 I welcome everyone to the health, social care and support committee's second meeting of 2022. I've received no apologies from any member for this morning's meeting. The first item in our agenda is to decide whether to take items 6 and 7 in private. Are members agreed? We agreed. The second item today is two evidence sessions as part of our short inquiry into health and wellbeing of children and young people. The first session will focus on mental health and child and adolescent mental health services. We have our panel today. I'll run through everyone who's joining us on our panel. Welcome to the committee. Shelly Buckley, programme manager for families, children and young people, the mental health foundation. Alex Cumming, the assistant director of delivery and development of the Scottish Association for Mental Health. Susie Fitton, the policy manager for inclusion in Scotland. Sam March, principal educational psychologist for South Lanarkshire Council, and also representing the Association of Scottish Principal Educational Psychologists. Joanne Smith, policy and public affairs manager for NSPCC Scotland. Dr Marri Start, Scottish officer for the Royal College of Pediatrics and Child Health. A little bit of housekeeping before we start. The clerks have allocated one member of the committee to lead questioning, each of our eight main themes that we've divided this session into. If any other member wishes to ask a supplementary question on a theme, then use the chat box, put an R in it. If time allows, I will bring you in for a supplementary question. Panelists have six of you this morning, so we will try as much as possible to bring all of you in when we can. However, with eight themes and possible supplementary questions, we might not be able to go round all six of you for every single. The members will always direct a question initially. If you want to contribute, you can use the chat box and put an R in the chat box. I will make sure that I come to you and I will prioritise your contributions rather than us having lots of supplementary questions if you get my meaning. You are our experts and we want to hear from you. I will kick things off and contradict myself straight away. I will go round every panel member so that we get everyone to give their initial thoughts. The programme for government had a lot of commitments around child and adolescent mental health and, in particular, getting more support in community settings. A couple of pledges that I have noted down here about the committee to every GP practice having access to mental health and wellbeing services and 1,000 more additional dedicated staff members. We have been hearing for years now that mental health services need to be in communities. We also know that there is a previous pledge but having school councillors in place, pandemic seems to have had an impact on the deployment of that local authority level. There are lots of interventions coming down the line, there are lots of interventions and there are lots of pledges being made. Can I get each of your assessment about what needs to happen in that community service and what variations you are seeing around Scotland about the deployment of previous interventions? If I go to Alex Cumming first of all and I will go round every panel member for this. Good morning all, thanks convener. So briefly, you are right that there are some really exciting building blocks, I would say, and previous pledges, as you have talked about, around child and adolescent mental health services. At SAMH, we have been certainly advocating and I am looking for further commitments around the community-based services. Children and young people and those that they work with are absolutely crystal clear that there is clearly a lack of services with that community-based services, particularly under the CAMHS threshold. The £30 million that the Government pledged for community mental health services is really positive and should be commended, but the vast are. From what we can see, a large number of those services are still very much in the implementation phase. Therefore, we do not know the impact yet, I think that it is positive and there will be positive impact there, but we do not know what that looks like yet. I think that the big thing for us or the big thing for me certainly is how those services are marketing and communicating about those services, particularly to the new colleagues within primary care that you have mentioned as well. Again, if all those things are not connected, we are not going to make the best use of those resources. I work for the mental health foundation, so much of the focus of our work is very much on motion and prevention. Ultimately, if we continue down the route where we are in the model where we are constantly treating the problem as opposed to trying to look at ways that we can reinforce the protective factors or the factors that we know protect communities and families. In the first place, I think that there is something about needing to rebalance and re-shift some of the resources into that sphere. What I mean by that is thinking about how we enhance and promote that whole-school approach. We have talked about councillors, but it is also about how we can promote healthy behaviours in families, young people and communities early on that promote good mental health and support positive strategies for stress management. That includes looking at how we can connect services such as your help the school nurses thinking about community-based organisations and how they can link more meaningfully into those schools and communities and understand better what the needs of those communities are. I think that there is something about supporting universal services and all community-based services on building those skills around health-promoting strategies and techniques that we can utilise to enable those services to work together and to connect more closely into statutory services and think more holistically about how we can bolster the skills of those staff. The big thing is about taking the pressure off statutory services. At the minute, we have a real bottleneck into crisis services where we are having to almost upskill or we are having to upthreshold families in order to get a service, and that is a really big problem. Things such as young people waiting for assessment because of neurodiversity. I am doing some work at the moment where we are doing a little bit of research on looking around CAMHS over in Dundee. What we have identified is key areas where families are really straightforward approaches that we could do with community-based services. It is about shifting the skills from CAMHS, those experts, and asking them to support those community-based organisations with really simple tasks such as managing sleep and positive parenting practices, helping families to communicate better with schools about what the learning and development needs are of their child. The feedback overwhelmingly has been that parents do not want their child necessarily to have a label or to have medication. What they want is that holistic support and advice, something that they can engage with and feel in control of instead of having to wait very, very long periods of time for that type of support. There are some really simple strategies that we can do in targeted ways to support families, communities and also strengthen those protective factors by utilising the skills of those specialist services to build capacity within the community-based organisations. I think that that relationship and the empowerment of that relationship is going to be really important. There is also the issue of changing our narrative around that because there is still such a lot of stigma and shame. In order to address some of those problems, earlier on, we still need to support families and communities to be able to articulate what the challenges are. We know that poverty and inequality and the cumulative impact of that is one of the biggest factors that contribute to poor mental health in our communities. That in itself is a really big thing for families to be able to articulate and address. Although we welcome the Scottish Government's strategies around free first passes, for example, for under-22s to enable them to move more freely and access things more freely in their community and opportunities for them, which we think is a social interaction that is really important. However, it is making access to those things much, much easier. It is making sure that there are not those practical barriers that can be quite difficult. I am only after just doing the bus pass for my family. What I noticed was that there are quite a lot of layers of bureaucracy and quite a lot of challenge for families who do not necessarily have the resource, the technology to access that universal benefit, that universal opportunity. There is something about that, as well as looking at it. Although the policy is good, how does it work on the ground? Are we further excluding people? That was a point and a topical question on that very thing last week, where I made those points with thanks for that, Shelly. Disabled children and young people are more likely to experience social deprivation. Social isolation and digital exclusion and to have poor mental health as a result. Children and adolescents with learning disability, for example, are over six times more likely to have a diagnosable mental illness or psychiatric disorder than children who do not have a learning disability. Therefore, timely access to child and adolescent mental health services is extremely important for disabled children and young people. Our research during the two lockdown periods and research from other disabled people's organisations has shown that disabled children, young people and their families have experienced what we can only describe as a mental health crisis during the pandemic. They have been hit hard by Covid-19 not only because they may be at greater risk of the virus and of severe illness, but equally or more so because the pandemic has supercharged the existing inequality that they have already faced and has made new inequality likely. We find that child and adolescent mental health for disabled children is being compromised by factors such as strained family relationships, digital exclusion, academic stress at school and loneliness and reduced social contact with friends. That has all been magnified with the reduced access to routine mental health support, including council provision. Care and rehabilitation services are a lack of access to those services that would take the pressure off families of disabled children. Disruption to routine—everybody has experienced during the pandemic—has been particularly pronounced for disabled children, particularly those children who do not understand why their lives have changed so much and why there has been so much disruption to routine. We have seen much more pronounced social isolation. In some cases, there has been poorly tailored public health messaging and a lack of emergency preparedness. I will be talking about the removal and the reduction of social care during the lockdown period for families of disabled children. The reduction of social care for disabled children but also for disabled parents has created anordinate matter of stress and anxiety that has exacerbated disabled children's mental health issues. Obviously, we have seen very positive pledges around CAMHS for the commitment for community services that has already been discussed and the £30 million for community mental health services. I think that there will be positive impact from those things. I think that there have been some very strong commitments from the Scottish Government to support CAMHS. However, as the last speaker said, the mental health issues that disabled children and young people face often relate directly to social deprivation and the link between disability and poverty. Disabled parents and disabled children and young people are much more likely to be living in poverty in Scotland. We need to address the poverty experience by children in families that experience disability. I will make further reference to some of the ways that we can do that in this session. Thank you very much, Susie. With regard to the Covid-19 additional pressures, one of my colleagues will be looking into that directly later on in the session. Can I come now to Sam March? The point about the connection that Alec made is a really good one. We really need to work on our connections and our single point of access. One of the things that we need to do is to avoid pinball-type referrals, where young people bounce through the system. Also, Shelley's point about whole-score approaches is fundamental. The whole-score approaches are preventative approaches. That is a really key thing. Last summer, we launched, ASPEP was part of that. There was a Scottish Government whole-score approaches document and framework, which should be a good building block for prevention within schools over the next few years. However, it is a challenging time to do that, and it is a challenging time to connect all of the dots in terms of the system, so we need to get it right. ASPEP and educational psychologists are involved in implementation of counselling and community mental health interventions. Counselling is probably a bit further on, and counselling is seen as an early intervention resource, but it is probably having to pick up a bit more across the country. It is probably having to pick up a bit more acute needs following Covid, but it is getting fairly well embedded in schools. Some young people want to work with those that they already know and have relationships with, so counselling is part of the solution. Community mental health, there are good things coming from that as well, and good use of the third sector, but it is quite early in terms of its implementation. Local authority partners are really excited about working with the third sector and some of the things that are already happening and are already involved. When we are getting it right, in particular, we are having a really good single point of access to make sure that families get that early intervention, and we really need to think creatively about routes that have been, for instance, the GP routes to CAMHS, etc., and alternative routes that come back and are able to provide earlier support. One of the interventions in South Lanarkshire that has been trialled is DBI. I believe that that is from a separate budget funding, but it is a really promising intervention. It has got a loop back into CAMHS, and it is also responsive in early intervention and easy to access as well. There is a lot that is going on as well, but it is actually connecting some of those things as well. It is a hard time to do a whole system implementation of that. My concern would be that the early intervention side of it, through counselling and community, is that funding dwarfed by the funding that the specialist services get as well. I think that it is right to be cautious about community mental health in some ways, because it is a hard thing to do. It is a new service, and it is hard to get right. However, as you say, convener, that is where we want to provide the support that is really accessible for families and for children and young people. I thank you for the opportunity to provide further evidence today. I agree with Shirley's point about the need to balance the urgent crisis with no work in a longer-term strategic service planning. We know that the Government's commitments around community mental health services have been introduced in January 2021. It would be really helpful for the committee to be asking questions of the Government about what we are learning from the robust mul agency monitoring process that accompanies the establishment of those services. What do we know one year on about the readiness of local areas to implement a community mental health approach? Can we be confident that our children and young people are now receiving timely assessment and appropriate referral? We are learning from child-line data through the pandemic, which suggests that we are not getting the right unsurprisingly given the pressures on the system. However, we know that children are contacting our councillors hearing their distress about the inability to access support about the long gaps between any support that is available, about the disillusion that comes with a decision that the criteria is not sufficient to warrant support. It sends a strong message to children about how we value their wellbeing, so there is much to be done. In terms of your question about what is happening around the country, the other speaker just mentioned that CAMHS is one element of a system of support around children and families. We know that that wider support system has been undermined by cuts to local authority budgets. NSPCC has carried out research by Susan Galloway, which looked at the availability of family support provision in Scotland initially in 2013 and then revisited it in 2020. A decline in the availability of that family support in the third sector and in statutory services. Of course, the pressures on our wider systems will undermine any attempt to create a community mental health offer for children and families. A critical first step is understanding what capacity exists locally within our systems, mapping our capacity not within single disciplines as is happening in some areas, but across disciplines. What are the strengths and weaknesses within our local systems and so that we can ensure that the investment that has been made available is targeted accordingly to ensure that we can deliver the best outcomes for children, babies and families? Thank you very much, Joanne. Finally, I come to Dr Maristar. Thank you, convener, for giving me this opportunity to discuss some of the issues that we are seeing increasingly in pediatrics. I am Scottish officer for the Royal College of Pediatrics and Child Health, and I am also a general pediatrician at the new children's hospital in Edinburgh. I was reflecting yesterday that I am a pediatrician, but I also seem to be becoming a child psychiatrist. A huge amount of my work is now child psychiatry. It is very difficult to get expert help for these children, and there are definitely children out there in crisis. Mental health has a lot of different issues. It includes anxiety, chronic fatigue, anorexia and your developmental conditions such as ASD. We are seeing increasing numbers of children coming to clinic with physical issues because of their underlying mental health issues that have not been met, which can be not met for years, and those children are not in school a lot of the time. We know that I have children that I am going to refer to for ASD assessments or mental health assessments, and they are going to have to wait 10 months to two years for that assessment. That might be two years further out of school when they are 12 or 13. That is our lifelong education. That is our career opportunities. That is our health as adults. We know that 50 per cent of adults with mental health problems had their difficulties before the age of 14. We are not just looking at children's difficulties, we are looking at adult difficulties further down the line. It is really important that we take that on board and start prioritising children. The Covid pandemic has severely affected children. They have not been dying in ITU, but their life chances are significantly reduced because we are taking services away from them. We really need to be building services up for young people. We are waiting times for our CAMD referrals and general pediatrics, which are full of children with mental health problems. It is easier to get into general pediatrics, so we are seeing in that area and doing our best to improve the life for young people. They are just getting longer and longer. It is months and months. We have people in our acute wards that we cannot get into acute. If you have anorexia, you will come to the general pediatric ward. At the moment, we have not started new over the weekend, we had no young people with mental health beds in Scotland available. That is across Scotland. It is difficult. We do not want to send children to England for community services that should be done here. We need to increase all services. We need data on the prevalence of mental health conditions in Scotland. How many children have got anxiety? How many children are waiting? How many people are seeing their GPs and their parents having been sent away saying that there is no point in doing a CAMD referral because they will just get bounced back? There are so many children out there that are not even getting referred because it takes a lot of time to do those referrals because they know that they are not going to get seen. How are we going to start this? We are going to have to do a lot of different things. I think that community interventions and basic community interventions are the poverty issue. If you are in poverty, you cannot afford good food and you cannot afford to go to groups. You cannot afford to do exercise opportunities. Young children tell us that poverty stops you feeling healthy, happy and well. That is underlying the meaning of all those things. However, if children are not getting help when they are toddlers, in my clinic, I can identify two-year-olds who I know will have mental health difficulties when they are 12, 13 or 14. We need to be intervening really early. We need to be looking at ways to try to improve children's health right at the beginning and giving all children opportunities to do exercise, to have healthy diets and things that we know that building blocks for good mental health. We need to be having neurodevelopmental services. I am finding increasing numbers of children coming to my paediatric clinic who are maybe 12 or 13 who have underlying ASD that has never been diagnosed. It takes two to three years to get ASD assessments and then to get your interventions and then you will be into adult services. We need to get school councillors and courts in place for those children. There is a whole group of children who are in second year at school. If Mr P7 residentials, if Mr S1 residentials, that may be the only time that child has had an opportunity to go away from the family home and make team building with their friends and do activities, that is gone. There are no plans for a catch-up of opportunities. It is just that you miss that tough luck. Those children feel that they are not being prioritised by Government. Businesses are great. Adults will get to go to restaurants and nightclubs. What about all the community groups that need funding? Some of them are quite cheap to run, but they are not getting the funding. The third sectors have to go for funding. Every few months, they spend half their time not looking after the children but trying to get funding. Youth work organisations need to have more youth work. We have now got youth navigators on our paediatric ward to support some of those families who are in crisis, because we know that we need to do something. However, funding is not necessarily going to continue. We need to keep going for funding. We need to get the building blocks. We cannot necessarily magic up lots of paediatric psychiatrists. We cannot even magic up lots of paediatricians, but we need to get more community services across the board. We need to be really helping those young people. We have heard a lot of things that my colleagues are going to specifically dig into. We will not have the opportunity for every member to have all-sex panellists, because we just do not have the time that I wish we did, because there is a lot in there. We are going to hand over now to accessing specialist support to my colleagues whoever. Thank you, convener. I suppose that we have heard at length that there is a challenge access services to the scale of the issue and the challenges that our young people are facing. We have certainly received evidence that referrals continue to rise year on year, and that resonates with what you said this morning. Why do you think that more children and young people are requiring specialist services for their mental health? We have just heard about Dr Stark intumating poverty as being one of the key factors, but is there anything else that you think might be driving that at the moment? Can you direct your question, please, Sue? Perhaps Dr Stark, first, as I referenced her previous statement. I think that there has always been mental health issues, but Covid has been very difficult, because some children were having difficulties and anxiety issues. We took them out of school. We put them on to virtual learning. They were told that they would stay in their bedrooms and go on a computer all day. The children that were very anxious are now like, well, I have lost that ability to go out and meet people and do things. Some children are desperate to get out and meet people and go on the bus and socialise. Some people have lost those skills and are becoming increasingly anxious. It is very difficult for children to gain that confidence. A lot of the opportunities that they might have had before just start there, so, if you are not doing things, you lose that ability. You lose confidence. We all lose confidence. That will not be helping. There are a lot of children with chronic fatigue. We have no chronic fatigue services in Scotland. I was hoping that some of that could be directed to long Covid services, but so many of the money and things that are available are all to adults. The children are the ones that are missing out. It is very difficult for families to work with young people because they do not have the tools. Can I bring in Susie Fitton, who would like to come in on that question? Yes, just to back up what Dr Stark is saying, we did some research in lockdown to find out what the impact that the pandemic was having on disabled people across Scotland, so both adults and children. It was very clear from an analysis of the responses that risk from Covid-19 for disabled children and young people was about much more than simply a risk to health. We found that stress, fear and anxiety and sleep disturbance were pervasive for disabled children and young people who were shielding or those who were self-isolating, and disabled children and young people who were trying to follow social distancing measures. It was very significant for disabled children and young people with pre-existing mental health conditions that were made worse by social isolation and anxiety about the future. Disabled children and young people at high risk of the virus who were shielding but who lived with key workers and were therefore at risk of the virus were under particular strain. Disabled children and young people who had limited social networks or who found digital or remote communication difficult or impossible, so digital exclusion has been pervasive for many disabled children and young people and has only exacerbated poor mental health. Disabled children and young and adult children who struggled to understand and follow social distancing rules were in very anxious and stressful situations. Disabled children and young people who were shielding but who relied on external care or family members for personal care. We had some really difficult situations for families of disabled children. Some disabled children went from having two-to-one support in residential accommodation to being sent home to parents trying to juggle childcare of other children with home working and getting no statutory support to care for disabled children. Some parents told us that their children were exhibiting behaviours such as self-harm, vocal tics, very low mood and challenging behaviour because of the removal of structure, daily activity, routine, face-to-face contact with friends and access to the outdoors. Just to reiterate some of what Dr Stark has talked about in terms of disabled children losing their social skills, losing their independent living skills, many parents talked of their children all of the efforts that had been made by residential schools or by schools in general to support disabled children's social skills. So much of that saw their children regressing particularly during lockdown. Obviously, our evidence is from the two lockdown periods and some of the stresses on disabled children will have lessened as some of the restrictions have eased. However, I think that this evidence is still important because evidence from previous pandemics such as SARS in 2003 has demonstrated the potential for long-lasting effects on children's mental health. The length of time that children felt lonely predicted mental health problems up to nine years later, particularly depression. The evidence from lockdown from disabled children is as important now as it was at the time in many ways because children who experience extreme social isolation are much more likely to require support from mental health services and to experience high levels of post-traumatic stress. It is a really big question. There is not one reason. We consulted with young people during lockdown and 72 per cent of over 3,000 young people said that the biggest thing for them that affected their mental health was family life followed by peer relationships. There is a mixed relationship in terms of social media, the school experience as well. If you track back over the last 15-20 years, children are slightly more likely to say that worry about the concern about school work is a factor. There is a range of factors. There has been loads of work done on school culture and ethos and around positive relationships. School does buffer in terms of mental health outcomes for many young people. It has not fundamentally changed the number of young people who say that they do not enjoy school, unfortunately. There seems to be a range of factors. We did some research during Covid and for some young people slowing down and having the avoidance of life stressors was something that they were seeking comfort for in early lockdown. We need to take a really holistic perspective to understanding exactly whether modern life is facing the greatest stresses on children and young people and families, and family stress is part of that as well. I do not want to repeat what the speakers have said, but I certainly agree with everything that they have said. Covid has certainly escalated or exacerbated the existing vulnerabilities that we already have in our community. The state of our state of a generation report, which was published just before Covid, is the issues that were highlighted in it. Our Covid study reinforced that. It is the young people who are experiencing trauma, abuse and neglect, refugees and asylum-seeking families, parents who have comorbidity problems and looked after children. Those are all factors that are influencing children's home life, the point that Sam talked about, the conditions and the family relationships that exist for young people are having a significant impact on their wellbeing and how they develop into adults. One of the other massive issues that has come out of that report is identity. This whole change in our society is changing. We have this technological and digital revolution. We have a generation of young people growing up and their perception of the world and the expectations and the roles that they perform within that are vastly different from our children, certainly my childhood experience. We are going through this kind of change in society where, in some respects, we are using this adult lens to analyse and assess the needs of our young people and our children. However, their perspective is skewed because how society functions, how they engage in relationships and how they communicate with each other is extremely different from what our experience would have been. Nonetheless, one of the significant issues that was coming out of the state of the generation report was that racial and ethnic identity was massively important. Are we speaking the same language, even in the words that we use? Are they understood in the same way when we talk to families about mental health and wellbeing? Are we taking account of diversity in terms of beliefs and values? Gender identity is massively important. One of the biggest issues that schools are dealing with today is that young people are trying to figure out who they are, how to form relationships, what healthy sexual relationships look like and intersectional issues that flow off of that. The previous speaker was talking about learning, disability and identity as being massive for such a long time and continues to be so for all the reasons that their vulnerabilities have been exacerbated for all the reasons that Susie has talked about. Identity and school transitions, leaving school, academic pressure and uncertainty have all been escalated because of Covid. That whole issue around body image and what a successful person looks like, what you have to be, what achievement looks like is incredibly influential in terms of social media, the narrative and the images that young people are being exposed to 24 hours a day. If there is no respite from that and thinking how that links in with bullying, and one of the big things from a survey that we did with young people, young people didn't find it all that useful to separate out bullying and cyberbullying to them, it was bullying because there is no separation necessarily between that virtual world and the real world. I have time for you to follow up with a question and then I am going to bring in Stephanie Killhan. Thanks, convener. Yes, Shelly Buckley stated that we look at everything through an adult lens and specifically she was talking about the look after children. So bearing in mind that, I'd like to declare an interest as a corporate parent and a councillor in the city of Edinburgh. But again, we met with a lot of young people last night that were in care or looked after children and we were talking earlier about that single point of access to services, but many of them struggled because they don't have that parent behind pushing. So what could it be done to inform children and young people and their parents and carers about the services available to them and to make them easier for them to navigate around? I see Shelly nodding, but can I perhaps ask Sam that question first given his position with Lanarkshire Council? Really, really good question. I'm trying to make very clear that children are care experienced and in our children's houses have access to our counselling service. We have a trauma counselling service as well and no. There's a piece of work being done with children's house managers in terms of advocacy and awareness and communication. I've got a responsibility to make sure when I look at the service use that it's reaching the right children and young people and proportionally. Alternatives are provided and speaking to young people and working out what are the individual barriers for services and why, and I mentioned earlier, not every young person wants to access counselling within school. Are there alternatives and trying to be creative around that? Speaking to young people in terms of the creation of services, one of the other interventions that we've used is a really good sector, intervention called BLUES, and that works for a lot of children and young people when it's earlier intervention and it's group work as well. Young people have rated that really positively, so we're continuing the use of that. It's a real responsibility to co-produce services fundamentally. Co-production features strongly in all the mental health project boards specifications, and we're doing it like never before because there's no point configuring and planning those services. There's a great resource from Ness about evidence-based interventions. There's absolutely no point in just plucking one off the shelf and saying, that looks great because it worked in Connecticut or something like that. We've got to speak to the young people that are the service users, work out what the barriers are, and we're doing work on that in authorities. Thank you, and Alex Cymru wants to come in. Sam Cymru has made me a point that I was going to make about co-production being absolutely key, and I'm sure that all the contributors around the room would agree with that. I think that just building on the question that whoever asked about what else can we do around single-point of contact for young people and parents. I think that co-production also relates to parents as well. Again, we want to bring in their thoughts and themes and ideas into this as to what would work, but really just what Shelly Berkeley and Dr Stark have said around are these adult services. I mentioned right at the start, or convener, you mentioned the number of additional resources going into primary care and mental health support within GP practices, but are they still focused on adults? We are certainly about to pilot in South Edinburgh a CYP link worker, and I know that there are a number of other initiatives going on in Glasgow and a number of other local authority or health and social care partnership areas that are doing something similar. Is that the place that children and young people can go? Will young people go and access? Will they feel that those services are for them? That's a big question, and it's really important for all of us and for the third sector and for primary care as well to promote those services as being accessible to young people, so they recognise that those are places that they can go and be linked in as part of that. That's a very good point. I know what Sue was referring to. I was in the same meeting with young people last night, and I'm quite distressed to hear young people say that they couldn't get past a GP receptionist when they were in crisis. Your point is well made and certainly resonates with some of the experiences that we heard last night. Can I bring in Stephanie Callan, who is a question on this theme, and then I'll move on to questions around CAMHS waiting times with Evelyn Tweet. Thanks very much, convener. It's certainly good to see the panel here this morning, and it's good to hear both Shelley and Joanne talking about neurodiversity and the kind of long wait for quite basic stuff like issues around sleep positive parenting, communications with schools etc. Certainly, what Joanne was saying is well about having long gaps in the dissolution that comes along when young people are told that they don't meet the criteria for support. It's something that certainly changed with me, so I should probably hear that I'm a parent to neurodiverse children and I'm also a councillor at South Lanarkshire Council too. In South Lanarkshire as well, there is the Arch Autism Hub, and they do an amazing job of really quick ground baking work as far as holistic support goes and integrating council third sector health, parents carers and all those things together there. One of the top things that you hear the parents ask for is advocacy support, so I'm really interested in whether or not panel members think that that should be a top priority as far as the Scottish Government can go and I'll be direct that to Mary. I think that the neurodiversity is a big issue. We need to be really having much more rapid assessments for young people, for young children and then school support. Advocates, people are needing advocates because they're having to fight through a system but should we not have a system where people don't have to fight through it, it should be easier. It's like somebody said earlier about the bus pass. It's not even gotten to my to-do list to figure out how I know to do the bus pass. All I've heard is that it takes a lot of time, it's difficult. Why do we need to make things so difficult? Some families will not be able to advocate for their children. We need to look out for those children, so the schools and anybody who's looking after the children need to be their advocates, but we should make the system easier for people. It shouldn't have to be a fight, it shouldn't be the case that only if you have a maybe referred to as a stroppy difficult parent will you get the help that you need. All families, all children should be able to get the help that they need without fighting. It should just be there. It's really difficult for all these families. It's really difficult if you have a child that's gotten you a diversity, but you don't need the system to be difficult. We need to make things as easy for families as possible so that we can provide good care at the right time, not with long waits. I think that it's an interesting project that I've been working on. It's this whole thing around working closely with CBOs, our community-based organisations and those statutory services. It's over in the Dundee area. Is that part of wider community mapping? What have we got? There are loads out there, but the system is so complicated that people do not know how to access it. Are they being diverted around the wrong way or around so many houses to get there in the first place? That actually takes a lot of energy. It also takes a lot of knowledge for the particular worker that you have approached for support to be able to signpost you in the right way or provide you with the right support. One simple thing that they are piloting at the minute is a system called FORT. The community-based organisations are the first point of contact. They are looking at how families can support triage and the needs of families, and they are looking at and advocating for the type of support that they need. I think that they thought that, in Dundee, that would be more beneficial because a lot of the community-based organisations had a better understanding of the cultural dynamic of some of the communities and the key issues that affected some sections of those communities. They had a better relationship with families and it was more accessible, but they understood that not everything needed to go straight. The default position is that, if it is mental health, it goes to CAMHS. The actual fact was about looking at what is causing families to stress. Is it because mum and dad have complex needs? They are under a lot of financial pressure and, therefore, the children are experiencing distress because of that. What would be better support if we refer the child into CAMHS or do we support the parents so that they can support their child better? It was taking that more holistic approach to being able to understand what the social and environmental factors and the cultural factors are to impact on the child's wellbeing. It is a pilot that is on-going, but it is trying to make the system more accessible and having one point of access so that families are not having to go around the houses. There are different things that we can do. The co-production piece that having conversations with those communities and families is going to be really important for the localities in terms of understanding what is going to work best. I am sorry, but we need to move on to questions from Evelyn Tweed. Committee members, can you keep your questions short, please, to the point and direct them, and then we will get round everyone. Can I come to Evelyn Tweed? Good morning, panel, and thanks for all your information so far and your answers. It has been really helpful. My question is about waiting times. It is great that the Scottish Government has made significant announcements about CAMHS, about funding. However, in my area and in other areas across Scotland, there are still significant waiting lists. I know that some of you have touched on that in previous answers, but what should you view on that? Why are there still significant waiting lists and what can we do to help them? I would like to direct that to Joanne Smith, please. Thanks very much for that. We are obviously very concerned about the demand for crisis services. I am just going to need to plug my computer in, so I am going to get that. SPCC would argue strongly for investment in the early years. We recognise that there is a balance to be struck between meeting that immediate crisis, but we also need to have that long-term strategic approach. It is informed by the evidence that it is a lot of mental health difficulties to have their roots in infancy. If we can get it right in the early years, we can lay the foundations for all future wellbeing in health, thus stripping out the demand for crisis intervention later on. Other people have spoken about how we find ourselves in this crisis. There are universal consensus on the role of poverty in impacting on family functioning and child wellbeing. We would endorse the findings from Catherine Trebeck's report that called for fiscal decisions that prioritise wellbeing over growth, which is required to improve mental health and wellbeing of children. We also need heavy investment in preventative services. The committee is really well placed to facilitate some of that thinking, because I know that you are carrying out the review into perinatal mental health. That is a really exciting opportunity to accelerate long-standing ambitions around prevention. We have an opportunity to build mental health infrastructure in an integrated early years offer that will support families at a point where we are likely to have the biggest impact when we are looking to drive down the demand for our crisis services and where for our waiting lists. It is a note of caution. It is worth pointing out that health visitor data, as we emerge from lockdown, shows an increasing developmental delay for children who are starting nursery. That, if not treated and responded to quickly, will grow and continue through life. Therefore, stacking up that demand continues to demand for crisis intervention later on. We need to have a robust universal early years offer for families now, and in Scotland we will get really strong foundations to build on because of the priority given to the early years by the Scottish Government over the past 10 years. It is fair that we can make the biggest difference, because, of course, the children that we are failing now are going to go on to have children, and so that cycle continues. We would make a plea for the early years to be a priority for this committee's inquiry. What support should be available for children and young people when there is a big gap and when they achieve their CAMHS appointment? Could I ask John Smith again, please? What can be provided for children where there is a gap in the availability of support? Yes. If a child or a young person has a long time to wait, what could we do in between to help? Yes. It is really critically important that we have that local community family support available. Again, because of our family support work in Scotland, we have really highly skilled professionals who are very grounded in communities and have those local relationships that allow them to get alongside families and provide that more holistic, integrated support. They have the relationships. A lot of the work that needs to be done for a small-page, integrated approach is happening locally, so we need to promote that and invest in that. There are good plans to do that and good examples of the holistic family services around GP practices. For that to work, we will need significant levels of investment, and it is unlikely that the £500 million fund is sufficient to plug existing gaps as well as build capacity. I think that we are about the vision right in terms of what good community mental health services look like and whether we are investing to deliver those in practice. I will follow up on a couple of those last points. In partnership with Young Scots, the Youth Commission into Mental Health Services three years ago recommended and the Government accepted the recommendations around a multi-agency approach to triage, which was a comment that Shelley and Joanna made. Again, while there are some good examples there, both Shelley and Joanna have commented on that that is happening in isolation and everywhere. Is that one key aspect that is going to reduce the waiting times and the number of people on waiting lists? Once someone is waiting for an assessment, no matter what that might be, it is about having that consistent point of contact for them. Sam mentioned earlier about pinball, going from pillar to post etc. Once they are in that system, it is about regular communication and giving them updates and having a consistent point of contact for support and help once they are in that particular system. I am afraid that we will have to move on to the next theme. We are rapidly heating up our time. I will pick up people as we go along. Can I move on to the theme of rejected referrals with Gillian Mackay? Thank you, convener. In their submission, the Royal College of Psychiatrists said that there is a wide variation by health board in how CAM set its expectation that it would likely need care in its services. That was dependent on particular geographies but also availability of resource. To what extent does regional variation impact rejected referrals? I go to Joanne Smith on that point. It is a postcode lottery in terms of what is available locally. I think that we really need to understand quite urgently what is the local capacity across health boards. There are examples of good practice in people who are working well to build multi-agency hub of practice. Obviously, the levels of provision are variable across the country. I think that we need to have a clear national picture of what that looks like. Because we do not want to be scattergun in how we are using any new investment, it is really important. The Scottish Government recognised that this is a huge challenge and that we need to take a tiered approach to implementing the changes. That does not require a stock take of where local areas are, what is the local infrastructure and how do we best enhance that? I would make the point that, as I mentioned before, a similar expansion of perinatal and infant mental health services is taking place. All the same issues that exist within CAMs around recruitment, retention and capacity issues exist within the perinatal expansion. Two parallel processes are happening, both trying to recruit in large numbers. The likelihood is that people will be moving between health boards and between disciplines rather than building capacity, because if specialism does not currently exist. To make it work in practice, we need to be meeting clinical needs, but we also need to seriously have the education recruitment and training so that we can be confident that a new post can be filled by new capacity rather than moving dentures. Thank you. I will pick up on some of the themes around workforce. Is it important that we hear from CAMs on that? I suppose that, just to follow what Dran has said, the reason why we got rejected referrals in the first place. Last year, through the programme boards and delivery boards, there were new CAMs criteria that were launched, but we are still seeing that there is a lack of understanding there within some areas around what CAMs is for and certainly within the wider public. People understandably, families want and want best for their children and young people. Young people want to try to get the best support, but is it the right support for them? I think that that is where a couple of other contributors have mentioned whole systems. We need to look at everything and, whether it be through the trier system, directing people to the most appropriate thing and the most appropriate support stops people from that disappointment, and we want to avoid that. No young person, no family should be rejected from CAMs. It is about finding up-skill information and knowledge across the widest community in Scotland about what CAMs can do and what is a school councillor there to do, what is a school nurse there to do. During Covid and prior to Christmas, lots of people through their letter box have had that really helpful leaflet from NHS around where do you go, if you have a dentist appointment, or if you go during this period. Is it the same thing around child and adolescent mental health and that breadth of services and that tiered approach that we know that we think is going to work and we know is going to work because there is good evidence for it, but whether it be through primary care or other referral routes, we are still sending young people and sending families to CAMs when they should be going elsewhere. There is still a bit of an up-skilling. It is no one's fault because they think that that is the best play for them or they think that they do not have the understanding of what is available locally. I think that that is really important if it is about information and knowledge across the sector. Thank you, Alex. Can I just correct myself? I said CAMs when I should have said Sam H. So what apologies for that. Gillian Cymru, can I bring you back in? Thank you, convener. The other thing I wanted to touch on was data. The lack of data on rejected referrals has been highlighted to the committee. Do we have a sense of whether children and young people from certain backgrounds, with certain conditions or those marginalised groups, are more likely to be rejected for support? Can I maybe go to Dr Stark on that one? I think that data is really useful. With data, we can see what is going on. I think that the prevalence of mental health difficulties is probably much higher than we realise. What we often see is the tip of the iceberg, but a lot of children could be doing a lot more support. We need to be looking at mental illness and mental health as well-being and making all children feel a bit more secure and happier and more resilient to developing mental illness, which we are not at the moment. The difficulties between waiting times and everything else, we need to stop the flow of patients coming. I am not sure how we would get the data of how many people there are, but schools are probably the best place, because they get much broader and you can see which socioeconomic groups are more affected. There is definitely needing to be more input for care-experienced children and families that have less support. If your parents have mental health difficulties, they are not equipped to give you as much support because they have their own difficulties. It is not always just one group, but across society there are difficulties. There will be some children who might think that they have professional parents and they are fine, but they are having difficulties too. I think that no child should be excluded. We should be looking universally, but there are definitely groups that need more intervention, particularly care-experienced and children living in poverty. I will move on to questions around the integrated services and the partnership. A lot of you have mentioned that already. Emma, if you can direct your questions and pick up on some of the things that people have said, that would be great. Emma Harper. You have touched a lot on what I was going to ask about integrated services and partnerships. Dr Stark has just mentioned poverty, and we know that that is a huge contribution factor for mental poor health. A lot of the submissions included better integrated services and partnerships, and the promise in our papers that talks about the promise of having 10 principles on intensive family support that will be embedded into practice. Some of those I will not read out all 10, but about community-based, responsive and timely working with family assets, empowerment and agency. I am interested to know, including that one of the submissions that came from Darren Littlund of Whoson Galloway on multi-agency strategic planning and implementation at local levels. We know that, if people work better together, that will support better outcomes. What impact would more integrated services have on the demand for CAMHS and the delivery of services? I guess that we will go with that one first and then I will wind the other two questions in at one. Emma Harper, would you like to direct your question? Yes, I was thinking about Shelly Buckley and then maybe Sam March. I completely agree that integration of services is incredibly important because having that range of perspectives in terms of understanding the needs of your community is really important for our special services. For example, social work, occupational therapy, TPN, psychiatry and psychology all working together is really important to be able to come at a problem from a variety of different perspectives and identify accurately what the needs of those families are. However, there is something else around integration that is that integration between at all levels. For example, during the summer time, we had a focus on mental health promotion. Using some of the Scottish Government money around the get-and-summer programme, we worked alongside Thrive Edinburgh, CAMHS services and 22 community-based organisations. The focus was very much on the—we used a tool called stress less, so essentially it is a mental health promotion tool. It is about gilling up staff around how you talk about how to promote mental health as opposed to identifying mental health problems and symptoms around mental health. What we did know was that the 2,500 young people that we worked with all experienced mental health problems. They all came from those family backgrounds, where there was a lot of adversity, distress and poverty. We knew that there were multiple challenges. One of the—by taking a mental health promotion approach, the outcomes of that were incredible because it was a very short project. However, what it did was address the risks that we often mitigate with that inequality and poverty. We found that staff in a really fast period of time all started to work together really quickly to identify the range of needs and share resources and share ideas and share skills because we got them together, working together across all the different teams in a really short space of time. This is over a period of two months, so that was really important because what they had identified in some areas, they did not have certain resources, they did not have access to certain skills and knowledge, but they very quickly formulated those partnerships. What we identified was that they knew those groups really, really well. They knew, for example, that certain families had huge confidence issues in the young people because perhaps they were young carers, perhaps they were dealing with multiple difficulties themselves. They were able to facilitate that support right from the young person's front door and support the parents to enable that child to engage in those community activities that enabled them to build their confidence over the summer. They were able to engage in activities and programmes that they would not otherwise have been able to afford because it was part of a wide, universally accessible programme, so they were able to do leisure activities, their travel, their food was all included, so the participation and the engagement, there was no shame or stigma and young people were supported to engage on new things that they were perhaps afraid or would have been frightened to do, but it also enabled them to revisit things that they hadn't done through Covid but were really, really nervous to do again, like things like getting into the swimming pool, going to the sea. We're not talking about really complicated issues here, but the feedback from the young people was overwhelming in terms of how that enhanced their wellbeing. I think that this has been highlighted by quite a lot of the panel members. It's about talking about wellbeing and promoting those protective factors that we know will enhance the wellbeing of young people. That is what is going to reduce the risk, that is what is going to support parents. We enabled parents to engage with their children in those social activities and give them those positive experiences and the youth workers were able to support them with that because they had specialist long-arm support from specialist mental health professionals and they also had been given these tools to enable them through the stress less programme to engage in proactive ways. We also acknowledged that the young people themselves came back and said that it's been so nice to be able to talk about mental health in a different way because we always focus on the things that are wrong, the things that are negative, but actually mental health is also about doing things that help you to feel good about yourself, understanding who the right people are that are good for you and who you can talk to, who is the best person to be your friend and to have the confidence to share your thoughts with your friends. It was about taking that different approach change in that narrative, having a different conversation and the consequences of that in that really short space of time. We are really empowering because you had empowerment between organisations, empowering conversations between the communities and the organisations. It has had a long-term effect in that a lot of this work has went on beyond the project and has now seeped into the schools and other parts of the community. Children have been brought on as professional staff and they have had employment opportunities from this activity. It shows you that small initiatives at ground level using that co-production and interdisciplinary approach can have a massive impact whenever we look at strengthening those protective factors. I would say that there is a lot of integration in terms of children's services and different agencies, including with a third sector, be it via Promise Board, Child Protection and different groups within children's services. We continue to meet, plan, share data and jointly commission where possible. The conversation around things like community mental health is a multi-agency conversation. The last conversation about sharing data with CAMHS is that we have local data and are using that to look at gaps. There is a high level of integration, including with a third sector. There are also some really good examples that other people have talked about in terms of multi-agency hubs. We have an early support hub that is newly set up to provide early intervention. There are other really good examples across the country. The triaging that Alec mentioned and my view is that signposting when you reach CAMHS is not really going to cut it. Multi-agency triaging is really essential. That is an area for development. We get money into local authorities that are sliced up in terms of this is for this and this is for that and this is your attainment challenge. It is short-term only. That can be a challenge in terms of intervention and early intervention as well and joint commissioning. Emma, with apologies, I am not going to come back to you because we have three more committee members who have not asked questions yet. If I have time at the end, I will bring you back in. I will move on to inequalities in that sense and mental healthcare. I know that we do not have a lot of time, so I will be quite direct in the question. We know that people from poorer backgrounds who have mentioned children with learning disability have more difficulty accessing mental health services. I would be really interested to know what we can do to improve that for children, young people and their families. I am particularly interested—we have talked a lot about or certainly mentioned about the cuts to local authorities. We would be really keen to know if people think that that has affected people. It is an issue that I am quite concerned about and possibly—I cannot see everybody now—I would give you a good idea to bring in Susie Fitton, given that I come to Susie first of all. If anyone else wants to come in, please use the chat box. Our research during lockdown highlighted a particular issue for families of disabled children and young people around cuts to social care provision. Some of that was austerity-driven and some of it was as a response to the pandemic. However, we found evidence of very concerning situations where children and young people's mental health had been directly impacted either because their own social care support had been stopped or reduced or the social care support that their parents relied on had been suddenly reduced overnight. People had no prior warning that the support that they received through social care and local authority provision would be removed. Families were left in really quite desperate situations because of that, with parents suddenly being thrust into caring responsibilities for young disabled people and trying to juggle caring responsibilities with home working and, potentially, homeschooling of other children. The strain on local authorities, particularly in relation to the provision of social care support, has exacerbated mental strain for families. In some situations, it has made either pre-existing or pandemic-related mental health issues worse for disabled children and young people. The other pandemic-related issues that created mental strain included families struggling to get food and medicine. Many families that experience disability are either because of a disabled child or because of a disabled parent reported to us that they were struggling to get the food and medicine required by a disabled person in the family. That created an additional layer of anxiety and stress on families, particularly in the early part of the pandemic, when it was very difficult to get delivery slots and it was very difficult for some disabled people to access supermarkets, and particularly for people who were shielding, they found it very difficult to get the support that they needed. That only exacerbated mental strain. Disabled parents were very concerned that they might lose their job and financial pressures, particularly during the beginning of the pandemic, and they only served to exacerbate family strain. In that context, services that families were previously reliant on, services that were accessed either via the school or via respite provision, families reported to us that they felt abandoned by statutory services, particularly local authority provision, at a time when they most needed support. That feeling of abandonment has not abated for some families, even though services in some cases have been reinstated. That feeling that emergency planning did not cater for the needs of families of disabled children and young people has left people very fearful for the future, particularly if we have to go into lockdown at another period. I will be very quick. Is there anything that can be done in terms of—I have a slight concern about the suitability of the school counselling and whether we need to be more flexible in services provided? The initial spec is very fixed on talk therapy, and there has been a lot of discussion in the networks about alternative types of therapies being more accessible for some children and young people, so that is an on-going consideration. You asked about local authority budgets, and I would say yes in a range of ways. The most obvious statistic that I have at hand is that education and psychology numbers have dropped by 20 across the country since 2017 and 2018. We have a significant role in mental health and wellbeing work on a whole variety of levels, including supporting the most vulnerable children and families. As part of our casework and a whole number of other involvements, which I have hopefully articulated some of. Carol, with apologies, I am not going to be able to come back to you because we still have two committee members who want to ask questions. We are going to move on to specific Covid-19 with Sandesh Gokhani, but we are having difficulties with the broadcast and getting them back. Can I come to my deputy convener, Paul O'Kane, to say today? You are here, Sandesh. Great. I thought that we could not see you, so I will come to you, Sandesh. Thank you, convener. Covid-19 would obviously take up the entire session that we have, so I am going to really focus my question. We have heard about the impact that Covid has had on people with disabilities and have been very well articulated, but what I would like to know is what impact Covid-19 has had on young children based on their ethnicity and how do we get this data and information around the prevalence of mental health, not just in the ethnic community but throughout the children in Scotland? I suppose that that is a question for everyone, convener. If there is anyone in particular that has decided to make it, it is hard to... We cannot go round everyone, so I am maybe going to go to Lauren Smith first on that, and if anyone else wants to chip in, please put it in our chat box. Thank you. It is a really important question. We recognise that there are real limitations on how we disaggregate data related to who is accessing mental health much better at that, but we know that there are cultural issues that would make it less likely that people will access a referral pathway that starts at the GP, for example. Some people would be... They would not be reached out for help, but it would be much more suitable to be able to provide a community-based resource that is embedded within local culture and practices. I think that that is obviously a massive issue. We have had a range of reviews and inquiries over the last 15 years that have flagged the lack of comprehensive data both on spend and planning, but also on outcomes. That is an area that will warrant urgent attention. By getting that much more in a robust evidence space again, we can design a system that would reach those groups that do not typically access specialist services. I would make the point that I looked after children, because in the year of the promise, we know that where children's mental health difficulties coexist alongside other adversities, they tend not to be accessed in specialist care either. They are often excluded from specialist care where their psychological distress is manifest in risk-taking, for example, or hypervigilance. We find that a whole tier of vulnerable children and young people who are not able to access mental health specialist care and whose difficulties are not even understood in those terms are often excluded from therapeutic support. Those children are much more likely to find themselves interfacing with police or with social work services. Any expansion of CAMHS needs to be coupled with that protection in our statutory services. If we do not have that expansion within communities, we have further exacerbated what is already considered to be a two-tier system of support for children. If we want to realise the promise, we need to prioritise investment within communities. I will also make one final point about looking after children, given that the promise is really what we have to be focused on. The NSPCC is trialling an innovative multi-agency intervention for very young children in care. It is multi-agency in that it is co-located. It is a one-team with NHS staff, social work staff and family support workers. They are working together to ensure that there is timely assessment of needs appropriate care and to increase the quality of the decision making around parents. The model is being tested by a randomised control trial that is due to report next year. The findings tell us that the integration of services to make sure that we are meeting a marginalised group requires dedicated time, resource and strategic leadership. Integration will not happen on its own. We need to make genuine efforts to build multi-agency teams to strip away the barriers that exist in multi-agency working because we have aspired to do it for a long time, but in many areas we are not delivering that. I would point to a really innovative work that is under way to make an integrated model working practice. In the case of the Glasgow infant and family team, it is really working with those most vulnerable families to ensure that both baby and parents get a very pretty input, and in doing so, the evidence suggests that we are improving outcomes for both that sibling and for subsequent siblings. It is that type of innovation that we need to be pointing to. I really think that there are really good examples that could drive that shift towards prevention that will long aspire to in Scotland. Thank you. We are now reaching the end of our session. I am going to have to extend it by about 10 minutes, but I cannot do any more than that because we have to stop with another panel and so much else to get through in our agenda. I will come to Shelley Butler quickly in response to Sandesh and then I will need to move on to questions from Paul. I will be really, really brief. I think that the data is important, but also I think that the difficulty that we have is that we need to address the issue of cultural humility within services. That means speaking the same language of different communities. The language that we currently use around mental health and wellbeing is westernised and it is culturally fixed within our communities, our culture in the UK. We are currently doing some research and some project work with, for example, young refugees. We are having to strip right back the language because mental health doesn't even translate how we articulate, how we treat, how we assess, how we understand mental health. From my perspective and from the perspective of, say, a young Vietnamese person is completely different. I think that there is a huge amount of work to be done within mental health services generally and just across the board in terms of truly understanding emotional wellbeing, spiritual wellbeing, all of those things look like for different communities. Instead of talking about cultural competence, which assumes that we somehow get to a point where we know what we are talking about, we don't. We need to talk about cultural humility and supporting that criticality within services. I will just leave it at that. Can I come to Paul Kane for a question on workforce and if you can direct your question please, Paul? Thank you, convener. I will bring out a few questions together just for the sake of time, but essentially we have seen the programme for government commit to 320 additional staff over five years in CAMH services. The first part of that is a sense that that is enough in terms of the next five-year period to be able to grow services and meet demand. I think that maybe a more open question is what levels of recruitment do we think are required and what sort of roles, are there additional roles that we are not already seeing in the system that would help to reduce pressure on waiting lists? I think that one of the things that we have to do with Talk to Already is stopping the flow. The community services are very important to try to stop children needing CAMHS in the first place. We are seeing increasing numbers of patients being referred, so the waiting lists are going to go up. It is difficult to magic up more and more psychiatrists and psychologists. We will need to have a look at how we are going to support our mental health colleagues. At the moment, CAMHS is separate from pediatrics, so we might need to be joined together so that we can work closely together on what different bits can do so that we have a much more unified service and that we have better links with the community services. Most pediatricians do not know what is out there for families in the community, so we need to be joining things up. We need to have a single-point contact with people in the community so that we can work with families in a much better and more robust way. I just want to refer to the types of roles that Sam March mentioned earlier on. We are currently in a number of areas across Scotland piloting a distress beef intervention service with under 16. There is the need for the clinical roles and to bolster the support in those settings. As Dr Stark mentioned, there are also the non-clinical roles in the community and in different services. We, as a number of other third sector providers, are involved in the delivery of the distress beef intervention services and programmes across Scotland. The under 16 pilots will be interesting over the next 12 months. Those are the roles while that is a slightly higher, escalated level of support, when a young person is in distress, not quite at that crisis level. I am definitely not tier 1 and tier 2, but those types of roles are going to be really important to support all the statutory services that are going forward. I agree that that is one of the services that needs to be closely looked at. We have had the ability to provide support, which is obviously the key thing, and to prevent escalation to CAMHS, but it needs an independent evaluation as well. I am not sure whether the answer is enough. We are dealing with the need and the pressures from Covid, so we need a balanced approach that includes focus on early intervention and the community mental health fund needs to be not become the poor relation, because those supports are ultimately what we want—our aspiration over the next 10, 15 years—and where young people and families will feel most comfortable getting support. I think that that task sharing to community-based organisations is really important, but that has to be done in the context of really robust community mapping, so that we are identifying the needs of communities and making sure that the correct interventions are being placed in the right—people are being skilled up in the correct interventions that are going to have the biggest impact for the greatest amount of people in those communities, because, again, we are not dealing with infinite resources here, so that community mapping assessment is crucial for underpinning that. There is also a piece about what Sam talked about, which is quality assuring. Any specialist intervention is making sure that there is that strengthened collaboration between specialist mental health providers who are skilled in those areas to support that warm arm, that coach, if you like, to the community-based organisations, and that it also improves the flow of prioritising and ensuring that people are getting the right support from CAMHS—the right people are getting the right support from CAMHS at the right time. There is a piece around mental health promotion and wellbeing—that universal piece that we need to change, the narrative, we need to strengthen. Those things that we know protect, communities protect people like free access to travel make it easy to get. We need to make sure that young people have access to leisure and activities and that parents who are under financial pressure are not worrying about those things, that children are not hanging about the streets and that they are engaged in meaningful purposeful activity. That is fun and engaging for them. All of those things are simple, but they make a massive difference. Making sure that the environments that people live in are safe, safe access to green space, safe access to community spaces has meaningful activity in places where families can be together. I am making sure that we are having a two-pronged approach and that we are filling that plug in that gap in the middle, in the interim period, where those people are not languishing, they are in between services that we are able to meet those needs, but at the same time reduce that bottleneck into services. We are playing the long game here. Essentially, we hope that the actions and activities that we take now, if we focus in that early intervention, impairing natal and health services and we get it right in those communities, that in 10, 15 years that is when we will see the benefit of what we do, but we have to hold tight and hold strong in that and be committed. Thank you. We have run well over time, so I am going to have to bring this session to a close. I want to thank every single one of you for the very compelling evidence that you have given us this morning and for the time that you have spent. We are going to suspend this broadcast briefly until 10 past. Welcome back to this meeting of the Health, Social Care and Sport Committee. The second panel that we have today will focus on the health and wellbeing of care experienced children and young people. I welcome to the committee Jackie Brock, the chief operations officer for the Promise Scotland, Helen Harper, the chief inspector of the Care Inspectorate, and Lucy Hughes, the policy development coordinator for Who Cares Scotland and Kate McKinnon from Celsus, the policy association from Celsus. Good morning to you all and thank you for coming along this morning. Last night, we had a private and informal session with a lot of care experienced young people. One of the things that struck me was a comment made by a young woman who said that local authorities know when care experienced young people are leaving the care system. They know how many, when it is going to happen, and they know that at that point it is a difficult time for them to have some mental health. Why is there not anything in place at that time that they can get in touch with somebody if their mental health is suffering? It struck me that two looked after children and young people and care leavers have access to that intensive support that ensures that the health needs are fully met. That is something that the Promise wants to be delivered. Can I put that question to you all and reflect on what that young woman said? It struck me as being a very sensible approach. Can I come to Helen Harper first of all? I think that that is a salutary statement for that young woman to say, because it sounds so simple. We know that it is very challenging period of time for any young person. If you are leaving a situation in which you do not have the on-going family support that your peers have, that makes it triply difficult for you. One of the challenges that is around is that we know that young people need to make mistakes. They need to try things out and see what works for them and what does not. That means sometimes leaving, coming back and you do not make decisions and then those just work out for you. That is extraordinarily difficult for local authorities to manage. Maintaining foster placements for example where children leave but have the option to come back is very difficult. There are some structural challenges in providing that and there are real structural challenges in terms of housing and in terms of financial support for children and young people. One thing that has been very clear for us is that our evidence in a lot of inspection activity has shown that the outcomes for older young people, those care leaving group and young people in continuing care, are much poorer than the outcomes for other children. We have seen lots of improvements in the outcomes for younger children as they are moving up through the care system, but the outcomes for older young people have been stubbornly stuck. We believe that there is a lot of goodwill around that but the structure that is around the pathway planning process that exists for care leavers is out of date. It has not been reviewed, it has been in place since 2003 and it is not as linked to the getting it right for every child approach that we believe has been quite successful in helping staff to work together across different services more effectively to plan for younger children. That is certainly an area that the committee might want to have a think about. It is time to address that and that might help that forward planning that that young woman who spoke to you was probably thinking about that forward planning of knowing that everything is not going to go smoothly because it does not for anybody and allowing those kind of contingencies when young people need that extra support. Jackie Brock Thank you for telling us what you heard last night from the group of young people. They reminded us that that should be reasonably straightforward. Helen set out some of the complexities but it is important to remember that the legislation is in place to fulfil what that young person asked you for. There are rights in place for young people leaving the care system or certainly in transition, for example from the children's services to adult services. What is preventing that happening? Of course, there will be issues around resources, etc. There are also challenges that Helen set out in that it is very clear that young people, if they need a relationship-based approach that will set down and say, right, what is your situation? Where do we need to go to support you? Is it into independent living? Is it to remain with your foster carers longer? Is it to support you to navigate through school and then into college, etc? There is an intensity around the support that is needed but that intensity will be worth it in relation to improving outcomes, which, as we all know, are completely unacceptable for young people in the care system. As you can see, hopefully, within the promise as a whole and the plan for 2021-24 and the change programme that we produced last year, there is a real sense that the framework is in place. We do have laws, duties, we have commitment, we have principles set out for what we should be achieving. What is necessary to make that happen? There needs to be a clear focus on this group of young people. That is not a large group of young people at the national level. How can we get it right for this group of young people that you were talking to last night, convener? That is a 16- to 17-year-old age group. We know that that transition at that age, together with the complexities of adolescence, the development, etc. We know that services do not build themselves around young people at that stage. There is the children and family service and the legal requirements there, and then there are a set of adult services. You lose, potentially, the scaffolding of school, and so how do we help a young person transition into that more complex system? There is a lot of progress in place and there is amazing work around through care and after care in place. As Helen Boyle has pointed out, there is the inspection and regulatory framework that should support it, but we really need a focus on keeping the promise and the very clear suggestions, proposals and plans that are in place through the promise. Let us use the inspection and regulation system to figure out what matters for children and young people. Let us ask them, as you did, convener last night. Let us look at how we can deliver that. That will mean some changes in relation to how the workforce is organised, but we are really convinced through all our discussions that the workforce absolutely knows and is desperate to deliver their services differently in line with the needs of those young people. We are hopeful within the promise Scotland, but we cannot keep hearing, frankly, the same easy questions that should be easy for you to have answered last night. We cannot keep hearing that, because what the young person said to you is perfectly reasonable in terms of their life experience and the support that they need. Jackie Baillie, before I move on to a colleague just talking about the promise, has Covid-19 impacted on the implementation of it? Thank you, convener, for the opportunity to answer that. The promise was accepted in full in February 2020. Keep the promise by 2030 at the very latest is a commitment that has been made by the First Minister and across Government, and indeed all parties within the Scottish Parliament. Then, of course, the pandemic hit. What we found over the past two years, convener, is that undoubtedly the workforce in its broadest sense has had to shift into supporting an emergency. That is fine, but again some really incredible work, despite that, has been done to maintain progress. We also have the national care service consultation that is also distracted possibly from or certainly raised additional questions about how the promise is going to be achieved, which has not always been helpful. It is mixed, convener, and, if I could make a brief additional point, what we have also found and reported in the change programme is that, if you like the real challenges in the system that the promise is designed to achieve, they have been stretched to the limit. In terms of those challenges, we have seen them exacerbated through the pandemic. The experience, for example, of children and young people in children's houses, has been stretched to the limit in terms of, for example, many of the workforce being forced to wear PPE and so on. The least like a home, you have seen, of course, the recent reporting around the use of restraint, which clearly is a symptom of the strains and stresses that have been exacerbated through the pandemic. It has not been helpful, convener, at all. Clearly, it is fantastic that keeping the promise is one of the key programmes within the Government's Covid-19 recovery programme, but it has not been helpful. We still have a commitment to deliver by 2030. Your inquiry and evidence and the building on what the promise has said and accelerating progress will be desperately needed. Just for those who are not aware of our work, Care Scotland does an independent advocacy and a national membership organisation for care-experienced people. Some of our members were those that you spoke to last night. One of the things that I want to address, first of all, is the language that we are using around the same system language, care leaver, where we are assuming that transitions will happen at 16-17 for young people and care. The message that we are hearing from our members time and time again is that care-experience is a lifelong experience. It does not just cut off because it turns a certain age. What we really want to do is work with the promise and with partners to understand how we can encourage the sector and the system of support to think about people beyond those age brackets, beyond what age someone is a young person coming into an adult. The support might not change what they need as they are at the moment ageing out of services. Just on the point on transitions, your initial question and what the members spoke to you last night is that that support really is not in place for a lot of older care-experienced people. We saw throughout Covid who had a helpline that was set up. The majority of calls were from people over 20 with care experience who had absolutely no statutory support in place, were not known maybe adult social work, but had left care at some point in their teens or earlier in childhood. There needs to be acknowledgement of the committee that older care-experienced people, whether they are talking 16 or 20 or older, also have significant mental health needs and health needs that are not being addressed. Sometimes they are an invisible population to statutory services. I encourage the committee to think about care experience beyond childhood and as a lifelong need in terms of what we should be doing to address that. On Jackie's point about the national care service, we see that as an opportunity. If policy occasion is addressed in terms of matching up what is happening under the promise to join up the approach that we have across lifetime from cradle to grave, in the same way that we have with the NHS in some ways, someone should not be leaving care and that is their support stock. It should be a lifelong offer. People in their adulthood can be affected by the experience in their childhood and that is something that we need to acknowledge. Beyond that care leave a language, which I think we are still very much stuck in as a nation. That came across very clear last night in speaking to the young people. Can I come to Kate McKinnon? Thank you and thanks for inviting me here to give evidence today. I really agree with some of the points that my colleague Scotland has made. It is really important to think about what all children and young people in their life when we know that in Scotland, for non-care experienced children and young people, the average age of leaving home is around 26 and rising. That is nearly 10 years younger for care experiential average age. When we are thinking about the help and wellbeing of care experienced young people and what they need as they grow up, it is really important to think about the wider stresses that they experience in their lives when they are having to move out so much younger and with support that is sometimes disappearing overnight in comparison to their peers who might have support that goes on for years and decades in lifetimes from their parents. The gap between what is a progressive and aspirational policy in the legislative landscape is felt in the lives of children and young people. It is really important and, thanks to Jackie from us for mentioning that, there is a real need for a sustaining agenda to implement the policies and the legislation that we know is really important. Some of that will involve systematic change. We know that there is too often, for care experienced people who are more likely to have experienced trauma and adversity and disrupted relationships, a drop-off when they move between services for children and services for adults. That is across the board in terms of care and protection needs or health. Ensuring that we have systems in place that meet the needs of a child or young person and not expecting the needs of children and young people to be dependent on the services that are available is crucial. The other aspect of the importance of implementing the legislation that I mentioned is that, as well as listening, it is so important crucially to be listening to children and young people who are able to meet with care experienced people last night and describe the experiences that we all agree should not be happening. That is the core of implementing any change. Secondly, it is important to be listening to and supporting practitioners about the barriers that they are experiencing in their day-to-day practice of preventing and implementing the legislation that we already have. Thirdly, we spoke at the beginning around the data that we have on care experienced people and leaving care and the needs in their life journeys. I would mention briefly that there is cell systems of publishing research that is going to the Scottish Government this week around this gap. We understand how many young people are assessed to become eligible for continuing care and how well we are implementing their rights and their eligibility for continuing care. We are glad to send that to the committee when it is published. I want to ask you all about national care service. I really want to give more time to my colleagues in this session, because we have nearly run out of time in the last one. I will move on to the health and mortality of care experienced children and young people and the statistics and reasons behind what that is with Sue Webber. Thank you, convener, and yes, we were both on the same break out last night, so it was so, so insightful in terms of today's session. The question is to yourself. What actions do you think could help to address the higher than average rates of restrictions and hospitalisations for care experienced children and young people? What actions could help to reduce the number of care experienced children hospitalised due to injuries, drug poisoning and other external causes? There is a lot in that, but it is all similar in the same theme to bring it all together. That is a really important question. I want to acknowledge in terms of health and mortality that, as a membership organisation that holds relationships with many care experienced people at all ages, we have felt personally the impact of loss of people who have died party young, who we work with and who we support. I want to take a moment to acknowledge that. In 2014, we began to create our own record of those people because we feel that their lives and their loss are not being recorded within the death stats that we have around care experienced young people. That is something to raise in terms of the invisibility of some of the early deaths that we are seeing. Sometimes, young people are living care before 16, so they are not being picked up in aftercare services. Sometimes, young people are off the radar of social work and others, but we know who they are because we hold those relationships. That is more of a data question that we can talk to you in a bit more detail if the committee would like to. In terms of actions around creating better health and reducing health risks for care experienced children and young people, we need to acknowledge that there is an inequality in terms of the experiences of health that we are seeing for looking after children. One of the things that we feel is really important is that there needs to be a right to healthcare and mental health from the point that someone is looked after or coming into care, especially around mental health. We need there to be a proactive approach in offering lots of different types of support from an early age and not waiting until crisis arises. I was shooting into the session earlier and it is echoing so much of what the general mental health community is saying that we are having to wait until people are suicidal at risk of taking their own life in order to have those interventions. From the earliest point possible, we should be offering all different types of support to young people. We know that care experienced people will have potentially greater needs in terms of their mental health, their wellbeing, some of the early experiences that Kate spoke to, complex trauma difficulties relationships. We need to have a proactive approach. That is not just about referral to CAMHS in clinical models, but all sorts of different types of support for wellbeing and for health. Those hospitalisations, substance misuse, some of the points that Sue raised, that unaddressed needs from earlier in life and when problems are left without that support and proactive questioning, curiosity and understanding of what does this young person need to thrive and have all of those needs met. For us, it is a really big ask for the committee to consider and think about how we can support the workforce and work alongside the promise and make sure that, from the earliest stage possible, children who are in care are having this proactive offer for support for their health and wellbeing across mental health, cross-physical health and any other health needs that they might have rather than waiting for that crisis point where hospitalisation might occur, whether that is later in life as an adult or while still actually looked after. I hope that I will answer your question soon. I think that I might bring in Jackie Brock on this and just maybe mention to our panellists that, although our members are directing a question to a certain individual, if you have anything to add of trying to take you, if you just use the chat box and put an R, can I come to Jackie on that? To build on Lucy's point of the key, I am really interested in what she is talking about in relation to how the current legislation could be improved, which is something that we would be really happy to look at how we can support that in terms of some of the plans and giving a bit more detail in the next steps for the Promise Scotland and, obviously, we will build on your committee's recommendations, convener, as well. I think that the key thing about what we can do, a contribution, I hope, by the Promise Scotland, is that we have brought together, and this will include who cares Scotland, a whole range of bodies looking at the data hand in hand with Celsus and others, and that is really focusing in on what matters to children and young people who are with care experience. It will be a really useful resource, and that is how we in the Promise are going to work with the Scottish Government and others to measure progress. So much of what you are battling with in the committee is with waiting lists and referrals, etc., but what actually has mattered to children and young people and what has been effective. There is a huge gap in the available data evidence and intelligence, convener, that we simply cannot achieve sustainable progress until we really get a grip on what data is important for us collectively in Scotland to measure based on what children and young people tell us about their experience. We, in the Promise Scotland, will be publishing something on behalf of and with our partners in July that will give a central database and proposal for how we can use the data based on what matters, because it is out there. It is just the pulling together and the mapping and the collection of it that we think will really start to make progress to help to link what we want to achieve in terms of our policy goals with knowing that that is having the right impact on individual children and young people. I should just say that that has also had significant support for this approach from local authorities and other partners, for example the care inspectorate and also the workforce. For example, we work very closely with Unison. That is helpful. Just to make an obvious point, our care population is not representative of the population just in general. We have a population of young people who find themselves in the care system and who come from backgrounds of poverty and disadvantage. We know that the health inequalities in Scotland are huge and that children are experiencing from an early age poverty and disadvantage their health, not just their mental health but their physical health, is blighted. So there are some structural things that really need to happen in terms of addressing poverty and disadvantage for children and young people. We have large numbers of children who we shouldn't forget who are looked after at home. They are still in the care system. They happen to be living with their families. Their families are often struggling to meet basic needs in terms of food, warmth and care. We really need to be addressing those things, as well as looking at what is happening within the system in itself. We need to be addressing those health inequalities, which we know as an impact all the way through life. That issue is not just your childhood, it is then how that follows you into your adult life. Thank you. Every single person that we have had in front of us in this inquiry has said that, Helen. Ahead of moving on to the next theme with Stephanie Callaghan, I bring in Kate McKinnon, and I will need to move on to the next theme. Thank you. I will be very brief. I completely agree with the points that have been made by my colleague. My colleagues absolutely need to improve how we collect data, to improve how we support people early and how we address the wider health inequalities that affect their experienced children. I will add a few more points to the considerations that we know. For example, from the Care Inspectorate's periodic reports around the area, the recommendations from those really chime with what we already know about what we need to be doing to support children and young people. The continuity of relationships in their lives is so crucial in looking at what structures and supports need to be in place across Scotland to ensure that we build and enable stronger relationships. For one other smaller example, the recommendations also mention earlier identification of risks. We know that those assessments are really skilled assessments that are being done by practitioners who we need to continue supporting and ensure that, in addition to skills, they have the day-to-day support to make those risk assessments and work coaching to ensure that their wellbeing is looked after while making those highly complicated assessments. Again, that chimes with the importance of relationships to make those complicated and complex assessments to support and protect children and young people. Having a strong relationship with them is so important. I will add a few other points that we know much of what we need to do in relation to the particularities that chime with other aspects of what we need to do. We want to ask you about sexual and reproductive health, Stephanie Callaghan, if you need to direct your question, please, Stephanie. Thank you very much, convener, and thanks for coming along to the day panel. My first question is, beneath the lack of water to the girls in care getting pregnant and care leavers at much higher risk of having their babies removed, what steps do you think we can take to tackle the stigma and also to help care-experience young people to plan for their future and to make confident decisions? Who would you like to ask that for? I will bring in Lucy or Jackie. Thank you so much for that question. The evidence that we submitted from members has done quite a bit of work to explore the areas of sexual and reproductive health. Recently, I have been doing some more focused work around care-experience parenthood and some of the challenges that you have spoken there about pregnancy and decision making. In terms of what we found, your members have told us in quite clear messages about what would really help. There are quite a few actions that we can take to improve how young people in care are supported, to understand sexual health, to feel they have the autonomy and control of their own bodies and to make decisions in a way that feels informed and safe. I think that one of the key messages for the committee is how we can support carers and families and those working with young people to feel more confident in this space. It is a really difficult area to get right in approaching these conversations. Again, as I was saying earlier, with other health inequalities that we were discussing, it is about a proactive approach that is not disciplinary and punitive around being risk averse, but a proactive, positive approach about a carer feeling able to start these conversations and normalise talking about sexual health, normalise talking about the changes that people will be experiencing and thinking about as they go through their young lives. I think that that is something that we can really work on and hear from care-experienced people themselves. How would they want those conversations to be led out in their homes, wherever they are living, whichever care placement they may be in? We need to understand the right to inclusive education for all young people, especially when people are moving to a placement where those relationships are being disrupted. A lot of those conversations are based around trust and honesty. I am being able to know that you can share something that might be quite scary and that you are not sure about, an experience that you might have had without feeling that you are going to get in trouble or that there is going to be a risk associated with it rather than seeing that there is a need for some guidance, information and just to be listened to in a judgment free space. The area around sexual health has made so much progress with RSHP. We have a new approach in schools from early years all the way up to secondary school now. We need to bring that conversation into homes and into the way that carers are giving their care to young people in the care system. My call to what members have told us is that they want that confidence in carers and others being able to lead out those conversations proactively and to create a safe space for people to bring up any concerns that they have. If we do not do that, young people will turn to the internet and to friends and peers. There are many other ways that people access information about sexual health, but that information is not always accurate and it is not about having someone to discuss those decisions with and work through some of the worries or fears or concerns that they might have as a young person trying to navigate those different issues. We often talk about young pregnancy and our risk-averse approach in terms of being pregnant. However, where the conversation needs to shift is how we can support proactive conversations around sexual and reproductive health that feel supportive. Our right space is about supporting young people to feel an ownership over their own bodies and their own choices that they are making around sexual and reproductive health. We have that report that we have submitted to the committee with our members' views on that, which has far more detail on the different topics that I have just been talking to. Bethany? That is great. Thank you very much for that, Lucy. I just want to follow on from that as well. I realise that you are talking about carers and families who are getting the support that they need from health and social care workers to do that really well. I am wondering whether, on a wider and more general level around sexual health and reproduction, what training needs do you think exists in the health and social care workforce? Is that directed to Lucy again? Yes, it was. Sorry. Thank you for that follow-up question. This is a really important point. Obviously, I was talking a lot about the home environment, but we do know that sexual health services will be needed and reproductive health services will be needed for many young people in care. The key messages that we are hearing is that we need trauma-informed practice across the whole of the NHS, across universal sexual health services. We have some amazing practice out there, the NERS training programme, the NHS Education Scotland programme, but we need that to be across the board. Part of what we are hearing is that young people interacting with these services need to be able to have choice about gender and professional. There needs to be more understanding of how trauma-informed can be a bit of a buzzword. How can that really play into the practice of the NHS and the services that we are providing? I think that not just choosing gender of doctor, but also just an awareness of what a history of sexual abuse may impact someone who is actually interacting with these services for the first time. I am not assuming things that people's family background. One of the key things that we have heard is that point care experienced people interact with universal services. They can be a lack of understanding of what care is and the fact that people will not always have a solid family network to fall back on, but they can get support after an appointment, after a procedure. There needs to be a much broader awareness of that. As corporate parents, the NHS and health boards have a responsibility to be thinking about tailoring those services and understanding how we identify the needs of care experienced people and how we meet those in a trauma-informed way. The key messages are that there needs to be more awareness of what care experience might mean for someone and that trauma-informed needs to play out in practice across the first point of call and GPs, especially sexual and reproductive health services. I hope that that is helpful for answering your question. That is really helpful. Thank you very much, Lizzie. Kate McKinnon wants to come in on that as well. Again, I will be brief. It is only to add on to the points of my colleagues that when we are thinking about the importance of training and skill in the workforce, an additional note is that it is also important to ensure that there is a capacity built in the workforce. My colleagues are rightfully pointing out the importance of young people being able to do that. The adult are practitioners that they feel that they are closest to and that they trust or have a good relationship with. We really need to be ensuring that skills and support and the time in their day to have what is really going to be a one-off conversation but an on-going conversation that the workforce is equipped to have all those resources across the board, so that, even in small ways, the receptionist at the GP office has the same trauma awareness from their teachers and schools or a youth worker. It is important to think about the capacity that people have when we are thinking about the importance of the trauma informed workforce. That is a very good point. We had an individual last night who pointed to the fact that the receptionist should be trauma informed as well. The gatekeepers often get to speak to somebody as well. I will add briefly to that convener. I am linking Lucy's work with some evidence that you were given earlier in the morning's earlier session around the 10 principles of intensive family support. Ms Gow has a question about dealing with stigma. We have a great opportunity to look at the commitment by the Government in relation to whole-family support. There is a significant amount of money being put into this over the years, but if we were to apply the principles of family support and now the resources and apply those in a way that Lucy set out for us about how you work and support with families that are going to be made up of children and young people with care experience who are now having children as well, we could apply those principles and that would give the best start in ways that Lucy described that is going to achieve the most effective outcomes for that family. I think that making sure that we do not continue to treat children and young people with care experience as those isolated figures know that they are going to be forming families and heading up families and they also deserve the support that is in place from health, social care, local authorities etc. to be considered that and making sure that the workforce is sufficiently trained to avoid stigma in ways that it is, as we have heard at many good practices, one of the key principles of intense family support is that it is non-stigmatising, it is underpinned by rights. We have a great framework in place to tackle some of those structural and systemic issues and making sure that those with care experience are seen as beneficiaries of the forthcoming resources that are available around whole-family support is critical. In fact, they should absolutely be prioritised and services plans and delivered and reshaped accordingly. We must move on with all those themes. There could be a theme in themselves and we could have two hours on each theme. Can we come to Covid-19 in the health harms associated with that and questions from Evelyn Tweed? If you direct your question, please, Evelyn. I think that we could have a whole hour just on Covid-19. Generally, what impact do you feel that Covid-19 has had on children and young people's mental health? I would like to direct that to Lucy Hughes. The first thing that I would like to address is that although the pandemic has put a huge strain on the mental health and wellbeing of care-experienced people of all ages, including children and young people, many of the issues that we have seen as an organisation through our independent advocacy, through the helpline that we set up during the pandemic were there before. As someone in earlier session described it, inequality has been supercharged by the pandemic. I want to draw attention to that. A lot of the things that we are hearing are not new issues, but it has just been exacerbated by Covid. One of the key points that I would like to raise from my evidence is that we saw the impact. During Covid, we all turned to our support networks, our families, loved ones, in order to have support through what has been incredibly challenging for all of our mental health in the past couple of years. There was an assumption that people would have that support and that it was up to the individual to try to support themselves through a lot of what was happening. However, what we know from people who were calling our helpline that were asking for support for a variety of different practical measures, financial impact and a lot of the time was that there was a real sense of social isolation and the lack of connectedness that there has just been a theme through so many of the sessions and the evidence that you have heard of the committee. That has a significant impact on character experience people who maybe do not have trusted relationships, have a support network, particularly for older care experience people who I was referring to earlier, who have left care, maybe have no longer got support networks of carers or family, living by themselves a lot of the time as well, and the pandemic has isolated many individuals through the past couple of years. For us, a huge part of our work is creating connection and belonging through programmes that we have, such as communities that care through our participation work. All of that face to face. Youth work and community development work have had to be paused for a long time. We have been able to do some of that online, but as many people here can definitely attest to, that has been really challenging. Digital exclusion and many other barriers have been in the way of that work continuing. However, the key message for us is that a lot of the health and wellbeing impacts that we have seen around loneliness, isolation, struggling to access services. They were there for the care experience community before the pandemic. It has just really brought it to light and has made a lot of the rest of the population understand those issues for the first time. We can now see that this is something that we need to have a lot more conversation about. Why are we accepting that people who are older, who are care experience, do not have access to the same mental health support, do not have support from statutory services in a specialist way? They very much have to try and access universal services like the rest of us, and that is really not good enough. We are hearing that with Covid, if anything, it has added fuel to our fire to really change that and make sure that we are working alongside the promise to address the needs of the community that exists now, whilst doing that prevention work to stop future instances of care experience people feeling unsupported with their health and wellbeing, whilst they grow up as well. I hope that that answer some of it is such a huge question. If there is anything that we want to ask us about, please let me know. Thank you. Evelyn, if you are okay, I would like to move on to talking about resources and workforce with Gillian Mackay. I am sorry to curtail your questioning, but I am very conscious of the fact that we have other items in the agenda to get to Gillian Mackay. I have heard from the social care sector that increasing workloads and reducing of undermining their ability to build relationships with young people, families and carers that they are working with and to take early intervention. How do you believe that that has affected the wellbeing of care experience young people? I put that to Lucy Hughes. Of course. Thank you for the question. Was that sorry about the impact that Covid has had on the ability for services to respond to health and wellbeing needs? Generally, on increasing workloads and things like that as well, obviously, the pandemic had an effect on that, but probably the number of young people needing support has impacted that, too. Thank you. That is definitely an important question. What we did see with Covid was obviously that so many people had to be redeployed to deal with crisis. I think that you have heard that from many in the sector and local authorities. We did see a withdrawing of services for various reasons. Obviously, many people were having to deal with crisis situations, but it meant that some of the support that was existing for care experience people was more difficult to access. Obviously, that need was hugely exacerbated. Like I have said, the existing needs that were already there for many care experience people became much more difficult. Themes around loss of grief and bereavement, I know that that is again something that has affected so many people across the pandemic, but those were issues that care experience people were already having to address before the pandemic. It has created even more challenges, bringing a lot of those things that will be below the surface to the floor through the help line that we had. We very much heard about the real difficulties and just not having someone to connect with and talk to about the issues that people are experiencing. The average call time that we had was over an hour. Even if that call initially had been around financial support, a lot of the time people just wanted someone to speak to and someone to connect with. I think that we can all relate to that in terms of how the pandemic has really made us feel less connected with one another. However, just to point to something that we did as an organisation to address what we were seeing as a huge unmet need in terms of mental health, was a counselling referral service that we set up during the pandemic. Because of Covid, we realised that waiting times were just going to get worse for a lot of those services that were experiencing such a huge need. We helped hundreds of people to access a counsellor of their choice. Sometimes waiting times were 24 hours, from when they would call the service and explain what their needs were and then access a counsellor. Many of the people that we spoke to through that counselling referral service were on waiting lists for 18 months, or maybe two years, by the time that they spoke to us. There are different innovative approaches that we can take to understanding that there is a specific need out there for care experienced people of all ages. We need to have something that is much quicker. It is not about, as we have heard in early evidence sessions, just saying that we are going to add you to the waiting list for cancer. There are other approaches that we can take. We are really keen that we have a report coming out about the impact of that counselling service, which we would love to share with the committee. Obviously, with yourself, Dylan, if you are interested, if you would like to learn more about that work. I think that it is a good idea to bring in Helen Harper, as well, from the perspective of talking about the workforce challenges. Helen, are you happy for me to do that? Yes, certainly. Lucy made the point and, in answer to the last question, that a lot of those issues are exacerbated by Covid, but they are not new. It is really important to say that the workforce in general for social care, let alone children's social work and social care, and other services for children, was pretty critical before the pandemic. It has been impacted by the exit from the EU and also now by Covid. We are in a difficult situation going forward in terms of workforce in general. The numbers of people who are needed are pretty mind-blowing when we think about the expansion of the early years workforce and the need for better resourcing in terms of care for older people. It is all coming from the same pot of people. It is a dire situation. When we are talking about the workforce, it is important for us to remember that foster carers and kinship carers and adoptive families are also part of that workforce, and they make that up. They do not always feel that. That is really important. We have seen the number of foster carers decreased year on year since 2016. We need to be thinking most broadly. The importance of a workforce that is harnessed around a common understanding of what young people who find themselves in the care system are experiencing and have experienced, but that trauma-informed practice is also really important. In terms of supporting the workforce that we have, there are a lot of good ideas about revisiting the common core of training and support, but I do not think that we can get away from the fact that the number situation is very challenging. We need to think about how we support people in our workforce and how we attract more people into the line of work. We feel that they are valued and cared for and that they are well supported. We know that a well-supported workforce is likely to deliver much, much better work and to support young people and their families much more than if they feel that they are built on the pile and that their conditions are poor and that they are not valued as contributors. As usual, time has whist past. We have to move on to our final theme with questions from Paul Cain. Thank you very much, convener, and good morning to the panel. I want to cover the theme of transitions. What does a good transition look like and how do we do more to achieve those good transitions? My first question is about whether the local implementation of policy on transitions resulted in improved transitions for care-experienced young people or have things not moved forward as much as we might hope? I would like to direct that to Lucy first. That is a very important question. We have, in the legislative sense, made a lot of progress. We have had after-care rights being extended to 26. We have had the introduction of continuing care, but what we are not seeing is full practice and implementation of these ambitious people commitments. We need to acknowledge that. I am not sure in terms of the most recent data around how many people are accessing those services, but I know that that does exist. There is still a lot of unmet need there. Going back to my earlier point, it is really important that we think about how we talk about transition. It is about life-long support for care-experienced people. One of the reports that we did was that being care-experienced does not leave you and does not just go away after a few months of supporting in a transition. Let us say that someone is having half-to-care support for a few months and that stops what happens next. That is where, potentially, the national care service could have a real opportunity to link up how we view a social care service over lifetime or how we view different support over lifetime for a care-experienced person. Very much we are still stuck in the sense that a care-experienced person is a child or a young person. We are a community organisation and we have many older members who have no ability to access support in a way that is based on the fact that they were looked after as a child at some point. We have seen huge developments in that in terms of the care-experienced person having no cap on age. There is so much that we could bring in a mental health arena with that same lens and focus. It is not about transitioning from one service to another, it is about continuity of support for your lifetime. That is something that our older members have pushed us on in terms of how we need to get much louder on how we are talking about that. My current thinking is that it is based on how the system works, how we have young people ageing out of services and then we are like, what happens next? Where do they go? Many of those young people do not have anywhere to go and we do not have that joined-up approach between housing and support services. In a lot of adult services, care experience is invisible. People are presenting to lots of different services with no acknowledgement of the fact that they were care-experienced or that they had experience and childhood of care. There are not robust ways to understand that across homelessness, unemployment and so many other life outcomes that we look at. I will also bring it back to the point about poverty, which I know that the committee has talked about with many different witnesses, but we know that from the relationships that we hold across a long period of time with care experience people, that lack of support in terms of the transitions leads many to end up living in situations of poverty, continued inequality. Even if there have been those interventions throughout childhood, they have come from a family where there is disadvantage. They could end up back in that exact situation in their own adulthood. As we were saying earlier, these are people who are going to have their own families, who will have their own children and should also have access to all the things that we want as adults to thrive and feel supported to live healthy lives throughout our lifetimes. I have covered so many things there but when we talk about transitions, it is very much thinking about the system as it already exists for care and protection. I think that we need to rethink how we support people across lifetimes with care experience. Thank you, Lucy. Thank you for covering all those things, because we have just gone over time. I apologise to Paul, but I cannot come back to you because we have got two more items. I want to thank all our panellists again for the comprehensive evidence that they have given us. Of course, if there is anything after today, I wish I had mentioned this. I wish I had flagged this up. Please email the committee and we will take that into account. We will break for five minutes while we allow our witnesses to transfer over. Our third item today is an evidence session on the provisional common framework on public health protection and health security. I welcome to the committee Humza Yousaf, the Cabinet Secretary for Health and Social Care, who is joined by Ellen McRady, sexual health and blood-borne virus and infectious disease team leaders of the Scottish Government. I want to ask—obviously, we have got the backdrop of the response to the pandemic in which the framework was not in place. I think that a lot of us want to know whether the framework would have made any difference to the Scottish Government's ability to respond in the way that it did. Is there still room for a differentiated response in public health threats by the Scottish Government in the future as a result of that common framework? First of all, good morning, convener, to you and all committee members, and I hope that you are all being safe and keeping well. You are straight in with the tough question, and I am not surprised that you are asking it. I think that that is a key question. If I take the questions in the order that you asked them, it is difficult to answer. If the framework was in place at the outset of Covid, would it have significantly changed the response of the four nations? I suspect not, because the data sharing has always evolved as we have gone through the pandemic, but the data sharing with the UK Government, certainly, I have to say, my time as health secretary, but I know that Cabinet, of course, in a different role at the beginning of the pandemic, the data sharing has been good. The collaboration on a four nations basis has been good in terms of response to the pandemic. There are times when it has been of concern and we have raised those, focalised those and articulated those, sometimes in private, sometimes quite publicly, and that is well understood. On the whole, I think that four nations collaboration on those matters and the sharing of information has been good. That being said, that does not mean that it will always be us. Therefore, for the future, whether it is the pandemic, which has still got to run its course, or indeed for any goodness forbid future public health threat, it is important to have this framework underpinning the principles of that collaboration. The second part of your question is equally an important one. Let me stress that the framework, although it has those overarching principles, it does not stop any of the four nations acting in a differentiated way, if it wishes. The framework, in essence, is policy neutral, so it does not stop the Scottish Government, the Welsh Government nor the Irish or, indeed, of course, the UK Government taking decisions that are divergent to other home nations. That is very helpful. Thanks for outlining that. I am going to move on to questions from Gillian Mackay on the role of Parliament and, indeed, this committee. Gillian Mackay. Thank you, convener. Cabinet Secretary, will implementation of the framework impact on parliamentary scrutiny and decision making in this policy area? If so, what impact do you think it will have? I certainly expect that Parliament would have no less of a role than it did in the previous system. It is absolutely open, I should say, from a Scottish Government perspective, that we are possible if that role could be enhanced. I suspect that that will only become clear, or more clear, as the framework becomes embedded in our public health infrastructure. For example, there is a review period that is built into the framework, and it may be that that provides quite a good opportunity or quite a good hook for Parliament to consider its operation and whether it is delivering as well as we hope it would. Those are the ultimate questions for Parliament, as I should say, as opposed to to the Government. However, if Parliament wanted further scrutiny and thought that that review point was the correct point by which to invite myself and self-secretary and my officials wanted to undertake a more detailed review, or, indeed, scrutinise, for example, work plans. I am really open to any role that Parliament wishes to have, because it is such an important agenda and issue. Thank you. That is everything from me, convener. In relation to international relations, I have questions from Paul O'Kane. Thank you, convener, and good morning to the cabinet secretary. My first question in this area is whether the Scottish Government is comfortable that the common framework will provide sufficient opportunity for it to provide input to any future negotiations or, indeed, for filming of international obligations in the area? Is the cabinet secretary's comment on that? For international obligations and any future negotiations in relation to that, the framework does not alter the devolved settlement at all, but it does not alter at all the devolved settlement. That is probably important. Paul O'Kane and I will have different views on whether Scotland should have more of a role or its own role in relation to international treaties, international engagements and international obligations, I should say, but it is notwithstanding those differences and we will pack those for a minute. It does not alter the devolved settlement, so the UK's fulfilment of international obligations are largely, not exclusively entirely, but largely reserved matters. Where we have a distinct, where we have a legitimate devolved interest in reserved matters, I do believe that the framework provides us with a useful set of tools that gives us a great chance of influencing negotiations. The process thus far in the framework has been really engaging. When it comes to engagement with the EU in terms of the MOU that the UK has signed with the EU in relation to, for example, the ECDC, Scotland has had the ability to represent that, so that is positive. Ultimately, I cannot promise you that there will always be alignment between what the Scottish Government or the Scottish Parliament wants in relation to international obligations and what the UK Government would end up doing. Ultimately, the framework does not alter that significantly. I suppose that following on from that, I know that I have asked the cabinet secretary about that before in other areas of the work, but essentially dispute resolution. When there is a difference of opinion, I know that he will use his good nature and strong relationships to try and find that way through in relation to the Scottish Parliament's position or Scotland's position on an issue. Is it his view that there is a robust resolution procedure that we would be able to use and would that be invoked more readily, or does he have concerns—I am sure that he does—about lateral decision making? Does he have a confidence that there is that procedure in place? Paul Kim will know that, if there is a chance for me to put on record my concern about the approach that the UK Government is taking, I would not be shy in doing so. I will do that regularly and rightly. My job is to stand up for the interests of the people of Scotland. I should say equally where things are working well. I am not shy or reticent to say that they are working really well. The process of the common framework has been a really good collaboration. Therefore, I would not envisage, in this particular area of the common framework, what it looks to address that we would get to that stage of dispute resolution. It is certainly not the evidence that I have seen thus far, but this is about the future. Ultimately, if we could not get that agreement, if every other lever that we tried through informal discussion with the UK Government, official-level discussion, ministerial-level discussion, correspondence, et cetera, et cetera, of all that did not work, then that dispute resolution mechanism exists there for a good reason. On the evidence thus far, I would not see that being invoked in the short or medium term. In terms of information sharing, we have questions from Sue Webber. Sue Webber, thank you cabinet secretary for coming along today, albeit virtual. I am here at length from everyone about how much pressure everyone's workloads are on under. I am hoping that you might be able to help to get a sense that this framework will reduce duplication in the lives of the scientific advisory and expert groups that we have across the four nations. Are there any plans to develop greater consistency in the way that the data is collected, analysed and presented across the United Kingdom? That is a really good question. It might well do that in terms of reduction of duplication, but what I would say is that it is important for each of the Governments across the UK nations to have bespoke advice. Although there will be some common themes that affect Scotland, England, Northern Ireland and Wales, there are also distinct issues that affect us uniquely. Having that scientific advisory group for the Scottish Government is really important for us, given the unique pressures that we might face. It might be different to parts of England and Wales, but Northern Ireland, perhaps, is the most obvious example of sharing that land border with a member of the European Union. It is absolutely to reducing duplication, for sure. I think that that probably will happen more as we see the framework embed. I would always reserve the right for us to make sure that we have that bespoke advice coming to us where we are appropriate. I come to Emma Harper on questions about cross-border co-operation. I am just interested in whether the cabinet secretary has any concerns about cross-border co-operation with the EU. Specifically, in our papers, it says that access to the early warning and response system is by ad hoc method, which means that, if there is a potential health issue, it will be up to the United Kingdom to write to the EU and ask if the UK can be part of its ad hoc process. I will labour the point. Everybody here would understand that the Scottish Government would have far preferred that we retained our EU membership. That would have given us greater access and would be part of ECTC, for example. Of course, we would not have to have MOUs, which, although they are positive, are suboptimal to EU membership. In one sense, there is no point in laboring that point, but it is important to put on record that any arrangements that we put in place in terms of cross-border co-operation with the EU are suboptimal in comparison to EU membership. In terms of co-operation, we would expect there to be a strong system of intelligence and data sharing. The UK, of course, as we know, has entered into an MOU—the UK Health and Security Agency, I should say—with the European Centre for Disease Control. We are pleased to see that the MOU has been signed, but, frankly, I am not convinced that it will give us the parity of access that we had previously. In fact, we will not have the parity of access that we had previously. In terms of the Scottish Government's involvement, which is an important point that Emma Harper asks around, if I were to go by the process of the framework, I would definitely be encouraged. Certainly, there was a role for Scottish representatives to be able to influence those discussions with the European Union, but, ultimately, if we were ignored, there would not necessarily be recourse for us that would be adequate to ensure that our outcomes and our desires in relation to that cross-border co-operation would be satisfied to really be met. I guess that I have touched on that as well. If we are talking about cross-border co-operation with the EU, as well as the cross-border co-operation with our neighbours south of the border, and I am thinking about the zoonotic diseases of SARS, MERS, swine flu, avian influenza and even Crushvelts-Yacob's disease in the past, we need to make sure that all the scientists are working together. Will the framework improve co-operation in the UK to make sure that everybody is sharing their scientific knowledge so that we are better prepared if there were any future pandemics that we needed to be worried about? I think about it, but, ultimately, what it will ensure is that we do not have any less co-operation. The danger, obviously, was with the exit from the EU whereby we were duty bound to have that co-operation with the exit with the EU and that we did not lose that co-operation. Therefore, the framework ensures that we do not have any less co-operation, which is important. I think that, for the purposes of looking forward, the framework and accompanying MOU that is set alongside it, I think that it absolutely ensures that there will be good collaboration within the UK but also with the European Union partners, which is important. In terms of the framework, members will be aware—I am sure that it is probably in your briefing—that there is the oversight group that is going to be really, really important. Of course, Scotland will have representation on that in order to ensure that co-operation is being maximised wherever possible. I think that the framework will evolve as it embeds, but, for me, the early signs are encouraging. I come to David Torrance, who has some questions around resources. Thank you, convener, and good morning, Cabinet Secretary. Will there be any plans to increase the health protection resources in Scotland where it has been identified as a need in the areas of review of disease notification, analysis of four nations working groups and the evolving science of genomics? The framework was developed not to impose or incur costs on any of the Governments that were taking the lead in certain areas. That is not to say that we would not bolster resources, I think that we would, particularly in the area of genomics. My goodness, the pandemic has taught us a lot, but it has clearly taught us the importance of genomic sequencing. We have committed, in fact, to the First Minister's references on a number of occasions that have put on record our desire to further increase our resources around genomics. Although the framework does not necessarily do that in those areas where we lead, I think that we would actually want to make sure that they are well resourced. Thank you, cabinet secretary. Thank you, David. I would like to follow-up with the question. Thank you, convener, and thank you, cabinet secretary. The common frame is good to hear what you are saying and the positives of the common framework. Does that mean that we have increased sharing in other areas of health research? The framework itself might not go into detail of that, but it is vitally important where we can share further research intelligence just to help us to build up our knowledge, particularly of the pandemic. That is the current issue that we are dealing with in facing research studies from across the UK that have helped to inform our thinking and our decision making. I think that we should look to do that. Dr Colhaney and I will have very different opinions on the constitutional future of Scotland. That is fine. Ultimately, whether we are independent and whether we are part of the union, sharing of that information across borders on those islands but also with the European Union is hugely beneficial. I would not want to lose that regardless of what our constitutional devolution setup is in Scotland at the time. That is the answer to your question about ensuring that we continue to share. The framework might not determine all that, but I know from my discussions with the UK Government that they are in the same place that I am. I know that my Welsh and Northern Irish counterparts are. The more we can share that research on health, the better to all of our citizens. Thank you to the cabinet secretary for giving us that feedback on our questions today and to his officials for joining us this morning. We are going to move on to our next item on the agenda now, colleagues. That is consideration of a notification from the Scottish ministers for consent to the following instrument. European qualifications, health and social care professions amendment EU exit regulations 2022. The purpose of that is to correct errors in the European qualifications, health and social care professions amendment EU exit regulations 2019 and to correct an error created by those regulations in the national health service performance list England regulations 2013. Under the protocol between the Scottish Parliament and the Scottish Government, consent notification has been categorised as type 1. That means that the Scottish Parliament's agreement is sought before the Scottish Government gives consent to the UK Government making secondary legislation and devolve competence. Do any members have any comments on the consent notifications? Thank you, convener. I want to put on to record the fact that I am against the idea of having a performance list. I think that it is outdated and something that we would be able to get rid of not only across the UK but in Scotland. As far as this particular motion is concerned, I think that it is something that probably does. It is just a correction, but I do want to put on to records that I am against the performance list. That is at UK level. You have put it on record that is something that you may want to flag up to our parliamentary colleagues in the UK Parliament. Emma Harper. In reading our papers, we need to be aware that when legislation is changed in England and that impacts or could impact our healthcare system in Scotland, we need to make sure that the cabinet secretary and that it keeps us informed and that we have an opportunity to pay attention to what is being taken forward. In a remote working environment, it is difficult to pick up non-verbals, look at what we need to do, find the right questions and make sure that the committee is kept completely informed about the issue as we go forward. Do any other members have any comments that I would like to make before I put the next question to you? I am not saying that anyone does. As the question is, if the committee is content that the provisions set out in the notification should be included in the proposed UKSI, I am not hearing anyone saying that they should not, but I take on board the comments made by Sondesh Gulhane and Emma Harper. Is there anything else? Are we content that it should be included in the UKSI? If you could just indicate to me by a nod or a shake of the head, we are all nodding. Are we all nodding? Yes, we are. Sorry, I am just looking at some members just to make sure that I have got their consent. Is the committee content to delegate authority to me to sign off a letter to the Scottish Government informing them of our decision today? I am saying that. I would not ordinarily ask for the robust shake of the head, but as Emma just mentioned, norm verbal cues are not very possible on this kind of platform. Thank you very much, colleagues. You have all given me your consent to do that. The fifth item on our agenda is consideration of a negative instrument, and that is the Food Withdrawal of Recognition Miscellaneous Amendments Scotland Regulations 2021. This instrument removes exemptions for certain products. In a number of regulations, it helps to ensure that imported products meet compositional rules for food in Scotland and ensure that Scottish business can maintain access to unfortified flour. The Delegated Powers and Law Reform Committee has considered this instrument and has made no recommendations to us and no motions to null have been received in relation to the instrument. Do any of our members have any comments on the instrument? You do not. Thank you. I propose therefore that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with that? Do you not disagree with that? Thank you very much. We are in agreement on this negative instrument. At our next meeting on 25 January, the committee will take more evidence from stakeholders and part of our inquiry into the health and wellbeing of children and young people, and we will also take evidence on the national planning framework 4. That concludes the public part of our meeting.