piece of work under the early help and enhanced support work stream, and we'll be ensuring that that is complete by the end of the programme.
  Suzy Davies AM: Okay. And you're confident that that will reach children who are being fostered and perhaps don't have very frequent looked-after children reviews, because, from all other perspectives, things are going fairly well.
  Carol Shillabeer: Yes. And, of course, there's the edge-of-care work that the Government have been supporting, and, certainly in my own area, under the regional partnership board, we have a Start Well programme, which is the old Children and Young People's Partnership programme, where there's a significant investment in supporting children and young people, families, on the edge of care, which does pick up fostering.
  Suzy Davies AM: Ah, lovely. Thank you. Thank you, Chair.
  Lynne Neagle AM: Dawn has a question on transition.
  Dawn Bowden AM: Yes. Thank you, Chair. We've heard, not necessarily just in the context of this report, because we've heard similar evidence around transition arrangements in another committee report when we did the suicide prevention, and I've in fact only recently--well, just this week, actually--met with community mental health teams in my constituency, and there is still some concern about transitional arrangements from children into adult services. Now, I know we had the--. The transition guidance was published a couple of years ago now, and the programme was involved in developing that guidance. But what's your assessment of the impact that it's had? Because we clearly are still seeing people falling through the gaps, aren't we?
  Carol Shillabeer: Yes, thank you for that. You're absolutely right; we developed that guidance and we are currently in the process of the evaluation of that. And, in particular, I know that the children's commissioner is very focused on transition, not just around children in receipt of emotional mental health support, but children in paediatric wards, and there is a working group with Welsh Government looking at this. The children's commissioner has used our guidance to put that on the table to say,'Well, if this works, this needs to be considered as a model for using elsewhere'. But the big question there is'if'. So, we do want to get evaluation. If I were just to give an estimate of where I think this will land, I think it will have made improvements, but there may well be some further work to do in enhancing, supporting, auditing that every child is supported in line with that guidance. So, I talked about community practice and clinical audit: is this something that we make, then, a mandatory audit, each year, that we do that double check? Because it's one of those things where we know when a child is 14,15,16,17, so what's stopping us? If indeed the evaluation says it's not happening everywhere, it's not happening early enough, what is stopping us? We really need to get underneath that. So, my sense will be it will show us, it will be better, but there's some further work to do, and following that up in terms of audit and making sure that we've got a systematic approach to dealing with those who haven't had the guidance fully implemented, because it can make a real difference.
  Dawn Bowden AM: Yes, and it seems to me--you've just talked about having a systematic approach, and it does seem to me that it is a systematic process, isn't it? So, it shouldn't be difficult. I know we're talking about in the health service things shouldn't be difficult and they are, and one of the gripes--I had a meeting with the community health team--was the problems of the new IT systems and so on--let's not go there at the moment. But, really, this is just about referring children and having a smooth transition from the service being provided to them as a child and then just shifting it over to the adult services. It shouldn't be difficult. It's really difficult to get my head around why that is such a problem and why that needs to be so difficult.
  Carol Shillabeer: Can I add one other dimension in, which I think is going to be quite interesting? We talk about transitions being an issue--and we know it's not just in mental health, but it's elsewhere--then you start to think,'What if we could reduce transitions?', so you reduce the number of transitions and you manage them better. We are doing a piece of work with Government on the potential to explore what a 0-25-type service would be. We know that in different places they have approached that--in Australia and places in the UK. There are probably some pros and cons, but should we be moving to a 0-25. That is moving the transition at the age of 25, but at least it's not at the eighteenth birthday. What's the argument around what adolescent, young people and young adults services are, for example? That piece of research and understanding--
  Dawn Bowden AM: You could probably have a gradual transition, then, couldn't you?
  Carol Shillabeer: Quite potentially. I've got some people who have joined my own health board who've worked in that 0-25-type service, and we're catching up--'Tell me what was good about it? Tell me what was not so good about it? What did the young people themselves think about that?'. Because if we can manage down the numbers of transitions, there really should be no excuse not to get transitions right, then.
  Dawn Bowden AM: Okay, thank you. Thank you, Chair.
  Lynne Neagle AM: Okay. We've got some really important questions now about legacy, because throughout the session this morning you've referred to ongoing work, really, and that is a major concern for the committee. Suzy Davies.
  Suzy Davies AM: Yes, thank you, Chair, we are a little bit worried that this programme is coming to an end in a matter of months when perhaps its work's not been completed. Obviously, we've got the Welsh Government's strategy for mental health running until 2022, which is a few years longer. Can you tell me whether you think your programme needs to continue, perhaps even if it's just for the same length of time as Together for Mental Health, or is its work done and it needs to be picked up now by a different system?
  Carol Shillabeer: Thank you for that. Can I just say, I've given this so much thought over the time, because I think you might have asked me this question when I came previously? There are two ways to look at this. I'm absolutely sure that the issue of children's emotional and mental health will be one that will be with us for a very long time. We have made a lot of progress, I think, as a society, in talking about this now. We talk about mental health so much more than we ever used to. When I was a child, we never talked about it. I talk to my own children and say,'What's going on in your lives at school?', and they talk about this. This is not an issue, if you like, that I believe you can pick up and solve literally in five years. This is one for the long term for us. So, on the one hand, I think my view last year was that, when you have a programme of work, you should have a start, a middle and end, really--otherwise it's not a programme of work, it's almost forever--and there is a moment to refresh and reflect on whether that mechanism has done all it should and it should move into a different mechanism. So, my position last year was,'This will have been running for five years--we've done a lot of work and made progress on specialist CAMHS, we have made progress on the whole-school approach and there is a different mechanism for this'et cetera. My position now is I want to just be really sure and secure that there is a strong arrangement going forward that takes this work, if this programme is going to close.
  Suzy Davies AM: Are you sure?
  Carol Shillabeer: Not yet. So, I think, in an earlier question I indicated dialogue going on between myself and Welsh Government officials. I don't think there's a barrier--people aren't saying,'No, it all needs to just stop; we've solved the issue', but the exact nature of the legacy arrangements, particularly for early help and enhanced support, are not yet fully determined, or for neurodevelopmental. If it was a choice between nothing being there and continuing this programme, I would be supporting continuing the programme. I don't think we can stop now.
  Suzy Davies AM: Well, I don't think any of us would disagree with that, but I suppose there might be a level of concern that the Welsh Government's preferred route from now on would be through the regional partnership boards and public services boards. You mentioned that you've done that work in Gwent, down in the south-east of your patch there. It's quite difficult for us to try and get a picture of how that will work successfully for the whole of Wales. I know you've got your experience in Gwent, but have you thought a bit more about how it might look elsewhere, if that's the route that Government decides to pursue?
  Carol Shillabeer: Yes. I think the key question in my own mind is: are the regional partnership boards yet ready and mature enough to take this forward? I'm the chair of the Powys regional partnership board, so I should declare that. There's a lot being asked of the regional partnership boards at the moment--
  Suzy Davies AM: Well, we'll be asking them to go with the'Mind over matter'report, to make sure that that's delivered upon.
  Carol Shillabeer: There's a lot, you know,'A Healthier Wales'--. Everyone does feel that the regional partnership boards are a route to really secure multi-agency working, so there is quite a high expectation. My understanding--and this is a rather informal understanding--is that different RPBs are in different places. So, some have retained what used to be the old children and young people partnerships, and perhaps where they have been retained, they may be in a more progressed position. Some are looking to have to re-establish those. So, my sense of this is that, I think, possibly the RPBs aren't yet in that position to be ready. Our piece of work on early help and enhanced support, in terms of your earlier question about what's the commitment--that feels that that may well be another year or 18 months of development work, alongside the RPB development work, to get that ready, before we can then more confidently say where we can hand over.
  Suzy Davies AM: You may not feel able to say it, then, but would be wrong in saying that, actually, it would be quite a good idea to extend the current programme, just to make sure that anyone else who might be able to run on with component parts of it is in the position to do that to our satisfaction?
  Carol Shillabeer: I'm happy to respond to it. My sense is that, whether it's the programme or whether it's something else, something needs to be there. The next stage is really multi-agency, so it may well be that the programme currently has been NHS-led--maybe it needs to be led elsewhere, maybe not. I think there's a view that this needs to continue. I'm less wedded to it having to be the Together for Children and Young People programme. It may be seen as a convenient mechanism--it's already established, we've got a programme team et cetera, so it may be seen as a ready sort of solution. I'm not wedded to that. What I feel strongly about is that we've got to have the right mechanism to take it forward.
  Suzy Davies AM: Can I just push you on one thing there? You mentioned, perhaps, the NHS could lead on the work, for example. Is there a risk of fragmentation if we start looking--? I'm just thinking--I mean, we've got the elements here: we've got the NHS, there's the whole-school approach, early help and enhanced support and intervention, as you mentioned earlier. If that goes to one of the players in that multi-agency approach, is there a risk that they might become too dominant, inadvertently--?
  Carol Shillabeer: If I can just clarify--apologies if I wasn't clear. I said the current programme has been NHS-led, and that might be a reason to change.
  Suzy Davies AM: To mix it up a bit. Oh, right, okay. Anything else you want me to pursue on that--?
  Lynne Neagle AM: Can I just clarify for the record, Carol--because we put this to the Minister last week--are you looking at asking the regional partnership boards to take this work over from October 2019? Are you saying clearly to the committee that you do not feel that all regional partnership boards are ready for that challenge at this point?
  Carol Shillabeer: I'm saying that on a more, if you like it, uniformed and informal basis, we're doing some work with the children's commissioner now in terms of--. I know the children's commissioner's very interested in how RPBs are managing, developing and dealing with the issues of children and young people's concerns. We're working with her to understand and to mirror alongside her the understanding of the RPBs. What I would say is that there has been some preparatory work by Government around supporting RPBs. So, for example, in the integrated care fund guidance last year, there was a specific reference to child and adolescent emotional mental health, which I welcomed. I've also welcomed, literally last week, a letter to all RPB chairs giving an allocation of PS200,000 per RPB to support this further work in terms of child and adolescent emotional and mental health and the early help and support element. So, all of these things are in the right direction. My sense, and I need to stress it's a sense because we haven't done that piece of work, is different RPBs are in different places. So, how confident can we be at the October date that we could hand over? My sense is, just to safeguard, having a mechanism in place for the next 12 to 18 months to guide this through might be advisable, and that's what I'm talking to officials about.
  Lynne Neagle AM: And that would either be an extension of the Together for Children and Young People programme or something else. Okay, thank you.
  Suzy Davies AM: Thank you. Because I think there is a question, isn't there, about whether the RPBs will make this enough of a priority? I'm a bit nervous that it might get lost in that huge amount of work you said they might have. Just a final question from me: how are you establishing what the young people themselves think about the end of the programme? Are they bothered about the structure of this at all or are they just concerned that they're getting help? How's the stakeholder group feeding into this?
  Carol Shillabeer: I've not been blown over in the rush of people saying,'Don't go anywhere.'[Laughter. ] It's a really important matter for young people. I know that later on you're meeting with the Youth Parliament, you're having a joint session, which is fantastic. We've had contact with the Youth Parliament because we know it's one of their top three issues. So, it runs in the vein of that this is going to be a long-term matter for young people, I think. Whether they have a specific view on the programme, I don't know. I've not heard that. But I'm pretty sure they will be vocal in saying,'We have to have these developments continue.'It is a major issue, we're not there yet--maybe some progress has been made but there's still a lot to do--and I think we'll need to be able to respond to that.
  Suzy Davies AM: Anything particularly you want in addition to that?
  Lynne Neagle AM: No, I think that's fine. And if I can just say that it was really great last week at the early help and enhanced day to see young people so central to the day all the way through. It was very, very important and very welcome.
  Suzy Davies AM: Carol, thank you for that. Thank you, Chair.
  Lynne Neagle AM: Okay. we have come to the end of our time. We had a lot of things that we wanted to cover with you. We might need to drop you a line about a couple of things that we haven't covered, but can I thank you for your attendance this morning? As usual, you'll be sent a transcript to check for accuracy following the meeting, but thank you very much for your time.
  Carol Shillabeer: Thank you, all.
  Lynne Neagle AM: Item 3, then, is papers to note. Paper to note 1 is a letter from the Welsh Youth Parliament--invitation to engagement events. Paper to note 2 is a letter from the Minister for Education clarifying some issues around the Welsh network of healthy schools scheme, following the task and finish group. Paper to note 3: letter from the Minister for Education on the implementation of the Diamond reforms, and that's ahead of our session on 4 July. Papers to note 4 and 5 are a letter from me to the children's commissioner and the Minister for Education seeking the update we agreed on the issue of elective home education. And then paper to note 6, paper to note 7 and paper to note 8 are all letters regarding the concerns that we discussed about the expectation of a target being set for looked-after children, to the First Minister, Children's Commissioner for Wales and the Association of Directors of Social Services. Are Members happy to note those? Thank you very much. Item 4, then, is a motion under Standing Order 17. 42 to resolve to exclude the public for the remainder of the meeting. Are Members content? Okay.
output: First, there was a close link between each member. Second, in terms of the question of specialist CAMHS in-patients, there was a need to bring the services together for stronger working.