Children and Young People's Mental Health Task Force: Preliminary View and Recommendations from the Chair
1. On 29 June 2018 the Cabinet Secretary for Health and Sport announced a joint Task Force with COSLA on Children and Young People's Mental Health. The Task Force is to provide recommendations for improvements in provision for children and young people's mental health in Scotland and, in partnership, develop a programme of sustainable reform of services. The Scottish Government and COSLA asked me to chair the Task Force and to provide initial recommendations by September this year. This has involved a great deal of work over these past weeks to hear from as many people as I could about the issues, and most importantly, potential solutions.
2. It is clear to me that whilst the Task Force will report to Ministers and to COSLA, it is answerable to the children and young people of Scotland and to their families. I intend to take a rights based approach to the work and to collaborate with children, young people and families to make sure that the right improvements are made. This will include consulting with those children, young people and families who fall between the gaps, actively seeking the views of seldom heard groups.
3. Due to the short timescale for this preliminary view, I have concentrated my efforts on gathering views and perspectives of children and young people, their families, services, agencies and practitioners. This preliminary, exploratory phase has formed my initial recommendations and will inform setting up the Task Force structure needed to take forward the work of making real improvement.
4. I am grateful to all of the people who have been so open in our conversations about their experiences, and have provided information about mental health provision and services. In particular I have been struck by children and young people's stories. I was impressed by the way that children and young people were so generous with their own experiences and, even when those experiences had not been good, how constructive that they were in wanting to improve things.
5. It has not been possible to reach the wide range of stakeholders requiring mental health services ( e.g. looked after children, homeless young people, rural communities, those with addictions) or explore the particular issues around protected characteristics. I have more to learn and more people to hear from. Nonetheless, I have heard views on particular needs, lack of equality of access, parity and stigma.
6. I have heard from many people about adverse childhood experiences ( ACES). As a mental health professional, I recognise that childhood experiences shape us and how we interact with the world. If those experiences are harmful or traumatic, without the right support, the negative effects can be deep and potentially last a lifetime. That's why I think it's important that the Task Force is concerned with the mental health of very young children and the need to support families.
7. I want to be clear that the policy and principles currently in place in Scotland are good. Getting it Right For Every Child ( GIRFEC) sets out a clear framework for all services working together in a holistic way to support children and their families. However, there is disconnect. Whilst I have seen innovative and effective practice, it is my view that services needed to deliver joined up, multi-agency services that listen to the voices of children and their families are not always there or working as well as they could. There are also barriers created by current systems that get in the way of the people trying to deliver services for the children and young people of Scotland. I'm committed to helping to improve working between all services that work with children and young people and I'm frustrated on behalf of the children and young people and the practitioners and services that I have spoken with. I want to give them the power to make the changes that will make a real difference.
8. I have been disappointed by the current lack of good data in Scotland. This is both around outcomes for children and young people using services but also around finance and spending on children's mental health and mental wellbeing. It is difficult to pin down where accountability and governance for children and young people's mental health services lies, how money is spent, the impact it has, and the value it brings to improving the mental health and mental wellbeing of children and young people. It is my view that services cannot improve without good quality data, which in turn brings transparency. The forthcoming Audit Scotland report will set out in more detail where some of these deficiencies lie and it is my view that we must act upon that in order to create services which are open, transparent and accountable to the people they serve.
9. I have heard about workforce shortages for specialist CAMHS services and I think there is a role for the Task Force in building capacity and capability across services. However, I would also say that there needs to be more innovation and flexibility in CAMHS team structures. There should be scope to use alternative members of the multidisciplinary team when one professional group is in short supply. For example, I saw evidence of posts advertised for psychology graduates that attracted six suitable applicants for one post. I also saw similar excess in applicants for Allied Health Professional posts. I would like the Task Force to promote and support development in a diverse workforce in CAMHS, whilst growing the workforce elsewhere in the system to support children and young people's mental health and mental wellbeing.
10. I'm disappointed - but not surprised - that the waiting times for child and adolescent mental health services ( CAMHS) are going in the wrong direction. I want the Task Force to work to address that quickly, and in a sustainable way. It will be important to change public perceptions about what CAMHS is for and who can benefit from accessing treatment. The information that we have around waiting times, and rejected referrals to CAMHS, is by no means the whole story, but I feel that it is a strong indicator that the system is fragmented and needs to change. Building on the recommendations from the Audit of Rejected Referrals will be a starting point for this work.
11. This has brought me to the understanding that in order for change to be sustainable, the Task Force must tackle the current issues with waits for CAMH services. This work must be combined with more services for those who need support but who don't require a specialist service. It will also be necessary to improve coherence within the system, bringing in all of those who provide services to children and young people, including health boards, schools, social services, youth justice and the third sector. Only by taking this whole system approach can we get closer to giving confidence to children, young people, their families and carers that they will be supported in good mental wellbeing and that they will get help fast when mental ill health occurs.
12. When I spoke with people, there was common agreement of what is required to reform and improve the system of children and young people's mental health services:
- A stronger focus on prevention, social support and early intervention;
- A wider range of more generic, less specialist interventions to free up specialist services to see those in most need of them; and
- Better information and understanding for the public, and all agencies and services, of where emotional distress and mental health and mental wellbeing problems are best supported.
13. I have been describing the Task Force's work in four strands, which bring together the views of the people I have met. These strands describe a grouping together of characteristics of people who may need similar services. The strands are not mutually exclusive. They will give the Task Force a starting point for different types of service development . My description of these strands has found support with both practitioners and young people. I offer a new framework for CAMHS that is essentially a paradigm shift in how we approach supporting those with mental health issues.
14. This framework represented diagrammatically in annex A describes connected activities in four areas around educational settings, community provision, primary care mental health support and specialist services . How these are delivered in each area is flexible but the functional components of the framework need to be in place and work together. This paradigm shift aligns with the expectations and rights of children and young people to know what mental health and mental wellbeing services are in their community.
1. A Generic strand of children and young people experiencing emotional distress and anxiety. This might be related to interactions with their peers, issues at home, or in school. These issues primarily require support in communities from peers, youth workers, third sector, or primary care mental health workers (supported by specialist services if required).
2. A Specialist strand of children and young people with serious mental health problems who require rapid access, assessment and treatment by specialist CAMHS, and who require to be supported by other services as they recover.
3. A Neurodevelopmental strand of children and young people who may show issues with their early development that may indicate a neurodevelopmental disorder such as such as Autistic Spectrum Disorder, Attention Deficit Hyperactivity Disorder or learning disability. These children require specialist assessment and support from paediatrics, educational psychology, third sector organisations specialising in this area working with specialist CAMHS.
4. An At Risk strand of young children who have serious or multiple adverse experiences in their early lives, and who may be looked after or in care. These children are often passed from pillar to post, and often not offered a service due to multiple changes of address, unstable home environment or lack of school attendance. They may have no diagnosable mental disorder, but do experience severe distress. Addressing personal and family issues with this group in infancy and before school would prevent more serious mental health problems later in life. This group would also include young people experiencing the multiple problems of addiction, homelessness and poverty. They are more likely to have experienced serious or multiple adverse experiences in their early lives. They may not have a diagnosable mental illness, but there is a role for mental health and mental wellbeing services to work together to improve these young people's lives.
15. Work for the four strands will build on - and plug the gaps in - community based support and responses, linked with education, third sector children's services, mental health and youth work, and primary care. Based on my discussions, there is scope to deliver early identification and support in schools and tertiary education, community based support from statutory services and the third sector, primary care mental health workers, advanced nurse practitioners offering a range of interventions, and stronger specialist CAMHS services. I welcome the commitment from Scottish Government in this year's programme for government to putting in place systems to fast-track those with serious mental illness to specialist treatment and to developing services for community mental wellbeing for 5-24 year olds and their parents to provide direct and immediate access to counselling sessions, self-care advice, family support, peer-to-peer support and group work with links to other care settings
16. A key aspect of this development will be the principle of 'no wrong door'. I want to see an end to signposting that is not effective. Instead, support for children, young people, their families and carers should be responsive to the needs of the child and family, stick with them, and help them to access the services that will best meet their needs.
17. I will convene the first meeting of the Task Force in October. At each meeting of the Task Force I will share the chair with a Young Scot Youth Commissioner. This is a crucial way to keep the views of children and young people at the centre of the work. I have set out my recommendations for the work of the Task Force. I hope this sets us on the right track for improving the mental health and mental wellbeing of children and young people in Scotland because we can, and must, do better.