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Making Wales a No Wrong Door Nation: How are we doing?

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In 2019/20, we visited every Regional Partnership Board (RPB) in Wales to find out what they were doing to support children and young people, particularly those with complex needs, in their region.

RPBs bring together health boards, local authorities, and the third sector to meet the care and support needs of people in their area.

We called for every region to adopt a ‘No Wrong Door’ commitment so that children and their families would not get bounced between services or get doors shut in their faces

In June 2020 we published our report on the findings from those visits called No Wrong Door bringing services together to meet children’s needs.

Between July and November 2021, we requested written updates from every RPB on their No Wrong Door plans in relation to that report’s five recommendations, and met again with every RPB in Wales.

Our report analyses the progress Welsh regions are making on multi-agency care for children and young people.

What we found

  • Every RPB has a plan for children’s provision, and has begun to make changes towards a No Wrong Door approach.
  • Every RPB now has a group dedicated to children’s issues, which reports to the main Board.
  • There are some really encouraging examples of taking a No Wrong Door approach which include:
    • Several Boards have improved how children’s mental health professionals support and train up other professionals in places like schools and social care.
    • Several Boards have improved how children’s mental health professionals support and train up other professionals in places like schools and social care.
    • Most Boards have plans to create new places to stay overnight or for a few days if they need it, for children and young people with complex needs, or who are experiencing a mentalnhealth crisis. These will help to avoid children being admitted to hospital, or being placed many miles away from home, when this is not necessary or in their best interests. Some of these plans are advanced and the new provision will begin in 2022.
    • In several regions, children’s mental health crisis teams have extended their operations. In some areas this means they will operate 24/7, which is very welcome, especially given the current difficulties around recruitment of NHS staff.
    • Most Boards have, or will soon have, new systems for supporting children with Learning Disabilities who are making the transition from children’s to adult services.
    • Most Boards have plans for new therapeutic accommodation for young people with complex mental health and social care needs who often have to move a long way from home to be looked after currently. Their start-up costs receive direct funding from Welsh Government and some will open in 2022.
  • Some Boards could tell us how they themselves have worked directly with children and young people, and how they have made information about services more accessible. One Board has a shadow RPB made up of young people, for example.
  • We are pleased with the development of the new NEST / NYTH framework, designed to support RPBs to deliver a ‘whole system approach’ meaning that children and young people get the right support from the right people, first time. The NEST/NYTH framework includes No Wrong Door as one of its key principles. Boards have engaged positively with the new NEST / NYTH framework and all have a plan to work within this framework.

Key barriers holding back a No Wrong Door Wales

Children still told they’ve come to the wrong door

Children and young people are still, every day in Wales, being told they have come to the wrong door when they reach out for support with their mental health, emotional or behavioural needs. We know this from our own case work service and also because RPBs themselves report this.

Continuing Care funding

We continue to have a situation where children with the highest level of need receive a service that does not meet their needs because health and local authorities cannot agree on the placement and the ‘Continuing Care’ funding required. Others face lengthy delays while funding is agreed and this is being discussed in their presence. There is Welsh Government guidance that says agencies must work together where continuing care is needed for children, but it only says that local health boards (LHBs) and local authorities (LAs) may jointly fund the care, which in practice is leading to regular disagreements, which leave children and their families in limbo and without the support that has been assessed to be required. It was striking that every Regional Partnership Board reported that they have not solved this issue. This is completely unacceptable. We think Welsh Government needs to step in and prevent this from happening; current guidance is not having sufficient impact on children’s experiences.

Safe accommodation for children with complex needs

Boards have committed to creating new safe accommodation for children and young people with complex needs. This is very welcome. However, at this stage these are mainly assessment units providing short term support while a further placement is arranged. We think that there may be a need to develop some longer-term provision for those young people who cannot be successful supported to return home or to foster care.

Waiting times

Waiting times for an assessment for a neurodevelopmental condition (for children with suspected Autism, ADHD and other similar conditions) are extremely long, and in the meantime children and their families can receive very little if any support. There are some good plans being developed at a national level on this, but in the meantime plans for improving support within the regions is patchy.

Disjointed service

When children may have both a neurodevelopmental condition and poor mental health they often receive a very disjointed service, despite this being very common.

The RPB’s role

Regions have different views on what the RPB’s role is. They should have oversight over the services in their region and make plans for delivering – making sure different parts of the region learn from other areas’ good practice, and making sure services are joined up to meet complex needs. Some seem to focus more on responding to national funding opportunities than on having a strategic overview, but this is improving in most areas.

Learning from others

Despite shared learning events being organised, members of the RPBs were often unaware of developments in other regions or areas within their own region, which may help them with their own No Wrong Door approach. This included plans for new safe accommodation where some RPBs felt barriers were significant, and would like to learn from others how arrangements have been brokered in their region.

Confidently delivering NEST Framework

Not all RPBs are yet in a position to confidently deliver the NEST / NYTH framework as part of their current operations. They need ongoing support, and to be properly monitored to make sure they are delivering. This needs to be organised by Welsh Government. The extension of the T4CYP programme to September 2022 is a welcome step in this regard.

Recruitment

Clearly there are other systemic issues holding back progress, including the current extreme pressure on services, with the well documented issue over recruitment which is affecting many services acutely.

What we want RPBs and Welsh Government to do now

RPBs

Tangible actions

Turn plans into tangible actions. All of the young people we worked with on this project reflected that they heard too much about plans for the future and not enough about service delivery in the here and now. They shared this feedback with the Deputy Minister and her officials, and we expect Welsh Government to hold RPBs to account on this important point.

Continuing care arrangements

Prioritise Continuing Care arrangements for children and young people as a matter of urgency. Board members and senior leads from local authorities and health boards should participate in a Government organised workshop, as recommended below, to find a reliable and swift method to pool funding between their services to deliver suitable and truly joint multiagency arrangements for children with complex needs efficiently and effectively in the best interests of the child. Any barriers from the current guidance need to be addressed by the Welsh Government in conjunction with the Boards.

Clear strategic plans and  measurable outcomes

Ensure No Wrong Door plans are backed up by clear strategic plans, governance structure, and measurable outcomes which cover early help and prevention, the ‘missing middle’ not reaching the threshold for specialist support, and those children and young people with the most complex needs.

Consider good practice examples

Consider the good practice example on the direct participation with children and young people outlined in our report, and the resources produced by our office, to organise direct engagement and coproduction with children and young people to inform their work.

Track current experiences to test progress

Continually test their progress by tracking current experiences of children and their families who need support and services. We recommend that contemporary case examples of successes and barriers should be presented at every board meeting.

Showcase work to young people

Showcase their work for children and young people in a user friendly way on their websites. We encourage all Boards to review and improve how they advertise the work they do online.

Better advertise plans for transitions

Better advertise plans that are in place for transitions protocols for children with learning disabilities, with suitable accessible resources. Where these regional protocols are not in place yet, they should be prioritised.

Welsh Government

Change funding arrangements

Review their planned response to the Rebalancing Care White Paper in light of this comprehensive update on the progress of RPBs. They should consider in particular the need to create RPBs as ‘legal corporate entities’ (bodies that can receive money directly and decide how it is spent without referring to other organisations for approval), and to mandate funding arrangements for RPBs. This could be either a national funding framework or by mandating pooled funding (requiring partners like health boards and local authorities to pay a proportion of money towards joint projects, rather than just giving them to option to do this). Without a shift in the funding arrangements, the changes still required, as highlighted by this report, remain unlikely to be achieved. This will continue to affect outcomes and experiences for children with complex needs

Strengthen statutory guidance

Strengthen the statutory guidance around the role of citizen, carer and third sector representatives to ensure they are active participants in every region.

Continuing care arrangements

Take the lead on ensuring the service leads in the health board and local authorities in each region produce a comprehensive written agreement in respect of Continuing Care arrangements. This should be supported by bringing together Board members in a workshop attended by senior leads of each relevant service involved in continuing care arrangements to sign up to a written agreement which commits to pooled funding between services to deliver suitable multiagency arrangements for children with complex needs efficiently and effectively in the best interests of the child.

Review and refresh the Continuing Care guidance following these workshops, so the approach is nationally agreed and locally delivered.

Detailed plan to support NEST framework

Provide a detailed plan for how the Welsh Government will support RPBs to deliver a No Wrong Door approach through the NEST / NYTH framework, beyond September 2022. This must include a robust monitoring framework which holds every Board to account, and longer term funding arrangements. 

Joined up approach to neurodevelopmental services

Support and deliver the joined up approach to neurodevelopmental services which recognises the full spectrum of neurodiversity, as developed by T4CYP.

Transitions and Handover guidance

Robustly monitor the implementation of the new Transitions and Handover Guidance for health boards.

Learning Disability transitions to adult services

Ensuring Learning Disability transitions to adult services are monitored and that RPBs report in to Welsh Government on this specific aspect regularly as part of NEST / NYTH implementation.

Shared learning events for RPBs

Continue with regular shared learning events for RPBs, including a focus on good practice examples between regions; as well as actively encouraging the upscaling of good practice within regions.