 I welcome everybody to the sixth meeting of the Public Audit Committee in this session of Parliament. Before we start our business today, could I just remind everybody in the committee room that social distancing measures are still in place and if you are moving around the room, entering or exiting the room if you could wear a face covering? The first item that we have of our business is to agree to take agenda item 3 in private. Is that agreed? It is agreed. Thank you. The principal item on the agenda today is a round table discussion on the subject that has been a recurring theme both for this committee and I think for Audit Scotland and for the wider Parliament and Public. That is the current state of child and adolescent mental health services in Scotland. It is a round table. I will ask members of the committee to ask questions in particular thematic areas but I do want to stress that it is quite informal and there is nothing to stop panellists asking questions of each other if that is felt to be useful. If you do want to come in and speak, if you are in the room indicate to myself or to the clerks, if you are joining us by video link, if you can use the chat box function and put an R in there and then we will take you as soon as we can. Again, for everybody just to remind technically speaking you do not have to activate your own microphone that will be activated for you. My final word is just to say that do not feel obliged that you have to answer every question that is put. It may be and you will see as the conversation develops that there are particular areas that are most obviously applicable to some of you and probably some less applicable. Come in whenever you want by indicating and please feel free to have quite a freewheeling discussion, albeit that we have got to stick to a timetable. What I would like to do first of all is to invite everyone to introduce themselves. I am going to start with the MSPs who are on the committee and then I shall come to those of us joining us virtually before returning to the witnesses in the committee room. Good morning, I am Sharon Dowey and I am the MSP for South Scotland. Hello, I am Willie Coffey and I am the constituency member for Kilmarnock in Irvine Valley. I am Craig Hoy, the member for South of Scotland and also just for the record also our party spokesman on mental health. Colin Beattie, MSP for Midlothian North and Musselborough constituency. Can I turn to the people joining us via video and can perhaps start with you, Martin? Hi, good morning. I am Martin McKay, I am unison's delegated representative for mental health north and mental health. I am Hannah Axon, I am COSLA policy manager with remit for mental health and I am here representing COSLA co-chair, the children and young people's mental health and wellbeing joint delivery board. Thank you, Donna. Good morning, everyone. I am Donna Bell, director of mental wellbeing and social care at the Scottish Government and joint chair of the children and young people's mental health and wellbeing delivery board. And Alex from Sam H. Hi, good morning everyone. Thanks for the opportunity this morning. My name is Alex coming in with assistant director with Sam H, with lead for children and young people services. And Alex from Grampian. Good morning, everyone. I am Alex Perry, I am service manager for childhood and adolescent mental health services in Grampian. And Caroline. Hi, I am Caroline Amos and I am the chair of mental health and wellbeing working group. Well, thank you very much and thanks to all of you for taking part in this morning's round table discussion. As I said, I am going to start with some questions from MSPs but feel free to come in when you want to make a contribution or a point. And I am going to begin with Sharon Dowie who has got a question to get us under way. Sharon. Good morning and if I could maybe direct the first question to Mr Boyle, the auditor general. Audit Scotland's blog presents quite a bleak picture of performance in terms of access to child and adolescent mental health services, particularly given the significant investment that's been made. The comment was, but the picture today is similar to 2018, despite significant investment. Do we have any idea to the extent of this funding to be able to track this spend against outcomes? And sorry, can I apologise for omitting to introduce our panels that are actually in the committee room before my very eyes? Katrina, do you want to introduce yourself? Good morning. I'm Katrina Morton. I'm a GP and here as Deputy Chair of RCGP Scotland. I'm the lead for policy there and my day job is working as a GP in Craig Miller in Edinburgh. Thank you. Thank you. And Stephen, before answering Sharon's question, would you like to introduce yourself? Thank you, convener. Good morning, everybody. I'm Stephen Boyle, the auditor general for Scotland. In response to Ms Doe's question and in terms of the investment that we've seen in response to the 2018 report, the blog that Audit Scotland produced in August references some progress, challenges that remain and what's an extremely complex system. We also have all seen the increasing demands that have come through from children and young people for mental health services, much of which has been exacerbated, of course, through the course of the pandemic. In direct response to your question, Ms Doe, whether we're yet seeing the impact of the investment in improved outcomes, we've not seen the, I suppose, two factors, enough time or enough data yet to make the direct correlation between improving outcomes from the investment that's being made. We would recognise the range of initiatives, new frameworks, new guidance that have taken place following the recommendations in the 2018 report and that some of those are planned to be implemented between now and 2023. The one observation that I think I would finish on is that by that point we'll be five years on from our original report and what's already a very challenging environment and all the more need for urgent progress to support Scotland's children and young people with their mental health. Okay, and I'm sure that we will return to some of those themes. I wanted to really begin by asking a question of the co-chairs of the delivery board, so perhaps taking Donna first and then Hannah could come in after that. One of the things that's in the blog that was produced by Audit Scotland spoke of, and I'll quote it directly, it said that there is a steep hill to climb and making it to the top will mean listening to and learning from the experiences of children and young people and their families. So my question to Donna and Hannah is, would you agree with that analysis and what action are you taking through the delivery board to get us further up that steep hill? Thanks, convener. It's always helpful to have contributions from Audit Scotland on our work and I think we've identified very similar issues to those that the joint delivery board has identified and has been working on for a number of months and in previous forms, years. I think that we're all agreed that change is still needed to make the necessary improvements for children and young people. Obviously, the discussion that Steven started to bring out there about the pandemic has had a significant impact on children and young people in addition to increased demand over recent years. I think that in terms of the engagement with children and young people it is something that the joint delivery board has prioritised. We now have three young people who regularly participate in the joint delivery board and they are very able and very helpful contributors to that. I think that that is an excellent start. We also have a children and young people's participation officer who supports us in the joint delivery board with engagement with young people about how services and support is working for them and routinely feeds back to us at the board about those experiences and what we should be doing as that joint delivery board to make the necessary change to support them better. On that point, can you confirm that those young people are members of the delivery board? Yes, they are. What about other family representatives? Do they also have a voice at that table as well? We have a representative from the national parent forum who is a member and joins us routinely to feed in from a parental point of view. We realise the impact that the issues that might arise from children and young people having mental health concerns and the impact that that has on their families. The engagement with parents is also really important. Again, the colleague who comes from the national parent forum is a really helpful and engaged participant in the board. Can I turn to Hannah Axon just to give us a local government perspective on that steep hill and where you see things? How far does the summit appear to be away from where you are? Well, it is a steep hill. It is a challenge for all of us. From a board perspective, the scope of the work that is being undertaken is really encouraging so that the board has a focus on preventative work but is looking at a set of deliverables that include community support and crisis and look at neurodevelopmental services and CAMHS and the support that is required for our staff. A broad cross-section of work is being progressed, but it is really encouraging. We have really good local government representation across that, although our colleagues from ADES, our educational psychologists, are really bringing the right people together to have those discussions and move up the hill. Going back to the children and young people's representation, that is happening in all parts of the board's work. We have the children and young people around the table at the board. We also have a set of youth engagement principles that we use across the full scope of the work. There are task and finish groups looking at the delivery of each of the aspects of the work. We are thinking about how we involve children and young people in those steps and how we involve them in a way that is really valuable and means that we can take that forward. We also look at how we involve children and young people at a local level. For instance, if we look at the community support framework, there is an ask within the framework. There is consultation with children and young people, so it is being built in throughout the approach that the board is taking at the board and in the resulting work at a local level. Alex Perrie is a member of the delivery board as well. Do you have any perspective on the steep hill and where we are on it and the engagement of young people and families? I think that, as Hannah said, we are looking in a broad scope. It is a steep hill, but we are definitely going in the right direction. I think that the key thing that we have to do is listen to the voices of lived experience, because they are the experts in their own lives. Certainly, the task and finish group that I sponsor is the implementation of the national cancer specification and how we are developing a support programme. We are certainly working with the participation officer to get the voices of lived experience to help to shape the direction of travel. We have to be mindful of how we engage children and young people. A key learning point for the joint delivery board is the fact that we are scheduling our meeting. That is to call for them to join us. We do not want to be meeting in school times, but it is a steep hill to climb. I want to pick up an honest point about the community mental health and wellbeing support framework. My own experience in granting has done a lot of scoping and planning, but I am listening to the children and young people and their families in a local community to find out what is needed. That is why the approach that we are taking is right for that local area. Aberdeenshire is doing something slightly different to meet the needs of the demographic, and it is the same city. It is a really good movement, and we are very engaged in what we are doing with our children and young people in communities rather than doing to. We are going to come on and look in a bit more detail at the Grampian experience. Can I turn back to Sharon Dowie, who has a question on referrals? The Audit Scotland blog refers to a task force set up by the Scottish Government and COSLA in 2018, which concluded that earlier guidance and support was required for GPs, health visitors, school nurses and others. In 2021, what guidance and support exists for those professions? What changes have happened? Could I direct that one first of all to Dr Morton? Maybe after that, if Mr Mackay for unison wants to come in? Is there any other comments from anyone else? That question was about two things. One was about guidance and support, and the other was about referrals. Prior to this meeting, we contacted all our faculties in Scotland. The RCGP is very closely involved with them, so I have feedback from GPs across Scotland, particularly in Lothian, where I work. The feedback is very consistent. There is a big yawning gap. Obviously, GPs offer universal services and holistic care. One of the advantages that we have is that we work closely with our health visitors and other members of the family. It is often the whole family that is involved when a child or an adolescent has a mental health problem. However, the feeling is still that the bar for referrals is very, very high. Some of the feedback was GPs, and I include myself in this. I will think three or four times, and I am quoting there before even considering a referral. We have high levels of referral rejections. The other thing about referrals is that we know how damaging it can sometimes be to the person referred and their family if they get a rejection, because they have often tried lots of other things before they get to us. Those things are often provided by schools, and that is more difficult when schools have been shut, and it is also more difficult for children who are excluded from schools or who will not go to schools. Schools are not open to everybody. In terms of referrals, early on in the pandemic, we were generally asked not to refer people unless it was extremely urgent. That went across the board, and we tried to stick to that. However, the feedback that I have is that the waiting times are often one to two years, and that is also a deterrent to referral. If you know that somebody is not going to be seen for such a long time and get treatment for such a long time, it means that it is difficult to say to a patient and their family that this is what is going to happen. Essentially, there are no tier 2 level services. The other thing that has been more difficult is that some of the third sector organisations that would be available to us and children and families during the pandemic have had to shut their doors completely understandably, so they have been less accessible. I read the 2018 Audit Commission report on rejected referrals, and I am just going to say that the feedback that I have had and my personal experience is that things do not feel very different from that. What has happened is that signposting has improved in some areas, but it does not feel very different from that. I have to say that your comments are quite concerning, because the comments that you are coming out with just now are the exact same comments that I have just read in the report that was put out in 2019, which is obviously why we are trying to look at where the money is getting placed and whether we can actually measure what the outcomes are. Mr Mackay, do you have any comments from unison? Yes, thank you very much. Reflect on the discussion that we have just had. In terms of the blog and the board waiting times from the previous years, I think that it is interesting to note that, apart from a few outliers, there is quite a lot of static data in there where there has not been a significant amount of change in the referrals, and I think that it would have been interesting to have, in this ties into the discussion that we have just had, about the blogs in the system and the waiting times that are experienced by others in the committee today, if we had data about the whole-time-equivalent staffing group within CAMHS services across the board. I can certainly speak for my own area. I am from NHS Grampian, and I have worked alongside Alex for quite some time. I know the changes that we made to the staffing cohort have probably brought the regular increase of the improvements in NHS Grampian. It would be interesting to see if we are looking about delivering services in equal access and equal quality of service across the country for the next five, 10, 15, 20 years, and I have worked in mental health services for 30 years. I have been around CAMHS services for quite a significant part of that in different roles in terms of service redesign. I know where we looked to plug the gaps to improve the service, and it would be interesting to see if models can be replicated elsewhere. It is concerning the data to see that some areas have dropped, and if that is in terms of their deliverable data and if it is in influence by staffing changes. That data will be there. Each board has data of what their staffing cohort is and what roles they have at what band, etc. It is one of the things that has to be looked at across the whole of Scotland. We need to look about that. The comment by the call is about tier 2 services and access, how we can improve access at an earlier stage to improve outcomes for children and young adults, because a lot of that is done to see who they can see and what that person can do and the actions that they can carry out in terms of their job role. I think that from a unison's perspective, the broader and the more effective the working team that you have to deliver a service with more skills improves the outcome for the service user, for the families, and improves the service and the work experience for the members of staff. That all goes to improve the entire experience. We need to look at more than just snapshots of some data and understand why the referral and the waiting times are a big priority, because it is something that you can latch on to and measure, but there are a lot of other impacts in there. The focus is quite a lot of our attention to see where it can be improved and where those improvements have been effective elsewhere. Is there anyone else that wants to— I think that we have a number of people indicating that they want to come in on this. I am going to take Alex Comeyne from Sam H first, and after that I shall come to Alex Peary from NHS Grampian. Alex, do you want to come in just now? Yes, thank you. Some of the stats that Ms Morton mentioned in the blog report are absolutely heartbreaking and distressing for families, but some of the comments that Hannah made as our first input are really, really key. This is about the breadth of work that is going on within the system. Overall, we need to shift the conversation from just CAMHS to that whole system change. I think that that is really, really important. The guidance that the programme boards about the CAMHS criteria is really, really helpful, but there is still a total lack of understanding within the wider public about what CAMHS is there for, what it can support, et cetera. I suppose that, probably understandably, children and young people and their families still assume and still want CAMHS to be the place that they can get support. Some of the campaigns and information over the past 18 months around by-fields, clear ahead, are all supporting that kind of foundational level around mental health understanding, mental health awareness and having that kind of conversation. However, I think that there is much more that we need to do collectively around the wider public's understanding of what CAMHS does. That actually CAMHS is not the only way and the only space to get into supporting mental health. I am sure that we will come on to talk about the tier 1 and tier 2 services at some point this morning. I think that, going back to what Ms Morton's point about CAMHS referrals and GPs, et cetera, we have had just in the past month a number of conversations with primary care and GPs are still saying that they are really disappointed and are not understanding why some referrals are not accepted. However, I wonder—again, this again comes down to the system around whether those within primary care have the time and the space to be able to pull all the information together that is required for a referral within a 10-minute appointment and also those barriers around some of the virtual appointments that are going on at the moment. Is that something that is challenging for young people to express their story and their concerns so that GPs can fully implement that referral? That is maybe why there is a number of referrals and information that goes back to GPs for more information. I think that that is where some of our initial recommendations from previous audit reports around that multi-assessment process for referrals should be considered, and we encourage the Government to do that. Within a well-functioning system, we know that we would not have any rejected referrals, but at the moment, our view would be that our concern would be whether they are meaningful and if they are personalised signposting from CAMHS. The CAMHS service works extremely hard to make sure that communication is compassionate, but we know what individuals do when that letter lands on a young person's door. Again, it can be really redistressing and people can be quite despondent about it. We do not know whether individuals are getting that additional support and accessing those additional services, but that is why at SamMage we are funding an 18-month system change project in South Edinburgh. We are speaking to our colleagues at CAMHS, children and young people families, and all those who have been rejected from CAMHS ensure that we understand how we make sure that the system, the information and the communication are appropriate. The initial findings so far suggest that we know that families and young people need more information and that they need a guided conversation following that CAMHS rejected referral. There are a range of services out there and they do not know how to navigate that themselves, so we need to be able to provide them that support. I do not think that that necessarily needs to be a role for CAMHS, but it needs to be funded and it is something that we are certainly going to be looking at in the near future. Thanks, Alex. GPs were mentioned a lot in that, so I will come to Alex Peary and to Donna Bell and to Hannah, but I do want to bring in Dr Morton back in at this point. All of that that was said there does ring true with me in lots of ways in the sense that it is not all about waiting times, but when we refer people that we consider to be tier 3 or tier 4, who then wait one and a half to two years—not for tier 4, obviously—we get a feel for how long people are waiting because they come back to us repeatedly. We get a feel for all that and the distress in the meantime. Throughout Scotland, those are the figures that people have been quoting me, just to come back to those waiting times. I think that in terms of other support, that is absolutely key. Having somebody follow up people who have been referred to CAMHS who are not seen would be so much more helpful than signposting, because often people have done all of that. They have done all the things to do with signposting. One of the feedback that we have had is that people referred to CAMHS and then told them, we will go and see your school nurse or go and see a third sector worker where their condition is far more serious and severe than could be managed by those systems. In terms of 10-minute appointments, as you will know from elsewhere, GPs are working flat out just now. It is very difficult if you are consulting with 30 or 40 people a day to give time to individuals, but, personally, we would always see a child with mental health difficulties. I cannot imagine not seeing them face to face. I referred somebody this summer who I saw several times face to face because it needed a lot of assessment. That person was in their teens, they were self-harming, they were anxious, they were depressed, they were no longer seeing their friends, they were isolating, I referred them and the referral was rejected. I consider myself a very experienced mental health GP and I felt that that was an appropriate referral. One of the other themes that we have from GPs is that there is nothing upstream. What happens is that people deteriorate until they are at a point where they have to be referred to CAMHS and it would be fantastic to have that upstream working. I am a member of the Royal College of GPs who attends the Scottish mental health partnership. We are one of 17 organisations. There are two medical colleges there and we talk a lot about mental health provision in medical terms. The other organisations talk about how we can change things now to help the future so that we do not need all this medical input. I do not see that here. I see children and young people not getting help at a point where some of that could be improved or reversed earlier so that they either struggle on by themselves or with facilities that cannot match the severity of their condition. We are really building up difficulty for the future for our NHS but also for those young people who will take these mental health problems into adulthood. We know that that happens. That is also what we need. I completely agree with that. It is quite heartbreaking to see that that affects not just the child but the entire family. Many of those families, adults, too, have mental health problems. It is not just the child. Increasingly, we are concerned about safety. We know that alcohol and drug deaths have gone up markedly in Scotland. We know that domestic violence has gone up during Covid and it is very hard to know sometimes what is happening to some children unless they present to us or unless we happen to come across them in other ways. Thank you for that powerful testimony from the front line. There were some other panellists who wanted to come in, so I am going to turn now to them. I am conscious that time is marching on, but I want to give an opportunity to come in on this point to Alex Peary and then I shall ask the two co-chairs of the delivery board to come in. Alex Peary, if you want to come in first. Thank you. I just wanted to touch base on some of the things that we are doing in Grampian to support the referral process from GPs to CAMHS. We have published quite detailed referral guidance, which is available to our GPs on our GP portal on the NHS Grampian Internet. I appreciate that our GPs are really incredible business. Dr Morton is highlighted in our 30-40 consultations a day, so we have done things such as visualising what the referral process is and what is an appropriate referral. We are also trying to look across our system in Grampian about how we raise awareness of the Tier 2 services that are being developed via the community mental health and wellbeing supports framework. Within Grampian CAMHS, we use a choice and partnership approach. A child or young person is referred to CAMHS and we take them for an initial assessment and appointment. It is very much looking at the assets and options available to the young person. It is their choice whether they carry on in CAMHS. Sometimes, CAMHS is not appropriate for them, so we will signpost them, but we write that to our GPs so that they are aware. Certainly, we have attended meetings with a GP sub-committee to see how we can maybe improve the interface between CAMHS and GPs. We have also aligned clinical teams into satellite teams so that they are more closely linked to GP practices. Dr Morton picked up earlier on some of the staffing challenges. For example, we know that we have got a national shortage of psychiatrists, what we are doing in Grampian as we are looking at other types of staff. For example, we are working to increase our nurse prescribers, which should help with patient flow. I am happy to say that the current waiting time to first appointment for CAMHS in Grampian is six weeks. It is very sad to hear that, in some areas, it is one to two years, but, along with the joint delivery board, we are looking to develop a support program to help other CAMHS services to move forward. Alex from Samhichael is a really good point. I think that CAMHS services across the board need to get better in terms of publicising what we do and what CAMHS is for. Certainly, that is some of the things that we are looking to do in Grampian around Facebook and other options for social media. I just wanted to highlight some of those things. I am going to turn to Donna. Forgive me, Hannah, I gave you the elevated title of co-chair of the delivery board, which I know you are not, you are here representing COSALAR and the voice of local government on that delivery board. Can I ask Donna to give us her observations? I think that colleagues have covered quite a lot of the issues that I would raise already. It is not common for people to wait for two years, but, obviously, where that happens, we absolutely need to improve it. I think that the position that Alex Piri has highlighted the arrangements that are in place for really much CAMHS point of view. We know that, for example, in Fife, there are arrangements in place for primary care mental health workers to meet with children and young people within two weeks. The position is very variable across the country. The other issues around GP referral are well made by Alex Cummings. The referral criteria were agreed with the College of GPs, so we are always happy to discuss that. If there is a communications issue or if there are other matters that we need to follow up on there, we are always happy to do that. The other point that I would raise is that, for particularly long waits, we have seen issues with neurodevelopmental referrals, which are often very complex. We have recently published a neurodevelopmental specification just at the beginning of September and some additional funding to support that of around £5.25 million. We are very aware that, for particularly complex cases, there is more action to be taken. Alex Cummings made points about CAMHS services and Alex Piddy. He also made those points about CAMHS services being able to signpost or refer children and young people to other suitable community services. The points about FRED are really important because one of the key things—Hannah mentioned that at the very beginning—is that we are clear, and I think that everybody in the sector is clear that CAMHS is not suitable for everyone, but we need to have suitable support in place. Certainly, and this might be what Hannah is about to talk about, is the additional support that we are putting in place in the community. Just on the accessibility of CAMHS, we know that CAMHS is the second-highest user of near me. Young people are very comfortable with digital appointments, and that has been a really, really important development over the course of the pandemic. We are really keen to see that carry on, because that obviously improves accessibility and engagement. We are also seeing GPs beginning to refer to those community supports that we are putting in place locally. It is early days there, but it is certainly a promising shift. We know, for example, that there have been more than 350 referrals from health professionals to community services in the past few months. The points about community services have been made. I would go back to what Alex had said about the need for systems change, cultural change and awareness. At a local level, we have a huge task around the promotion of those services. A significant amount of funding is £15 million on community-based support to be in place from January of this year. Services are still quite young, and there is a lot of awareness raising to do with parents to make sure that they are aware that that is an alternative, with children and young people to make sure that they are aware that that is an alternative, because a lot of them are self-referral. I am aware, for example, of CLACs having done an immense amount of work with cinema advertising, with their sports staff going out and doing a lot of promotional work with the children, young people and broader. I think that we are really aware that needs are done and that is actively being done. At a local level, we are also looking at the board, so there is a task and finish group within the board looking at communication across the system. GPs are an area that we are certainly looking at working with in terms of information and making sure that we can support that join up. I am sorry, Hannah. Can you clarify which local authority we were referring to that was using cinema advertising? Clackmannanshire. I want to move on now to another area. One of the people that we have not heard from so far is Caroline Amos, who is the chair of the mental health in schools working group, which was set up by the Scottish Government. We understand that the group has recently produced an online training resource. The first thing that I wanted to ask you was the extent to which there has been take-up of that and how much engagement there has been with it. That is part of the next stage of our work. It has been monitored and the data has been gathered in relation to how many people are engaging with it. It is a resource that can be used by everybody, not just for school staff. The next step for us as a working group is to look at that data and to have qualitative conversations with people who use the resource and are engaging with it and have volunteered to participate in that evaluation. At this point, we do not have that specific data. At the moment, it is about ensuring that as many people as possible are aware that it exists and have access to it. Two questions. First, do you think that when the data is available, you will publish it and put it into the public domain? Secondly, have you picked up any at this early stage any anecdotal evidence of the extent to which the package is going down well or has been taken up or not? It is highly accessible. It is easy to navigate. It has very useful information on it. It has been produced and used in consultation with young people and families. It is the first point that we are debating on how we are involving the young people who have lived experience. Anecdotally, yes, people are engaging with it because it is accessible and easy. Teachers in particular have become very used now to online professional learning throughout the pandemic. It is a time and place of their choosing to engage in professional learning. It is also the kind of resource that you can pick up, leave and then come back to engage with. It is not something that you have to sit with for an entire period of time. I do not think that there will be any issue with publicising the data once we have it. It will be useful because one of the absolute actions of the working group is to make sure that the resources that we have produced are used and have an impact on those that are at risk, because we are expecting them to have an impact on. Caroline, can I just check? Is this aimed at all school staff or is it just teaching staff? No, it is aimed at all school staff. In fact, it can be accessed by members of the public group, by parents too. It is not just open to those groups or those professionals, but it is aimed at all school staff. I know that Alex Cymru, from Sam H, wants to come in on this point. Alex, I will welcome you back in. Thanks, Caroline. Just to say that we were absolutely delighted when, earlier on in the summer, when the information and the new training for all school staff was distributed right across the board, just in relation, it might be helpful in relation to statistics. We also produced some training that was specifically for teachers, e-learning and for school staff. The first month of lockdown was accessed 4,000 times, so I have absolutely no doubt that the new training that has been produced by the mental health and schools group will be really well used. I suppose that a bit of feedback that we had from our previous training was that the youth work sector was key as part of that in supporting. I know that part of the committee papers was about universal support for practitioners. We are just about to launch a specific e-learning for youth workers around mental health as well, which is very foundational. Once they have had an opportunity to complete that, they will maybe see the additional training that Caroline and the team have produced as the next step. With all of that, particularly knowing a lot of the work that is going on in the schools at the moment, it is very much around how leadership in the schools can allow staff the capacity to be able to access those things. I know that everyone, whether it be school, GPs, everyone, we are all at absolute capacity at the moment, so that is going to be a huge challenge. I am sure that all the leadership across the schools in Scotland will be working hard to do that for teachers and practitioners. I can swiftly go back to Caroline Amos. There has been quite a lot of a push for counselling services to be available to secondary schools in particular, and I think that some data came out about that. Some analysis of that came out fairly recently, but I just wondered from your perspective how you think that roll-out of counselling services is going on the ground, either from a Scotland-wide or a North Aesha perspective? This is not part of my remit and it is not part of the working group as such within North Aesha, which is where my day job is. We have counsellors, and we have had them since the Scottish attainment challenge was introduced. It was part of our attainment challenge commitment, one of our work streams. We have introduced them, and we have continued. I am talking about North Aesha, in particular, we have continued to engage with counselling services and increase them across sectors. It is also part of that community, mental health and well being that we have introduced further counselling services as a result of that, to support our younger young people. It has been a positive introduction for us in North Aesha. There is a lot of data in North Aesha in support of that introduction and the impact that it has had on our young people, as we have to report to the Scottish Government for the Scottish attainment challenge. However, I cannot speak widely about counselling services across Scotland. I presume that the delivery board has some oversight of counselling services, so I do not know whether you can answer that question more directly. I know that all our local authority partners have confirmed that access to counselling support services is now available across Scotland. We do not have specific data on numbers of appointments and outcomes as yet, and Hannah might be able to give a bit more feedback on that. We have a colleague from the Scottish Government Learning Directorate, who is also a member of the board. Their feedback is that, certainly, school counselling has been very well received, uptake has been very good and that the teaching staff and other school staff welcome this as an additional intervention to provide additional support on top of pastoral care. I am not sure if Hannah would want to... I know that I should not be dropping my colleagues. It might be that Hannah will want to say a bit more about that. I said at the start of the session that you can ask each other questions, it is not just a matter of fielding questions from members of the Scottish Parliament. Hannah, over to you. Do you have anything that you want to come in? I think that, as Donna said, that we have access to school counselling in all local authorities at this stage, and we have had the first round of reporting on it, which has generated the data that I think the committee has seen. We are looking at shy of 10,000 children and young people having access to counselling at this point. The outcomes data report positive outcomes. I would have to look at the data to come back to you on a figure, but I think that that is encouraging. It is also early days looking at the first round of reports. What is interesting is that we are getting to see some trends. We believe that coming out of that data, where we have young women and more girls accessing counselling than boys. Something to consider there and something really interesting to do around how we align our community services and support where school counselling is not the option that people are ready for or would choose. Early days are interesting learning and I think that that is positive to this point. Thank you. I think that that is useful to put that on the record. My final question for now is really to Alex at Sam H. I suppose that my starting point is that this is a challenge poverty week, isn't it? We know from the Audit Scotland report in 2018 that if you are living in a low-income household, you are three times more likely as a child to suffer mental health problems than if you are living in a more affluent household. There is an issue there of poverty and how that has an effect on mental health, self-esteem, self-harming, anxiety, stress, depression and so on are going to be accentuated if you are being brought up in poverty. Educational performance will be affected as well as overall life chances. My question to Alex from Sam H is, is enough being done to recognise the scale of that challenge and the inequality that that produces? I think that we have been having conversations just this week that inequalities or the inequality of accessing services is almost our number one priority. There have been a couple of comments about virtual access and use of near me. We have absolutely got to continue to use that. That has been helped improvement and has helped access to services. We still know that it is probably those families and communities with slightly greater resources that are accessing services or driving forward towards accessing those services. Whatever happens, I think that we need to have services that are community-based, accessible in some parts of Scotland. I know that it is not possible everywhere, but we are talking about your 20-minute city, so access in some places is more urban areas. We want to make sure that those things are available 20 minutes from your doorstep. I know that it is probably not possible for Alex and Grampian, but that is absolutely critical for anything going forward, particularly around mental health services. We could all be and should be doing more, but I certainly do not think that it is not a focus of all the colleges around the room, I would not say, but it is something that we need more of a focus on. I am going to invite Katrina Morton. You work in a relatively deprived part of the city of Edinburgh, which is where your practice is. I do not know whether you have any reflections on the impact of poverty and inequality on the mental health of the people that you see. I think that it is difficult to sum up very quickly. We know that poverty has a huge effect on mental health on alcohol, drug addiction and wellbeing. Prior to the pandemic, we consulted with about 11 per cent of our population every week, so that was our consultation rate, and around half of those consultations were largely to do with mental health. That has gone up and we did have a quieter time at the height of the pandemic, but people with mental health problems are in distress. We have seen people who have never been mentally ill before presenting with new mental illness and people who are already mentally ill a lot worse. I think that one thing that has helped us and Edinburgh HSCP has been good at identifying the most deprived practices in Edinburgh and making sure that they are prioritised for mental health nurses. We have mental health nurses in our practice. That is part of the new GP contract, but it is something that the college has asked for more generally. However, there are very few practices that have that, and that is just transforming. Often, we are the first port of call, but we also know other members of the family. It is extremely helpful for children's health, but we cannot take on work that other agencies should do. As I saw the rejection rate for referrals from deprived areas, I would argue that those people probably need to have a lower bar because there is often a lot going on in that family that may not always be apparent initially. I am going to try and move the conversation on a little bit. I want to invite Craig Hoy to ask a number of questions. Craig Hoy. Thank you, convener. One is for the auditor general. First and foremost, it is really just a clarification. You noted in the blog at point eight that following referrals to CAMHS looks like the only one bright spot. I was slightly surprised by the fact that even the number was down, but I note that you had the caveat that there is probably a number of extenuating circumstances. To compare that with a report that I read recently from the Royal College of Psychiatrists that pointed to data from Public Health Scotland that said that in the second quarter of this year there were 10,193 referrals to CAMHS, which was the highest ever, and now equates to 100. If you have any update on that data to point to the fact that maybe that may have been a mirage almost. I think that you are right. I think that there is a pandemic-orientated aberration in some of those stats. I think that effectively what has been highlighted by Dr Morton in our previous contribution is that referrals and access to services more generally would have fallen right at the height of the pandemic, and we think that that is what is informing those statistics. What we do not yet have is validated data to confirm that that is the case, but I think that what I am hearing over the course of this morning's conversation is that that is probably the circumstances that led to the drop that we reported in the blog. Nonetheless, clearly there have been very significant factors behind the rates of referrals, but the point that we are making more widely is that emerging but yet incomplete data around what happens to referrals to children and young people who are engaged in the system, who are rejected, and then the extent of wait times that we sought to highlight through the blog. Just assuming that we are broadly in a position where maybe we do have the highest level of referrals, what we also seem to have is the highest ever level of rejected referrals. Obviously, in the 2018 report, I think that SAMH and NHS Information Services Division came forward with 29 recommendations that were all accepted by the Scottish Government as a way of trying to bring down those rejected referrals. Perhaps the next question, maybe for Hannah, Donna and then perhaps Alex from SAMH, is how effective do you think the Government has been in implementing those 29 recommendations? Also, what level of comfort or discomfort do you presently have with the overall level of rejected referrals? Is there a level that you would be comfortable with because you think that that would not be the right route for those individuals? If that 25 per cent would you be comfortable with 10 per cent for example? Perhaps Hannah, I think, is first up. I think—sorry, I'm not sure that that's gone off, as it has. I think we want a minimal in terms of rejected referrals. Once we have a—I guess that young community services are up and established, the principle would be that the young people were caught earlier, they got the support that they need before a CAMH's referral was required, but I don't know that anyone has determined what an ideal level within the system would be. I defer the question to Donna about the Scottish Government actions around the recommendations. Donna, do you want to come in on that? Yes, thanks. We have made some significant progress on the 29 actions set out. I'm very happy to give the committee a breakdown of the actions taken against the 29. I think that some of those have now been superseded by actions taken and commitments made, but I'm very happy to provide that first reference for the committee, if that would be a helpful thing to do. I think on the point about what would be an acceptable level of rejections, that's a really difficult question to answer. I suppose, ideally, there wouldn't be any at all, but there will always be—and it may be useful to ask the clinicians about this—different clinical opinions about what's needed. I suppose that the important thing there—and we've talked about this quite a lot already—is that appropriate support is in place for the people who aren't accepted by CAMHS. I think that I would probably align closely with Hannah on saying minimal and not want to commit to a percentage there. Do any of the other panel members want to come in on that point? Yes, Dr Morton. Thank you. I realise that I've spoken quite a bit. I think that the ideal would be virtually none. If you've got a congruence of understanding between the GPs' referral and CAMHS, that should be achievable. Part of the problem now is that it was mentioned earlier about the referral criteria. I think that we understand the referral criteria. We believe that we understand that, but we refer people that we believe are in tier 3, who are then rejected. That's what's difficult. Alternatives to referral does make a difference. If you've got nowhere else to refer for somebody who's got very significant and enduring problems, then it ends up being a CAMHS referral if there feels like there's nothing else. I've been very encouraged to hear about the community developments that we've been talking about. I also work as a referral adviser for NHS Lothian, and I know that there are lots of things that can be done to help that mutual understanding, so that you get the right person to the right place. I think that the problem here is that often there isn't a right other place for that person. The other thing that I would say is that it has been encouraging hearing all this. It is very difficult for GPs to keep up with rapid systems change. Third sector organisations and access them are changing all the time. It is almost a full-time job trying to keep up with that. It is also how we inform GPs and keep GPs live to those new possibilities that are opening up. I am also going to say that GPs are sympathetic to CAMHS. What I said earlier may have sounded quite stark, but it is very difficult emotional work to help to manage, listen and speak to people, children and adolescents in distress. The GP view is that there is just a capacity issue, and that is often what it comes down to. Alex Cunning also wants to come in on that point. Alex, I will bring you in. Just to respond directly to Mr Hoy's request or query. Dr Martin is right there in relation to the community-based services. To respond quickly to that point, the community-based services and the sustaining of those services, we know that some of the procurement process has only just come to an end there. We do not know the impact, but it is really important for the link workers within GP practices, the mental health nurses, as Dr Martin has mentioned, to be super aware of everything that is going on locally so that they can then upscale the rest of the staff within the practice and make sure that that might provide the information and allow a reduction of that referral rate as well. In a well-functioning system, ideally, there will be no rejected referrals, but I appreciate for all of us that the term referral is quite emotive and distressing. In direct response to our CAMHS audit, one of the recommendations was that that term should not be changed and we should continue to use that term until we have appropriate systems in place so that we know that individuals are genuinely being redirected rather than necessarily just being signposted. From what we see, it is still very much a signposting. We know that young people are not accessing those services in the community or that they do not know how to access some of those services. I would encourage the Scottish Government to maintain the rejected referrals until we feel that we are starting to get all those building blocks and there are a lot of really positive stories out there, but until we have everything fully in place, fully implemented, I would encourage that we continue the rejected referral terminology. I welcome Donna's comments about an update on the 29 recommendations and where we think things have been superseded. We know that, as I said, there has been a phenomenon at work through the pandemic and prior to that as well. In direct response to Mr Hoy's question, I think that we still have quite a long way to go, as I suppose the audit Scotland blog has indicated. Just one final question perhaps for Alex. Obviously, the Government has made £40 million available for CAMHS improvement work based on the CAMHS service specification to try and achieve a national standard of service. The referrals pathway was one of the key issues that was identified in those 29 recommendations. What are the most significant gaps that need to be addressed in the referrals pathway in your view, Alex? Thank you. I think that going back to our original recommendations, we want a pathway or a system that removes any inefficiencies. As Dr Morage has mentioned, a number of GPs are referring because they genuinely feel that it meets their criteria, but things are rejected. I know that some of our working colleagues from CAMHS feel that there is bits of information missing. Again, that is all clogging up the system. As part of our recommendations, we suggest a multi-agency approach to make sure that people are getting input at an early stage. I know that, in some CAMHS services, they have set up opportunities for primary care to meet and have quick discussions about complex cases and see whether referrals are appropriate. We know that that comes down to capacity, but we would still advocate that multi-agency approach for referral. If there is an opportunity and it is very clear that tier 1 or tier 2 services are appropriate, who is that navigator? Who is that link worker that can support the young people and the families to access those services so that, hopefully, we have a positive outcome? Young people and families are not feeling let down. A lot of it is around expectations of the system and within the system. We need all those things, as I said, if the building blocks are there, but not necessarily fully implemented. Again, I want to just try to nudge things on a little bit. We have a number of questions that I know that Willie Coffey wants to ask, so I will invite Willie Coffey to ask those questions over to you. I wonder if I could start with Donna. It is in the area of the 18-week standard, Donna, and it is partly to clarify what it means for me and for constituents whom I represent. When does the clock start ticking on the 18-week standard? Is it at the point where a family has a meeting with someone to then get a meeting with CAMHS? Is that the 18-week that we are targeting? The referral is made to CAMHS and the clock begins to tick at that point. I suppose that the other thing in Alex Piri might want to add to that as well. That is not the only thing that might happen. I think that this is one of the points that we have been trying to make here about bread. There are a range of other things that might happen for children and young people while they are waiting. I would probably bring in Alex on the specifics about when the clock starts ticking and the process as the expert on the CAMHS spec and implementation. Alex Piri from Grampian. Alex, just on this, the standard says that treatment should start within 18 weeks, but some parents say to me, well, I got a meeting within 18 weeks, but a meeting is not treatment. What constitutes treatment? In Grampian, treatment will be ticked. It is clinical judgment point when treatment would start. Within Grampian, CAMHS, we work in the choice and partnership approach. The initial assessment point could be the first clinical assessment and possibly started treatment, at which point clinical information is given advice and access to resources in the meantime while they are waiting for their next appointment with their advocated clinician, be that a psychologist on us, etc. It is very much in a case-by-case individual basis in terms of what is relevant to that child or young person. Certainly, within Grampian, we used to stop the clock at our second appointment, but when we dug a bit deeper and started looking at the clinical processes and those appointments, in some cases we were actually finding the treatment for the child or young person started that first appointment where they were agreeing what the next steps is, what their care plan is. For some children and young people in their families, they need to do that homework in preparation for their next appointment, etc. It is very much an individual thing. For us, it is guided by the clinician, the child or young person and their family when that treatment starts. It is a very individualised approach. Certainly, as I mentioned earlier, within Grampian, our waits to the first appointment from point of referral is six weeks. That could be the start of treatment, depending on the circumstances of that individual child or young person. That is really interesting. I have read the comment in the papers about Grampian, which is really impressive, but it says that it is seen within the average of six weeks. Parents say to me that being seen is not necessarily the same as treatment, so I was really hoping to get some kind of clarification or sense around the panel about what exactly we mean by treatment, because some parents ask me that having a meeting was not treatment and they are still hoping and waiting for treatment along the line, so there is a little bit of confusion there. Does that possibly explain the discrepancy of what we are hearing today? Dr Morton said that it can be one to two years and then there is Grampian saying that it is a six-week average. Are we all talking about the same thing for some treatment to happen for a young person? Is it the same thing that we are talking about, or in one hand are we talking about having a meeting and, on the other hand, having some kind of treatment that is defined for a young person? Maybe Donna could help me to come back in on that, please. Treatment is defined in the national data definition standards for CAMHS that is published by PHS. It is interesting what Alex Piddy says about what people feel constitutes treatment. It might, as a clinician, be more appropriate for her to say a wee bit more about what is a clinical perspective and what treatment is and what parents might feel, because that is what you are trying to get at, Mr Coffey. Is that fair? Why is there such a discrepancy? If we are all talking about the same thing, convener, why is there such a discrepancy still across Scotland three years on from the previous audit Scotland and audit committee's report on this, where we are seeing families waiting one to two years in some parts of Scotland and we are turning it around within six weeks in another part of Scotland, what on earth is going on there and what can we be doing to try to bring that into line, perhaps, of the Grampian experience? Donna? Alex has been put on the spot by Donna. Alex has indicated in the chat box that she wants to come back in, so I am going to ask Alex Puri for a NHS Grampian to come in and respond from your perspective to Willie's questions here. I might bring Martin McKay in as well while I'm at it, but anyway, I'll bring in Alex first of all. Thank you. I think that the first thing to highlight is that children and young people that refer to CAMHS can be referred for a range of different reasons. For example, anxiety, a neurodevelopmental assessment, depression, eating disorders, etc. The actual type of treatment really does depend on what that particular mental health problem is for that individual child or young person. For example, the treatment plan might be a psychological therapy or, depending on the circumstances, there could be a need to start a young person in medication. I think that that is what I was getting at. Possibly there is something there about expectations as well. I am seeing an increase in parental expectations around how quickly can you fix my child, can you give them medication, etc. We have to be on the mind that our parents have been through a very difficult time during the pandemic as well. They are managing the risk and the challenges with their own child's mental health problem. The treatment is defined based on the reason for referral and what is going on for that individual child or young person. It could be a psychological therapy, it could be medication, it could be a group, etc. That is what I mean when I say that it is very much defined in an individualised basis. There is not a one-size-fits-all, because we are dealing with people at the end of the day. My final point is that the Auditor General's blog in point 7 tells us that people waiting more than a year for the treatment has trebled in the past 12 months. That is quite a worry, but it could be a marker of the pandemic, Auditor General. I still feel that that is a bit inconsistent with the Grampian experience, and I am not entirely certain to understand why. It is such a discrepancy that we have probably met its further investigation when the committee has time to convene about it. Could anyone offer a reason why there should be such a difference between the great performance in Grampian and elsewhere in Scotland if that trend is up-deserved, Auditor General? Stephen, could you offer a possible explanation? I think, Mr Kofi. I am probably best to defer to the experts and the clinicians around the table for their insight. I think that what we sought to do through the blog is to raise the profile again of children and young people's mental health and also, as we signal at the end of the report, that this is not the end of our interest. It is our intention, along with the Accounts Commission, to undertake some further audit work in this. As the committee, I am sure, will be interested, we are also very keen to follow through on Donna's contribution about the progress against the original recommendations. However, in terms of the analysis between the Grampian experience and the rest of Scotland, I am extremely interested in the factors that have led to that, and it remains our intention to undertake further audit work in this area. I will probably leave it at that convener and allow other colleagues to come in. Thank you to the panel for trying to answer those queries from me. Thank you. Willi, you will be delighted to hear that I have got a couple of participants who want to give a brief contribution on the questions that you are asking. I know that Alex Pryddy wants to come back in again. I think that that is for the third time in this little session. I do want to invite Marty McKay, because we have spoken quite a bit about the NHS Grampian experience as well as on the ground about how the service is delivered and how it is navigated. I am going to invite Marty McKay if he wants to come in just to reflect on that, and then I shall bring in Alex Pryddy. I think that Donna wants to come back in briefly as well, but Marty McKay is over to you. Thank you, convener. Mr Coffey's points are well made. I think that the discussions that were had earlier by colleagues around education and communication are important, because it is such an understanding. Personally, as a mental health nurse, a 30-year service, the understanding of what you are doing for me or what you are going to do for me or what you are going to do for my family member is difficult in our role, because it is not a job where you can take an X-ray and show someone where it is broken. Sometimes that is the first barrier that you have to get through. I think that it is Mr Coffey's point. If he is unclear working around those levels, then the individual and their family are going to be unclear if it is first contact as well. In my lead-up to the committee, I spoke to colleagues from our education sector. I will reflect on some of the discussions earlier about the training aspects. There are some good examples of how our staff members within education are being assisted and trained to understand and support children in their care, because when you think about it, apart from your own family, that is where the children and young adults are going to spend most of their time. It is in education, hopefully. In good work done, you keep them in education, so the staff and the information that they have and the support that they can give to the children and young adults, their support and their families is vital as well. I think that some of the points that Alex Cummings has made earlier, I am very interested in the project that he is speaking about, about how to support projected referrals. My education colleagues had indicated to me that one of their great concerns was how to support children when our referral has been rejected and the impact that it has on the child and their families, and then it has on staff to try to support them through that if they have to go in for another referral again and again and again. I think that those supports to the primary care aspects and how we deliver them are important. As I said at the outset of the meeting, there is a scope here. I think that Mr Coffey might have spoken about the investment, and others have mentioned that there is a scope here to build new roles that can plug those gaps. Your invitation for me to come in. My experience of working in the service review, the IRICAM service in Grampian, which Alex will remember as well as I do, was a very long complicated review, but I think that the data shows that it has delivered results. It is always in my role as working service redesign within NHS Grampian as a staff side partnership rep. I always look at the gaps in servicing the risks and where the negative aspects are because you cannot ignore them because they inform you where the service is not working. I have had this discussion within Grampian in recent weeks in terms of the funding and I think that when we look at it, it is not a negative approach. It is a sensible and it is going to deliver information of where you need to improve your service. As I said, I have worked in adult mental health for over 20 years and at that time my word was the adult word that held the remit for CAMHS admissions at year 4. It is always a hard thing to have children and young adults admitted into adult words. It was always my view of how we could get there and how we could stop that. Looking at other roles that would improve the connections and fill the gaps between other parts of service to have earlier support and early impact on mental health of children and young adults is the important thing for us to look at the next 5, 10, 15, 20 years. As my GP colleagues stated that if we do not have an effective early intervention, that will continue into adult life. Those transition points are very important areas that we need to look at within the whole service across Scotland. The gaps and the points where things fall down and where people drop through the net is where we have to focus on improvement. If we keep doing the same thing and throwing money at the same thing, we are going to get the same results. We do not have the amount of clinicians that we need. We cannot train them quick enough and we do not get them into service quick enough, so we need to look at building other roles and other effective roles that are going to improve the outcomes for the people that access the service. It is sensible to look at where we fail because that is where we need to improve. There were several other panellists who wanted to come in on that point, but you are all likely to be in the scope of some of the questions that Colin Beattie is about to ask. Do not feel that you need to strictly answer the question that Colin asks only if you want to go back and make any points that you think are important to making that conversation with Willie about how things are working on the ground. Colin, over to you. In general, you have so far escaped a bit of questioning here, so I have got a couple of questions for you. In paragraph 7, as has been pointed out, the number waiting for treatment has tribbled over the past 12 months, yet, at the same time, the number of referrals to CAMHS has gone down by 17 per cent. How do you equate those figures? That is probably two things that Mr Beattie and partly touched on to the response to Mr Hoy. I think that we rightly caveat the drop-in referrals with the people's appetite and access to services during the height of the pandemic. We make reference to school closures and acknowledge all that Dr Morton has said about the on-going work of GPs and the extent to which children and young people were able to access GPs services. We recognise fairly that near me stepped in and increased significantly during the course of the pandemic. We think that that is a key component of it, but the travelling of the wait times is probably another component of the pandemic, the extent to which all the factors that we have heard about this morning, the pandemic has already exacerbated mental health in children and young people. The difficult circumstances that Scotland's children and young people, particularly those from our more deprived communities, were found in the home about their access to education, concerns with the adults in the home about their mental health and all those factors being that groundswell of demand for services and the ability to cope. We think that those two things are relevant, but I understand that this is something in the contradiction that you make. I will be following up on that in a second, but if CAMHS referrals are down 17 per cent, people are waiting three times as many people are waiting for referrals over a year, would that imply that CAMHS capacity has reduced during the pandemic? Is that a core issue? I think that it is hard to be definitive and support that with concrete data. I think that that is one of the themes that we make in the report about the need for more data. Interesting point, I think that Martin Mackay makes about the sense of capacity that exists within the system across the wide and varied partners that are contributing to service provision and the analysis to see the availability of services across the piece and the number of people who are working, recognising all the challenges that we know about the availability of psychiatry services, and more into the space that I suspect that we would see. What does the future workforce look like for the provision of mental health services? Colleagues will be available to expand on that, but absolutely that capacity is no doubt a factor behind some of the numbers that we put in our blog. Just a second question for you, looking at paragraph 13, you refer to geography matters too. How do you make that linkage when you have NHS Grampian, who over a three-year period has significantly increased their capacity and even NHS Tayside from a low level has made some significant improvements? Those are a couple of NHS boards that have been a naughty step in the past. How does that link—you seem to be implying by saying geography matters and so forth—that it's more difficult if you've got a spread population to be effective and yet Grampian and to a lesser extent Tayside have a spread population? I think that what we set out in the exhibit is probably just one factor around wait times, and we've touched on already this morning the progress that Grampian has made and the exploration behind some of the factors, and also that Tayside similarly has made progress. I think that we would also note—and Government colleagues may wish to comment further on this—that that's not a universal picture, that there are still some boards and areas in Scotland that aren't experiencing that level of progress. We know that there are seven health boards in Scotland who are receiving additional support for services to generate some of the improvements that are necessary. I think that it's a point of equity that you're making, Mr Beattie, about that really regardless of where somebody lives in Scotland—and again, I'm very interested in Alex Cummings' contribution about the number of minutes away from services that, really regardless of where you live in the country, your access to services—whether it's direct, face-to-face, use of technology—should all be played into that people can get the right level of service where they need it on a truly equitable basis. However, there are clearly factors in geography that are worth further exploration beyond today's discussion. We've established that CAMHS referrals have dropped 17 per cent, and the suggestion is that it's a result of possibly school closures and limited access to GPs rather than an actual reduction in overall demand. To what extent do you think that there's an unknown backlog of cases that CAMHS is not seeing yet? Maybe I can bring Alex Cummings in first on that one. Thank you, Mr Coffey. To be honest, I would only be speaking anecdotally, and I think that probably colleagues around the room might be able to give a better answer. We know that, right across the board, as Dr Morton has mentioned, through the pandemic, lots of different services—CAMHS, as well as others—had to reduce intake and had to change delivery mode. I wouldn't—and obviously things have, in relation to a number of referrals, are starting to recover. We are starting to see those increased referrals, but I'm afraid I apologize. I don't think I can give a concrete answer that you may be looking for. Anecdotally, certainly it would make sense that there is going to be—as we've talked about in relation to the recovery from the pandemic—a wave of mental health problems across our communities. Therefore, it would make sense that CAMHS is going to see an increase in the number of referrals, as well. Maybe we can ask Caroline Amost if she has any input on this one. Can you hear me? Yes, we can hear you. Sorry, I apologise. I suppose that the focus for us in education is on positive mental health and wellbeing. That is what we have been trying to do as schools. It is the focus of that whole-school approach, which sits within a whole-systems approach, to ensure that we are considered out of the children and young people's wellbeing and that we are working in a partnership way, in a collegiate way and a cooperative way, with the other services around us. Anecdotally, too, I can see that there has been significant distress and challenge for some young people, some of the children in North Ayrshire. We can see that coming through in the use of our service, the education psychology service, the conversations that we are having in schools, with other partners and other services and agencies. In education, we are looking at it in two ways. One, how can we support those who are experiencing challenge and how can we signpost them to other services that are required? Two, how can we focus specifically on ensuring their wellbeing and making sure that the activities and the curriculum that we deliver have that focus on positivity and resilience at nurture? Okay, perhaps Katrina Morton could come in there. It's automatic. All right, I can speak loudly anyway. I suppose that I was just going to come back to this issue of equity and I wonder whether part of this is about definitions. I agree with earlier speakers that a consultation, a detailed consultation and assessment can also be therapeutic and the start of therapy, but then we need everybody across Scotland to have that definition of start of treatment and we can't have different definitions. On the other hand, an initial consultation may be an assessment that says that this person has very, very severe anxiety and needs to see a psychologist and definitive treatment might then be six months down the line if it's a six months away for a psychologist. I'm just making that figure up, I have no idea what it is. So we just need standard definitions. Some of the feedback that I've had from GP's, from Grampian and Tayside, have not been quite as optimistic as what we've heard. Grampian say, waiting this along and patients and parents are often having to fend for themselves. I received a text from a GP. I just hope this is okay, just to very briefly read this. This GP is a mother and she's talking about her daughter. So the daughter is a patient and it's a GP who's given me permission to share this. She says, my soon-to-be 13-year-old daughter has been on the CAMHS waiting list for over two years. In this time, her anxiety has progressively worsened and has become critical in the past two months to the extent that she can barely leave the house. She's been to school on less than six days since the start of term. School had been contacting CAMHS almost twice weekly asking for her to be urgently seen. Our GP has written again asking for her to be seen urgently but she has no appointment. The impact on children and their families cannot be overstated. I just want to say that because when we talk about a two-year waiting list, that's what that means. People don't get on a waiting list easily, as we've heard. It's a high bar to refer. It's a high bar to then be not rejected and then to go on a waiting list. I just wanted to say that, thank you. Mark Ruskell, you might have some input here. In the original question, where I'm saying, do you think that there's an unknown backload of cases that aren't yet evident? I can speak from my experiences sitting around the national stakeholders group for mental health for unison. At the start of the pandemic, the work that we were doing at national level in strategic policy and delivery changed to focusing on direct impact of the pandemic and how we would have to change the direction of services, the delivery services for mental health and wellbeing of the nation. We know from not just mental health services but from all clinical services, we know that the impact of trauma only begins to really show quite a way down the line. 18 months to years, you can start to have a significant impact just beginning to show, because during the 18 months to the pandemic, people are dealing with what they're having to deal with. When those, when their resilience levels disappear, the impact on them in their mental health and wellbeing starts to show. We have been expecting what many people have called a tsunami of ill health and mental health and wellbeing. We're seeing it during the pandemic, we've seen the acute, the level of ill health of admissions in the hospital in case I know from my colleagues in community services, and it's the same across the whole of Scotland that they're dealing with more and more cases within the remit of people who have become unwell. What we have found, and we've got data in this nationally, is that we have had more and more new admissions in the caseloads and in the hospital that have never been known to services before in the mental health services, and that will be exactly the same for CAMHS. Unfortunately, those may or may not be in the waiting area of the delays in the referrals waiting lists. We know that this was coming, and we know that it hasn't finished the wave, the impact, certainly of the pandemic, when in terms of mental health referrals and in hospital admissions will continue. Most of our services are at full capacity, most of our hospital beds are full. At the top end at tier 4 level, when that is full, the pressure just expands right through the rest of the system, out to our community teams, to our third service, our third sector, colleagues in health and social care settings, and our staff who work in education who are having to support children and new adults on a daily basis during the school day. I don't apologise for painting a bleak picture because it's the information that I have on the ground. It's what I know from my working colleagues on a daily basis in the words and in the communities and what I get from my colleagues in unison branches and health boards and in other sectors and other employers across the country. We are at a significant point. When I hear a comment that we are now in the post-pandemic phase, that doesn't equate to how our staff feel on the ground and how they are trying to support the either the patients that are dealing with and having to treat in hospital or any community or clients in other sectors. We're not in post anything. This is a tsunami wave that just keeps coming and isn't slowing and it's just constant pressure. That's why I've said already that the funding that's come in, we need to look at how we use it differently to try and build the resilience and early intervention in health and wellbeing because, otherwise, we're just throwing money at the same gaps and services that we've always had and we will not change. We don't have enough nurses. We don't have enough psychiatrists. We don't have enough psychologists. In parts of the country, we can't recruit them in their remote and rural areas. Grampian, Highland, our large areas across the country that have significant difficulties in attracting staff from the core, from the central belt, for instance. Even there, we still recruit. We've got a significant retiral rate within the services, certainly within mental health, but we can retire early because of their state of pension status and their service status and changes to pensions, et cetera. The pressure within service are making people change how they're thinking and they're going earlier than they were planned. That's putting significant pressure at the top end of staff. We keep working to recruit more people in the front end, but that's always a constant fight. I apologise for that. No, Martin. Time is running away from us, but I think that you are making some extremely powerful and important points, which I am pleased are now on the record and will allow us to follow some of that up. We are drawing towards the end of this session. I would ask any panelist who wants to come back in if he could possibly keep any final remarks short. Colin, I don't know whether you've got any further lines of inquiry. The only thing I was going to add to that was that Martin rightly mentioned that money and money is the lifeblood of any service. The Scottish Government has earmarked £40 million for improvements to CAMHS. What should those improvements be? I think that I would go back to some of my previous points, and I know that colleagues will have lots of other ideas as well. However, I think that it's about how we ensure connections at referral and connections when a young person or their family are rejected. It's not fair for them to navigate the system themselves, and we need to support them to do that. Link workers across Scotland have had such a positive impact. We know that, hopefully, there will be more mental health link worker type roles coming as part of the Government commitment. However, there also needs to be something specific attached to CAMHS to improve those connections for young people and for families as part of that. I think that basing things on Martin's point is about changing our focus slightly on not necessarily just clinicians, experienced practitioners, but I don't feel that it has to be CAMHS that has those conversations and helps people to navigate a very complex system that is changing all the time. Individuals around the room are saying that it is difficult to keep up with the changes, but again, for the wider public, as I mentioned at the start, we just need to do more there. Donna, do you have anything on that? I think that there are a few areas where we want to focus. Obviously, some of the issues that have been raised today highlight the variation, both in practice and in funding across the country. One of the key areas for us is the implementation of CAMHS specification in a robust and reliable way across the country. Mr Coffey also mentioned the specific issues around long waits. There is a real need to focus on those, and there are seven NHS board areas that we are working with really intensively, where the biggest challenges are being felt at the moment, so I think that that is another key area. Improving community child and adolescent mental health services is another important area, particularly with some of the work that we are doing on the expansion for 18 to 25-year-olds and targeted groups for those who wish it. One of the other areas that the board is focused on is the crisis response in particular, so out-of-hours assessment, intensive and specialist CAMHS service, which really benefits children and young people with complex needs and their families, particularly in a home setting. I think that that would be the areas that I would want to highlight. I know that a couple of other people wanted to come in on that area, but I want to use the final few minutes that we have just to have a quick look at the absence of data issues that have previously been highlighted in some of the work of the committee, as well as of Audit Scotland. I know that Sharon Dally has a question or two on that. The session 5 committee stated that the absence of basic data was a concern. I will read some of the comments. In relation to spending on children and young people's mental health services, the numbers are so variable as not to be credible. We saw gaps and problems throughout the system in terms of how the money is accounted for and, critically, in terms of what difference any of it makes to children. We have made a series of recommendations in the report on those things that need to be sharpened. We understand that boards will choose which ones they want to measure, which will make benchmarking very difficult. It was a common theme. We understand that the minister for mental health outlined work that the Scottish Government was progressing with NHS National Services Scotland to improve the quality and scope of the data that is available. Considering that report, it is two years old now. What extent has this work been progressed, if I could ask the owner of that question first? Yes, I am happy to respond to that. I am conscious of the time. There has been some progress already made and I have highlighted a couple of areas that we have made progress on. We are also working with Public Health Scotland, particularly on outcomes data, and on some of the work around benchmarking. I am very happy to come back to the committee with a more detailed response on that, because there has been a significant amount of work that has taken place. The one area that we need to do more work on is tracking the finance input and linking that to outcomes. I am fairly sure that we will be working with Audit Scotland on that over the next few months on an on-going basis. I do not know because of the time. I do not know whether anyone has indicated it. As we have the Auditor General here, it would be useful to get your reflections on where you think things are with the collection of data, not just data for data sake but data that tells us about the outcomes. That would be exactly our conclusion, convener, on recognising the point that Donna has made and the role that Public Health Scotland has taken around some of the analysis of referral rejections and why that has happened. Our sense would be, as we have said, not just in this context but across a number of different themes, that the consistency, the high quality measurement analysis of data is an essential component of understanding how well public money has been spent and what the outcomes have been achieved from that. Probably it is our sense that we are not yet in a position to be definitive or much in the way of concrete evidence that we have moved terribly far beyond where we were from our own Audit report in 2018 and the predecessor committee's report in 2019. Progress to happen is probably what we have heard over the course of this morning and some degree of urgency around that, too. That sense of urgency is absolutely right because those children and young people are only that age once and we need to get it right now. We cannot come back in five years' time and decide that we should have done things differently. We need to try everything that we can do to offer them the support and their families and their support that they need. I am going to draw the public part of our committee session today to a conclusion by thanking everybody for the very useful but also very informative evidence that you have given us, which will allow us to consider what our next steps are. I have to say that I am really sorry that we ran out of time and I know that some people did want to come back in. I would simply say that if you are inclined, we would really appreciate you submitting any written evidence to us through the clerks so that any of the points that you wanted to make that you were not able to make at the round table session this morning will still be captured by the committee and will be a matter of record and we will obviously look closely at that. I would also again, as I think the Auditor General did, like to thank Donna Bell who gave a commitment that she would come back with some more information to us both about the stats that were the data that was being asked for by Sharon Dowie at the end but I think also in relation to the 29 recommendations. I think that it would, we as a Public Audit Committee would find it very useful just to understand what progress is being made in the pursuance of those recommendations from the previous Audit Scotland report. I once again thank everybody for your endurance this morning. It has been quite a long session but certainly I know that we as a committee have got a great deal out of it. I thank you very much for both your time and your energy and clearly a good deal of preparation that you have made before coming to this morning's session. Thanks once again and I now draw the public part of the committee's work to a close.