1. Information and working context of Barnardo’s Cymru
Barnardo’s Cymru has been working with children, young people and families in Wales for over 100 years and is one of the largest children’s charities working in the country. We currently run 86 diverse services across Wales, working in partnership with 16 of the 22 local authorities.
Every one of our services is different, but each believes that every child and young person deserves the best start in life, no matter who they are, what they have done or what they have been through. We use the knowledge gained from our direct work with children to campaign for better child and social care policy and to champion the rights of every child. We believe that with the right help, committed support and a little belief, even the most vulnerable children can turn their lives around. We aim to secure better wellbeing outcomes for more children by providing the support needed to ensure stronger families, safer childhoods and positive futures.
2. Specialist CAMHS
Waiting times
The experience of Barnardo’s Cymru is that, in some parts of Wales, the prioritisation of funding towards intake and assessment for CAMHS, has resulted in positive outcomes in terms of reduced waiting times.
However, whilst we welcome the reduction in waiting times in these areas, there are concerns that:
■ There is a lack of investment in support services required to manage the increased identification of need.
■ There is a perceived absence of suitably qualified professionals available to offer a range of psychological treatment options, such as CBT, DBT and family therapy.
■ The increased focus on diagnosis of children and young people will result in those without a diagnosis being denied the appropriate support they require, which is particularly the case for younger children, whose symptoms may not necessarily fit with a particular diagnosis.
In some parts of Wales, it was reported that waiting lists remain increasingly high, with some young people waiting up to a year for an appointment with CAMHS.
Variations in practice and equity of access across Wales
The view of Barnardo’s Cymru is that there is a continuing issue of inequity of access across Wales in terms of both availability and variety of services to support children and young people with mental health issues.
There seem to be pockets of good practice, with strong service offers for certain conditions, whereas other services are chronically underfunded and overwhelmed. Access to services in rural communities is still proving challenging to some of our service users due to reduced levels of service delivering across wide geographical areas.
There was a concern amongst our staff that service closures are resulting in a loss of expertise and learning as well as the loss of service provision for children, young people and families.
There is a need for more sharing of knowledge in certain areas. In many local authorities, there are knowledge exchange fora. However, there are inconsistencies across Wales in terms of how they operate and which professionals or organisations are included in each network.
Over-referral to CAMHS
The majority of Barnardo’s Cymru services work with children, young people and families with high levels of social and emotional need. Practitioners are familiar with dealing with trauma and negotiating crisis with individuals and families. However, inevitably, there will be issues that arise for staff where they feel they have a lack of knowledge, confidence and back up in addressing distressing presenting issues or behaviours. What helps in these situations is having access to specialist mental health consultation and support and having clearly laid out pathways whereby other services can be engaged in support, decision making and, where necessary, onward referral.
In Newport, a CAMH service offers psychological consultation to professionals working with children, young people and families and, where necessary, training. As well as helping to reduce inappropriate referrals to CAMHS, this helps to ensure an appropriate, safe practice response.
Referral and access to CAMHS according to individual health boards, restrictions and thresholds
Barnardo’s Cymru notes that there remain concerns of high thresholds for CAMHS, which can leave overworked and underqualified professionals to handle cases, which should have more specialist support.
Lack of communication between CAMHS and other services working to support children and young people with mental health needs, can also create siloed working.
Out of hours, emergency support and A&E
We are aware of some positive developments in this area, including dedicated CAMHS nurses being available at hospitals and on-call for the overdose monitor in Newport for example. This dedicated service, means that children and young people presenting at A&E, including those with suicidal behaviours who may be seen as high risk, are able to be seen and assessed by a CAMHS nurse and referred onto CAMHS as appropriate.
Where young people do present at emergency departments during crisis points, there is a need for professionals to communicate with health and social services to identify the root causes of distress and offer the most appropriate long term support for those individuals. However, this follow up work is not always carried out consistently.
In-patient capacity
Some children and young people using our services travel long distances to access in-patient services. This removes them from their families and support networks, which can cause stress and add to their overall distress.
Rather than remaining in an in-patient facility, which can further alienate children and young people from their family and support networks, our staff suggested that there may be opportunities to offer more intensive support in communities.
The transition back into community based services for those leaving in-patient units can be difficult. This suggests that, where possible, a young person’s mental health might be better supported by having intensive services delivered within the community teams, though we understand that this would not always be appropriate.
3. Funding
Commissioning processes and relationships between local authorities and third sector organisations are extensive, established and generally well understood. However, our limited experience of being commissioned to deliver services by LHBs is different. These commissions have been more complicated and difficult to achieve.
There is variation between LHBs across Wales, with some being easier to engage and work with than others. However, it seems to us that a new ‘language’ and framework for commissioning services from the third sector may be required. Certainly, if the ‘Together for Children and Young People Programme’ aspiration of growing a platform of more psychological and trauma informed non-medical community support services is to be achieved, then this is an issue that will need to be addressed.
Access to psychological therapies, reductions in medication
Our experience is that there remains a need for wider access to a variety of psychological therapies, which should be evidence based and carried out by professionals who are sufficiently qualified to offer these treatments.
In some areas, we think that the prescription of medication to children is at a suitable level, whereas in other areas, medication can be seen as a first resort rather than the last, as we would hope it should be.
In one area, we are aware of parental demand for medication for their children being met with an option to access parenting groups which have focused on alternative strategies to medication to respond to and manage issues presented by their children. In other areas, parents accessing Barnardo’s Cymru services have reported benefits, in terms of being able to understand and manage their children’s mental health issues, from accessing some wider peer support networks.
Primary Mental Health
Our experience is that although Primary Mental Health Care is good in some parts of the country, the quality and accessibility of provision is not consistent across Wales, with some services experiencing very large caseloads.
Vulnerable children and young people
There have been examples of good practice in terms of CAMHS staff being situated within multi-agency teams, working with vulnerable children, young people and their families, such as in Youth Offending Teams. Other services delivering to vulnerable groups, such as substance misusing young people or care leavers, might also benefit from this approach.
A recent report produced by Barnardo’s[1], looked at mental health
needs for care leavers in England. Within the recommendations was a call for specialist mental health workers to be embedded into leaving care teams and for more training on mental health to be offered to all professionals working with care leavers. We recognise that leaving care teams in Wales would also benefit from these developments.
There can be real barriers to engagement with families who have multiple needs and vulnerabilities. Our services report that in some areas work has been done to enable better engagement with these families, by improving communication between health, social services and the third sector.
4. Transition to adult services
The experiences of transition for young people using our services are mixed. There are issues relating to the difference in practice culture between CAMHS and AMHS which present barriers for young people. Within AMHS, the stricter policies around not attending appointments can be difficult for young people to adjust to. In some cases, young people may be at risk of losing their options for support.
Barnardo’s Cymru, in partnership with Welsh Government, has developed a service user led guide, for those transitioning from CAMHS to AMHS called the Transitions Passport. The passport speaks directly to the young people, in the hope that this will empower them to have an improved experience of moving from children to adult services. It is the intention that the passport will be rolled out across Wales. In order to be effective, a dedicated transitions worker needs to support young people in using the passport.
5. Links with education
Assigning health and wellbeing as a key area of learning and experience, and the increasing awareness of emotional health within inspection frameworks creates an opportunity for improved emotional intelligence and prevention of illness.
However, we are concerned that funding should be put in place to ensure that schools are not put under any extra strain, in terms of resources and budgets, which could jeopardise the good intent of the curriculum. We would argue that a whole school approach is important to implementation.
School nurses
We are concerned about the resourcing of the school nurse provision. In some areas, school nurses are working across a number of schools, and carry heavy workloads. Barnardo’s practitioners sometimes found it difficult to establish lines of communication with busy school nurses.
School based counsellors
Issues raised by practitioners in relation to school based counselling include the following:
■ Many young people report positive benefits from receiving this support. However, counselling does not suit all young people and we didn’t receive any information of other emotional health support available within a school environment.
■ It has been the experience of a Barnardo’s Cymru school based counselling service that delivering some of the counselling sessions outside school can benefit those who feel stigmatised when accessing a service in school.
■ There remain problems in relation to young people with more profound need being referred on in order for them to receive more intensive support. These young people sometimes do not meet the CAMHS thresholds. Again, this reflects the paucity of psychological therapy available in Wales.
■ Due to high demand, and a loss of ring-fenced funding for the service, counsellors are often overworked and concerns were raised about their wellbeing.
[1] Smith, N. (2017) Neglected Minds: A report on mental health support for young people leaving care http://www.barnardos.org.uk/19222_neglect_minds_a_report_on_mental_health_2.pdf