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?

So, with regard to the 75 to 300 increase—in the space of a year was that?


So, with regard to the 75 to 300 increase—in the space of a year was that?


So, with regard to the 75 to 300 increase—in the space of a year was that?

Did you anticipate that or was that something that just came totally unexpected?


So, with regard to the 75 to 300 increase—in the space of a year was that?

Did you anticipate that or was that something that just came totally unexpected?

I think we anticipated a few more, and just to say that in my—


Did you anticipate that or was that something that just came totally unexpected?

I think we anticipated a few more, and just to say that in my—


Did you anticipate that or was that something that just came totally unexpected?

I think we anticipated a few more, and just to say that in my—

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?


I think we anticipated a few more, and just to say that in my—

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?


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?


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?

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.


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.

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?


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.

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?

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.


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.

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?

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.

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 Tŷ Llidiard.


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?

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.

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 Tŷ Llidiard.

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.


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.

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 Tŷ Llidiard.

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.

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?


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 Tŷ Llidiard.

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.

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?

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.


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.

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?

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.

Okay, thank you. Hefin David has got some questions on workforce now.


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?

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.

Okay, thank you. Hefin David has got some questions on workforce now.

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?


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.

Okay, thank you. Hefin David has got some questions on workforce now.

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?

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—


Okay, thank you. Hefin David has got some questions on workforce now.

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?

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—


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?

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—

They have more skill mix in their workforce. We're catching up a bit more on that now.


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—

They have more skill mix in their workforce. We're catching up a bit more on that now.

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—?


They have more skill mix in their workforce. We're catching up a bit more on that now.

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—?

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.


They have more skill mix in their workforce. We're catching up a bit more on that now.

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—?

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.

Does the workforce profile remain different, or are they starting to—?


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—?

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.

Does the workforce profile remain different, or are they starting to—?

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.


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.

Does the workforce profile remain different, or are they starting to—?

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.

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?


Does the workforce profile remain different, or are they starting to—?

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.

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?

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.


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.

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?

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.

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?


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?

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.

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?

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.


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.

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?

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.

What about the Welsh language in the health board?


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?

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.

What about the Welsh language in the health board?

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.


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.

What about the Welsh language in the health board?

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.


What about the Welsh language in the health board?

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.

Thank you. Suzy Davies has a question about looked-after children.


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.

Thank you. Suzy Davies has a question about looked-after children.

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?


Thank you. Suzy Davies has a question about looked-after children.

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?

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.


Thank you. Suzy Davies has a question about looked-after children.

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?

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.

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?


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?

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.

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?

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.


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.

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?

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.

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.


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?

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.

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.

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.


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.

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.

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.

Ah, lovely. Thank you. Thank you, Chair.


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.

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.

Ah, lovely. Thank you. Thank you, Chair.


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.

Ah, lovely. Thank you. Thank you, Chair.

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?


Ah, lovely. Thank you. Thank you, Chair.

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?

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.


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?

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.

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.


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?

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.

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.

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—


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.

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.

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—

You could probably have a gradual transition, then, couldn't you?


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.

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—

You could probably have a gradual transition, then, couldn't you?

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.


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—

You could probably have a gradual transition, then, couldn't you?

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.


You could probably have a gradual transition, then, couldn't you?

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.

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.


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.

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.

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?