 Fy oedden nhw i gweithio gydag o'r 26 ystafelladol o'r gweithio cyd-dysgu oedd y dyfodol a'r Sgrwttyn Cymru i'r Ffwrddol. Felly, rydw i'n gweithio gael i'r ffordd o'r gweithio ac i gael ei ddweud o'r eich gennych. Roedden nhw'n ddweud o'r ddweud o'r busnes yn ei gael. Roedden nhw'n ddweud o'r ddweud o'r ddweud o'r ddweud o'r gweithio'r ddweud o'r gweithio'r gweithio'r gweithio. Thank you. Item 2 is the section 23 report, Children and Young People's Mental Health. I'd like to welcome our witnesses for our first panel this morning. Dr Lynn Taylor, lead consultant psychologist and clinical director of CAMHS, NHS Grampian, Bernadette Cairns, head of additional support services, Highland Council, Stephen Brown, director North Ayrshire Health and Social Care Partnership, and Dr Dame Denise Coya, chair of the joint Scottish Government and COSLA task force on children and young people's mental health. Just for the official report and any public watching when we refer to CAMHS this morning, we are of course referring to children and young people's mental health. I'm going to open questioning for the committee this morning from Colin Beattie. I'd like to focus a little bit on NHS Grampian to start with and I was quite interested in the written submission from NHS Grampian, which states that a new multi-agency meeting has been commissioned to focus on supporting mental wellbeing in order to prevent mental ill health. Can you give maybe a wee bit of information around that and what the expected outcomes from that work might be? Yes, sir. Good morning. Thank you for giving us the opportunity to come and share some information with you. We've developed a pan-grampian child and adolescent mental wellbeing group, which is commissioned and chaired by the director of Public Health, Susan Web. The purpose of that group is to try and think about mental wellbeing and mental ill health across what currently we know as the four tiers, tier one to tier four. We've been thinking in that group not just only about tiered language but using models of language around, for example, iThrive, which is a different model around people getting help, getting more help and risk support. We've actually just met again quite recently and we're trying to develop a pan-grampian vision around mental wellbeing and provide a framework for children and young people across the whole of the tiers that are available within third sector, within education, within councils and also within health. We've identified going forward from that there are three carers and grampian that we'd like to focus on and target our interventions currently, which are around the parenting programmes, so the similar parenting programmes are delivered for all families, whether they live in Aberdeenshire, Aberdeen City or Murray, that it's the same that's delivered across the grampian region. The second area we're going to focus on is looking at adverse childhood events to think about targeting interventions around children who have problems in that area. The other area that we're developing is around anxiety management. For example, in the CAM service, we've got money from the national education board for Scotland to run a programme called Liam, which is around low intensity anxiety management. Our psychologists in our CAM service provide teaching, supervision and consultation to school nurses or support for learning staff or guidance teachers on the ground so that they can deliver six sessions of treatment to young people in schools with our supervision. We would like to develop and roll it out across the whole of grampian as well. That's some of the work that we have just started with, but it's very much across all tiers around wellbeing and a joined-up vision between health, council, education and third sector. I realise that it's probably early days yet, but how are you going to measure success? What would success look like? We've been having some discussions around that and we've just run a workshop as well with all of our stakeholders, giving examples of good practice. Within CAMs, but also generally, it's recognised that we need to require a process around a minimum data set for gathering evidence about outcome and functioning and wellbeing for children and young people, not only within CAMs, but also within tiers 1 and 2 of services. We've been looking at that generally around thinking about global assessment scales, so even simple scales of a scale of 0 to 7 for severity of symptoms, the improvement that have been seen in symptoms and also the level of functioning that young people have. For example, if it was anxiety, we would also add on a specific anxiety measure to make sure that at the start of treatment, at the end of interventions, we can demonstrate effectiveness, not just efficiency of what we're trying to do. Excuse me if I still stay within NHS Grampian. I'm looking at workforce. Again, in the submission from NHS Grampian, it's estimated that Grampian lost 23 per cent of its workforce capacity due to travel between four separate sites, and this is where the CAM service is delivered. That seems extraordinary. Is there a way to make this more efficient? Is it part of the improvements that you're looking for? Where are you going on this? We undertook a whole service transformational redesign in CAMs in 2015. Services were fragmented and were delivered out of four separate sites. We have a site in Murray, which is excellent, but for staff serving Aberdeen City and Aberdeen Shire, there were people working out of different buildings. It was very difficult to deliver safe, effective and efficient care, but we also had internal transitions in our service. There was a department for children up to 13, a separate service for children between 13 and 18. Part of that redesign was to make a whole service approach to children in young people aged 0 to 18, so there are no transitions. As part of that redesign plan, we have been campaigning and working with our local asset management group, and have been successful in securing £1 million from the Scottish Government to develop a new building that is currently in NHS premises that we will be refurbishing with an opening date of 1 April. That means that all of the CAM staff are now going to be coalesced in one building, which is going to be a fantastic resource, including an education and resource room, to help us to develop our wellbeing work with our colleagues around tier 1 and 2. Our 23 per cent loss in capacity is between a nurse travelling between two or three buildings to support a medic who has an unwell patient. There was no facility currently that could coalesce all the staff together in one building. You are saying that you are bringing all the staff together from those four sites into one site. Does that mean that the patients have to travel to you? I need to travel the sites still very close by to the hospital, but what we are doing is we are using an innovative way of delivering treatments called attend anywhere. This is our NHS system, which is encrypted virtual clinics, where children and young people can be seen over IT in a secure way, perhaps if they are being seen in school. The guidance teacher might join them in school to be seen over that clinic. We are also looking at rural and remote clinics based within schools and GP practices so that people can be seen as close to home as possible. For our Aberdeen Shire team, who will be based in that building, they will be doing more out-and-about work locally. They will also be able to use the virtual clinics called attend anywhere, which is proving to be really successful. The data and feedback from young people as well is that they really, really like that system. Clearly there are specific challenges. Given the shared geography of who the service is delivered, you are talking about delivering a virtual service. How effective comparatively is the virtual service using IT, as opposed to face-to-face? It has been used in other areas in the evidence and the outcome is that it is as successful. However, you have to be very careful about what young people and children feel that that is a suitable medium to deliver your treatments with. For all first appointments, they would come to the CAMHS service or be seen locally by a clinician face-to-face. If we felt that there were any risk factors at all, we would continue to do face-to-face treatment. For some families and young people, it is very exciting and new and novel way that young people are used to using media in that fashion. The evidence is really quite good for that at the moment. It is not the only way forward, but it is just one aspect of things that we are looking about delivering within Grampian to help us to think about not only improving waiting times, but just thinking about different ways that we can deliver care to young people. Another really interesting offshoot of that attend anywhere provision is that it is quite difficult as well for lots of CAMHS staff because we are obviously so under pressure. We have got an extremely dedicated workforce, but it is really hard, for example, to attend school meetings for children and young people because that takes travel time to schools and reduces capacity in the service. We have been able to use attend anywhere for the clinician within CAMHS to be able to join the school meeting from their clinic base, and that reduces travel time, but it helps the connectivity between schools and the CAMHS service to deliver more joined up working. We are very much in Grampian going for a regional centre of excellence. We have a very strong vision and ambition to deliver fantastic care for children and young people within our region, and I cannot stress how dedicated and hardworking the staff are to making sure that we can achieve that aim. That is where we want to go with that. We have started with a snapshot from Grampian, which is very useful. Dr Clya, you have done the joint task force for the Scottish Government and COSLA. You have seen the Auditor General's report, which highlights some issues. Can you give us an overall flavour this morning of some of the challenges that you see, some of the challenges and obstacles to service improvement? I have started over the last couple of months. We have been out and about looking at and talking to people around health, social care, housing and justice to the children and young people themselves. We have met the families of the rejected referrals and a significant number of young people from the Youth Commission and other organisations about the issues. What has come up from everyone and led to my recommendations was a complete consensus about the issues, which were that the problems with mental health in Scotland with children and young people are increasing exponentially. That is not related to the incidents or prevalence of serious mental illness—that is unchanged. The rises in the emotional distress in young people at schools and issues around bullying, body image, depression and anxiety are on the increase and have massively changed. We have a huge amount of data around that from the Scottish Surveys. The other area that has been causing issues around Scotland is about neurodevelopmental disorders, Aspergers, autism, ADHD and the varying provision around. Sometimes it is in CAMHS, sometimes it is in pediatrics and outside CAMHS. Those two areas have grown significantly and that has accounted for the massive increase in referrals, not just to CAMHS, but across the system. What came out of that were the recommendations where we wanted to look in a completely different way at child and adolescent mental health and divided it into four strands. That was one that was about neurodevelopmental disorders, requiring really quick assessments that children are struggling to get at the moment, requiring quite specialist support from the third sector, requiring input from acute pediatrics, and the problem with community pediatrics at present is that it is having to move back into the acute system. There is a real dearth of community pediatrics. In that neurodevelopmental pathway, it is quite specialist and those are the families that are mainly in the rejected referrals report. There are serious issues about how we are managing neurodevelopmental disorders in Scotland. The second strand is a generic strand of emotional distress. That is much more about supporting children in schools, putting additional input into schools and into primary care. A third sector that is focused on mental health problems is not—we believe that universal third sector services for children and young people have to pick up mental health problems, and that is the big gap in the generic strand. The third strand is specialist mental illness, which is the province of CAMHS teams, and it has to have fast-track referral with either immediate assessment or at least within four weeks. That is the aspiration in the task force. Finally, there is a group that people told us about of children who we were calling the at-risk children, children who are born into poverty, physical abuse, sexual abuse, the children of families with addiction problems, and many of them are ending up in care. The responses to them need to be much more wraparound, far more generic, supportive services, because they are children who are very traumatised, very over-anxious and often act out some of the issues. The reason for the strands coming was because that is what people told us that they are not my recommendations. What we do about it now is that we are putting that into work programmes to deal with them, because the responses in each of those areas is very different. That is where part of the issues in the CAMHS services come from, in that people are not really getting the right service at the right time and in the right place, and that is the job of the task force and our delivery plan. We will start to tackle that. The other final issue before I stop is, apart from the conceptualising, and those recommendations have found favour across the board. With COSLA, with the third sector, with health people we will recognise those strands as a good way forward to commission services. The other issue for me is actually growing a workforce, because there is a workforce out there. At the moment, what people are doing is when they cannot employ a fully trained psychiatrist or a fully trained clinical psychologist, they then just freeze the post, whereas in fact there are enormous numbers of psychologists out there who only require one year's MSc. We have doubled the numbers in training this year, and there are about 19 new staff coming out. There is a workforce. The issue that people raise about is that we cannot provide a service, because we do not have a workforce. There is a different workforce, and it is going to include the third sector, and it is going to include primary care, and probably a lot of psychology and nursing. That is one issue. The final issue for me is related to the resource. The Government is completely committed to CAMHS. I think that there is cross-party commitment to child and adolescent mental health. The policy is great. The commitment from the people on the ground delivering service is great, but when the resource goes out there and children are a third of the population of Scotland up to the age of 24, the resource has to be targeted at that group of individuals. At the moment, we have to highlight and call out the issue that mental health services, particularly child and adolescent mental health services, while everyone is taking cuts, they are taking bigger cuts proportionally than everyone else. They are not a priority on the lists of the community planning partnerships, so we need to call that out and say, no use putting new resource in the front door if it is being frozen at the back door. That is the biggest issue at the moment. Dr Coy, I think that that overview was extremely helpful for myself and my colleagues. Let me just ask you one more question and then I am going to move on. I think that you have outlined there the challenges and perhaps even a framework for how mental health services should look in the future, but then you touched at the end on some of the resource challenges. For me, the Auditor General's report, I think that you could summarise it by saying that in terms of spend and knowing where this money is across Scotland, it is a real mess at the moment. What kind of challenges do you think we face and what timescale to get to perhaps a service level that you would find acceptable? I think that what people would find helpful is that we have a very good relationship in the task force across health and social care, that the joining together of COSLA and central government is extremely good. What we are looking at is how we start to develop in our delivery plan a framework that helps the system and local council areas to know what it is that they perhaps are needing in their areas and it will be different in each of the different areas, what they are actually needing, what good looks like, because we have lots of good practice around Scotland, how we can support people to move into that good practice and then how people start to actually look at the resources that they have already got. There is a lot of new resource going in, but there are existing resources across the whole of a locality area that could be better utilised into focusing on how we deal with mental health. Our issue is to go out and support the commissionings, to support frameworks and to really highlight good practice but also to call out the issues. Because we have the young people and the youth commission co-chairing this, they are doing a lovely piece of work at the moment going around every part of Scotland looking at what is out there. They are the voice in years of the task force going forward about when we put the guidance out and the recommendations, how does it get picked up locally. Thank you very much indeed. Liam Kerr. I just have a very brief clarification to call you, if I may, on something you said. You said that mental health incidents are increasing exponentially and there has been a massive increase. Is there something new in the young people's world that is causing them a problem with mental health, social media or such? Or is it that children and young people have always had mental health challenges but we are now better at diagnosing or understanding those issues? I think that it is a bit of both. Across the developed world, it is interesting to look at international comparisons, particularly in Europe. This is a problem that everyone is experiencing and there is nothing new. The important thing to say is that there is no increase in mental illness, schizophrenia, bipolar disorder or any of these. It is the issues around young people growing up in developed countries. I do not think that we have enough research evidence at the moment. There is research evidence around social media and there has been some nice work done in Scotland about if you are on your phone for over five hours as a young person, particularly young girls, it is not helpful to your wellbeing. There is research that is doing that. We think that, in the task force, we are going to have to pull some of that research together. However, we live in the age of social media and there are really good things about it. It is perhaps more about how do schools—this is where we see education as crucial to this because we have seen fantastic work going on in some schools in Scotland of educating young people to use social media more responsibly, to deal with the multiple demands that are coming in them. Some of the issues are related to pressures and expectations around succeeding in life. It is a very complicated world. I do not recognise this world. Having met the teenagers over the last two months, I do not recognise their world. I am having to learn their world, which is why the Youth Commission and the Youth Parliament are so important to the work, because they are the people who can tell us what is required and we have to listen to them about what they need to navigate their way through this world. That is the bit that we have to address in the task force. Just a follow-up question. You mentioned right at the end of your opening contribution around cuts. Is that cuts that are being made by IJBs, health boards and is that connected to council budgets and the reduction in council budgets and pressures on health board budgets because they are not increasing in line with health inflation? Which cuts specifically were you referring to? I think that cuts are the wrong word for it, to be absolutely honest. I think that we live in age of austerity and we are all grown-ups in the age of austerity. We know that we have to all meet our commitments to try and live within our means. That is the important thing to say. The issue for me is that, as we attempt to live within our means, if the population in Scotland a third of them are under the age of 24, we have to make sure that living within our means gives them a fair percentage of the resource that we have. It is important that, going forward, we keep calling that out, that we do not prioritise other areas at the expense of children and young people if there are as many needs in the areas of children and young people. There are issues around how we prioritise the resources that we have. In terms of cuts, the two things to say about that are, one, as a country, we spend more. When we look at the figures, we spend more than most European countries on children and child and adolescent overall mental health services. We need to get good value for that. The issue for me is that, when we are looking in areas, my concerns are when people are freezing posts in child and adolescent services in other areas, and the reason they can do it is because the data is more difficult to find. It is about prioritising child and adolescent services, the breads of them, including community and third sector services, and making sure that the rest of the system, both in the acute sector in NHS and in local councils and in IGBs, is all of them, because that is the big issue. The providers have to make sure that they are giving eco-priority to child and adolescent services, and that is what we are not seeing going round a country. Just to clarify, the term cuts is what you are using in your opening contribution around there are cuts that are then new money, which is welcome. It is having to make up for some of the cuts that are taking place. I am just referencing your own term cuts and what you meant by that. That is exactly what I said at the beginning, but what I meant by cuts is when you get a reduction in resource at the same time as you are putting new money in the top. There is no point in putting new money in the top if people are using it to keep the service at the same level. The reduction in resources is universal. That includes in third sector organisations where people are having to provide generic services but are not providing the mental health add-on to those services. Dr Taylor rightly referenced the use of technology. Is that something that has been reflected across the country around better access to, for example, FaceTime or whatever app is being used? Is that something that has been looked at across the country around emergency services when someone needs urgent support from a mental health specialist? There is perhaps one other board that is looking at using that system that we are looking at the moment. It has certainly been used, for example, a lot in the tend anywhere system, for example, and orthopedics are using it in the central belt to see people in remote and rural areas on the west coast. It is a very effective system if used in the correct way. Certainly, young people's feedback is that they really, really like it. Is the task force taking that up across the country? We have a work stream around looking at the whole concept of IT and how we are going to deliver services. What I think is important is that local areas know their own, as you are describing, in Grampian. What works in Grampian might not work south in another way. I think that it is really important that we leave it to people to decide what is going to work best in their area, but, yes, we are looking at that. We are also looking at the out-of-hours services in NHS 24 and in accident emergency, where there are issues. Dr Coy also listed all the people that you rightly engaged with in looking at the issues around referrals and identifying the key actions going forward. One of the things that you did not mention, which I am sure you did engage with, was about clinicians and GPs, in particular around issues around the language that they use and the referral letters, on how those referrals are taking forward. What engagements happened with those clinicians? We met with the College of GPs and we have met with local GPs as well. We have also met with our Scottish Government colleagues in primary care. As you said, there are a number of issues around that. The vast majority of referrals to CAMHS come from GPs. The GPs are saying to us that the reason that happens is because they do not have anything else to refer to. At times, there are things for them to refer to, but they are just not aware of them. The issue of the referral letters is important because, when we met with the rejected referrals families, the reasons they had been rejected were because the referral letter did not describe the problem in a way that triggered the response when the CAMHS team read the referral letter. What the GPs are asking for, and the whole primary care team is asking for, is more support through their health visitors, more primary care mental health nurses, more of the psychology graduates that we are talking about. Those are psychologists who have one year's training post their degree, who are ideal to work in general practice. They are looking for that kind of support, and that is the kind of support that needs to be provided to them over the next couple of years. I am just going back to workforce. Has there been any assessment around what proportion of schools in Scotland have access to a school nurse or a mental health nurse more specifically, and what your ambition would be for what that should look like in next year, three years or five years? We have been out to quite a number of schools. We have visited the schools that have excellent, amazing practice in this year, and they have used their PEP money incredibly to set up services. We have talked to the education directorate in Scottish Government because they are now putting together the plans that they are agreeing on how we would start to roll out systems. The good practice now would commend places such as Kilwynning academy, like Wallace high school to the Ayrshire schools in Cumnock. They have put in place basic services where the teachers are involved, have had mental health first aid training, they have their pupils involved as mental health champions, and they have a baseline of raising awareness about mental health issues and tackling bullying. They are then superimposing on that. Either counselling services or, in some cases, they have put in primary care mental health nurses going into schools or they have family groups. It is different in different areas because of the different resources in council areas, and they all work just as well. It is up to them how they put that in. Their missing link, all of them describe, is how they manage to get referrals in that does not always have to go through the GP picking up things. Can they get into CAMHS? Can they get into third sector services? We are seeing the roll-out plans. That part of the work is jointly with education, and that is in the delivery plans going forward. Education is crucial to the success of the task force. I am only here for two years doing this task force. This has to happen in the next two years. We have a three-month plan, a one-year plan and a two-year plan. That two-year plan is where the First Minister has announced the programme for government around access to mental health nurses in every second school, which is very welcome by all political parties. The important thing is that counselling will roll out. The mental health nurse rolls out, but it has to be done in a way that is helpful to the schools and primary care in the local area. How it is done is how they use that money in primary care. They need to do that, because what we do not want to do is to start very good practice in Western Bartonshire, for example, where they have family groups attached to the school and to the primary care setting. They need to put that capacity into that area, not just one school nurse per school, if that is not right for them. I think that it is important to do the right thing. It is a final request, which would be around the informative years, so around four, five and six years, when the kids at school will have their exams and the results of those exams, how they do those exams, will impact on their life chances for the rest of their lives. Are you looking at specific support around what can be done to support those children, particularly if an issue is flagged up? Very much. I think that that is a huge issue. I think that parental expectations are a huge issue in that area. The transition period between school and tertiary education. We have been talking to the colleges as well about how we support young people into that area, so that is crucial. Dr Coya, have you met any educational psychologists on your travels? Yes, and we have an educational psychologist on the task force. We have not mentioned them yet, but they are part of all that package. Are they enough in schools? The numbers have decreased over the past few years. I think that it is back to the issue of looking at—we are starting from a position of what are the functions that are required in a school. The families and the children themselves are telling us that they want early assessment of neurodevelopmental disorders. If that takes an educational psychologist or a community pediatrician, that is what is required in that area. They are telling us that they want a trusted person who is attached to the school, who they can go to. At times, in the area that you were talking about later on, they might not want to discuss things with their parents in the first instance. The numbers, I think, depend on. The important thing is for us not to promote individual groups of professionals. I think that what we have to do is promote the functions that are required in a school, in primary care and in the community. What is available in those areas needs to fill those gaps. If the gaps are still there, that is when we have to call it out as they are still there. Indeed, but one of the problems has been with the declining number of educational psychologists. There has not been an intervention at school level and then more referrals to CAMHS have been happening. I take what you are saying as a vision for the future, but the reality in schools over the past few years has been quite different from that, would you agree? That is exactly true, but I think that everything is ended dependent on each other. The big issue for us is what has happened to community pediatrics. The pressures that that has put on the CAMHS teams at the moment, because community pediatrics used to do the assessments along with educational psychologists. Both groups are lacking in that sense, but I think that I was not aware until I started going out into communities how community pediatrics has disappeared and how the acute sector has pulled pediatrics back into working within the acute sector. That is something that, in order to fill those gaps, might be appropriate, but we need to be aware that it has happened. We will come back to that. Thank you very much, convener, and good morning to everybody. I wonder if I could bring in Bernadette and Stephen a wee bit here and refer you to the Auditor General's report, page 19. It shows quite a variation in the amount of time it takes from referral to treatment amongst various health boards. For example, NHS Highland, we can see a figure there of an average of six weeks. We can see Grampian in about 21 weeks. Can I ask you all for your perspective on why that is and what you would need to do to try to improve that, please? Some of Dr Coy's comments earlier on probably give you a flavour of the picture across the country and the variations. I think that clearly what you see played out in some of the waiting times, the average length of time that it takes. I am very clear that, certainly from a nearsher and aran wide perspective, we have protected the new monies that have come in and at the same time attempted wherever possible to fill vacancies as quickly as possible and maintain that. I think that that has been helped because we have children's services, strategic planning and all three airshare community planning partnerships that are absolutely committed to improving the emotional and mental well-being of children. I think that that has helped in terms of protecting some of those strands of money. Clearly, when you do that, it helps to keep enough capacity in the system to try and see those young people who are most in need as timeously as possible. I think that, while there is over leaf on page 20 again, it looks great from an nearsher and aran perspective around the number of young people that we are seeing within that referral to treatment time target, but 18 weeks—I think that you touched on it, Dr Coy—18 weeks is still a long, long time in a young person's life. Over and above that, there is still a small percentage of young people who are not being seen within even those 18 weeks, so there is still much to do. I think that a load of the work that we are looking at doing, which is about upskilling and building confidence in many of our universal services from teaching staff to pastoral staff and some of the models that are being developed working alongside community planning partners, is not a CAMHS issue in the traditional sense. It is an issue for all community planning partners and include that in its widest sense in terms of how we best utilise the resources that are either community led or third sector led as well. I think that that helps those waiting times if we can make sure that we get the sounds easy, the GERFEC agenda, the right support at the right time, provided by the right professional. If you say it really quickly, it sounds like something that is one of the hardest things in the world to do. I think that that has probably helped, and what you see in those figures are some of the variations across the country that have been played out. I would echo that. I think that the figures look quite good from a Highland perspective. We have got two quite different halves of CAMHS, if you like. We have a lead agency model, so I manage the tier 2 service and the tier 1 services around additional support needs, educational psychology services, allotail professionals, etc. They are preventative services, so they can respond very quickly and pick up referrals very quickly. Our tier 3 and tier 4 services deal with much more complex cases and tend to have longer waiting times, so the average may average down, but there is huge variation in that from a week up to well over six months in terms of wait times. I think that that is the thing that we grapple with as a whole system, is to try and get much more consistency in terms of the wait times, so not look at an average, but actually look at the variation and try and reduce the variation, because that is how we would get a much more coherent service delivered on a more consistent basis. In terms of the figures that are there, a grampion has managed to improve its waiting times by 27 per cent since September 2017 to September 2018. We have a model that we use in a grampion called CAPA, which is called Choice and Partnership. It is a very good model at looking at demands and capacity modelling, where we can flex the system for children and young people to be seen for assessment and treatment. Grampion has been one of the lowest staff or is the lowest staff board in the whole of Scotland and at one point last year by 53 per cent less staff than the national average. I have come into post at the start of this year and we have been able to demonstrate through our CAPA modelling with capacity and demand the exact amount of staff we need to improve our waiting times. The senior leadership team has agreed to give us £1 million in recurring new funding for CAM staffing in grampion. Another thing that it is helpful to point out is that the point at which boards stop the clock perhaps varies. Grampion very much stops the clock after the second appointment. We class the first appointment as assessment and the second appointment as the start of treatment. However, we offer signposting and treatment advice at the first appointment. The reason is that it is called CAPA is that the first appointment is called choice. It is about giving young people, when they come into the service, choices for their treatment, choices for engagement, choices for feedback in terms of what we feel we can do to help them or what community supports we feel can help them at that point. The whole process is around engagement. Our waiting time for choice is only six to seven weeks, and of the people waiting more than the 18-week targets, we only have six people who have not been seen for their choice appointment. The figures need thinking about how data is necessarily reported and that something is not right. I was just speaking about that before coming into the room today. The other area that we are looking at in grampion is that a large proportion of our longest waits are for neurodevelopmental work. We have really welcomed the work of the mental health access improvement team. They have been working with us around our whole-cam service to help us to think about improving waiting times. We are now doing a large piece of work with them to look at neurodevelopmental pieces of work, because about 40 per cent of our service referrals are for neurodevelopmental work. We have also done some work recently on rejected referrals and started to audit why that is happening. Of the rejected referrals, 24 per cent of them were around neurodevelopmental work. We are now working on a joint programme with pediatrics to think about how to jointly assess and coalesce our services between CAMHS and pediatrics for that neurodevelopmental piece of work. As in the paper, I am confident for Aberdeen City and Shire that we will be meeting the waiting time target after the accommodation move and was in new posts by next autumn. We are doing a dedicated piece of work with the MACE team now around our Murray team, because our longest waits are in that part of the service in grampion at the moment. There is lots and lots of work going on. That is really helpful. There is clearly an issue about consistency of data and what it means even within the health board. Dr Coy, you and your presentation earlier talked about four strands, you talked about neurodevelopmental, emotional distress, specialist mental illnesses and children born into poverty. Where are the biggest spikes occurring that are giving us cause for concern in all of these strands? In the neurodevelopmental strand, the biggest issues are around getting access to assessment first of all, because if you have ADHD or autism, you cannot access other services until you have a diagnosis. That is what we were talking about in terms of assessment by educational psychologists or by pediatricians or psychiatrists. The second issue in that neurodevelopmental strand is that the families—I have met huge numbers of the families now, not just the rejected referrals—are desperate for some kind of community support drop-in. Those are children who are very disturbed, the behaviourally disturbed, they upset their siblings, families break up because of the issues that are going on. While they by and large get good assessments and then get good treatment when they go to a CAMHS team, what they are asking for is drop-in centres and community support from third sector organisations that have experience in that area. That is the spike in the emotional distress and generic one. Again, the spike is the gap in the third sector. There are organisations out there doing really good work, but it is about how does the community primary care and the third sector deal with mental health problems. That is not just about providing some support in communities, it is about dealing with mental health problems and needing to have the skills and expertise in those organisations. We are planning training programmes for individuals, but it is important in commissioning through the IJBs, the health boards and local authorities that they commission third sector organisations that can deliver support for mental health problems. Some of that can be quite distressing. The spike is, as Dr Taylor described, in the specialist services getting round to being up to capacity and being able to keep fully staffed and looking at the two really good models, the CAPA model, which we have seen and is also used in Glasgow. I thrive, and those are internationally evidence-based models. They reduce your waiting times. Why would you not do it around the rest of the country? The Atres group is the group that we can really do something about at the zero to five years. Those are the groups that really need parenting programmes, that need breakfast clubs, that need wraparound caring services that are not really mental health services. They just need that kind of support so that by the age of five they feel that there are other responsible people out there that can support them. We have a huge opportunity in Scotland, and that needs to belong very much in community planning. That is the group that needs to be the focus is on there. I was just going to ask you to read me. We have all had, as MSPs, families coming to us with issues like that, on behalf of our children, some pretty tragic, of course, over the years, and I am sure that we have all shared. I just wanted to ask Kate what is the main thing or the key thing that we should be doing. I think that you have kind of alluded it to a doctor quite, but what are the main things that we should be doing to try and improve how we spot children at risk at an earlier stage as possible to make the kind of interventions that we need to make to help here? For me, that is in education. I suppose that I would handle it, because I think that you are the expert. Ayrshire has done this really well, in linking and picking up people early in education. I think that that is absolutely right, and what we have done in some pockets of Ayrshire, and Dr Clare spoke about a couple of schools, is bringing people together. We have spoken a lot today about referrals, and the Auditor General's report talks about children being bounced from one part of the system—I think that bounced is a word—at one part of the system to the other. What we have done is alongside police colleagues, education colleagues, we have some camp resource, we are utilising the school nurse resource to form where at all possible in predominantly high schools, but working with feeder primaries to work with families at the earliest stage as possible to identify young people that may be struggling a bit before they get to crisis. This is a challenge across the piece. How do we protect those services and those supports at the same time as austerity kicks in? We know that all public bodies are struggling at times to manage those demands and making sure that we preserve the prevention and early intervention agenda, because that will be the public sector demands of 30 years' time, 40 years' time. It is really important that we do that. I think that we have worked hard with local politicians to maintain that and keep that priority there. However, what happens is that we move away from referrals so that those teams around these schools stop thinking about, I am going to refer to CAMHS or I am going to refer to social worker. They have discussions, we want another about. Actually, I am a wee bit worried about this young person. Could you have a chat? Could you have a look at what you may know about them and beginning to move away from this rigid referral bit so that they can work as a team? What we are finding is that actually where we have the right leadership in place, that makes a big, big difference and gets the right support to those young people as quickly as possible. Bernadette Lynn, would you agree with that? We have a similar situation. We use the Highland Practice Model and the National Gyrffec Model for the same reason, so that we have people who are requesting assistance. They are looking for other partners to assist them whenever they have any concern about a child or a young person. Our primary mental health workers, who are our tier 2 CAMHS service that I directly manage, are associated with every single school. We have an educational psychologist, a primary mental health worker who is linked to all of our schools in Highland. That means that we have specialists that are around that can provide consultation. We have spent quite a lot of time developing a consultation model that supports other practitioners to be able to have just that conversation. I am a wee bit worried about so-and-so because they have not turned up for English for the last couple of weeks. I am not quite sure what the situation is there. That allows us to have a conversation about what might be happening, who should be or could be involved, and we can start to pick things up at a much earlier stage. We are seeing the benefit from that preventative work. People have talked about signposting, but looking at who should be involved and where they should be involved is not always a referral to a specialist service. Sometimes it is, but sometimes it is about other people who are already around the school or the earlier setting to become involved to support family. It is a model that can work best to support our very specialist services to provide what they can for people who have real significant mental health issues. Bill Bowman Can I ask a question on the section in the Auditor General's report, which is headed up data on performance and outcomes is limited, in particular Para 37, which starts off not all services and organisations have electronic systems that are fit for purpose so that they can improve efficiency, share information and collect data on performance and outcomes. I just wanted to ask if your systems were fit for purpose. From a grantee perspective, the simple answer to that is actually no. It is something that we have been raising nationally at Leeds meetings because the data systems across all boards are different. In terms of getting a minimum data set, in terms of outcome measures, in terms of patients being seen, for example when the clock is being stopped, all those issues need to be looked at and data for us to be able to plan and develop services in a consistent way with the rest of Scottish boards to be comparable would be helpful. With regard to our capacity and demand modelling, we have good data in terms of how to manage the workforce and fruitier proof of the service and to think about internal capacity and demand. When you are looking across the whole of Scotland in terms of how data is recorded, it is quite hard to think about how services work in a comparative way across the rest of Scotland. In terms of demand and capacity modelling, it is fit for purpose because we use a CAPA model, but there are much more significant pieces of work that we could do. For example, each board has had a data analyst in place. Grampian has not had one at all until October this year where other boards have had data analysts in place. We are looking to learn from staff who are in those positions in Tayside and Lothian, and we are looking at replicating models that they have found to be useful. Again, we do not have consistent data around the effectiveness of how services are being delivered. That is something with regard to the minimum data set for outcome measures with regard to functioning, severity and improvement from young people coming into the service. It is not necessarily data around just efficiency, but we would also like to look at measuring effectiveness. I am sorry that I was hoping to hear from the others. Sorry. Do you have any other witnesses of anything that you would like to add to that? We are looking at this in the task force. We are pulling together all the different data sets that are essentially there. That is data in ISD that is cleaned up data. What we are wanting to look at is how we do some linkage work into what is going on in the community. I think that there would be a big prize to get with that. We will put some resource into that now to begin to try to get that community link up. The other point is that the useful data can also be local data—I suppose that we call it dirty data—that is the data that you get from the CAPA models that tells you what you need in terms of your service requirements, which is useful locally, but you cannot compare it because it is different in different areas. Can I just ask if the others believe that their systems are fit for purpose? I think that, certainly from an Ayrshire Nardin perspective, they are constantly improving in terms of being able to produce reports in a variety of ways. A few years ago—I am not sure what the number will be now, but when we looked at this previously across Scotland—there were eight different social work systems in use. There were 250 different systems across the NHS. Obviously, we have one system now for schools, which is CMOS. The difficulty is that, although there are really good systems in amongst all of that, they do not always talk to one another, and that is what Dr Coy has talked about—how do we begin to make sure that those systems can talk to one another in as effective a way as possible, and that we can see the whole journey for a young person as opposed to one particular component of the service. Similarly, we do not have one system that cuts across a local authority in NHS, so quite a lot of the data gathering that I do in terms of the effectiveness of the teams that I manage is about reading across different systems. It is manual comparison rather than a systematised process. Sorry, Bill. Thank you, convener. Good morning. I would like to go back to Willie Coffey's discussion around referrals and talk in a bit more depth about rejected referrals. According to the Auditor General's report, there were over 7,000 referrals rejected in the previous year. The first question would be, is data collected on why those referrals are being rejected? What are the key reasons for those rejections? We have been thankful that someone in our service has been able to start looking at some auditing around that. We, as part of our redesign, have adopted the national CAM's referral criteria, which was developed in 2012, to think about referrals coming into the service. As part of that, we have increased the number of staff that can refer into CAMs. For example, previously it would have been just GPs and school paediatricians, but it is now open to headteachers, educational psychologists, people who perhaps might know on the ground that the children and young people are better than the GPs who can more easily refer it into our service. We are starting to look at the data around now, around the referrals coming in from a wider pool of staff. In terms of the rejected referrals, the areas that are coming back into the service are not just around rejected, but the ones that have been rejected, what do they get re-referred for? The figures that we have at the moment are 24 per cent or are re-referred in who have been rejected for neurodevelopmental problems. The other are for anxiety, which is about 18 per cent, and the remainder are for low mood, which is around 21 per cent. We are now trying to look at a bit of work around why they have been rejected and why they have been re-referred back into the service. We have also identified that our re-referral rates are higher for the under-12 age group than is for the adolescent population. We need to do some work around thinking about why that is particularly, but it is helpful just to us to start unpacking some of that. Before I throw that question to the others if I may, can I just pick you up on that, Dr Taylor? The submission that you have very helpfully provided beforehand talked about NHS Grampians getting a wider range of referrals now. Have the changes that you have just described led to a reduction in rejected referrals as far as you are aware? We have only just opened up that new referral pathway from April of this year, so I do not think that we have enough data yet to look at that in enough detail. Certainly, the rejected referral has not been going up exponentially during this period of time. It has remained relatively the same, but I think that the number of rejected referrals on paper still looks very high. It is important for us as a service to think about why that is happening. The partner agency work around tier 1 and tier 2. As colleagues have been talking about today, thinking about those conversations about picking up the phone and checking them with people. One of the other things that we are developing is a daily telephone service for a clinician on call within CAMHS to be able for a GP or a head teacher to pick up the phone and say that I am thinking of referring this young person is appropriate. Do you know of any other information that might be useful to think about? Having more conversations is important with our partner agencies who are referring in. I will come back to that in a second. Can I throw my first question out to the rest of the panel about the de-collect data on the reasons for the rejections and, if so, what are the primary ones? We certainly do, and we have a look at that. I think that some of the discussion to date has been around. We know that there have previously been inappropriate referrals that have gone to CAMHS, young people who are potentially struggling, no one knowing what may be available locally, and either a teacher or a GP deciding in the absence of anything else will refer to CAMHS. Clearly, what has been happening in some places is that CAMHS has huge waiting lists. Amongst that will be young people who are perhaps showing behavioural issues in schools, but amongst that, too, will be young people who are self-harming, suicidal ideation, possible early indications of psychosis, and how do you wade your way through a whole sea of—I would expect there to be—a number of rejected referrals. Certainly, in the short term, as we begin to change models, what we are keeping a close eye on for those rejected referrals, as Dr Coy and Dr Taylor have outlined, is trying to see whether those young people then refer back into the other systems that will give them the right support, and we are trying to track that through to make sure that that is the case. Over and above that, what we will do locally around places such as Mark College, Cawinning Academy and Ayrshire, is to look at, are we reducing, in those areas, those inappropriate referrals that have previously gone to CAMHS? I think that we will, but it is too early yet to say, I think. If I might pick up on that point, unless Bernadette Cairns you have something specific that you want to answer on that question. It is not something different. I think that the point is well made about the conversations and consultations. Our focus on consultation has reduced the number of referrals that have been considered rejected. Sometimes we would consider them to be redirected rather than rejected. Having the conversation with a specialist beforehand allows the potential referer to know where that referral is best placed so that we can get the best service to the child at first bounds rather than going around a system. I think that that is really important to hold on to. If I might explore that point, because I think that that is quite crucial, the referrals, according to the Auditor General's report, the reasons for referrals being rejected, primarily boiled down to three, two of which are focused on the referer and suggesting that it is poor communications, it is a lack of communication, which leads to the question, how are you supporting it? It sounds like Bernadette Cairns you have started to answer that question, but how do you support the referers to change that poor communication going forward? We have spent quite a bit of time training, having conversations with GPs, having conversations with schools and health visitors to talk to them about what would be appropriate for whatever services that there are out there and investing in training so that they can contain situations much more and feel more confident doing that. Their first port of call usually will be the primary mental health worker and to have a consultation with the primary mental health worker who is linked to them, they know who they are, their local worker. They can have that conversation which can then start to explore how they might be able to support the young person themselves, or if there is a need to bring another service in, what that service might look like and where they should put that. It also means that that is a direct route, if you like, because that is part of the CAMHS service. It is a direct route into maybe tier 3 CAMHS or the community service at tier 4. Noting the fact that, quite often, people are not using the right language, they are not communicating effectively the needs of the child, primary mental health workers can frame those referrals much more appropriately so that the information is clearer for the people then picking that up, so that has been a really helpful process to put in place. I have one final question, which I will direct to Dr Taylor, if I may. At page 20 of the Auditor General's report, we are talking about people starting treatment within 18 weeks. You will immediately understand why I am referring this to you, because the figures for NHS Grampian appear significantly lower than across the rest of the board. In answer to Mr Bowman's questions, you were suggesting that you were the lowest staffed board. You talked about the systems not being fit for purpose, or there is significantly more that can be done, and you talked about stopping the clock at a different time. That leads me to two questions, which I will roll into one. First of all, is this about, as the Auditor General suggests at paragraph 33, interpreting when the clock stops in different ways across the boards? If so, how much of the figures are due to that and wouldn't you change it so that you are more aligned with everyone else? Or, and or, is it about funding? Certainly, I have heard in the chamber many times that concerns have been raised about NRAC funding, and NHS Grampian appears to receive significantly less. Can you just talk me through the reasons for that figure and whether it is to do with funding and or how you assess things? Certainly. From my perspective, it is a bit of both. We have looked quite a lot at across our Grampian system. One thing to point out to start with is that the figures are from 2017-18, so, as I have indicated earlier, by using our CAPA modelling, we have improved performance by 27 per cent. At the moment, we have employed nine new staff since the start of this year. Prior to that point, our staffing had not increased at all between 2013 and 2018. Part of the reason for that is that some money had been taken out of our core camp service by our partner agencies in the council. Therefore, the core posts within camps had to be filled by the board for that deficit. By doing the capacity modelling through CAPA, we have now been able to clearly demonstrate to the senior leadership team exactly what our gap in staffing is. We have a very detailed workforce plan, so they have committed to giving us £1 million, as indicated for new posts. Staffing is absolutely key. At the moment, we have gone from 52.3 whole-time equivalents to 60, with the national average still sitting at 92.8, so we are still significantly lower staffed than the rest of Scotland. That is certainly one factor. However, with the transformational redesign that we have been doing, I am really encouraged and I feel very confident that, with the progress that we are making, we will be able to meet waiting times, certainly with Aberdeen City and Shire, but also with Murray going forward. I think that this is around us using efficiency within the service, looking at how many patients our joint worked for example, and the types of referrals that are coming in. With going back to your first point about data, I do not think that we should do something different. In Grampian, we pride ourselves in saying very much that you have talked about first and second appointments and first being assessments and second being treatment. As I have indicated earlier, once I have looked at the data, there are only six patients who have not been seen out with eight weeks for their choice appointments. The weights are mostly around our neurodevelopmental assessment area. We also prioritise patients and people according to clinical needs, so emergencies seem within 48 hours and urgent within seven days. I agree with you that there is a data issue around when the clock is stopped and not necessarily comparing like with life across the rest of the board. I widen the debate out a wee bit because I am interested in the causes of mental health and how we prevent as well as how we treat mental health. What struck me most about the auditor general's report was Exhibit 1, which showed that the children who are brought up in low-income households are 300 per cent more likely to suffer mental health problems than children in better off peer households. In all of this, it strikes me as with physical health, if we are really long-term going to be able to address this the way we all want to address it, we need to address the issue of poverty. As we know, poverty among children throughout the UK is rising exponentially, including in Scotland. We are chasing our tale as long as poverty increases. Do you agree with that? I certainly agree with that, because I think that what we are doing at the moment is putting the bucket under the leaking roof and we are not actually repairing the roof. There are significant issues about child poverty in Scotland. That is why I put in the strand of at-risk children, because it was to tease out that very issue as trying to get that strand to be the way that we would begin to focus on the prevention agenda and the whole public health agenda. For those children, that is very much about good parenting. It is very much about having support systems in place, but it is very much in the third sector about organisations that provide things like breakfast clubs that go in and support schools and have after-schools, where it is probably safer to be in an after-school programme than it is to be back at home. I think that we should tackle that. I suppose that what we were doing in our recommendations was two things. One was that we were trying to make sure that we did tackle it, but in a way that we might make some progress by putting it in a strand that we could actually say, here is the group that we are really going to focus on. We might only focus on a couple of areas. We have identified the children in care—huge issues around mental health issues for that group and how they get into care. We have identified the children of asylum seekers who are struggling in households with significant poverty. We have identified some key areas, but we can all talk about a good game. That is my concern. We all talk about it and we all agree how dreadful it is, but what could we do about it? The doing for me is trying to get commissioning of those third sector organisations to a place that they might target some of that. Maybe targets the wrong word about not using that with cuts. It is something about encouraging people to understand what is going on, as you say, underneath it and focus on that. Sitting here in the committee for two and a half years is two things. Number one, I think that the evidence that you have given this morning denies among the best evidence on any subject that we have had in this committee in the two and a half years has been fascinating. The second thing is, as with closing the educational attainment gap, as with closing the health gap, or reducing crime long-term, it seems to me that there is one theme underlining all of this, and that is that we do not have a hope in hell of achieving any of those things, unless we have a much more ambitious programme for dealing with poverty and, in particular, child poverty. Would that be a reasonable statement to me, as far as mental health is concerned? I would agree with that. I think that, although I stated earlier that Ayrshire Narn do well in terms of the referral treatment times from a North Ayrshire perspective specifically, one of the things that I am most ashamed of, and I speak on behalf of the community planning partnership, is overseeing a level of child poverty that has gone from 29 per cent up to almost one in three children living in poverty. That creates and brings its own pressures to many parts of the system, and mental wellbeing, emotional wellbeing and clearly being part of that. There is a study that was undertaken in America called the Great Smoky Mountain study, and it sticks in my mind because it sounds like a great study. It has been tracking the well-being of children from the most deprived areas in North Carolina. Over a long period of time, and what the researchers noticed probably about two years ago, was that there was a sudden spike in the emotional and mental wellbeing of children, their educational attainment, everything seemed to go up for a group of these young people. When they looked a bit more closely, they realised that it was geographically driven, and when they looked at it in a bit more detail, it was a Native American Indian reservation that had essentially opened a casino and every family on that reservation benefited to the tune of $4,000 a year, which is not a great deal of money, but every single child suddenly started to outstrip their peers in that study. And again, that difference in terms of just the best way of tackling child poverty is to put money in the pockets of parents. Absolutely. Kate, did a Grampian and Hyland want to come in? We obviously, even in Grampian, you'll get significant pockets of poverty within what's a relatively rich region, and obviously in the Highlands, rural poverty is a big issue. Absolutely. Can I just say something about the answer, Miss Cairns? We could sit all day, and discuss this. I know that that's an important point. No, I'm just about to come back to Miss Cairns, but I think that if we can wind up here, we'll move on to our next panel. Miss Cairns. I think that my point is that that's why we need a whole service and a whole system approach, because these things are all interlinked, and we've had quite a lot of discussion across the country around adverse childhood experiences, which also links to poverty. If we don't get that right in the very early years and at school across the piece, then we're doing our children a disservice, so I think that the connection and the whole system approach is really what's very important for our children and young people. Alex Neil. I agree. I'm happy to—I think that it was an important point to make. I just want to final ask a more specific point, and I'm very interested in what you're saying about the improved performance in Grampian, and clearly the link between staff resources and performance. However, that again raises a wider issue for probably Denise, but I'm happy for anybody to answer it. That is—in one of my frustrations when I was a cabinet secretary of health, there were so many good things going on right across the health service, but my God, trying to get people to share or adopt good practice was a nightmare. Do we not need to do much, much more—a major improvement in Grampian in this relatively short period of time is a good example of that? Can we not do a lot more to share and adopt good practice where we come across it? We've got a practical solution to this, which we discussed before. Part of the task force's dream that we think in the next two years is to run workshops, conferences, to spread the good practice, to showcase something. We've got one starting in February to launch the whole task force. We were just asking about showcasing some of the work in Grampian. This is how you do it. This is how you do it in Ayrshire. Bring the schools along so that schools can show how they do it and how they link to primary care and what work they're doing. We do see that we actually have to keep—we're going to have an online platform to do that digitally as well. In Scotland, we've got fantastic good practice, and we should actually really just keep the momentum going about where it works. I would just like to say that we've also had the Mental Health Access Improvement team with us, and they've asked about sharing some bits of work that they've done with Grampian and other boards, which is another avenue that we can all learn from each other and share pieces of work. We're moving into a phase 2 piece of work with that maced team now, when we very much welcome their involvement with Grampian to help us to think and also learn from other boards in terms of what practices they've found useful to. Can I thank you all very much indeed for your evidence this morning? I'm now going to suspend the meeting for two minutes to allow a chain do-over of witnesses. I'd like to welcome our witnesses for the second panel this morning. Paul Gray, director general health and social care, Scottish Government and chief executive of the NHS in Scotland. Donna Bell, director for mental health, Scottish Government. Nicola Dickie, chief officer, children and young people from COSLA, and John Wood, chief officer, health and social care at COSLA. I'm going to ask Colin Beattie to kick off for us. There's a certain consistency in the fact that statistics and figures tend not to be available in any great quality. What progress has been made in developing quality indicators for mental health services? I think that the first thing to do, Mr Beattie, is to acknowledge that your point is correct. I don't want to go off into something that sounds as though I'm disagreeing with it. We do need greater consistency. In the immediate point, some of the work that's done being done by Healthcare Improvement Scotland in relation to Tayside will produce evidence about how we might have greater consistency. We've also commissioned work on data collection to support that, but I wonder if Donna Bell would like to say a wee bit more about the detail. You heard from Dr Coy earlier on about the work that the task force is undertaking at the moment and the engagement that they're having with local areas to get underneath the skin of the data that they're collecting and to try and deliver more consistency on that. We expect, over the course of the forthcoming months, that we will have a better understanding. What's up with the timescale that you're talking about? You said a few months, is there a target dead? We don't have a target yet. Dame Denise will be publishing her delivery plan in December, so we expect to set that out then. And will all NHS boards then be reporting in a consistent way? There's work underway at the moment to look at the consistency of data. We will be engaging with IJBs and boards in the coming months to agree with them in the reporting. Will that specifically result in a better understanding of the demand for mental health and wellbeing services at all levels? That's work that needs to be done as well, and I think that you heard some really compelling evidence from the panel previous, which set out work, for example, that's going on in Grampian to understand demand, and we would hope that that would be replicated elsewhere. But you're specifically working towards that? Yeah, and that is what Dame Denise will include. What are the reasons that children and young people's needs are not really being met at the moment, according to their channel's report? What are you doing to achieve that? I don't want to exclude COSLA colleagues from their responses, Mr Beattie, so I'll make way for them, but I would say three things. Child and adolescent mental health staffing has increased by nearly 70 per cent over the last 10 or 11 years, so there have been significant increases in staffing. However, as those who are clinically qualified would say, there has also been a sharp increase in emotional distress among young people in schools, and neurodevelopmental disorders have also appeared to be increasing, and so we need to understand, to some extent, the clinical underpinnings of some of that in order to respond appropriately. There have been increases in service and there have been announcements of funding of £250 million to increase services further, but we also want to make sure that those increases in services are aligned with the appropriate levels of clinical advice, so that we're not simply putting people in so that we can say that we've added numbers, but rather putting the right people in the right places. I had a very useful engagement with the Youth Commission advisory panel on this, which I am happy to speak about, but I'm also conscious of the committee's time, so I'll leave that to you whether you want to follow that up. First, to say that we welcome the initial recommendations from Denise Coyer that have gone to COSLA and to the Scottish ministers, we think that the direction of travel that she set in the first few months of the task force has been really welcome in terms of understanding the answer to the question that you've posed. I think that if we look to the questions of data, a lot of the data that's harvested at the moment and that is focused on either politically or in the Audit Scotland report is very much focused on the end product and what happens after the fact, I think that somewhere where we could focus our efforts a little bit better and hopefully will come from the strand of Denise's work that looks at data would be to improve our understanding of the causes, as I think it was touched on earlier in the morning session. I think that better data to look at the causes of poor mental health is something that we should be focusing a lot more effort into. So, your position is that we don't at this moment have a clear understanding of the root cause of mental health issues among children. I think that our understanding is not as it should be, but it's improving and I think that a lot of that is down to the changing nature of the issue. As I've been mentioned this morning and also by Paul, emotional distress is something that is creating a lot more activity in the system and that's something— Can you tell whether there's more emotional distress? I think that hopefully some of the product of Denise's task forces work will be to get a better understanding of that. I do think that, as was again touched on earlier this morning, we don't yet understand the impact of social media on young people's lives. I saw a very interesting statistic produced by the behavioural insight team at a presentation around public health a couple of weeks ago, which showed quite a clear correlation in the US and in the UK between the boom in social media and levels of adolescent self-harm. That evidence is just emerging, but I think that there are now numbers to support the anecdotal evidence around the impact of social media. I think that that's one among many that we are probably as a whole system trying to catch up in getting our heads around it. What specifically does COSLA do to support councils in particular in tackling this? I think that Denise Clya's task force will produce, hopefully, a bed for improvement work to come out of. In terms of raising it on the political agenda, the statements that we've made around the task force and our response to the reporting question this morning has, hopefully, helped to raise that among our councils. There appears to be a considerable reliance at all levels on the task force producing the raw data that we need to understand the root causes and so forth. Is that correct? There's certainly a lot of emphasis placed on it. I think that we would look to the integrated joint board chief officers as well, who I know have been doing a lot of good work around mental health and better understanding what the integration authority's contribution to improving children and young people's mental health outcomes can be. Good morning, panel. Both the Scottish Government and COSLA have mentioned the data inadequacies already in this session. What are the Scottish Government and COSLA doing to understand and collate what is spent on children's mental health services in Scotland? That's part of the improvement that we want, Mr Kerr. We already have some data from boards, which we can share with the committee if that would be helpful. One of the things that we want to be able to do is to trace expenditure through two outcomes. We're not as good at that as we should be. What we can say is that we already have plans to increase the number of people in different disciplines involved in the delivery of response to mental health requirements in children and young people. There is a measurability about that, but I think that we need to step through to measurability about outcomes and we need to get better at that. I'll come back to that, if I may, Paul Gray. I'll throw the same question to COSLA, so this is purely about how we understand what is currently being spent at the moment, because reading the report from the Auditor General, we don't seem to know what is directly being spent because of different ways of measuring. How are we addressing that? I think that, again, we would want to look at the global resource that is available rather than just simply the health spend, which is probably a little bit more traceable, if Paul Gray would agree with me on that one. Rather than looking at exactly what is spent on acute services and on CAMH services, we would rather have a conversation about shifting the balance of spend into preventative services, which is always very difficult to quantify. I don't think that we would want to get ourselves caught into a numbers game of setting targets at a local level, as to how much was spent in different service areas because of the very different make-up of service delivery and the bits of the system that are within the responsibility of the IGB or not, and services that are delivered across different agencies. Taking that point, it might be more a question for the Scottish Government, because in the programme for government, the Scottish Government announced an extra £250 million over five years to support mental health services, but given those data problems and a lack of consistency about data capture and what is being measured, how are we going to know if that money is actually being spent on the things that actually make a difference to children and young people's mental health? Part of that, as I was seeking to say in the earlier response to Mr Beattie, is understanding what the root causes are and also understanding what we can do preventatively. In other words, we are not waiting until there is an acute presentation, but we are doing much more preventative work. What I can say is that having said that there would be 60 million available for additional school counselling services, that supports 350 counsellers, that is directly measurable. We either do or we do not have that in place and that is the plan to have that in place. I can go through the list of the other things, but for one time I will not do that. That is part 1. We can tell if we have done a measurable thing when we say that we will have so many people doing it. Part 2 is what outcomes are being achieved. That is harder. For example, it can be at the moment that a young person in their teens goes to a GP with a presenting issue and there is alongside that a mental health issue. There is a question there about the level of granularity that we would want to associate with that. Someone goes and says, I have an upset stomach and I am not eating. The GP through their professional intervention detects that yes, there is a symptom but there is also a cause of that symptom. That is where it becomes more complex. The disposal might not be to give medication or advice on eating or on something for a stomach upset, but rather a disposal might be to some talking therapy or other opportunity. You will understand why I am giving that example because it is slightly broader. That is where we have to be careful, as John Weed is saying, of not trying to overanalyse this but to make sure that we get the right outcome. I accept that. The question that I will throw back to you is how will the public know that an extra spend over half a decade of £250 million is actually delivering results? It is going to the right place and it is delivering the right results. There must be a methodology, at least in progress of being created, that will allow you to at least measure a definable outcome of the 250 million. What is being proposed includes things that we know work. In other words, we are not simply guessing that this might be a good thing to do. I am saying that, if Dame Denise comes up with recommendations on route cause prevention, we might want to adjust that slightly. It would be better to have 320 councillors and 95 more school nurses. We are not going to be full, I should say. Those have to be absolute numbers that we stick to, but what we have done is set aside the funding and we have said that we know that counselling services and school nurses are likely on the evidence that we have so far to make a difference. We are talking about putting 80 additional councillors into further and higher education as well, because you do not suddenly become not in need of these when you reach 18 years of age. We are putting in the things that the evidence supports but we are listening to the further emerging evidence to make sure that we have that as right as we can. That is why I referred to the Youth Commission advisory panel, because the young people who gave us advice and are giving us advice through that have experienced mental health problems, and they are telling us how they would like to access services and what they feel about avoiding the stigma of having a room in a school that says that counsellor is on the door and that creates a stigma rather than a desire to go and take up the service. The counsellors are needed, but the way that we provide them has already been adjusted in my mind by having the opportunity to speak to these young people. Mr Greer, we heard this morning from Dr Coya about the welcome fact that we have new money coming towards mental health services, but she used the cuts word in terms of cuts coming in advance of the new money, and a lot of that new money having to go and fill the gaps that have been created. Where are those cuts coming from? Do you recognise that? I recognise that health boards have to make, as they have made every year for many years, 3 per cent efficiency savings year on year. Dr Coya, I did not hear the evidence, but I understand that she somewhat modified her statement during the evidence. I recognise the fact that we make efficiency savings year on year and not pretending that we do not. Actually, any health service that did not would not be doing its job properly, but there has been a 69 per cent increase in child and adolescent mental health service provision since 2007. There is another £250 million, and I have enumerated some of the types of professionals that we think will be provided by that, based on the evidence that we have so far. The issue is how we make sure that we have convergence between that and the increasing incidence of neurodevelopmental issues and the increase in the incidence of general emotional distress among young people that John Wood and others have referred to. I can tell you what the numbers are, and that would be my answer. Are you aware of any health boards that have cut services of mental health due to budget pressures? I do not have specific detail. If the committee is asking me to provide specific detail, which is entirely within its rights to do it, I am happy to provide it. Obviously, you cover both health and social care, so there is a local council perspective. Are you aware of cuts to local government budgets that have impacted then on services provided in mental health, whether that be direct services or services through third sector organisations, and what the scale of any such cuts might be? I would very much rather let COSLA respond to points about local government. I think that it would be appropriate for me to do that. Are you aware of any? I am aware of services that have been reconfigured, and I am aware of services that have been delivered differently in terms of specific cuts within local authorities. I am not personally aware of that, but that does not mean that they do or do not exist. Do you want to respond to that? In terms of local authority budgets allocated towards mental health services, it would be very difficult to trace that in terms of the being cut. I do not think that we would have detailed information to offer on that one. What I would point towards is the overall 4 per cent reduction in the local government budget that we have seen over the years. Although that will not necessarily have had an impact on mental health services as defined by some, the preventative benefit of local authority services, a lot of which are provided by third sector partners on our behalf, are the preventative services that we want to try and direct attention towards when we are talking about children and young people's mental health. Those are the sorts of services that are vital to stop people getting to the sharp end of services. I am aware of cuts of third sector organisations in my own local authority around that provide mental health services because of budget constraints on the council. You must have some examples of that as COSLA is looking across the country. We have very difficult conversations with the third sector around the availability of budget to maintain the services that we would like to in partnership with them at the moment. Are you able to do an analysis of the resources provided to either direct services that councils provide or to third sector organisations that councils fund about how that funding has gone over the last, say, five years, particularly on mental health issues? Specifically on mental health, we could provide information if there was a request from the committee on that. I think that we will probably point towards our essential services document that has been published recently that outlines, in quite a bit of detail, some of the specific funding pressures that we see on local authority services at the moment. I just really wanted to come in on that point. It is very difficult because what we are trying to do here is protect communities. So much of the evidence that we heard in the first session this morning was around about resilience, robustness and communities. If you take it, that local government are the ones who are providing much of the leadership in those areas, any cuts that come through the local government settlement ultimately will affect communities, how resilient and how robust those communities are. That includes our school communities as part of that wraparand support. We probably have some very specific examples, but we also have the global figure. What we are looking for here is a whole system shift, and we have to recognise that there are different parts of the system that are being treated in a different way at the moment when it comes to financial sustainability moving forward. That sounds as if you do not really have a clear picture of where those cuts are coming, Nicola Dickie. I think that we have global figures of where we have pockets of support. What I think is more difficult to put our fingers on at the moment is what are the specific points, the point that was made earlier in the first session and around about how poverty affects young people's mental health and their wellbeing. How can you track something that you change over here and track that right back? I think that that is where we start to have the difficulty. If you do not know where the cuts are falling, how can we redirect that money to where it is more effectively spent? I think that, again, pointing to the causal essential services document, we can tell you exactly across the board where these cuts have come in global terms, but I could not say with any degree of certainty that a very specific cut here has a cause elsewhere in terms of young people's mental health. The work that Denise and her task force are doing when they are going out in their hearing from people on the ground who are delivering these services, they are starting to hear a flavour of that. It is the strain that the system is under that makes it difficult for us to cope and make sure that our communities are resilient. I completely accept that and take the wider point that you made around the reduction in budgets and the impact that that is having across services, but I think that some kind of analysis would be very helpful from COSLA specifically around mental health services. Particularly when we have a national strategy, we want to increase support for mental health services at the same time that councils are having to make some very severe cuts, not out of choice, but out of being forced to do it because they have got to make their budgets balanced. I think that some set of analysis, particularly on mental health services, would be appreciated. I think that it works the other way around as well. If I can give an example of the council, I represent North Lanarkshire Council, which has introduced the 365 club to ensure that every kid gets a decent meal throughout the year. I suspect that that has led to a reduction in the need for expenditure, for example, on mental health, because it is helping to address poverty. It works both ways, so I do not know if it is possible to do the analysis both ways. Sometimes it is not a cut because of a cut in budget, but sometimes it is a cut in demand, resulting from a better service provided elsewhere. It is too way traffic. The challenge that you have is that a poverty reduction will lead in our reduction in the need for mental health services, but a poverty reduction will not happen immediately with the introduction of a breakfast club. We will still need to have the mental health services to support people who are in poverty as they are out of poverty. I think that looking at the services now is really important. I spoke to Dr Coyle this morning about the analysis of the number of school nurses that there are in particularly mental health nurses. That is obviously a key commitment from the Government that is recognised and supported right across the Parliament. Do you have a timescale for when we might have an introduction of a mental health nurse in secondary schools across Scotland? At this stage, Mr Sarwar, we would hope that the guidance and plan coming out of Dr Coyle's task force will assist with that. I would also be happy to ask the chief nursing officer to provide the committee with an update on mental health nursing, generally, but with a specific focus on mental health nursing for children in different settings. I think that it is important that we join up the settings. Of the 7,000 rejected referrals, do we know that, amongst them, there were incidences of self-harm, attempted suicide or suicide, and, if so, how many cases? I would like to provide accurate information to the committee and I will do that in writing. I think that that is fair enough. I asked the previous panel about the section on data and performance and outcomes that is limited. We have had data raised by a number of people here. I do not think that, in my mind, I have a feeling for the actual timescale over which things would be improved. I might ask you to be a little more specific. The Auditor General in point 36 talks about developing a new indicator over six different measures. Even the new one that you are working on might allow the boards to cherry pick, which indicates that they report on, and therefore not adding to the comparability of data in the future. Could you undertake that you will not let them have that ability and perhaps provide us with a timescale that, again, is marked as not confirmed? As Donna Bell said in her evidence a moment ago, we will draw the timescales out of Dr Coy's report, which is due very shortly. I want to make it clear that I have heard the committee very clearly on that point. As you put it, Mr Rowman, I would be happy to give an undertaking to the committee that we want to be able to have comparable data across Scotland. I am very clear about that. That comparability—I want to be clear so that I do not mislead the committee—should focus on outcomes. I am not going to insist that the way we deliver services in Easterhouse is going to be exactly comparable with the way we deliver services in the Black Isle, because that would be foolish, but I want comparability of outcomes. I have also made the point that, when we say that we are going to count the number of people who are being employed as a result of the additional investment, we will count that. The answer to your question is yes. Any timescale for this particular item? That was the previous answer. I am not going to pre-empt Denise Coy's report, but you will give us one. We will. Can you just give us a timescale, Mr Gray, for Denise Coy's report? What are you expecting? Sorry? Timescale for the timescale. Paul Gray, can you answer the question? December. December. Thank you. Willie Coffey. Thank you very much. Mr Gray, you mentioned the £250 million extra funding that is being made available by the Scottish Government. Could you clarify as there has been an apportionment taken place so that each of the health boards and authorities know what share that will get? Is it somehow protected or hesitate to use the words ring-fenced? I think that one of the previous panels told us that some of the funding for mental health services had been pulled away—I think that it was Grampian who said that—pulled out of mental health to be used elsewhere. Will that money that is going to be protected for those services? That is the current intention. Just to be clear, we are looking to ensure that every high school has a counselling service, so just to be precise and clear about that, Mr Coffey. There are other services that I have mentioned, such as school nurses, counsellers in further and higher education. An important point, which is not so much numerical, is enhancing support and professional learning materials for teachers so that every council has access to mental health first aid training for teachers. That, too, is important. We are also proposing £65 million to develop a community mental well-being service for five to 24-year-olds that will, in due course, offer immediate access to counselling, self-care advice and family and peer support, because no person operates as a single individual with no contact with anything else. Sometimes the family and peer support is an essential component of what we draw together. There was an issue raised in discussion that Liam Kerr touched on. It was about the assessment process and the referral process, and you can see from the urgent general report that there is a variety of different people who make the referrals. The suggestion was made that sometimes we are tempted to push everything towards calm, which may result in a backward rejection or even a redirection. Are we looking at that process to make that a lot better? I do not think that it is money that achieves that. It is something else that will achieve improvements in that area, so that the assessments are done more accurately at the beginning to make sure that children are not directed to the correct service that they need. I will speak briefly and hand over to Donabella, if I may convene her. In Canada, some years ago, there was an approach to public service delivery that was called No Wrong Door. In other words, wherever you made the contact, there was a means of getting you to the help. That would be my ideal for this. Young people do not have to work out who they need to ask. If they ask their teacher, their GP or dentist, if they ask their hairdresser, I mean that quite sensitively. The person who is able to spot that there is a need ought to be able to know what to do. That is the ultimate aim. It will take years, but that is the ultimate aim. Donabella might be able to say a wee bit more. I think that you heard some really great evidence from Steven from Ayrshire and Arran earlier on about the whole system approach that they are operating and how that is enabling children and young people to get the help they need when they need it. That approach is beginning to be replicated elsewhere in Scotland, so I think that we would want to encourage others to work in that way. Is it too early to expect these figures to come down so that there is not that kind of delay and redirection that takes time and causes delays improving that at the moment? You heard from colleagues in Grampian who have been able to demonstrate a 27 per cent reduction in waiting time. I think that the very promising approaches, I do not know if colleagues from Coleslaw would like to add to that. I think that we are aware of some good practice that is going on, where it is, that whole system. Having spent some time in a school yesterday, we were down in Musselbrahe yesterday, and they were already discussing how they view some of their pupil equity funding, and one of the things that they have done is very much increase the confidence of everyone in the school community to actually have these discussions and perhaps if it requires it make referral. I think that we do have pockets of good practice going on. I think that you heard Dame Denise Coyer alluding to the fact that we need to get sharing that good practice, and I think that the fact that we are going to have a delivery plan that will have short-term things that we can do, medium-term things that we can do, and then things that will take longer, I would expect that sort of good practice to start to be shared and just to make sure that we can get some of those results if there are some wins there. Let's get on and do them. To reflect something that has come quite strongly from our elected members, as well as that we really need to maintain a focus on special services, and to celebrate the generalist as well. I suppose that it reflects Paul's hairdresser point in terms of when we are looking at the various ways that people interact, not necessarily with hairdressers but with the system, whether it is the third sector, the local authority, social work or health, so long as there is a one-pullock sector attitude among that workforce and people are aware of the services that are available in their local area, that will improve sign posting and hopefully eventually improve referrals as well. I asked the question of Denise Coyer's team earlier about sharing good practice, and obviously you guys are very much in a position to ensure that that happens. Obviously we heard about grampian and the transformation in grampian in a sort of period of time, not completed yet but on the way, so what are you doing between the Scottish Government and COSLA to improve the sharing and adoption of best practice? Clearly an early priority of Denise's is to look at the sharing of best practice. I think as well I would point to quite welcome statements that we've heard from the Cabinet Secretary for Health and Sport on the spreading of good practice and really making sure that we're not just showing one another what good practice is but fertilising across local partnerships to make sure that that good practice really does embed in other areas. I've heard that for years and years and years, so how are you going to monitor it because it doesn't happen? I don't know about monitoring, but I think that it's really important that we put resource into the sharing of good practice and improvement support as well. I think that services do a very good job of learning from one another, but pressures are such at a local level that I think that it would be really welcome to invest in more improvement support across health and social care partnerships. Obviously the Denise Coyer's task force is a partnership approach, so all the appropriate people around the table are sharing practice and it's incumbent upon us all to make sure that that is embedded at a local level. Healthcare Improvement Scotland is also doing some work with a range of all boards and IGBs around specific work on reducing waiting times, which is a collaborative approach. And there are around 40 projects that are under way at the moment across the country, which is a really good example of how good practice is being developed and shared across the piece. So I would point to that as one area of work. A good example, I thought, was from Grampian with history. I think that it was a CAPAS system that allowed them to look at the resource issue, what was getting in, what was coming out. If there had been any move so far to share that, that is good practice. That is exactly the sort of thing that we would expect, the collaborative approach that Healthcare Improvement Scotland is leading on, to be both promoting and sharing. There are other good examples across the country that exactly that is happening. I think that we are all agreed that poverty is a major driver of poor health, whether it is physical or mental. There have been some interesting examples of local initiatives, not just in Scotland but elsewhere, of helping to drive down levels of poverty, including child poverty. I know that this is not just a health issue, it is an education issue, it is a social security issue and all the rest of it. Is there any attempt across the Government to look at such initiatives and share them as good practice? Paul Gray. Yes, Mr Neil. The thing that I wanted to say in response to your point is that Sally Loudon and I are co-chairing a review of integration with a view to putting a report to the ministerial steering group that was co-chaired by the Cabinet Secretary for Health and the President of COSLA at this time in January. One of the things that we will be speaking about is the point on sharing our best practice, because you are right. We have best practice, we showcase it, but we are not as good as we should be embedding it across the country. We want to respect that there are many localities and they are all different. I have made that point already, but nevertheless, where we see good outcomes, we need to be asking ourselves more robustly. If you are not going to adopt that approach, how are you going to achieve those outcomes? I think that the imposition of common approaches has its limitations, but the desire for common outcomes has to be a key objective. Paul Gray, just at the start of this session, you referred to his report on CAMHS and Tayside. Is that correct? Can you tell me what you know about that report, please? I know that it is in draft. I have not seen it and that is what I know about it. Do you know what his policy is on publishing those reports? Are they all to be published in the public domain? It is my understanding that it was finished and I have been desperately trying to track it down. As far as I am aware, convener, this report will be published. That's good. Do members have any further questions for the panel this morning? Can I thank you all very much indeed for your evidence? I now close the public session of this committee and move into private.