Together for Children and Young People Programme

Information submission to the Children, Young People and Education Committee

April 2019


1.  Introduction

This information is provided as a companion document to the evidence submitted to the Committee on the overview of progress of the Together for Children and Young People programme. It seeks to set out key elements of the performance and benchmarking information that assists in understanding the previous and current position on a number of indicators. The information set out below is from a number of sources and historical trend data has been made available where comparable information has been recorded over a period of time.


2.  Information sources

One of the key elements of the Programme was to seek to improve the ability of meaningful information to guide service development and aid a judgement on performance. The NHS Benchmarking Network (NHSBN) runs an annual CAMHS collection, covering inpatient and community services. Every Welsh Health Board now takes part in this collection and has done since 2015. Data is submitted directly by Health Boards to NHSBN, who then analyse and validate the data with the Health Boards. The other key source of information for the purpose of this supplementary report is the Welsh Health Specialist services Committee (WHSSC) information collected from providers of tertiary (inpatient) services.

Some information streams are under development, with neurodevelopmental service information collection and validation processes being tested, with an intent for publication by March 2020.



3.   Specialist CAMHS: Referrals

Wales has experienced a 51% increase in referrals from 2016 to 2018 (3 years period), in comparison to the broader UK increase of 68% increase from 2013 to 2018 (1,857 per 100,000 population to 3,113 per 100,000 population). Wales now has a higher number of total referrals received (3,539 per 100,000 population in 2018) than the UK (3,113 per 100,000 population in 2018). Graph 1 below indicates the comparator benchmarking information.

There was a 61.5% increase in referrals to CAMHS in Wales during the two year period. This means a significant increase in the number children and young people being referred by GPs or other services. It will be key to understand the 2019 data in relation of the continuation of the increased rate of referral.

There are multiple reasons for an increase in referrals, however the underlying prevalence of mental health concerns in children and young people is thought to have increased by less than 2 percentage points according to the NHS Digital Prevalence study in England. Greater awareness of mental health matters, and improved access times and modes may be the key reasons for increasing referrals.

Graph 1 - Total Referrals received per 100,000 of Population

Source: NHS Benchmarking Data






4.  Specialist CAMHS: Referrals Accepted


Referral acceptance rate is the proportion of referrals received which were accepted for assessment by the CAMHS teams. There has been an increase of 39% in accepted total referrals from 2016 to 2018.  Wales is now largely comparable with the rest of the UK based on 100,000 population. Graph 2 outlines the key comparator trend. Noting that the first reporting year was 2016, it will be important for further years benchmarking for Wales to be gathered. There could be multiple factors relating to an increase in accepted referrals including some of the new ‘up-front’ discussions taking place regarding potential referrals, the increased capacity of specialist CAMHS teams and a greater understanding by referrers as to the role and function of specialist CAMHS.

Graph 2 - Referrals Accepted per 100,000 of Population

Source: NHS Benchmarking



5.   Specialist CAMHS: Waiting Times

Wales has seen a 45% reduction in the mean waiting time from 11 weeks in 2016 to 6 weeks in 2018. Wales is now reporting a lower mean waiting time to first appointment than the UK. It is fully recognised that some people will be experiencing a longer wait, however since the introduction of the new waiting times standard for children and young people there has been a significant improvement in access times. Ensuring that this can be sustained is key, particularly given the rising number of referrals and the increased referral acceptance rate. Graph 3 outlines the comparator position of Wales and the rest of the UK.




Graph 3 - Mean Waiting Time from Referral to 1st (routine) Appointment

Source NHS Benchmarking






6.  Specialist Inpatient CAMHS

There are 4 key indicators drawn together in this report that demonstrate the position of specialist inpatient CAMHS. These include the occupancy rates, numbers of admissions, out of area placements and workforce information.

There is a recommended 85% occupancy level for inpatient facilities to maintain sufficient flexibility to manage variation in demand. Wales has seen a largely consistent occupancy level when taking the annual data, with a slight reduction of in the bed occupancy of 4% in 2017/2018 (equivalent to approximately one person) as demonstrated in graph 4 below. This occupancy level is despite the introduction of the Community Intensive Service.

Not highlighted in the graph below, there does appear to be a particular increase in demand during the months ofSeptember and October, and January and February.





Graph 4 – NHS Wales Tier 4 Inpatient Units Yearly Occupancy Rates Source: WHSSC Monthly Returns


As outlined in Graph 5 below, there has been a reduction in the number of admissions to the South Wales inpatient unit (Ty Llidiard) from 90 in 2015/16 to 76 in 2018/19, with an increase in the number of admissions to North Wales inpatient unit (NWAS) during the same period from 26 to 29.

Coupled with the occupancy rates above and the out of area placements data below (graph 6) there is evidence to suggest that this is an overall stability in the numbers of young people requiring inpatient support. Given the increased number of referrals the expected increase in inpatient episodes appears to have been managed through the introduction of the Community Intensive Teams and their focus on early intervention and support closer to home.

Graph 5 – NHS Wales Tier 4 Inpatient Admissions

Source: WHSSC Monthly returns





Graph 6 - CAMHS Out of Area Placements

Source: WHSSC Monthly Returns

Wales is seeing a return to the 2015/16 number of out of area placements after an increase in 2016/17.  

An out of area placement can be within Wales (independent sector) or in England (NHS or independent sector). The reasons for using an out of area placement could be because of lack of capacity within NHS Wales units or because the person has specialist needs, such as learning disability or requires a high level of security. Young people who are placed out of area have the support of quality assurance reviews of their care and case management to support a return to home or close to home as soon as possible.

Graph 7 - CAMHS Inpatient Workforce, Total WTE per 10 Beds

Source: NHS Benchmarking


There has been a decrease in the number of whole time equivalents per 10 beds in Wales from 47 in 2016/17 to 41 in 2018/19, however Wales has more WTE per 10 beds (41) compared to the rest of the UK (38). There has been a shift in some staff from an inpatient setting to the community setting, as well as an overall shortage of workforce supply in some professions.


7.  Community CAMHS

There are several pieces of information that help present the picture of community CAMHS, including caseload, number of contacts and staffing.

Caseload is the number of active patients seen by services. The caseload figure is a snapshot at a point in time, in this case 31st March 2018. Caseloads reduced by around 20% between 2016 and 2018. This may be due to either:

·         caseload ‘cleansing’ (removing from caseload people who are no longer receiving support) or, 

·         reducing the length of time people spend on caseload (by discharging sooner)

Graph 8 - Community Caseload - Number on the Caseload as of 31 March of each year per 100,000 of total population

Source: NHS Benchmarking












Graph 9 - Total Number of Contacts per 100,000 of Population Covered (0-18)

Source: NHS Benchmarking

A contact is a therapeutic intervention with a child and young person. Contact rates include both face-to-face contacts (physical meetings) and non-face-to-face contacts (video calls, telephone etc.)  

Wales has experienced a 47% increase in the total number of contacts per 100,000 from 2016 to 2018. The UK experienced a 5% increase in total contacts during the same period.

There was a 53% increase in contacts between 2015/16 and 2017/18. This probably reflects increased activity in CAMHS services due to expanding workforce and could also reflect improvements in the way contacts are recorded.

Graph 10 - Total Number of Contacts per 100,000 of Population Wales: Source NHS Benchmarking


Graph 11 – Total Staff Number of Community staff (in Whole Time Equivalents (WTE)) per 100,000 of Population

Source: NHS Benchmarking


Wales has seen an increase in the number of community based WTE per 100,000, from 53 in 2016 to 87 in 2018, an increase of 64%. The UK has seen an increase of 14% in the number of community based WTE per 100,000 from 66 in 2016 to 75 WTE in 2018.

Wales’ average workforce WTE has been increasing and Wales now has more staff per 100,000 population than the rest of the UK. The size of the workforce is a good indicator of capacity within a service, and across the UK the CAMHS workforce has grown substantially in recent years following new investment and prioritisation of these services. 

A 62% increase in posts in Wales was reported between 31st March 2016 and 31st March 2018 due to NHS Wales and Welsh Government focus and investment.  

Graph 12 – Total Staff Number of Community WTE staff per 100,000 Population (Wales)

Source: NHS Benchmarking



Graph 13 - Community CAMHS Workforce Profile

Source: NHS Benchmarking


The workforce profile differs between Wales and the UK. In 2018, in Wales 37% of staff were from nursing whereas in the UK this was 30%. Medical staff rates were largely comparable between Wales and the UK, at 9% compared to 8% respectively. In relation to psychology staff Wales has 12% of their staff from this discipline whereas across the UK this is at 16%.

Wales has a higher vacancy rate per 100,000 population than the UK according to 2018/19 data. Further information on provision will be available following completion of the Delivery Unit peer review due in June 2019.


8.  Neurodevelopmental Services

The introduction of the 26 weeks waiting time from referral to treatment has now been fully implemented across Wales. The first full year of performance information will be available in April 2020.

The tangible outputs from investment into this area of work has seen the implementation of the six standards and pathway, with the focus during 2018/19 has been on implementation of the pathway and supporting service improvement.

The prevalence data from NHS Digital (England) shows a significant increase in demand for services by 2-4 year olds (5.5%), and it is reasonable to conclude that Wales will also experience a similar increase in demand.

It is anticipated that the current service will struggle to meet capacity and as a result further work will be commissioned this year to scope the ‘perfect world’ model for the provision of future services. Demand and capacity modelling will seek to quantify the impact of a number of scenarios in terms of increased prevalence rates.



·         Demand for services: In relation to specialist CAMHS, there has been a significant increase in Wales in referrals over the past few years. Although not as steep, there has been an increase in demand in the rest of the UK. There appears to be some variation in demand for inpatient services, suggesting that the impact of the Community Intensive Teams has been to help support young people and their families in a different way.


·         Accepted Referrals: There has been an increase in the ‘accepted referrals’ for specialist CAMHS, suggesting an increased awareness by refers of the role and function of specialist CAMHS, and the increased availability of the specialist CAMHS resource.


·         Waiting Times: There has been a significant improvement in waiting times for young people accessing specialist CAMHS, with the average wait for a first routine appointment at six weeks. The waiting times in Wales are currently shorter than the rest of the UK comparator.


·         Staffing: Wales has seen a fifth consecutive year of increase in community CAMHS staffing across the UK.  The additional investment in workforce has seen an increase in staffing levels based on WTE per 100,000 and as such Wales has higher than UK average staffing.