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SP Paper 309 HC/S3/09/R7

7th Report, 2009 (Session 3)

Inquiry into child and adolescent mental health and well-being

CONTENTS

Remit and membership

Report
INTRODUCTION

What are CAMHS?
Remit of the inquiry

FRAMEWORK AND IMPLEMENTATION

Background
Implementation
Training and work-force development

DELIVERY

Capacity
Services provided by the voluntary sector

ACCESS TO SERVICES

Waiting times
De-stigmatising mental health
Confidentiality

THE EARLY YEARS

Background
Identification
Universal monitoring by statutory services
Role of nursery schools

TRANSITION TO ADULT SERVICES
OVERALL CONCLUSION

Annexe A: Extracts from minutes

Annexe B: Oral evidence and associated written evidence

Annexe C: Other written evidence

Remit and membership

Remit:

To consider and report on (a) health policy and the NHS in Scotland and other matters falling within the responsibility of the Cabinet Secretary for Health and Wellbeing and (b) matters relating to sport falling within the responsibility of the Minister for Public Health and Sport.

Membership:

Jackie Baillie (from 2 November 2008 until 29 April 2009)
Helen Eadie
Ross Finnie (Deputy Convener)
Christine Grahame (Convener)
Rhoda Grant (until 1 November 2008 and then from 30 April 2009)
Michael Matheson
Ian McKee
Mary Scanlon
Dr Richard Simpson

Committee Clerking Team:

Clerk to the Committee
Callum Thomson

Senior Assistant Clerk
Douglas Thornton

Assistant Clerk
Seán Wixted

Committee Assistant
Euan Bain

Inquiry into child and adolescent mental health and well-being

The Committee reports to the Parliament as follows—

INTRODUCTION

1. Mental health and well-being is a major public health issue for Scotland. Although a national clinical priority, mental health services have been perceived by some as the ‘Cinderella service’ of the NHS. Young users of these services are especially vulnerable and early identification, intervention and, at the older end of the range, successful transition to adult services are paramount.

What are CAMHS?

2. The term child and adolescent mental health services (“CAMHS”) tends to be used in two different ways. It is commonly used as a broad concept that embraces all services that contribute to the mental health care of children and young people, whether provided by health, education, social services or other agencies. The term is also used more narrowly to refer only to specialist child and adolescent mental health services. A four-tier model is often used to illustrate CAMHS and, within this model, specialist services would operate at tiers 2, 3 and 4—

  • Tier 1 – CAMHS at this level are provided by practitioners working in universal services who are not mental health specialists. This includes GPs, health visitors, school nurses, teachers, social workers, youth justice workers and voluntary agencies. Practitioners are able to offer general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development and refer to more specialist services.

  • Tier 2 – Practitioners at this level tend to be CAMHS specialists working in community and primary care settings in uni-disciplinary teams (although many will also work as part of tier 3 services). They can include, for example, primary mental health workers, psychologists and counsellors working in GP practices, paediatric clinics, schools and youth services. Practitioners offer consultation to families and other practitioners, outreach to identify severe or complex needs requiring more specialist interventions, assessment (which may lead to treatment at a different tier), and training to practitioners at tier 1.

  • Tier 3 – This is usually a multi-disciplinary team or service working in a community mental health clinic or child psychiatry outpatient service, providing a specialised service for children and young people with more severe, complex and persistent disorders. Team members are likely to include child and adolescent psychiatrists, social workers, clinical psychologists, community psychiatric nurses, child psychotherapists, occupational therapists and art, music and drama therapists.

  • Tier 4 - These are essential tertiary-level services for children and young people with the most serious problems. They include day units, highly specialised outpatient teams and in-patient units, which can include secure adolescent units, eating disorders units, and other specialist teams (for children who have been sexually abused, for example), usually serving more than one district or region.

Remit of the inquiry

3. The Committee undertook a series of visits in the autumn of 2008 to inform the remit for its inquiry. The visits, during which members met both practitioners and service users, were to—

  • Penumbra self-harm drop-in project in Kirkcaldy;
  • an NHS child and adolescent mental health service in Argyll & Bute;
  • Barnardo’s family placement services in Edinburgh;
  • Barnardo’s Rollercoaster bereavement services in Dundee.

4. Following these visits, the Committee agreed the following lines of inquiry—

  • how children and adolescents potentially at risk of developing mental health problems are identified and how those problems should be prevented;
  • what obstacles there are in identifying children and adolescents with mental health problems and how they might be overcome;
  • what action is being taken to facilitate early intervention and what else can be done;
  • how access to services and ongoing support can be improved; and
  • what problems there are around transition from CAMHS to adult mental health services and how a smoother transition may be achieved.

5. A call for written evidence was issued on 2 December 2008; responses and other submissions of written evidence to the inquiry were posted on the Committee’s website1.

6. On the basis of written evidence received, the Committee agreed a programme of oral evidence-taking, which concluded on 6 May 2009. The Committee would like to record its thanks to those who gave evidence to, or otherwise participated in, the inquiry.

7. A series of key themes emerged from the evidence taken. These themes are addressed in turn below.

FRAMEWORK AND IMPLEMENTATION

Background

Scottish Needs Assessment Programme report on child and adolescent mental health

8. The Scottish Needs Assessment Programme was set up in 1992 across all NHS boards to assist them in carrying out health needs assessment. In the autumn of 2000, a needs assessment on the mental health of children and young people was commissioned, leading to the publication in 2003 of the Needs Assessment Report on Child and Adolescent Mental Health: Final report – May 20032 (“the SNAP report”).

9. The main aim of the work leading to the SNAP report was to identify ways of better addressing the mental health needs of children and young people in Scotland. The report looked at how best to promote mental health, at how to prevent mental health problems and at when and how to provide appropriate help for those children and young people experiencing mental health problems. The key findings of the report were that­­—

  • NHS boards had concerns about the increasing prevalence of mental health problems, in particular those related to attention-deficit hyperactivity disorder and autism – with further concerns about the ability to provide an appropriate response;
  • CAMHS available were patchy;
  • Links between CAMHS and the wider network were limited, with delays in referrals and access;
  • Specialist CAMHS teams were under very heavy pressure;
  • Highly specialist services, such as in-patient units, were difficult to access;
  • Existing specialist CAMHS were basic, working at and beyond capacity;
  • There were long waiting times at specialist CAMHS;
  • There was a lack of training in the wider non-specialist, tier 1 network;
  • There was a lack of readily accessible routes of support for non-specialist workers;
  • Young people were reluctant to be referred.

CAMHS framework

10. When the Scottish Executive produced The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care3(“the Framework”) in 2005, it credited the SNAP report with providing its “strategic vision for the mental health of children and young people in Scotland, across promotion, prevention and care” and stated its intention for the Framework to “help local agencies in working together to deliver that vision”

11. In oral evidence to the Committee, Shona Robison MSP, the Minister for Public Health and Sport (“the Minister”), described the Framework as being the one strategy amongst the range of strategies in this area that is “key”, adding that the Scottish Government’s new investment in CAMHS “would make it all the more certain that full implementation” would “be achieved by 2015”.4

The position today – the view of the SNAP group

12. The Committee embarked on its programme of oral evidence-taking with two ‘scene-setting’ sessions, one of which was a panel composed of some of the members of the former Scottish Needs Assessment Programme core working group on child and adolescent mental health – the group that produced the SNAP report in 2003 (“the SNAP group”). The panel members were all still involved in CAMHS and so were able to give a view on developments in CAMHS since publication of their report.

13. The Framework was singled out as being a “clear change” that has happened since 2003 and was described as a “positive achievement”, founded on evidence and an assessment of need.5 The SNAP group also spoke of the “enormous blossoming in the evidence base” on ways of identifying in early life the children who are going to follow a “problematic and painful trajectory” and on what works to prevent the bad things from happening. Improvements in training for those working in specialist services were also discussed.6 Asked about the aptness of the current Framework and whether any review would be desirable, Dr Graham Bryce responded—

“The framework has to be implemented. In a sense, that means having it all ways. After examining the issue closely, we came up with a framework that encompasses promotion, prevention and care. We need all those elements. To emphasise one to the detriment of the others will not do. People might say that that will take a lot of time and resources, but so be it—this is about the mental health of our children. I think that the framework is good enough, as is the evidence base—although it is still growing. The problem is that we have not found a mechanism to drive the implementation of the policy reliably. That is what is most needed.” 7

14. This was echoed by his colleagues. The clear message from the SNAP group was that the framework covers all the issues raised by stakeholders and that it is a very comprehensive policy that “just needs to be implemented”.8

15. Notwithstanding their clear and firm belief in the Framework, members of the SNAP group identified three main areas of disappointment—

  • There not having been a “step-up in the capacity to embark on mental health improvement work with children and young people” in a way that is proportionate to the level of need identified in the SNAP report.9 See paragraphs 45 to 51.
  • Severe problems affecting health visitors and the important work that they carry out.10 See paragraphs 111 to 125.
  • There being “no change in the development of services and no increased or enhanced resources in specialist teams” and, despite better networks across agencies and services, “little progress on joint training” and training for front-line staff who could deliver care to children and young people in schools and who could contribute to promotion and prevention work.11 See paragraphs 27 to 44.

Implementation

NHS boards

16. Having heard from the SNAP group about the challenge of implementation, the Committee was keen to hear about progress with implementation from NHS boards. The Committee took evidence from representatives of a range of NHS boards, which, as services providers, share responsibility for implementation. The representatives were specifically asked how far along the line they were in implementing the action points contained in the framework, more than three years into the 10-year implementation plan.

17. Whilst all of the witnesses stated that the principles set out in the framework had been incorporated into their work plans and gave helpful examples of some of the activities that are underway in the interest of making progress, they were unable to give any specific indication of how progress was being gauged and whether interim goals were being achieved.12 Professor Alex McMahon, Deputy Director of Strategic Planning and Modernisation, NHS Lothian, acknowledged this disconnect—

“We are doing what you asked about. Perhaps our presentation of the information is not as robust as you would like it to be, but I do not think that anyone in NHS Lothian or other agencies is not using the framework—and the principles and action that it sets out—to ensure that we deliver the best care to children.”13

18. The Committee went on to ask about responsibility for and ownership of the implementation agenda. In response, witnesses acknowledged the importance of partnership working with social work and education departments and with the voluntary sector and emphasised that “no one is not taking responsibility for implementation of this work”.14 Jan Baird, Director of Community Care, NHS Highland, assured the Committee that NHS Highland’s implementation plan is the means through which the NHS Highland board and the joint committee for children and young people are reported to—

“It makes clear who is responsible for each of the actions that are detailed in the plan and how they are being delivered. Progress is monitored—we have reported to the board twice in the past year.”15

Local authorities

19. Representatives of three local authorities were asked about the implementation process. One representative, Anne Ritchie from West Dunbartonshire Council, explained that, whilst there would not be one document outlining the implementation process – as that would result in a separate implementation plan for every strategy – the SNAP report recommendations have been built into integrated children’s services planning—

“We have tried to integrate: that is our overriding instruction. We have to integrate new guidance, instructions and frameworks into the existing process as they come in.”16

20. She also reassured the Committee that all partners were signed up to “working together collaboratively to implement all those strands of work to improve services for children and young people” and that, in her own local authority area—

“…there is a sub-group of the integrated children’s services planning process, which is a working group on children who are affected by issues of mental ill health and emotional wellbeing. That group covers early intervention, building resilience and emotional wellbeing issues for our whole population right through to children who suffer from a diagnosable mental illness. That is where the report went.

Within that framework, health needed to do a lot of things. The higher level measures—the tier 3 measures—are very much in the sphere of health, but the people in health report back to the rest of us on what they are doing.”17

Scottish Government

21. The Minister was asked what was happening at a central point in Government to ensure that health boards and local authorities throughout Scotland are reaching the Framework’s milestones. She explained that, twice a year, in addition to the annual review process, the Scottish Government’s Mental Health Division engaged with each NHS board to check that they are making progress against the Framework and milestones. She described this twice-yearly check as part of performance management as being “pretty robust” and that it left boards in no doubt that, if they were not on track, they would “have to get back on track in order to meet the targets”. She also stated that she was “confident” that she would find out if a board was having issues and added that, whilst boards have adopted different approaches and some boards have made more progress than others, “the bottom line is that, by 2015, they must all implement the framework”.18

22. In relation to overall progress towards full implementation of the Framework, the Minister acknowledged that there was still work to be done but emphasised that it was always expected that the Framework would not be fully implemented until 2015. She added that the key recommendations expected to have already been implemented have been implemented and that there was nothing to suggest that any implementation activity was off-target. Finally, she pointed to new investment of £2 million per year to NHS boards in the current spending review period, to accelerate the development of specialist CAMHS, and a further £1 million in 2009-10, rising to £3.5 million in 2011-12, to support an increase in the specialist CAMHS workforce. This investment, she said, will make it “all the more certain that full implementation will be achieved by 2015”.19

Conclusion

23. The Committee recognises that some progress has been made in improving the situation of children and adolescents accessing mental health services. For example, progress has been made against the Delivering for Mental Health commitment to halve the number of admissions of children and adolescents to adult hospital beds by 2009. However, the target has yet to be met and the Committee has concerns that there are insufficient specialist beds for children and adolescents and that meeting the target will, therefore, prove challenging.20

24. The consistent message throughout the evidence submitted to the Committee was that the Framework is a very well-considered policy – at no point was there any suggestion that it needed to be improved or otherwise revised, only that it should be implemented. The Committee recognises that the Framework is not intended to be prescriptive and that the witnesses gave helpful and interesting examples of implementation activity. The Committee is also reassured by the evidence given by local authority witnesses and, in particular, by the Minister for Public Health and Sport and welcomes the sense of priority evident in her oral evidence.

25. The Committee is concerned, however, that there was a lack of clarity in the evidence from NHS boards about progress and ownership of the implementation agenda. There appeared to the Committee to be a lack of a strong drive to implement the SNAP report principles as embodied in the Framework. According to the Framework, “responsibility for ensuring delivery of this Framework rests with both NHS and local authority Chief Executives”. There should, therefore, be no doubt about with whom the ownership and responsibility rests: these are the people who should be championing the Framework. Whilst it was evident that the Framework was a priority for the Scottish Government, as it had been for the previous administration, it appears that this sense of priority has not transferred more widely into the delivery of services and has not, therefore, translated into a momentum for effective implementation of the Framework.

26. The Committee accepts that the representatives of NHS boards understood that they had responsibility for delivery, in co-operation and close collaboration with their partners, but remains most concerned that they were unable to articulate clearly any barometer of progress, more than three years into the implementation period. Whilst the Committee notes the Minister for Public Health and Sport’s statement that “there was nothing to suggest that any implementation activity was off-target”, the Committee is concerned that 2015 is a very far-off target and that there may, therefore, be some complacency amongst those responsible for delivering the target. In the interim, NHS board annual reviews are unlikely to be an adequate monitoring mechanism for ensuring steady and consistent progress. The Committee recommends, therefore, that the Scottish Government establish further and more detailed interim targets and milestones by which implementation may be actively measured.

Training and work-force development

27. Training and work-force development are crucial to the success of the Framework. There are two key aspects, which were recurring themes throughout the evidence presented to the Committee: the training of non-specialists (tier 1) and continuing professional development for specialists.

Non-specialists

28. The important role of non-specialists was apparent in much of the evidence given to the Committee, not least in the opening evidence session with non-specialists themselves – i.e. those involved in school nursing, health visiting, social work, personal support in schools (formerly known as “guidance teachers”), Childline, Home-Start and Sure Start Scotland. Describing what he called a “patchwork quilt of different opportunities”, head teacher and former president of School Leaders Scotland21, Brian Cooklin, put it thus—

“The important issue in identifying children with mental health problems is that we provide as many opportunities as possible for them to be identified or to self refer. Our major worry in school is that children slip through the net or that we do not find out about the problem until relatively late.”22

29. He went on to explain that, at school, children and young people have access not only to “excellent pastoral care, pupil support or guidance systems” but also to school nurses and/or school counsellors.23 This view was echoed in a later evidence session by Dr Kathy Leighton of the Royal College of Psychiatrists – a consultant in child and adolescent psychiatry and the specialty adviser on child and adolescent mental health for the Scottish Government, who commented—

“There is a good research base that shows that universal services in our schools—school nurses, school counsellors and so on—which are walk-in, drop-in services, are well used, particularly by adolescents. They can start to break down the stigma, provide some early intervention and do hands-on work that might prevent the young people from deteriorating to the point at which they have to be referred on to specialist services.”24

30. Linda Paterson, a Choose Life Co-ordinator in Aberdeenshire, explained that people were inclined to “panic, avoid or dismiss” something – for example self-harm – that they did not understand and described raising non-specialists’ awareness as, consequently, a “key issue”. She emphasised the importance of training for non-specialists on the basis that, in many cases, young people can be supported by non-specialists without any need for specialist services.25

31. Heather Muir, a schoolteacher with responsibility for personal support, pointed out that tutors have not necessarily had any training and that “more expertise might be needed”.26 Brian Cooklin went on to describe training as a “critical issue”, calling for an understanding of mental health issues and a child’s development to be incorporated in initial teacher training. This issue was also raised by Carolyn Roberts of the Scottish Association for Mental Health: in her experience, while teachers were willing to support children and young people, they had not had any training on mental health and well-being—

“As far as we have been able to find out, teacher training does not seem to involve such training, and neither is a consistent or comprehensive approach to training taken for existing teachers.”27

32. Brian Cooklin developed the point further and spoke of a need for training to take place jointly with other disciplines—

“More cross-sectoral and joint training would be even more helpful so that people would understand what social work, health and education services could do other than act separately and then come together to share thoughts in meetings. We often say that, but I have not seen such training happen.” 28

33. Similar calls were made in oral evidence given by the Royal College of Nursing29 and by the SNAP group. It was stated, for example, that teachers, in addition to their subject specialism, should have a “wider awareness of the issues facing young people” and “some capacity to recognise the early signs of psychological distress that leads to subsequent mental health problems”. Mary Gallagher of the SNAP group stated—

“The idea of cross-profession training and bringing professionals together has to be explored. I know that some of that has been happening, but it has probably not been happening enough.”30

34. The SNAP group also made the point that specialist services are focussed on “severe and complex difficulty” and are, consequently, unable to contribute to promotion and prevention work, which could, however, be delivered by front-line staff in schools if they were trained to do so.31 It was added that training for this purpose need not be extensive and would not require intensive support as, typically, those who work closely with children in schools or in primary care, deliver very good care but currently lack confidence in the system and in their actions.32

Specialists

35. In respect of specialists, a round-table evidence session with representatives of professional bodies raised two related but discrete issues: research and its translation into practice.

36. Professor Mick Cooper of the British Association for Counselling and Psychotherapy spoke of research at the University of Strathclyde but cited as a major problem finding funding to research what is effective and how effective it is and to identify the young people for whom it is most effective. Dr Leighton of the Royal College of Psychiatrists described this problem further, stating that the modernising medical careers programme places less emphasis on supporting academic doctors and psychiatrists, making it “more difficult for academic child and adolescent psychiatrists to access training”. She added that the only professor’s post in Scotland has not been filled “for a number of years”. She claimed that the resourcing of academic departments for child and adolescent psychiatry across the country is “low” and “being cut”, giving the example of the senior lecturer post in Edinburgh being cut following the incumbent’s retirement. She summed it up by stating that “a whole can of worms is associated with keeping research alive”.33

37. As for the translation of research into practice – alternatively known as knowledge transfer and management – according to Professor James Law of the Royal College of Speech and Language Therapists, “academic work does not filter down well” and a lot of what is known is not carried through into practice. He described a “gap” in knowledge transfer around CAMHS activity, where practitioners often adhere to what they were taught in college, without keeping up with the literature. Other witnesses attributed this situation to resourcing. Dr Leighton pointed out that clinical psychologists and many multidisciplinary colleagues, including nurses and all therapists, completed research as a core part of training but argued that, in practice, research time is marginalised owing to the pressures of delivering clinical services. Dr Chris Wiles of the British Psychological Society stated that “clinical psychologists’ research skills are undervalued in CAMHS because of the pressure on services”, explaining that, because of resourcing problems, “clinical psychologists often forgo research to keep services alive, to keep response times minimal and to meet the multiple demands on CAMHS”.34

Scottish Government

38. The importance of workforce development in relation to identifying children's needs at an early stage and ensuring the provision of the right services was raised with the Minister for Public Health and Sport and the Minister for Children and Early Years. In response, the Minister for Children and Early Years spoke of his keenness to “support the workforce in its desire to upskill and increase its qualifications” in the interests of enabling the introduction of the early identification and intervention approach that the Scottish Government wants to take. He also referred to the childhood practice degree, a new degree course that focuses on child development in the early years and is particularly aimed at non-specialists employed as service managers by local authorities, stating that the Government has laid down a timetable for managers to have that qualification.35

39. In relation to the workload pressure limiting the opportunities for staff to take time out and engage in professional development, the Minister for Children and Early Years agreed that it was “vital” that local authorities and others ensure that staff have continuous professional development opportunities. The Minister for Public Health and Sport went on to explain that NHS Education for Scotland was developing a workforce development plan, to be completed by the end of the calendar year, which would include the skills and education needs of the existing workforce and how to meet them, as well as new posts.36

40. The Minister for Public Health and Sport also assured the Committee that NHS boards are pressed “quite hard” on the knowledge and skills framework in the annual reviews. She acknowledged that the “balancing act” – between maintaining services and releasing staff for training – is a challenge for NHS boards, and for boards covering remote and rural areas in particular. She contended, however, that they “are certainly giving the matter more attention” and “are getting better at it”, for example through use of e-learning and teleconferencing and through organising back-filling on a managed basis in order to maintain service while staff members are released.37

41. In relation specifically to the training of non-specialists, the Minister for Public Health and Sport stated that the training of staff who work in schools or who come into contact with children and young people has been implemented as a key element of the Framework.38

42. The Minister for Public Health and Sport also addressed the issue of resourcing of clinical psychologists. She outlined further investment in the specialist CAMHS workforce of £12.5 million over the period 2009-12, to be targeted on increasing the number of clinical and masters-grade psychologists working in specialist CAMHS, supporting both additional training places and additional posts to ensure that the investment in training results in increased capacity.39

Conclusion

43. There is evidently a will in the non-specialist sector to embrace children and young people’s needs and there are obvious benefits to be gained from developing that will. It is also evident, however, that non-specialists often lack either the awareness, the skills or the confidence to deal with emerging mental health problems effectively. The Committee notes the Government’s stated commitment to this area but is concerned at the Minister for Public Health and Sport’s statement that the element of the Framework on the training of staff who work in schools or who come into contact with children and young people has been implemented40, given that evidence from a range of stakeholders consistently indicated continuing problems in this area. The Committee urges the Scottish Government to examine again training needs in this area, in particular how mental health and well-being are covered in initial and continuing teacher training.

44. The Committee welcomes the announcement of further investment in the specialist CAMHS work-force to secure increased capacity, which should result in a greater ability amongst clinical psychologists to increase their involvement in research activities. However, the Committee remains concerned at evidence that the resourcing of academic departments for child and adolescent psychiatry across the country is low and being cut, with important research posts being left vacant.

delivery

Capacity

45. The impact of human resources on the capacity of CAMHS was a recurring theme throughout the inquiry, both in terms of the size of the establishment, or staff complement, and in respect of filling vacancies.

The size of the establishment

46. The national policy document, Getting the Right Workforce, Getting the Workforce Right – A strategic review of the Child and Adolescent Mental Health Workforce41, found that there should be a mixture of about 20 CAMHS staff per 100,000 population and stated that, if the service were smaller than this, then some aspect of the comprehensive service would, by necessity, be missing.42

47. The level in NHS Lothian is arrestingly low: eight per 100,000.43 This picture is replicated in other areas of Scotland. NHS Dumfries and Galloway reported a figure of around 13 per 100,00044; NHS Greater Glasgow and Clyde acknowledged that the level of staff in its area was some way off the target45; Aberdeenshire Council stated that, in its area, there are 62 per cent fewer CAMHS staff than recommended for the size of population46, and the representative from North Lanarkshire Council described the size of the establishment as a “significant concern” and gave a figure for the NHS Lanarkshire area of 4.5 members of staff per 100,00047.

48. Professor Alex McMahon, Deputy Director of Strategic Planning and Modernisation for NHS Lothian, stated that the problem is not limited to the number of psychiatrists but needs to be addressed across the disciplines.48

Filling vacancies

49. A shortage of specialists was raised as an issue affecting some areas. The Aberdeenshire Council representative, for example, stated that there is “certainly a problem” in the council’s area, where it has not been possible to fill the consultant psychiatrist post.49

Scottish Government

50. Asked how the additional investment in CAMHS would be converted into staff and how easy it would be for NHS boards to recruit additional psychiatrists and nurses with the appropriate qualifications, the Minister for Public Health and Sport referred to work being undertaken by NHS Education for Scotland on the workforce development plan, stating that it would be “critical in ensuring that the phasing in of that new workforce is achievable”. She said that work already underway in this area would now be stepped up to maximise the effect of the new investment. It was also stated that the psychiatry work-force has seen a steady growth over the last 10 years and that, over the next five years, that work-force was expected to grow by about 50 per cent – or by about 35 psychiatrists. Additionally, plans were outlined for an increase, over the next three to four years, in the number of training places for clinical psychologists, which “should result in about 22 specialist CAMHS people qualifying each year”.50

Conclusion

51. The Committee notes the efforts being made by the Scottish Government to increase the size of the work-force. However, the Committee is aware of the Audit Scotland overview of mental health services which found that staffing levels were affecting the availability of mental health services51; was surprised by the extent of the problem outlined by the NHS board and local authority representatives in oral evidence, and fears that the Government’s plans as outlined in oral evidence may not be sufficient to address the problem. The Committee calls on the Government to establish what the number is of CAMHS staff per 100,000 of population in each NHS board area, review its plans in the light of this and report to the Committee and the Parliament on its findings.

Services provided by the voluntary sector

52. Relevant to the issue of capacity is the role of the voluntary sector: services provided by the voluntary sector can relieve pressure on statutory services and, potentially, meet demand unmet by statutory services. However, the voluntary sector cannot do so without secure funding and resources.

The value of the voluntary sector

53. As has been discussed above, statutory services are often focussed on “severe and complex difficulty” and are, consequently, unable to contribute to promotion and prevention work.52 Professor Alex McMahon from NHS Lothian spoke more specifically about the need for statutory services to be complemented by the voluntary sector—

“The NHS cannot deliver on its own; implementation depends on our working with local authorities and the voluntary sector to maximise each organisation's capacity to deal with the agenda, which is significant.”53

54. He added that the voluntary sector throughout Lothian was playing a “key role in supporting and enabling a lot of the parenting and play skills work that has to be done”. Other NHS witnesses concurred on the “key role” of the voluntary sector.54

55. This theme was developed in a round-table evidence session with representatives of voluntary sector organisations. Amber Higgins, from Penumbra, called for a focus on early intervention, explaining that the “voluntary sector can come in” where statutory services have to deal with crises at the expense of putting resources into early intervention work.55

56. Pauline Bell, from Partners in Advocacy, argued that statutory and voluntary services “should work much more closely together”. She pointed out that many voluntary organisations work with young people daily and are, therefore, fully aware of their situations and family circumstances. She believed that “better communication between statutory and voluntary services would go a long way towards allowing us to offer more flexible services to meet individuals' needs”.56

57. Cliff Watt, a Choose Life Co-ordinator in Aberdeen, told of a long-standing “unspoken boundary” between the voluntary sector and statutory services. Whilst he acknowledged efforts on both sides to overcome this, he complained of a perception, particularly in relation to health, that the voluntary sector is “unqualified” and called for “an opportunity to consider the value that both sectors can bring to the common problem and to acknowledge that neither sector can do the job on its own”.57

58. Ilena Day, from Depression Alliance Scotland, dismissed perceptions of variable quality of services in the voluntary sector—

“Most voluntary organisations have a complex funding make-up. They receive some money from the Scottish Government, some trust funding and some health and local authority funding. From my experience of bigger funding work in health boards, I know that the work of the voluntary sector is scrutinised and evaluated rigorously; if objectives and outcomes are not met, funding is held back. Over the past three or four years, the voluntary sector has had to work hard to ensure that targets are met. In the work that we have been doing with young adults, we have had to demonstrate improvements in both clinical and subjective outcomes and in the quality of life of that group.”58

59. She added that “questions in different sectors about the quality of the services to which people are being referred cannot continue to be a barrier, as otherwise such reservations will become a self-fulfilling prophecy”. She argued for “real, not tokenistic, recognition” of the voluntary sector’s value—

“Homage is always paid to the idea of working more closely with the voluntary sector, but there is huge scope for the sector to deliver in problem areas. It needs to be commissioned to do so, which is always a challenge.”59

Funding and resources for the voluntary sector

60. Pauline Bell, from Partners in Advocacy, related the issues above to the question of funding. She described a reluctance amongst statutory service staff to refer to the voluntary sector because voluntary agencies’ funding is for short periods and, therefore organisations often change—

“New organisations are created, but they lose their funding after two years. There is often reluctance to refer a young person to an agency when there is no guarantee that that agency will still exist in six months' or a year's time.”60

61. Speaking about appropriate services for self-harm amongst children and young people, Cliff Watt, from Choose Life Aberdeen, described support that was provided as typically being from the voluntary sector but also “underresourced”. 61

62. The issue of funding for the voluntary sector was also raised in the round-table session with non-specialists. In the interests of not “constantly” having to bid for funding, Joan Hoggan, a schoolteacher with responsibility for pastoral care, suggested stable funding for voluntary organisations that are highly rated by their partner agencies—

“There needs to be consistent funding for school counselling services throughout Scotland, because they are one of our most valuable resources.”62

Scottish Government

63. The Minister for Public Health and Sport acknowledged the value that the voluntary sector may add. According to the Minister, services in the sector, such as those that have been effective in gaining the trust of young people, have “a major role to play”.63

Conclusion

64. The Committee is well informed about the precarious and short-term funding of the voluntary sector. Even where they have already demonstrated success, organisations repeatedly have to prove the value of their work to get funding. This situation has persisted over a number of years.

65. The Committee believes that there needs to be a distinction made between project funding and funding for continuing work. One of the big difficulties in the voluntary sector is that there is often funding for a project, but that is not followed up by mainstreaming. Once a project has been mainstreamed, the Committee believes that, in a true partnership, voluntary organisations should be funded on the same basis as local authorities and health boards, which receive three-year rolling funding.

66. The Committee is concerned at the apparent friction between the voluntary sector and the statutory sector; it was not clear from the evidence whether this continued to be a live issue and the Committee would be very concerned if this friction threatened to jeopardise implementation of the Framework. The Committee seeks reassurance from the Scottish Government that organisations across all sectors are working together to ensure timeous implementation of the Framework and, if the friction persists, that the Government is taking action to address the situation.

Access to services

Waiting times

67. Historically, there has been no national target on waiting times for CAMHS. However, in November 2008, the Scottish Government announced a commitment to develop over the next year a target to deliver faster access to CAMHS.64 At present, this is included within the HEAT targets as "NHS boards to deliver faster access to child and adolescent mental health services"65 but there is no nationally set measure to which all boards must strive.

68. Waiting times were outlined as being a significant problem. Some witnesses reported that how quickly somebody gets an initial appointment can vary greatly depending on the condition; others focussed on the time lapse between assessment and service commencement.

Initial appointments

69. Linda Paterson from Choose Life Aberdeenshire described waiting times as “a big issue”, stating that the standard waiting time for young people with mental health issues in the Aberdeenshire area is eight months but about 16 months for young people with an autism spectrum disorder.66 She explained—

“Although it is not the case across the board, it is well recognised that people on the autism spectrum are more likely to suffer from mental health problems as a result of their difficulties. In my area, the waiting list for such people to receive help is far longer than the normal one, which is already long.”67

70. Aberdeenshire Council’s representative also described problems in the area, singling out access to specialist services as a particular problem—

“There are fairly long waiting lists. Our particular interest is in looked-after children, but there are no specific CAMHS specialist teams in Aberdeenshire for looked-after children.”68

71. An example given by Heather Muir, a schoolteacher with responsibility for personal support, showed that problems with waiting times also affect voluntary‑sector services, describing a situation where a “really vulnerable family” in bereavement had to wait a year to get any help.69

72. Waiting lists were described as “extensive”70 by Martin Gemmell of the British Psychological Society and as “a travesty” by Dr Kathy Leighton of the Royal College of Psychiatrists, who also highlighted variation across the country, with some services better resourced than others.71

Time lapse following initial appointments

73. The length of time that may elapse between an initial appointment and commencement of service delivery emerged as a discrete issue. Speaking about autism spectrum disorders and learning disabilities, Linda Paterson from Choose Life Aberdeenshire said that, in some cases, it can take years before there is an assessment of the underlying problems behind behaviour being exhibited, depending on the severity of the symptoms.72

74. Delay in obtaining an assessment was also raised as an issue affecting children’s panels. Brian Lister, representing the Scottish Children's Reporter Administration (“the SCRA”), stated that it can take around five months to get a report—

“In the life of a young person of 14 years of age, that timeframe is unacceptable.” 73

75. He clarified that the type of report that he was speaking of was a psychological assessment report by CAMHS, i.e. before any intervention would be made.74

Scottish Government

76. Minister for Public Health and Sport stated that the Scottish Government’s “priority attention” to child and adolescent mental health services was reflected in its work with NHS boards in setting a target to deliver faster access to CAMHS. She explained that, to support that, the Government is focusing its attention on work force, services, data collection, quality of care, referral protocols and information systems.75

Conclusion

77. The Committee is deeply concerned at the extent of the waiting time problems in different parts of the country, as described in the oral evidence. This is of particular concern, given the suicide rates in Scotland: although programmes such as Choose Life appear to be making a useful contribution to the reversal of the previous growth in suicide rates, the rates in Scotland are twice as high as they are in England76.

78. Furthermore, the recent overview by Audit Scotland77 found that waiting times continue to be a problem for child and adolescent services. The report stated that, in July 2008, 27 per cent of children and adolescents in NHS Tayside and 40 per cent in NHS Highland were waiting over eight weeks for a first assessment by community mental health teams and some had been waiting for outpatient appointments for over a year; and that, in February 2009, NHS Greater Glasgow and Clyde reported that 59 per cent of children and adolescents in Greater Glasgow were waiting over 8 weeks to see a community mental health teams and 16 per cent had been waiting for over a year.

79. As described above, the Scottish Government is developing an NHS target on delivering faster access to mental health services for children and adolescents during 2009-10. The specific requirements and timescales for the target have yet to be agreed. Given the importance of this issue and the recent evidence that it is an ongoing problem, the Committee calls on the Government to accelerate its work towards setting a target for CAMHS waiting times.

80. The delays facing children’s panels are totally unacceptable: the children and families affected are in crisis, very often with associated and ongoing antisocial or criminal behaviour. Furthermore, any significant delay in addressing problems of mental health and well-being are particularly detrimental to the individual concerned: the effects of the problems are compounded as times goes on, exacerbating the deterioration of the individual’s condition. Addressing problems quickly and with continuity of support contributes to the fostering of resilience in an individual, with highly important consequences for that person’s future mental health. Additionally, as covered later in this report, for very young children, there is a window of opportunity for the addressing of mental health problems; if that opportunity is missed, the consequence can be life-long poor mental health.

81. As problems that are not addressed can create recurring and/or life-long mental health issues that could have been avoided, it therefore follows that there is a consequential pressure on public resources that could have been avoided if timely action had been taken at an early stage. The Committee, therefore, acknowledges the priority stated by the Scottish Government on this issue but calls for extra resources to eradicate long delays in delivering mental health services for children’s panel cases.

De-stigmatising mental health

Stigma

82. Many respondents to the Committee’s call for written evidence identified stigma about mental problems as being an obstacle to identification as it makes children and their families reluctant to admit that there is a problem or to seek help from the appropriate services. Suggested solutions included building on the national See Me anti-stigma campaign and undertaking more work in schools to tackle the issue.

83. The Scottish Association for Mental Health, part of an alliance of five Scottish mental health organisations that run the See Me campaign, outlined in its written submission the importance of tackling stigma—

“There are many myths about mental health problems. These myths create a stigma that can stop children and young people getting help when they need it or prevent them talking openly about their problems. It can also make them feel guilty, isolated or ashamed if they become unwell.”78

84. This theme was picked up in oral evidence by Pauline Bell of Partners in Advocacy—

“What still comes up often in advocacy is the stigma and fear associated with mental health, which prevent young people from wanting to access services. I second the idea of the peer support model. We often hear about the fears of 18 or 19-year-olds who, when they are first admitted to hospital, think, "Oh my God, this is my life. I'm going to be using services for the rest of my days." We need people—whether it is celebrities or just ordinary, everyday people—to stand up and say, "I went through this period in my life but I've come out the other side. There is hope. There is recovery."”79

85. Karen Cromarty from the British Association for Counselling and Psychotherapy linked the issue of stigma to the difficulties that older adolescents face when transferring to adult services, discussed later in the report. mThe association’s evaluations of school counselling services showed that, if young people accessed non-stigmatising counselling services at school, they were “quite happy to access adult services” when they moved into adulthood. In Karen Cromarty’s opinion, if it is ensured that adolescents become de-sensitised to any stigma around mental health, there may follow an adult population that is less concerned about the issue.80

Changing the approach

86. Ilena Day of Depression Alliance Scotland called for a greater emphasis on education around good mental health and drew a parallel with the healthy eating agenda, where the starting point was to increase awareness of good physical health, diet and lifestyle choices, and exercise. Applying the same principle to mental health, she explained, would involve thinking about what it meant for young people to have good mental health and what good mental health was. From that starting point, young people could be empowered to recognise when problems are starting to arise and to develop skills for “life and resilience”. She further explained that a lot of the work that Depression Alliance Scotland did with over-18s was around problem solving, increasing confidence and developing people's ability to manage the difficulties that anyone could experience from time to time.81

87. The location of CAMHS services in hospitals or in community settings was discussed during the round-table evidence session with representatives of professional bodies. The British Psychological Society’s representative, for example, suggested that CAMHS should “forge much closer links with schools” as there did not appear to be a “particular need to be based in a hospital when delivering a mental health service”.82 He called for professionals to drop current models, designed to suit the professionals, in favour of developing models that better suit the client—

“To do that, NHS staff should come out of their hospitals and work more in communities and in schools and nurseries, to help children and young people with mental health issues.”83

88. This view was echoed by Amber Higgins, of Penumbra. Stating that young people themselves are the experts in their own mental health and well-being, she called for services to be developed to suit young people rather than to suit those that deliver them.84

89. Similar points were made by the witnesses from the British Association for Counselling and Psychotherapy. They were in favour of implementing a service across all secondary schools providing an “easily accessible, non-stigmatising form of early intervention” and called for a strategy for school-based counselling to be introduced, pointing to similar strategies adopted in Northern Ireland and Wales. They said that such counselling is both cost-effective and favoured by children, young people and their families—

“Counselling in schools is rated as highly effective by young people, and pastoral care staff respond positively to it.”85

90. The written submission from the Highland Users Group supported this view—

“We liked what had been done by ‘see me’ at a national level. Although many of us said that we always need to challenge stigma, some of us were pessimistic about eliminating it.”86

91. Brian Cooklin of School Leaders Scotland, who gave his backing to calls for more support to be available in schools, also called for greater consistency in what is provided. Whilst he valued what is already happening, he pointed out that there was “no package of resources” and, therefore, “the resource situation is fragmented” from a child’s point of view—

“They often have only limited access to services and resources and it is a hit-and-miss affair regarding what is available in any given school. It is just a matter of luck if a child happens to be in an area and school that has an array of opportunities. That is a major concern across Scotland.”87

92. However, Dr Graham Bryce of the SNAP group described himself as “a little bit perplexed” by the calls to shift mental health services from hospital-based to community settings—

“I had thought that this policy area was very clear and that we had been making progress. When people were considering mental health services for children and adolescents, a clear decision came out of SNAP that such services should be community oriented, and that decision was reflected in policy. The number of children who receive mental health services by coming into hospital is infinitesimally small. The vast majority visit particular bases, are seen, and then go away again.”88

93. He went on to describe an initiative whereby the point of contact with people who have experience and training in mental health services had been shifted away from clinics and into “more ordinary settings”, such as schools and primary care centres. He added that, “over the past few years, there has been growth in the number of primary mental health workers”. Affirming that the “direction of travel” was both clear and in line with the aspirations of those calling for more community-based services, he conceded, however, that the development was not moving as fast as hoped. 89

Conclusion

94. The Committee recognises the concerns raised by a variety of witnesses about the need to shift the centre of gravity from hospital-delivered services to community-based services. The Committee also notes the commitment in the Framework to delivering this shift and recognises that work to this end is underway. The Committee is concerned, therefore, that some witnesses reflected the opinion that the transfer from hospitals to communities and schools has not happened and seeks further reassurance from the Government that the shift is on track.

Confidentiality

The role of the teacher

95. An important issue in getting children to come forward is confidentiality and potential fears that seeking help in relation to an issue might result in action being taken – for example, when turning to teachers for advice about sexual activity. The evidence showed confusion and misunderstanding amongst teachers about their statutory duties when faced with this situation.

96. Heather Muir, a schoolteacher with responsibility for personal support, described the situation as follows—

“When an underage person discloses information to a teacher about their sexual activity, that teacher has to follow child protection procedures. As teachers and as people who want to support kids' health and wellbeing, we are put in a difficult and frustrating position; after all, because we have on-going daily contact with these kids, we might well be the closest to them.”90

97. She drew a distinction between teachers and other agencies, explaining that, if young people wanted to disclose that they had had unprotected sex or to express concern about their sexual health, they could do so to, for example, their GP or to the family planning clinic “without necessarily being afraid that their parents or social work will be contacted”91. However, according to Heather Muir, if they told a teacher, s/he would be under a “statutory obligation” to contact social work and possibly the parents. She also explained that this distinction was reflected in the way children were educated about issues like sexual health and substance abuse, so that it was clear what would happen if they disclose personal information that the teacher considered to show them to be at risk.92

98. Head teacher and former president of School Leaders Scotland, Brian Cooklin, described this possible sequence of events as a difficulty that many teachers faced regularly and pointed out that the teacher’s role could conflict with the health promotion aims of, for instance, school nurses, operating under their own protocols. He outlined an example of a school nurse who might, in the interests of reducing the incidence of sexually transmitted diseases or tackling the issue of teenage pregnancies, suggest that condoms or the morning-after pill be offered to any child who asks for them. He said that such an approach would “immediately ring alarm bells in schools, because our role is always in loco parentis; in other words, we can do nothing without parental consent”.93

Scottish Government

99. The Minister for Public Health and Sport acknowledged that the issue of confidentiality and whether to involve a child’s parents was “a complex area” and that it is important that young people could speak, in confidence, to someone that they trusted. She felt that services that had been effective in gaining the trust of young people – such as services in the voluntary sector involving projects for young people – had a “major role to play”. She also drew attention to the drop-in services that had been developing in schools, where young people could seek advice on a range of issues such as smoking, alcohol or bullying.

100. The Minister for Children and Early Years added that “concerns over child protection would override concerns over confidentiality”. He outlined the Scottish Government’s expectation in accordance with the ‘getting it right for every child’ approach that, in the first instance, teachers should check whether their concerns were shared by any of the other agencies that might be involved.94

101. In relation more specifically to the proposals under the Sexual Offences (Scotland) Bill, the Minister for Public Health and Sport was asked whether a teacher would have to pass on information about an illegal activity if a girl of 14 confided to that teacher that she was having sexual intercourse. The Minister explained in supplementary written evidence that it was not a criminal offence to fail to report the commission of a criminal offence—

“So it would not be a criminal offence for a teacher to fail to report the fact that two under 16s had engaged in sexual intercourse. Where the teacher learns of the fact "after the event" there would be no possibility of inciting, or being involved art and part in, the commission of the offence. Equally failing to report a suspicion that they may engage in sexual activity at some time in the future would not be an offence either. Whether it would be appropriate to report such activity would depend on the facts and circumstances of the individual case.”95

102. She went on to explain that, in relation to providing advice to the child, section 39 of the Sexual Offences (Scotland) Bill would protect those advising children on matters relating to underage sex from being charged with “incitement or being involved art and part in the commission of sexual offences concerning children at Parts 4 and 5 of the Bill”. She stated that this “should cover most interaction which a member of school staff may have with a child but this will depend on the individual circumstances of the case”.96

Conclusion

103. Precocious sexual activity in children may be a sign of mental disturbance; it is therefore extremely important that children are able to seek confidential help and guidance on a difficult area. The Minister for Public Health and Sport’s supplementary written evidence makes it clear that it would not be a criminal offence for a teacher to fail to report the fact that two under 16s had engaged in sexual intercourse. On the basis of the evidence received, the Committee is gravely concerned at the apparent misunderstanding amongst professionals of their duties in relation to all aspects of confidentiality. A head teacher stated in evidence to the Committee that in loco parentis means that nothing can be done without parental consent; however, in loco parentis actually means the opposite. The worry is that a teacher may be told something by a child in confidence and then unnecessarily break that confidence.

104. The Committee recognises that teachers have difficult decisions to make in situations such as those described above and believes that there is a role for the Scottish Government to ensure that training in this area is effective. The Committee also calls for clear guidance for teachers on their role in those complex circumstances and, in particular, following the passage of the Sexual Offences (Scotland) Bill.

the early years

Background

105. The importance of identifying mental health problems in the under-5s was an important theme in this inquiry. Disturbingly, the Committee uncovered evidence that this group is neglected. Central to this was the approach of statutory services to monitoring very young children.

Identification

The importance of identifying mental health problems in the very young

106. Dr Philip Wilson of the SNAP group also talked about the importance of work with this age group, stating that it is the group that should receive the most thought and the most resources. He spoke of the “enormous blossoming in the evidence base on ways of identifying early in life the children who are going to follow a problematic and painful trajectory” and of a “big increase in the evidence base on what works to stop the bad things happening”.97

107. Dr Wilson later referred to a major American study showing that early neglect – i.e. before the age of two – was the strongest predictor for later childhood mental ill health. He explained that that neglect could take many forms and was not limited to neglect by parents whose drug and alcohol problems meant that they were so preoccupied that they could not connect with the child. He described the lack of an early relationship and of early and secure attachment as “powerful predictors of mental ill health”.98

108. He went on to outline two other strong indicators. First, that there was strong evidence that children with problematic behaviour at two-and-a-half-years of age were highly likely to end up with major problems later in life. He referred to work in the United States suggesting that it was “possible to predict at the age of three as many as 70 per cent of the children” who would “end up as in-patients in mental hospital or in prison”. Secondly, that 70 per cent of children that could not “put two words together meaningfully” or did not “have 50 words at the age of two and a half” would go on to have a mental health diagnosis aged seven. He emphasised that almost all of those children would require “major input from health, education, social work and criminal justice services”.99

Impact on later life

109. Professor James Law of the Royal College of Speech and Language Therapists explained that children with attachment disorders or difficulties with attachment can be identified by about 10 months to a year. Taking communication skills as an example, he advanced the view that children with attachment problems went on to develop communication difficulties and were likely either to have externalising behaviour problems or to be more reserved in their schooling. These were not psychiatric cases but children who could be offered support in school in the early years of their lives. According to Professor Law, the majority of such children could be identified in the first five years of life. Referring to recent work that looked at people with language and communication difficulties at age five and followed up on them in their mid-30s, by which time any mental health problems were clear, he informed the Committee that a “relationship between problems with early communication skills and what people are like as adults” can be detected.100

110. The Chief Medical Officer also examined attachment disorders and the effects of social and emotional deprivation in the context of his 2006 Health in Scotland annual report. In his report, he highlighted the “huge influence” of pregnancy and the first years of life on the future mental health of the child and future adult—

“Adverse events during this time can lead to irreversible problems for future ability to cope with everyday life and increase the probability of future poor mental and physical health. Such problems can then run on across generations. It is essential that we recognise the need to invest in the health of infants, young people and children as action by effective Child and Mental Health Services and other agencies can reap substantial long-term rewards for our future child and adult populations.” 101

Universal monitoring by statutory services

Data collection

111. According to Dr Phillip Wilson of the SNAP group, the only piece of information relevant to mental health for all children under five being collected nationally is whether they could smile at the age of six weeks. As outlined above, he explained that there were “robust early indicators of mental health" but—

“…we seem to have stopped collecting information, so an opportunity is being lost and we now identify those children only when they start school and cannot cope.”102

Health visitors

112. At the crux of whether statutory services are able to identify mental health problems in the very young is the way in which those services interact with that group. This key role was traditionally fulfilled by the health visiting profession, who would uncover such problems in the course of general, unstigmatised interaction with families with young children.

113. In 1988, the Royal College of Paediatrics and Child Health established a working group to review routine health checks for young children. The resulting report was entitled Health for All Children. In later years, the remit of the review was extended beyond routine checks for detecting abnormalities or disease, to include efforts designed to prevent illness and promote good health. The report of the most recent review was published in February 2003 as the fourth edition of Health for All Children103 and is commonly referred to as ‘Hall 4’. This report recommended fewer routine universal checks for all infants and greater targeting of resources towards those with higher needs and was followed by Scottish Executive guidelines104 in 2005. Changes to the health visiting profession following the Hall 4 guidelines were not welcomed amongst those giving evidence to the inquiry.

114. Professor James Law, of the Royal College of Speech and Language Therapists, said that “one real problem” was that health visitors were no longer doing much in the way of universal services and were instead focussing from the outset on additional services and on the children who have complex and intense needs—

“The universal service that has been provided is beginning to slip away. As an illustration, I can tell the committee that traditionally about half—40 or 50 per cent—of referrals to speech therapists in the pre-school period used to come from health visitors. The Royal College of Speech and Language Therapists carried out a review at the end of last year about how much had changed post "Health for all Children 4", and it found that the figure is now about 15 per cent.”105

115. According to Professor Law, health visitors were not identifying children with needs and referring them to the same extent, except in cases where there were very risky family situations or identifiable issues in the first few months of life. In respect of children with problems not falling into that category, he said that their chances of being picked up without their parents coming forward were “non-existent”.106

116. Dr Phillip Wilson of the SNAP group put it thus—

“The bad news is that catastrophic damage has been wrought to the health visiting profession. The number of health visitors has declined, and the morale of the profession is the lowest that it has ever been—and the importance of its work should mean that its morale is high. Part of the reason for the decline in morale and the loss of numbers is that there have been some unfortunate policy developments.”107

117. He singled out the Review of Nursing in the Community as “perhaps one of the main problems". He explained that the review provided for a policy whereby the health visiting profession would be abolished altogether and replaced by a generic community nurse, in the interests of care of the increasing number of elderly people with multiple morbidity. He argued that children had been “completely forgotten” and that, as a result, there had been no health visitors being trained in NHS Highland or, until recently, in NHS Lothian, NHS Tayside and NHS Borders. He emphasised that this was “one bad development”.108

118. Speaking about a separate development that, aiming to protect health visitors’ work with children and vulnerable families, proposed that health visitors should be moved into social-work-led teams, Dr Wilson explained that, because of the stigma attached to social work, “major problems” would result from such an approach. He also criticised the Hall 4 report as having an evidence base that was now dated and as not having “much regard for the mental wellbeing of very young children”. According to Dr Wilson, many NHS board and community health partnership managers had interpreted the report’s recommendations literally to mean that a decision on whether a family needed help could be made in the first few weeks of a child's life, with the result that decisions about whether a family requires core, additional or intensive services were now made by the time that a child was two, three or four months old. He stated that there was strong evidence109 that that was “far too early”. For him, the Hall 4 recommendation that families need not be contacted after two, three or four months was a “dangerous development”.110

119. The issues raised by Dr Wilson were raised with representatives of local authorities when they gave oral evidence to the Committee. West Dunbartonshire Council’s representative acknowledged “considerable debate” around Hall 4 and the targeting of health visiting services—

“From a social work point of view, the relative neutrality of a health visitor calling was certainly seen as a benefit. People are not too alarmed if the health visitor comes, but they might have a different reaction to social work.”111

120. The local authority representatives outlined the current risk-based approach, whereby the higher-risk families were identified and included in the health visiting workload. They also set out how strategies in, for example, education services, such as nurture time and circle time, would identify children with difficulties who could then be helped, initially within universal services or by referral to specialist services for additional support. However, the representative from North Lanarkshire Council conceded that, unless a child had a parent who was in contact with a statutory service for that child’s issues, it was “quite possible” that no service out there would pick up on any problems.112

Scottish Government

121. The various serious issues raised in relation to health visiting and the impact on identification of mental ill health amongst the very young were raised with the Minister for Public Health and Sport and the Minister for Children and Early Years in oral evidence. The Minister for Children and Early Years acknowledged that certain simple interventions can be made very early on via the universal services, with “far lower human and resource costs”. He said that this was the aim of the ‘getting it right for every child’ approach, to ensure that, when a child came to the notice of one professional and a need became established, all the other services grouped round, discussed the case and put together a plan to meet the child's needs. He added that health visitors were “clearly important front-line practitioners in that process” and conceded that, in terms of the Hall 4 guidelines113, there had been “some inflexibility” in some of the NHS board areas.114

122. The Minister for Public Health and Sport expanded on this point, defending the principle of Hall 4 in its aim to have a universal service with contact and then focussing in to give additional attention to those children who need it most. She conceded, however, that six to eight weeks was “a bit too early to identify those needs” and revealed that a working group had been looking at whether there needed to be more flexibility on that point. She also explained that certain assumptions on which Hall 4 had been based had worked out differently in practice – for example, it had been assumed that immunisation would mainly involve health visitors but, in practice, it has “almost exclusively” involved practice nurses – and, consequently, the opportunities for contact with health visitors have perhaps not been as originally envisaged. She said—

“That is why the working group has considered some of the concerns that have been raised by health visitors about having to allocate on the health plan indicator at six to eight weeks the interventions that are required for the child. Health visitors want more flexibility and a period of support and assessment in which they can revisit and see the child again. That has been recognised, and the working group is considering that. I hope that we will soon be able to have some revision to allow more flexibility.”115

Conclusion

123. The Committee recognises the tension between universal and targeted screening, caused by inevitable limitations on resources. The Committee believes, however, that it is imperative to identify in the early years, via universal screening, mental health and well-being issues – in both the child and parents – that have not been recognised at the time of the child’s birth or in the first six to eight weeks. Furthermore, it is vitally important that there are standard health checks and developmental checks on every child at crucial stages of the early years.

124. The Committee understands that, following the Review of Nursing in the Community, the role of health visitors may be integrated into a new generic ‘community health nurse’ post and that it will be a local decision as to where such posts are located. In some parts of the country, a possible move away from the traditional model of health visitors being attached to GP practices is evident. For example, in NHS Greater Glasgow and Clyde, a review of health visiting recommended that health visitors should be realigned alongside social work children’s services teams rather than within health teams. 116 Given the great difference in how health service and social work roles are perceived, as described in paragraph 119 above, the Committee is of the view that, notwithstanding the outcome of the four pilots testing the recommendations of the Review of Nursing in the Community, community health nursing teams should be aligned with health services throughout the country, in the interests of delivering a truly universal service.

125. The Committee is very concerned about the extent of the problems provoked by changes to the health visiting profession in response to the fourth edition of Health for All Children (“Hall 4”). Of particular worry is that, in some NHS board areas, the changes made following Hall 4 may have gone so far that either they cannot be reversed or there is no desire amongst some local decision-makers to reverse them. The Committee notes the Scottish Government’s acknowledgement of these issues and calls for urgent action to address these problems as they affect a vulnerable group at a critical stage of development.

Role of nursery schools

The impact of Hall 4

126. The role of nursery schools in the light of developments under Hall 4 was also discussed. Jacqueline Kerr, who participated in the round-table with non-specialists, has been in the nursing profession for 30 years, working for the past 17 years in health visiting. Her current post as a public health nurse team leader involves managing a team of health visitors, school nurses and support staff. This team is aligned to a learning community (nursery, primary and secondary schools) and she has particular expertise in working with families who have pre-school children. Early identification of behavioural problems and appropriate referrals are part of her remit and she has significant experience of working with families with substance misuse. She related the changes under Hall 4 to the role of nursery schools as follows—

“After Hall 4, it was decided that we would work more intensively with families in the very early weeks, and that every child would have a six-week assessment. Only the children in our additional and intensive case load would have a two-year assessment. After that, there would be no formal assessment. That is practised throughout Scotland. Many health visitors have been unhappy with that, because they now rely on parents coming to them or to their GPs with problems, and their work is much more focused on those intensive cases. There are many other families in which children will probably develop problems, but if the parents do not realise that there are problems, the health visitor will not be alerted and will be unable to offer help and support. Most children now have nursery places from about three years old, so we are relying on nurseries to alert the health visitor.”117

127. Elizabeth MacDonald of the College of Occupational Therapists, and previously an occupational therapist in a community paediatric occupational therapy service in a child development centre, gave reassurance from her own experience about the capability of nursery school staff to take on this kind of role—

“My experience is that nursery staff are extremely capable of raising awareness of children in their nurseries who have developmental difficulties of any sort. The staff often know the parents and the backgrounds, and they should be used to identify children at that stage. Occupational therapists go to nurseries a lot, and nursery staff often highlight children who are not on our books or who are not known to the child development centre but whom the staff are worried about because of a behavioural or other problem. Children with a developmental co-ordination disorder or ADHD can be identified very early. We need early intervention so that children do not end up with mental health issues and issues such as school exclusions, behavioural problems and underachievement.”118

128. She acknowledged, however that nursery staff needed support from services and that, whilst she knew that they received significant support from child health services, she was uncertain about CAMHS.119

129. However, Dr Kathy Leighton from the Royal College of Psychiatrists pointed out that, although nursery provision was available for all children, not all children accessed it, “particularly those in some of the most vulnerable families”, such as families in which there were mental health or drug addiction problems that had not been fully identified. Moreover, young people in those circumstances might be “in itinerant families who move from area to area”, which she described as “a gap group”.120 Dr Leighton also spoke of the pressure on tier 4 CAMHS and the hope that “developments at the more generic, universal level will provide more ready and less stigmatised access for young people who have difficulties such as the wish to self-harm”.121

Scottish Government

130. Asked whether staff in the nursery sector were trained to pick up potential developmental, speech, communication and mental health issues, the Minister for Children and Early Years reassured the Committee that the “current big drive” was to “upskill the early years workforce” which, he said, had showed “enthusiasm to register with the Scottish Social Services Council”, which put them under the obligation to “extend their qualifications and take extra training”. Speaking about “significant workforce development”, he gave an example of former nursery nurses in Angus being put through additional training to become outreach workers with families—

“So the teacher might pick up on something in the pre-school setting and pass it on to the early years worker who arranges to go out and see the child in the family environment. Alternatively, a parent could come in and say to the nursery teacher, "Wee Johnny doesn't seem to be developing skills in this direction", or whatever. That contact is made, people go out into the family home and we kick off the whole process of identifying a need. We then pull in all the other professionals as required. That is the kind of system that is being developed.”122

131. Responding to the same question, the Minister for Public Health and Sport referred to one of the six priorities laid out in the then-imminent plan, Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011123, on mentally healthy infants, children and young people. She said that there would be a lot in the plan about how those who are working in pre-school provision can be better supported in respect of their training and support needs.124

Conclusion

132. The Committee notes that the Towards a Mentally Flourishing Scotland document does not specifically refer to nursery staff.

133. The evidence given on the role of nursery staff serves to demonstrate the impact of the changes to the health visiting profession under Hall 4 and the Committee finds that this raises key questions about the role of nursery staff. First and foremost is the question of their training, qualifications and experience: the Committee understands that all workers in pre-school education must now register with the Scottish Social Services Council by 2014 and that registration is subject to eligibility criteria which include holding qualifications or gaining them within three years of registering. The Committee notes that there is a range and variety of qualifications listed in the eligibility criteria and seeks assurances from the Scottish Government that these qualifications cover to an appropriate degree the identification of problems of mental health and well-being in very young children. If these assurances cannot be given, the Committee would call for an audit to be carried out to assess the content of existing training courses.

134. The Committee is also concerned that practice in communicating information on a child’s development may not be consistent across Scotland. For example, national care standard 4 makes a commitment that nursery staff will—

  • regularly assess the development and learning of each child and young person;
  • use this assessment information to plan the next steps in the child or young person’s development and learning; and
  • share this information with the child or young person as appropriate, with parents and carers and others professionally involved in the child or young person’s development.125

135. While this national care standard is to be welcomed, the Committee’s concern is that the wording of the standard may be open to interpretation, for example whether “regularly” should be taken to mean ‘daily’, ‘weekly’ or ‘monthly’. There is scope, therefore, for the standard to be implemented differently: Committee members are aware from their own caseloads that practice differs across the country.

136. The Committee recognises that there is a valuable role for nursery schools to play in relation to monitoring the mental health and well-being of very young children, especially as monitoring carried out in the home is limited insofar as observing interactions with other children is concerned. Given that nursery places are now available for every three- and four-year-old, this opens up new potential for early identification of problems with mental health and well-being.

137. The Committee considers that it is vital that this opportunity be taken, with HM Inspectorate of Education (“HMIE”), the Care Commission and local authorities all playing their roles. The Committee recommends that there should be joint reporting by HMIE and the Care Commission on the schools’ programme to promote and support good mental health and well-being in nursery schools.

138. Furthermore, the evidence also highlighted that attendance at nursery school is not quite a universal experience and cannot, therefore, fully substitute for the universal service previously provided by health visitors. The Committee reiterates its call for urgent action to address the problems arising subsequent to Hall 4.

transition to adult services

The challenge of transition

139. The general picture painted by respondents to the call for written evidence was that the transition from child and adolescent to adult services was a challenging area across Scotland. As several respondents noted, entering adulthood was in any case a stressful time for young people and transition to adult mental health services was a time of particular anxiety as it could exacerbate fears about long-term mental health prognosis. One example came from Barnado’s Scotland—

“Barnardo’s Scotland is aware of long-standing issues relating to the transition of young people from CAMH services and adult mental health services. In essence this is about young people moving from a child focused service to an adult focused service. This can be a time when there are other significant changes in the young person’s life, for instance moving from school to training or moving from care to independence. Barnardo’s experience is that young people and their families have been left anxious due to the fact that they were unclear of the processes in the transition and uncertain future service provision.”126

140. The Committee raised the transition from CAMHS to adult mental health services with representatives of local authorities. Linda Morrison, from Aberdeenshire Council, recognised the challenge, stating that, in the council’s area, if CAMHS patients have a recognised mental illness, their transition into adult services is “easy and smooth” but, where there are difficulties but perhaps not recognised mental illnesses, meeting needs is a “continuing challenge”. She identified 17 to 25-year-olds as the range of young people for whom that transition can be difficult.127

141. Anne Ritchie from West Dunbartonshire Council echoed Linda Morrison’s point, explaining that there is sometimes a “mismatch between the need for a diagnosis and a service that tries not to label” and that the transition is “definitely more difficult when it is not clear what is wrong or if there is no actual illness but considerable disruptive behaviour, a conduct disorder or clear signs of marked emotional distress”.128

142. This point was also picked up by Dr Kathy Leighton from the Royal College of Psychiatrists, who highlighted the fact that the criteria for accessing CAMHS are “significantly different” from those for accessing adult mental health services. She reiterated that young people with “diffuse and non-labelled disorders” have difficulties in accessing appropriate services once they have passed the cut-off boundary for CAMHS locally and that this leaves them “very vulnerable”.129

A different approach

143. Martin Egan, representing North Lanarkshire Council, advocated establishing services around the adolescent and young-adult age group, services that “bridged the gap”, rather than separating children and adolescent services from adult services.130 Asked whether this idea would require a bundle of new resources or would mean restructuring the current services, witnesses explained that the starting point would be existing CAMHS capacity, where “tier 3 is the area where the significant difficulties lie” for the transition stage. Anne Ritchie, from West Dunbartonshire Council, said—

“There is clear evidence that they are stretched so, however we organise the services, they will be stretched.”131

144. The idea found support amongst the representatives of professional bodies giving evidence to the Committee. Dr Leighton, for example, concurred that the group was particularly vulnerable to more severe disorders, explaining that adversity or problems identified early in life could “become cumulative around the crucial transition from adolescence to adulthood” or, alternatively, that people could “reap the benefits of good early intervention”. The Royal College of Psychiatrists, she said, would “certainly welcome work on developing the concept of services to target older adolescents and younger adults”.132 Dr Leighton added that models exist for transition services that embrace 16- to 25-year-olds.133

145. Dr Chris Wiles from the British Psychological Society welcomed the concept of bespoke services, emphasising the need to “capture the fact that experience of transition varies between individual young people”. He explained the significant difference between services for children and those for adults, the former being “much more integrative”, the latter tending to be “much more linear and based on a medical model”. He said that “much good work disappears” because of an absence of an “encompassing structure”. He added that this issue was not limited to NHS services.134

146. Brian Lister, from the SCRA, outlined the importance to the children's hearings system of the transition to adulthood of 16, 17 or 18-year-olds, who are still within the remit of the system. He believed that an effective service for that age group would result in better outcomes for children and families.135

Scottish Government

147. The issue of transition to adult services and the idea of a bespoke service straddling the older adolescent and the young adult age groups was raised in the session with the Minister for Public Health and Sport and the Minister for Children and Early Years. In response, it was stated that the transitional issue was being picked up more in work with clinical leads. It was explained that it was not straightforward to design services as the transition between child and adolescent services and adult services falls at different stages for different problems. The Scottish Government’s latest approach was to look at the development of a “care pathway” for CAMHS, which, as with adult care pathways, would seek to address assessment and admission to and discharge from that pathway. The aim of this approach would be to reflect an individual's experience and needs better than the current system does.136

Conclusion

148. The Committee welcomes the idea put forward by witnesses to establish a bespoke service for adolescents and young adults. The Committee notes that the Scottish Government is currently considering how to approach this area and urges the Government to give close consideration to how a new service for this age group should be delivered, paying particular attention to the need for support to be determined on a case-by-case basis and for service transition to be tailored to need rather than based simply on age.

overall conclusion

149. The Committee has been struck by how variable a picture of CAMHS has been conveyed to the Committee in the evidence that it has taken. Despite the commitment of the Scottish Government and previous Scottish Ministers at a policy level, the existence of an agreed framework and the devotion, good work and admirable efforts of many individuals across the field, mental health and well-being seems not to have been a priority amongst those responsible for delivering the policy.

150. CAMHS appear to be in need of champions. The Committee urges the key players throughout Scotland – especially in the NHS and local authorities – to pay close attention to this report and to ratchet up the implementation of the CAMHS Framework for action. Given that this has been slow to date, the Committee calls on the Scottish Government to hold NHS boards, local authorities and responsible officers to account in ensuring that they give this issue the consistent and sustained priority that it requires to improve the mental health and well-being of Scottish children and adolescents.

Annexe A: EXTRACTS FROM MINUTES

27th Meeting, 2008 (Session 3)

Wednesday 12 November 2008

1. Decision on taking business in private: The Committee agreed to take item 4 in private.

4. Mental health services inquiry (in private): The Committee considered its approach to the inquiry in the light of members' recent visits to mental health services across Scotland and agreed to consider an approach paper at a future meeting.

29th Meeting, 2008 (Session 3)

Wednesday 26 November 2008

1. Decisions on taking business in private: The Committee agreed to take items 3 and 4 in private.

4. Mental health services inquiry (in private): The Committee agreed the remit for its inquiry into mental health services and agreed to remit to the clerks and the Convener the arrangements necessary for issuing and publicising a call for written evidence.

4th Meeting, 2009 (Session 3)

Wednesday 4 February 2009

Mental health services inquiry - witness expenses: The Committee agreed to delegate to the Convener responsibility for arranging for the SPCB to pay, under Rule 12.4.3, any expenses of witnesses in the inquiry.

5th Meeting, 2009 (Session 3)

Wednesday 11 February 2009

Mental health services inquiry (in private): The Committee agreed its approach to taking oral evidence as part of the inquiry.

10th Meeting, 2009 (Session 3)

Wednesday 25 March 2009

Inquiry into child and adolescent mental health services: The Committee took evidence, in a round-table discussion, from—

Ruth Stark, Social Worker, Professional Officer, British Association of Social Workers;

Benjamin Napier, Childline Services Manager, Edinburgh, and Julie Burns, Childline Counselling Supervisor, Children 1st;

Heather Muir, Head of House, Falkirk High School;

David Milliken, Director, Home-Start Scotland;

Kathryn Howieson, Senior Co-ordinator, Home-Start West Lothian;

Graeme Rizza, Area Manager, Central Moray Children and Families Team, The Moray Council;

Susan Kayes, Public Health Nurse Team Leader, and Jacqueline Kerr, Public Health Nurse Team Leader, NHS Lanarkshire;

Joan Hoggan, Principal Teacher of Pastoral Care, Smithycroft Secondary School;

Brian Cooklin, Headteacher, Stonelaw High School;

Rosemary Howe, Group Manager, Specialist Services and Social Policy, West Lothian Council;

and then took evidence from the following former members of the Scottish Needs Assessment Programme core working group on child and adolescent mental health––

Dr Graham Bryce, Consultant Child and Adolescent Psychiatrist, NHS Greater Glasgow and Clyde;

Mary Gallagher, Operations Manager Children and Families, East Renfrewshire Community Health and Care Partnership;

Dr Margaret Hannah, Project Lead, International Futures Forum Kitbag and Acting Director of Public Health, NHS Fife;

Dr Elaine Lockhart, Consultant Psychiatrist for Children and Young People, Royal Hospital for Sick Children, Yorkhill, Glasgow;

Dr Philip Wilson, General Practitioner and Senior Research Fellow, General Practice and Primary Care, University of Glasgow.

11th Meeting, 2009 (Session 3)

Wednesday 1 April 2009

Inquiry into child and adolescent mental health services: The Committee took evidence from—

Carol Fisher, Healthcare Manager, NHS Ayrshire and Arran;

Jan Baird, Director of Community Care, NHS Highland;

Professor Alex McMahon, Deputy Director, Strategic Planning and Modernisation, NHS Lothian;

Jennifer Milligan, Child Health Commissioner, NHS Dumfries and Galloway;

Julie Metcalfe, Clinical Director for Child and Adolescent Mental Health Services, NHS Greater Glasgow and Clyde.

12th Meeting, 2009 (Session 3)

Wednesday 22 April 2009

Inquiry into child and adolescent mental health services: The Committee took evidence from—

Linda Morrison, Strategic Development Manager (Children’s Services), Aberdeenshire Council;

Martin Egan, Service Manager, Children and Family Support, North Lanarkshire Council;

Anne Ritchie, Head of Social Work Operations, West Dunbartonshire Council;

and then took evidence, in a round table discussion, from—

Professor Mick Cooper, Professor of Counselling (University of Strathclyde), and Karen Cromarty, Senior Lead Advisor, Children and Young People, British Association for Counselling and Psychotherapy;

Dr Chris Wiles, Faculty for Children & Young People, and Martin Gemmell, Scottish Division of Educational Psychology, British Psychological Society;

Elizabeth MacDonald, Scotland Policy Officer, and Gwyneth Bruce, Head Occupational Therapist, College of Occupational Therapists;

Fiona Bonnar, Senior Charge Nurse, Royal College of Nursing;

Dr Kathy Leighton, Consultant Psychiatrist in Child and Adolescent Psychiatry, Royal College of Psychiatrists;

Professor James Law, Director of Integrated Health Care Research, Royal College of Speech and Language Therapists;

Brian Lister, Reporter Manager, Central-West Region, Scottish Children's Reporter Administration.

13th Meeting, 2009 (Session 3)

Wednesday 29 April 2009

1. Decision on taking business in private: The Committee agreed to take item 4 in private.

3. Inquiry into child and adolescent mental health services: The Committee took evidence from—

Cliff Watt, Co-ordinator and Locality Manager, Choose Life - Aberdeen;

Linda Paterson, Co-ordinator, Choose Life - Aberdeenshire;

Graham Morgan, Advocacy Project Manager, and Kenny MacIvor, Member, Highland Users Group;

and then, in a round table discussion, from—

Ilena Day, Chief Executive, Depression Alliance Scotland;

Pauline Bell, Advocacy Worker, Partners in Advocacy;

Amber Higgins, Project Manager, Fife Youth Project, Penumbra;

Carolyn Roberts, Research and Influence Manager, Scottish Association for Mental Health;

Roger Catchpole, Principal Consultant, YoungMinds;

Brian Donnelly, Director, Young Scotland in Mind.

4. Inquiry into child and adolescent mental health services (in private): The Committee considered issues arising from the evidence taken to date.

14th Meeting, 2009 (Session 3)

Wednesday 6 May 2009

Inquiry into child and adolescent mental health services: The Committee took evidence from—

Shona Robison MSP, Minister for Public Health and Sport, Adam Ingram MSP, Minister for Children and Early Years, Margo Fyfe, CAMHS Nurse Advisor, Geoff Huggins, Deputy Director, Head Mental Health Division, and Boyd McAdam, Head of Branch, Getting It Right for Every Child, Scottish Government.

15th Meeting, 2009 (Session 3)

Wednesday 13 May 2009

Inquiry into child and adolescent mental health services (in private): The Committee agreed to defer consideration of the draft report to a future meeting.

18th Meeting, 2009 (Session 3)

Wednesday 3 June 2009

Inquiry into child and adolescent mental health services (in private): The Committee considered a draft report. Various changes were agreed to, and the Committee agreed to consider a revised draft at its next meeting.

19th Meeting, 2009 (Session 3)

Wednesday 10 June 2009

Inquiry into child and adolescent mental health services (in private): The Committee considered a draft report. Various changes were agreed to, and the Committee agreed to consider a revised draft at its next meeting.

20th Meeting, 2009 (Session 3)

Wednesday 17 June 2009

Inquiry into child and adolescent mental health services (in private): The Committee considered a draft report. Subject to a number of changes, the report was agreed to.

Annexe B: oral evidence and associated written evidence

Please note that all oral evidence and associated written evidence is published electronically only, and can be accessed via the individual links below or via the Health and SportCommittee’s web pages at:

http://www.scottish.parliament.uk/s3/committees/hs/inquiries/mentalhealthservices/index.htm

10th Meeting, 2009 (Session 3) Wednesday 25 March 2009

WRITTEN EVIDENCE

Children 1st

Dr Graham Bryce, Consultant Child and Adolescent Psychiatrist, NHS Greater Glasgow and Clyde & Dr Philip Wilson, General Practitioner and Senior Research Fellow, General Practice and Primary Care, University of Glasgow

Dr Philip Wilson, General Practitioner and Senior Research Fellow, General Practice and Primary Care, University of Glasgow

Dr Elaine Lockhart, Consultant Psychiatrist for Children and Young People, Royal Hospital for Sick Children, Yorkhill, Glasgow

ORAL EVIDENCE

Ruth Stark, Social Worker, Professional Officer, British Association of Social Workers

Benjamin Napier, Childline Services Manager, Edinburgh, and Julie Burns, Childline Counselling Supervisor, Children 1st

Heather Muir, Head of House, Falkirk High School

David Milliken, Director, Home-Start Scotland

Kathryn Howieson, Senior Co-ordinator, Home-Start West Lothian

Graeme Rizza, Area Manager, Central Moray Children and Families Team, The Moray Council

Susan Kayes, Public Health Nurse Team Leader, and Jacqueline Kerr, Public Health Nurse Team Leader, NHS Lanarkshire

Joan Hoggan, Principal Teacher of Pastoral Care, Smithycroft Secondary School

Brian Cooklin, Headteacher, Stonelaw High School

Rosemary Howe, Group Manager, Specialist Services and Social Policy, West Lothian Council

Dr Graham Bryce, Consultant Child and Adolescent Psychiatrist, NHS Greater Glasgow and Clyde

Mary Gallagher, Operations Manager Children and Families, East Renfrewshire Community Health and Care Partnership

Dr Margaret Hannah, Project Lead, International Futures Forum Kitbag and Acting Director of Public Health, NHS Fife

Dr Elaine Lockhart, Consultant Psychiatrist for Children and Young People, Royal Hospital for Sick Children, Yorkhill, Glasgow

Dr Philip Wilson, General Practitioner and Senior Research Fellow, General Practice and Primary Care, University of Glasgow

SUPPLEMENTARY WRITTEN EVIDENCE

Dr Philip Wilson, General Practitioner and Senior Research Fellow, General Practice and Primary Care, University of Glasgow

Dr Philip Wilson, General Practitioner and Senior Research Fellow, General Practice and Primary Care, University of Glasgow

11th Meeting, 2009 (Session 3) Wednesday 1 April 2009

WRITTEN EVIDENCE

NHS Ayrshire and Arran
NHS Highland
NHS Lothian
NHS Dumfries and Galloway Child and Adolescent Services
NHS Greater Glasgow and Clyde Young People's Specialist Services

ORAL EVIDENCE

Carol Fisher, Healthcare Manager, NHS Ayrshire and Arran
Jan Baird, Director of Community Care, NHS Highland
Professor Alex McMahon, Deputy Director, Strategic Planning and Modernisation, NHS Lothian
Jennifer Milligan, Child Health Commissioner, NHS Dumfries and Galloway
Julie Metcalfe, Clinical Director for Child and Adolescent Mental Health Services, NHS Greater Glasgow and Clyde

SUPPLEMENTARY WRITTEN EVIDENCE

NHS Ayrshire and Arran
NHS Dumfries and Galloway & Dumfries and Galloway Council
NHS Highland
NHS Lothian & East Lothian Council

12th Meeting, 2009 (Session 3) Wednesday 22 April 2009

WRITTEN EVIDENCE

Aberdeenshire Council
North Lanarkshire Council
West Dunbartonshire Council
British Association for Counselling and Psychotherapy 10.10.2008
British Association for Counselling and Psychotherapy 20.01.2009
British Psychological Society
College of Occupational Therapists
Royal College of Nursing Scotland
Royal College of Psychiatrists & Royal College of Nursing Scotland
Royal College of Speech and Language Therapists 12.12.2007
Royal College of Speech and Language Therapists 20.01.2009
Scottish Children's Reporter Administration

ORAL EVIDENCE

Linda Morrison, Strategic Development Manager (Children’s Services), Aberdeenshire Council

Martin Egan, Service Manager, Children and Family Support, North Lanarkshire Council

Anne Ritchie, Head of Social Work Operations, West Dunbartonshire Council

Professor Mick Cooper, Professor of Counselling (University of Strathclyde), and Karen Cromarty, Senior Lead Advisor, Children and Young People, British Association for Counselling and Psychotherapy

Dr Chris Wiles, Faculty for Children & Young People, and Martin Gemmell, Scottish Division of Educational Psychology, British Psychological Society

Elizabeth MacDonald, Scotland Policy Officer, and Gwyneth Bruce, Head Occupational Therapist, College of Occupational Therapists

Fiona Bonnar, Senior Charge Nurse, Royal College of Nursing

Dr Kathy Leighton, Consultant Psychiatrist in Child and Adolescent Psychiatry, Royal College of Psychiatrists

Professor James Law, Director of Integrated Health Care Research, Royal College of Speech and Language Therapists

Brian Lister, Reporter Manager, Central-West Region, Scottish Children's Reporter Administration

SUPPLEMENTARY WRITTEN EVIDENCE

Royal College of Nursing Scotland
Royal College of Speech and Language Therapists

13th Meeting, 2009 (Session 3) Wednesday 29 April 2009

WRITTEN EVIDENCE

Choose Life - Aberdeen
Highland User Group
Depression Alliance Scotland
Partners in Advocacy
Penumbra
Scottish Association for Mental Health 14.04.2008
Scottish Association for Mental Health 20.01.2009
Young Minds
Young Scotland In Mind

ORAL EVIDENCE

Cliff Watt, Co-ordinator and Locality Manager, Choose Life - Aberdeen

Linda Paterson, Co-ordinator, Choose Life - Aberdeenshire

Graham Morgan, Advocacy Project Manager, and Kenny MacIvor, Member, Highland Users Group

Ilena Day, Chief Executive, Depression Alliance Scotland

Pauline Bell, Advocacy Worker, Partners in Advocacy

Amber Higgins, Project Manager, Fife Youth Project, Penumbra

Carolyn Roberts, Research and Influence Manager, Scottish Association for Mental Health

Roger Catchpole, Principal Consultant, YoungMinds

Brian Donnelly, Director, Young Scotland in Mind

14th Meeting, 2009 (Session 3) Wednesday 6 May 2009

ORAL EVIDENCE

Shona Robison MSP, Minister for Public Health and Sport, Adam Ingram MSP, Minister for Children and Early Years, Margo Fyfe, CAMHS Nurse Advisor, Geoff Huggins, Deputy Director, Head Mental Health Division, and Boyd McAdam, Head of Branch, Getting It Right for Every Child, Scottish Government

SUPPLEMENTARY WRITTEN EVIDENCE

Minister for Public Health

Annexe C: OTHER WRITTEN EVIDENCE

Submissions were also received from the following organisations in response to the original call for evidence. Please note that written evidence is published electronically only, and can be accessed via the individual links below or via the Health and Sport Committee’s web pages at:

http://www.scottish.parliament.uk/s3/committees/hs/inquiries/mentalhealthservices/index.htm

Access to Health Project
Action for Children Scotland

Association of Directors of Education for Scotland

Auditor General for Scotland

Autism Rights
Barnardo's Scotland
BMA Scotland

Bob Fraser
Children and Youth People’s Health Support Group
Children in Scotland
Choose Life - Angus

Choose Life - North Lanarkshire

Diabetes UK Scotland

Dr Katherine M Leighton
Dr RM Wrate
Early Detection and Intervention Evaluation Research Study, Glasgow
East Glasgow Community Health Care Partnership
FBS Advocacy
Includem

Medical Research Council
Mental Health Pharmacy Strategy Group
Mindspace Counselling Service

NHS Borders
NHS Grampian
NHS Greater Glasgow and Clyde ESTEEM First Episode Psychosis Service
NHS Orkney
NHS Scotland
NHS Shetland
NHS Tayside
North Ayrshire Council Children Services Plan
Perth and Kinross Council
Quarriers
Rowan Centre Royal College of Psychiatrists
Royal Pharmaceutical Society of Great Britain Scottish Pharmacy Board
School Leaders Scotland
Scottish Association For Mental Health, Aberdeen
Scottish Commission for Children and Young People
Scottish Commission For The Regulation of Care
Scottish Division of The Royal College of Psychiatrists, Section of Child and Adolescent Psychiatry
South Lanarkshire Council
Sure Start
The British Psychological Society Scottish Division of Educational Psychologists
The Chartered Society of Physiotherapy
The City of Edinburgh Council
The National Deaf Children's Society
The Royal Edinburgh Hospital Division of Psychiatry
The Scottish Commission for the Regulation of Care
University of Aberdeen Child Health Institute of Applied Health Sciences
Volunteer Development Scotland
Walter Dean

Submissions received during the inquiry:

Dundee City Council
Falkirk Council
Fife Council
Glasgow City Council
NHS Borders
NHS Fife
NHS Grampian
NHS Lanarkshire
NHS Quality Improvement Scotland
NHS Shetland
NHS Tayside
Orkney Island Council


Footnotes:

2 Public Health Institute of Scotland. (2003) Needs Assessment Report on Child and Adolescent Mental Health: Final report – May 2003. Public Health Institute of Scotland. Available at: http://www.headsupscotland.co.uk/documents/SNAP1.pdf [accessed 18 June 2009]

3 Scottish Executive. (2005) The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care. Scottish Executive. Available at http://www.scotland.gov.uk/Publications/2005/10/2191333/13377 [accessed 18 June 2009]

4 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1882

5 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1726-7

6 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1729-30

7 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1747

8 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1747

9 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1727

10 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1728-9

11 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1727-8

12 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1749

13 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1757

14 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1761

15 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1765

16 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1804

17 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1803

18 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1887-8

19 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1882

20 Audit Scotland. (2009) Overview of mental health services. Audit Scotland. Available online at
www.audit-scotland.gov.uk/docs/health/2009/nr_090514_mental_health.pdf [Accessed 18 June 2009]

21 Formerly the Headteachers Association of Scotland

22 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1702

23 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1702

24 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1821

25 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1845

26 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1703

27 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1857

28 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1706

29 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1819

30 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1728

31 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1730

32 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1743

33 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1829-31

34 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1829-30

35 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1888-9

36 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1889-90

37 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1889-90

38 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1882

39 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1879

40 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1882

41 Scottish Executive. (2006) Getting the Right Workforce, Getting the Workforce Right – A strategic review of the Child and Adolescent Mental Health Workforce. Scottish Executive. Available at: www.sehd.scot.nhs.uk/workforcedevelopment/Publications/camh_workforce_strategic_rev.pdf [Accessed 18June2009]

42 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1759

43 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1759

44 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1779

45 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1779

46 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1795

47 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1805

48 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1763

49 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1805

50 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1897

51 Audit Scotland. (2009) Overview of mental health services. Audit Scotland. Available online at
www.audit-scotland.gov.uk/docs/health/2009/nr_090514_mental_health.pdf
[Accessed 18 June 2009]

52 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1730

53 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1759

54 Scottish Parliament Health and Sport Committee. Official Report, 1 April 2009, Col 1759

55 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1861

56 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1860

57 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1850-1

58 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1866-7

59 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1867

60 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1867

61 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1844

62 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1724

63 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1894

64 Scottish Government news release. Available online at www.scotland.gov.uk/News/Releases/2008/11/14104125 [Accessed 18 June 2009]

65 NHSScotland HEAT target. Available online at
www.scotland.gov.uk/Topics/Health/NHS-Scotland/17273/targets/Access
[Accessed 18 June 2009]

66 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1841

67 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1854

68 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1796

69 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1711

70 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1827

71 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1821-22

72 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1854-5

73 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1821

74 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1821

75 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1879

76 O'Connor, R.C., Rasmussen, S., Miles, J., & Hawton, K. (2009). Self-harm in adolescents: self-report survey in schools in Scotland. British Journal of Psychiatry, 194, 68-72 Available online at www.psychology.stir.ac.uk/staff/roconnor/documents/BritishJournalofPsychiatry.pdf [Accessed 18 June 2009]

77 Audit Scotland. (2009) Overview of mental health services. Audit Scotland. Available online at www.audit-scotland.gov.uk/docs/health/2009/nr_090514_mental_health.pdf [Accessed 18 June 2009]

78 SAMH. Written submission to the Health and Sport Committee.

79 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1874

80 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1819

81 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1857

82 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1827

83 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1832

84 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1874

85 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1833

86 Highland Users Group. Written submission to the Health and Sport Committee.

87 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1702

88 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1736-7

89 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1737

90 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1720

91 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1720

92 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1720-1

93 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1721

94 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1895

95 Scottish Government. Written submission to the Health and Sport Committee.

96 Scottish Government. Written submission to the Health and Sport Committee.

97 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1728

98 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1737-8

99 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1734

100 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1824-5

101 Chief Medical Officer for Scotland. (2006) Health in Scotland 2006 - Annual Report of the Chief Medical Officer. Scottish Government. Available online at www.scotland.gov.uk/Resource/Doc/203463/0054202.pdf [Accessed 18June 2009]

102 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1734

103 David M B Hall & David Elliman. (2003) Health for All Children: 4th Report. Oxford University Press

104 Scottish Executive. (2005) Health for All Children 4: Guidance on Implementation in Scotland – Getting It Right For Scotland's Children. Scottish Executive. Available online at www.scotland.gov.uk/Resource/Doc/37432/0011167.pdf [Accessed 18 June 2009]

105 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1824-5

106 Scottish Parliament Health and Sport Committee. Official Report, 29 April 2009, Col 1824-5

107 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1728

108 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1728-9

109 Such as: Olds, D. et al. (1998) Long-term effects of nurse home visitation on children's criminal and anti-social behaviour: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, Vol 280(14): 1238-1244

110 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1729

111 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1807

112 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1807-8

113 Scottish Executive. (2005) Health for All Children 4: Guidance on Implementation in Scotland – Getting It Right For Scotland's Children. Scottish Executive. Available online at www.scotland.gov.uk/Publications/2005/04/15161325/13269 [Accessed 18 June 2009]

114 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1883

115 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1884

116 The NHS Greater Glasgow and Clyde case was the subject of public petitions PE1198, PE1199 and PE1200, each calling on the Parliament to urge the Scottish Government to ensure that, when changes are proposed to the structure and role of health visitors, transparent, effective and meaningful public consultation with service users and health professionals is carried out. On 2June2009, the Parliament’s Public Petitions Committee (“the PPC”) agreed to close these petitions on the grounds that, in terms of the specific situation that gave rise to the petitions, the petitioners were now contributing to the local implementation plans with the NHS board concerned. The PPC also agreed to draw the letters received from the petitioners to the attention of NHS Greater Glasgow and Clyde.

117 Scottish Parliament Health and Sport Committee. Official Report, 25 March 2009, Col 1716

118 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1825-6

119 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1826

120 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1828

121 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1821

122 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1884-5

123 Scottish Government. (2009) Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011. Scottish Government. Available at www.scotland.gov.uk/Publications/2009/05/06154655/5 [accessed 18 June 2009]

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125 Scottish Executive. (2005) National Care Standards – early education and childcare up to the age of16. Scottish Government. Available online at www.scotland.gov.uk/Resource/Doc/37432/0010250.pdf [Accessed 18 June 2009]

126 Barnado’s Scotland. Written submission to the Health and Sport Committee

127 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1808

128 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1808-9

129 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1818-9

130 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1808

131 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1808

132 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1817

133 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1819

134 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1817-18

135 Scottish Parliament Health and Sport Committee. Official Report, 22 April 2009, Col 1818

136 Scottish Parliament Health and Sport Committee. Official Report, 6 May 2009, Col 1899-1900