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‘No Wrong Door’
This report is about how children and their families who seek support for a range of needs often find that they have to navigate a very complex system, may fall through gaps where there are no services to meet their needs, or be on a waiting list for a long time only to be told that they were waiting in the wrong queue, or have been knocking on the wrong door all along.
The Commissioner and her team believe that services should wrap around families, rather than them having to fit into what is out there, and that help should be provided as early as possible to prevent more serious problems developing.
‘No wrong door’
- The global pandemic has laid bare how stretched mental health and social care is for our most vulnerable children and young people. Our health and care services are predicted to see a significant increase in need over the coming months, and a regional, coordinated, response will be required to ensure that our support offer is sufficient to meet this demand.
- In most areas of Wales, children and young people experiencing distress with mental health, emotional wellbeing and behavioural issues are waiting too long to get the help they need, and are being ‘bounced’ between services who cannot agree who is responsible for their care. We want to see services wrap around children and young people and their families, not for them to have to navigate complicated systems.
- Regions need to move rapidly towards a ‘no wrong door’ approach in responding to children and young people’s emotional wellbeing and mental health needs. This means that they should not keep being told that they are knocking on the wrong door when trying to access help. This could include early help panel or hub models, drop-in centres, models that make sure children and young people get the right help so that they don’t need to go away from home to receive specialist care, or plans for specialist residential care closer to home.
- Children and young people with learning disabilities still too often face a complicated and stressful experience as they move from child to adult services. There are promising signs in some regions, but we have not seen the change ‘on the ground’ that we would like, and encourage all regions to re-visit their plans for this vulnerable group.
- We are encouraged that all regions now have specific multi-agency groups to consider the needs of children and young people, although some of these are very new.
- There have been recent welcome changes to Welsh Government policy, such as earmarking significant funding specifically for children with complex needs, strengthening the duty on regions for children’s participation in their work, and the publishing of a broader definition of children with complex needs so that regions should be providing integrated services for all children in distress.
What needs to improve?
- Welsh Government needs to do more to support regions in achieving ‘transformation’ of services for children and young people with complex needs, for example by working with regions to share learning and support projects, and providing longer term financial support beyond ‘kick-starter’ funding.
- Regions need to work with children and young people, their families, and the adults that care for them to re-shape the way services work. This includes being more accessible and transparent about the work they do.
- Funding and resources need to be seen as ‘whole-region’, not just as the property of local authorities or the local health board.
Here are some recent real life examples that have come to the attention of the Commissioner’s Investigations and Advice team ahead of the original publication date in March 2020:
- A child who has experienced complex trauma and attended A&E multiple times following suicide attempts. Due to the severity of violence towards their parents, police were called out to the property most nights of the week, attending for several hours each time. The child was receiving support from their local social care department, but no therapeutic support. The family were told that Child and Adolescent Mental Health Services (henceforth CAMHS) are unable to help.
- A family believed their child needed a secure placement, as they were a danger to themselves. We were told that social services were trying to source alternative placements and had approached dozens of residential facilities, none of which could accommodate the child. We were told the reasons given were because they did not meet their criteria. The child remained at a mental health in-patient unit, even though professionals agreed it was not an appropriate placement. The child then spent months on a paediatric ward, which was not a suitable setting for their needs.
- A child with a learning disability whose home environment was no longer safe for them to stay at. The child has been placed at several different locations across Wales as services have struggled to deal with the child’s behaviours. At one of these placements there were no therapeutic interventions available and as the child was much younger than others at the placement, the older children bullied them, causing further trauma.
- A child with a life limiting condition and related significant healthcare needs had been receiving health care in one local authority, and then changed foster placement to another Health Board area. The two Health Boards involved were now disputing who has the responsibility for the health needs of this young person as they had reached the age of 18 over the course of the move.
- A child was kept in mental health facility for weeks despite having no mental health diagnosis as there was no alternative provision.
- A child had attempted suicide three times in three weeks. Their parents felt that they would not be able to keep the child safe at home but felt no one listened to their requests. Eventually the child was discharged, without appropriate follow up.
- A child displaying behaviours and difficulties which suggest dyslexia and dyspraxia who has not been in school for over four months due to social and school anxiety issues. They were referred to CAMHS, who said that the young person did not meet the criteria for further support. CAMHS stated that the young person may have Autistic Spectrum Disorder (ASD) traits. The child’s school completed a referral to the neurodevelopmental team. In the meantime, the concerning anxiety behaviours got worse and the family were extremely worried. The local education service has identified an EOTAS provision that would help the child study for their school exams but this cannot be actioned unless the child is actively receiving mental health support through CAMHS. The family asked the GP to re-refer the young person to CAMHS. The child has recently been seen by primary care CAMHS and offered therapeutic support to help with their anxiety. The child is still not in school.
- A child had taken an overdose which resulted in them being admitted to hospital. Since being discharged from hospital, we were told that the child received no support, despite the family being told that the child would be able to access support in the community. The family called the local CAMHS service and were told the child is on the waiting list for an appointment with CAMHS but they were unable to provide a date. The child was also on a waiting list for their school counsellor. The social services department told the family that it is CAMHS’ responsibility to support the child and as a result they did not offer any support.
- A child had been detained under the Mental Health Act and was taken by police to A&E. The child had not been diagnosed with a mental disorder. The child was placed at the hospital on an adult ward and supervised by two agency staff from the mental health unit they had previously been at. The child was unable to return to the unit as they were unable to manage the young person’s behaviour. The child was moved to another hospital, again on an adult ward but this time segregated from the rest of the ward. A multi-agency meeting was arranged to agree next steps. The meeting was attended by 16 professionals, including one from the child’s local CAMHS, the relevant social services department, and one of their lawyers. The meeting was chaired by the Clinical Director for CAMHS in the child’s Health Board. Social Services maintained that they were not able to provide the child with any form of secure accommodation as the young person was about to turn 17, and not subject to a Care Order.
Powys RPB have a sub-group called the ‘Start Well Partnership’ which focuses on children’s issues. Underneath this sub-group sits 5 key work streams: developing a multi-agency early help hub; integrated emotional health and well-being and youth support; placement and adoption; developing resilience; and active and healthy lifestyles. Each work stream has its own action plan to track progress against. There is also a cross-cutting group for issues such as safeguarding advocacy and the Welsh language. These work stream groups meet every 8 weeks and feed up to the Start Well partnership which meets every month; which in turn feeds into every other meeting of the RPB. Work that has been taken forward through the Start Well partnership includes Powys’ Early Identification Partnership meetings in schools, held termly in every high school in the region.
Cwm Taf Morgannwg RPB have made involving children and young people more in their work a priority. The Board’s own strategic priorities have been shaped by working with young people, for example through Youth Forums and individual projects which have taken a coproduction approach to designing services with young people. The Board are now working to develop more long-term arrangements for co-production. For example, the scoring criteria for third sector ICF grants available to projects with a focus on children with complex needs includes the need to develop a co-productive approach to improving children and young people’s mental health and wellbeing. Successful applicants will also need to attend a coproduction workshop.
The next step for the RPB is to hold a workshop with young people, with the RPB Chairperson attending, to develop with young people a longer-term more strategic approach to how they want to be involved in co-production of the Board’s work. Young people did not want to just to come and sit on the region’s sub-group for children or on the board, as they felt this could be tokenistic, and they have told the RPB they want their involvement to be meaningful. The board’s strategic group for children and young people have worked with children and young people, including representatives attending Youth Forums in the region, to come up with a set of priorities, of which the key concerns are around emotional health, wellbeing and mental health. The strategic group will be guided by this priority in their work.
As Cwm Taf Morgannwg is a newly-formed region, they are taking the opportunity to undertake a mapping exercise of the current provision across the region from universal to specialist provision, from conception to age 25. ICF revenue funding has also been identified for developing third sector and community support for children and young people.
Cardiff and Vale RPB undertook a ‘Listening to Families’ exercise in 2018 which asked for both the experiences of people with learning disabilities, and their expectations. These expectations included a proactive not reactive early intervention response, pooled budgets, continuity of staff, to be listened to, streamlined appointments and reviews, suitable environments for children while attending appointments, services meeting their needs, a key worker or lead person, and someone to assist with minor tasks without the need for continuous referrals.
Gwent RPB has developed a model of Single Point of Access for Children’s Emotional Wellbeing and Mental Health (SPACE-Wellbeing) panels. These panels are in place across the 5 local authority areas of Gwent.
The panels meet once per week and take referrals from multiple sources: GPs, schools, social services, but also parents and families. The referrals are taken for children who have complex needs which might include a history of trauma, family issues, mental health disorders, social care needs, and disability.
Attendees at the panel which the Commissioner visited in Monmouthshire (the Monmouthshire Early Help Panel) include representatives from a wide range of services: including social services, primary and specialist mental health services, substance misuse services, the local authority’s sports and leisure service, youth services, school-based counselling service, Building Stronger Families service, third sector mental health provision, learning disability transitions service, young carers organisation, housing services, and youth enterprise services.
In this panel meeting, over 20 children and young people were discussed in the space of 1 ½ hours. All children and young people were given an immediate intervention (or if appropriate a sequence of interventions). These ranged from a simple visit to meet with the young person over a cup of tea and discuss local support options, an offer to join the young carers’ support group, support to join a social or sport activity, bereavement counselling or play therapy to, in a small number of cases, the involvement of specialist CAMHS. The panel aim to take into account the whole of the family’s circumstances where this is available to them and respond to all needs relevant to that young person, as far as they can.
An evaluation of the panels is currently underway, but the board are able to display a reduction in demand to specialist children’s mental health, as a result of children and families being allocated to other more appropriate sources of support through the panels.
A pledge from the Children’s Commissioner, Sally Holland:
“I will meet with all Regional Partnership Boards during the 2021-22 financial year to follow up on this piece of work, specifically to check in on progress against the following recommendations. I will invite young people to also meet with the Boards so that they have the opportunity to scrutinise each Board’s progress.”
Recommendations for Regional Partnership Boards:
- As part of our national response to children and young people’s mental health and well-being needs following this period of lockdown, all Regional Partnership Boards should plan and implement a ‘no wrong door’ approach to mental health and well-being which could include integrated teams, panel and hub models to provide timely joined-up help, drop in centres and plans for integrated residential provision where needed. All Boards should review their current Area Plan to ensure they are taking sufficient action to address the needs of children and young people with complex needs, and that local authorities and local health boards are truly working in partnership towards this. This should include consideration of the Plan in light of the Covid-19 pandemic and how this impacts on the remaining years of the Area Plan, and longer term strategies.
- Regional Partnership Boards must ensure they are compliant with the newly amended Part 9 statutory guidance by:
- Ensuring funding is not seen as ‘held’ by either the health board or the local authority, and that these arrangements are subject to a written agreement between partners. The funds should be owned by the whole region and all services should feel they have an equal stake
- In light of the new statutory requirement for section 12 duties to extend to Regional Partnership Boards, all Boards should review their current arrangements for engagement and coproduction with children and young people. RPBs should use my The Right Way framework for taking a children’s rights approach to working with children and young people to guide their approach, alongside the National Participation Standards. This must include the Board itself hearing directly from children and young people, and for children and young people to be empowered to shape the work of the Board.
- As part of their duty to support effective, integrated transition arrangements from children’s to adult services, Regional Partnership Boards should publish multi-agency transition protocols, if they have not already, for children and young people with learning disabilities, considering how they deliver an approach so that the current multiple and pervasive issues of cross-local authority border and cross-sector disparities in transition arrangements are integrated as far as possible.
- Regional Partnership Boards should work with the Together for Children and Young People Programme (2) to explore how they can better organise and publicise the role and work of the Regional Partnership Boards to make it more accessible to families. This should include accessible descriptions of multi-agency pathways for children with complex needs, as well as those projects which are of direct relevance to children and their families.
- Regional Partnership Boards should work with citizen and third sector representatives who work with children and young people with complex needs to make sure they are sufficiently involved in meaningful work as part of the Board, and feel fully valued as equal partners by the statutory members on it.
- Regional Partnership Boards should develop a memorandum of understanding with Public Services Boards on potential cross-over issues where these related to children and young people, which includes an agreement on how to approach those issues which would benefit from joint working between Regional Partnership Boards and Public Service Boards, such as having arrangements in place for funding applications or joint commissioning.
Recommendations for Welsh Government:
- As the responsible body for the administration of funding for Regional Partnership Boards, Welsh Government need to demonstrate leadership by clarifying their responsibility for the framework within which Regional Partnership Boards operate. Welsh Government should ensure that robust accountability mechanisms are in place for Regional Partnership Boards to report on their work on multi-agency arrangements for children with complex needs, including transitions to adult services. This should include proactively reviewing Regional Partnership Boards’ Area Plans and monitoring progress against their ambitions through Annual Reports and meetings.
- Welsh Government will need to support Regional Partnership Boards with their long term strategies. This support will be needed more than ever because of the current circumstances, and should make clear how Welsh Government will make funding available to achieve better experiences and outcomes for children and their families. This should include system change that will help families experience a ‘no wrong door’ approach in every region such as integrated teams, panel and hub models to provide timely joined-up help, drop in centres and plans for integrated residential provision where needed.
- Welsh Government should amend the Partnership Arrangements and Population Assessments Regulations to require pooled funding for a ‘no wrong door’ approach for children and young people.
- The current Welsh Government review of ‘safe accommodation’ must lead to concrete action being taken to develop new residential provision in Wales for children with complex needs upon reporting.
- Welsh Government and the Together for Children and Young People Programme (2) should work with their partners and with Regional Partnership Boards to organise further shared learning events to focus specifically on a ‘no wrong door’ approach for children and young people with complex needs.
- These shared learning events should include discussions of barriers between services’ use of language (particularly but not confined to health, social care and education) around children with complex needs, in order to promote the new broader definition under the revised Part 9 statutory guidance, as well as being guided by the National Commissioning Board Wales’ definition. The events should also include discussions of the issue of how information is shared and resources are pooled, and whether the current information sharing system needs improvement.