Children and young people’s mental health

Prepared by Audit Scotland
September 2018

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Key facts

1 in 10 - Children and young people aged five to 16 with a clinically diagnosable mental illness
22 per cent / 5,999 - Increase in the number of referrals received by specialist services since 2013/14
24 per cent / 1,414 - Increase in the number of referrals rejected by specialist services since 2013/14
74.1 per cent / 11,498 - Children and young people referred to specialist services who started treatment within 18 weeks in 2017/18
11 weeks - Average time children and young people waited for their first treatment appointment in 2017/18
£56.6 million - Published spend on children and young people's mental health services in 2016/17
1,014 whole-time equivalent - Child and Adolescent Mental Health Services (CAMHS) staff employed by NHS boards as at 31 March 2018

Summary
a step change is required to improve children and young people's mental health services

Key messages
1.	Children and young people’s mental health and wellbeing is a priority for the Scottish Government. It is central to achieving its ambition for Scotland to be the best place in the world for children to grow up. The Scottish Government’s mental health strategy focuses on early intervention and prevention. However, in practice this is limited, and mental health services for children and young people are largely focused on specialist care and responding to crisis. The system is complex and fragmented, and access to services varies throughout the country. This makes it difficult for children, young people, and their families and carers to get the support they need.
2.	Mental health services for children and young people are under significant pressure. The number of referrals to specialist services increased by 22 per cent, from 27,271 to 33,270, between 2013/14 and 2017/18, with rejected referrals also increasing. Children and young people are waiting longer for treatment, with 26 per cent who started treatment in 2017/18 waiting over 18 weeks, compared to 15 per cent 
in 2013/14. 
3.	Data on mental health services for children and young people is inadequate, with a lack of evidence of what difference existing services are making to children and young people with mental health problems.
It is not possible to track all spending, but available information shows that six per cent of spending on NHS mental health services is on children and young people. Overall, between 2013/14 and 2016/17, published 
NHS spending on children and young people's mental health increased by 11.9 per cent in real terms, from £50.6 million to £56.6 million.
4.	Directing funding towards early intervention and prevention while also meeting the need for specialist and acute services is a major challenge. A step change in the way that the public sector in Scotland responds to the mental health needs of children and young people is required, with integration authorities having a major role to play. Transforming services will only be possible with a clearer view of what works, a plan for how the system needs to change and a move away from reliance on short-term and isolated initiatives.

Recommendations
It is not possible for one organisation to address all the issues raised in this report. To improve support for children and young people with mental health problems in Scotland, a wide range of organisations, both nationally and locally, need to work together with children and young people. 
The Scottish Government should:
•	act on the findings of current reviews and set clear timescales for when recommendations will be implemented. This includes:
	the scoping report into provision of a specialist inpatient Child and Adolescent Mental Health Services (CAMHS) unit for children and young people with learning disabilities and/or autism
	the work on rejected referrals
	the review of personal and social education (PSE), counselling and pastoral support in schools
•	provide more support to NHS boards, councils and integration authorities to help them improve how they meet the needs of children and young people with mental health problems. This includes:
	improving the quality of nationally published financial data to build a comprehensive picture of spending by both councils and the NHS on children and young people’s mental health across the whole system
	building the evidence base on what works, particularly in relation to early intervention and prevention
	providing support to share good practice, including implementation of the newly launched Transition Care Plan
•	develop a long-term financial plan for improving mental health services for children and young people. This should be a strategic plan which improves transparency about how resources are used to support children and young people’s mental health and wellbeing. It should include: 
	the anticipated balance of spending across the whole system of mental health services for children and young people
	a framework to support all partners to prioritise activity and spending on prevention and early intervention, while also meeting the need for acute and specialist services
	modelling of future demand for services against workforce and training plans.
The Scottish Government and Convention of Scottish Local Authorities (COSLA) should:
•	ensure that the newly commissioned task force on children and young people’s mental health, which reports to both the Scottish Government and COSLA, takes account of the recommendations in this report when taking forward its work
•	produce a joint plan for supporting improvement in services for children and young people with mental health problems, to be developed in partnership with all relevant Scottish Government portfolios and with integration authorities. This should include:
	specific actions with clear timescales to show how the system will improve to better meet the needs of children and young people
	a clear framework to measure progress and support improvements in performance.
The Scottish Government, COSLA, NHS boards, councils, integration authorities and their partners should work together to:
•	determine what performance and financial data should be collected and reported publicly, at both a national and local level. This should include measures of quality of care and outcomes for children and young people. This data should be used at a local level by delivery partners to better understand performance and inform decision-making about:
	how to target funding to best meet the needs of children and young people
	the type and level of mental health and wellbeing services required locally
	the size and skills of the workforce
	which interventions have the most positive impact on children and young people
•	routinely monitor the current balance of spending and activity at a local level on children and young people’s mental health and wellbeing services, from prevention and early intervention to specialist services 
•	develop local plans for how the balance of spending and activity will be shifted towards early intervention and prevention over the longer term
•	review alternative models of children and young people’s mental health services, and consider a coordinated approach to piloting alternative models. Any review should ensure a human rights-based approach is followed.
NHS boards, councils, integration authorities and their partners, should work together to:
•	identify and address any gaps in services, in partnership with children and young people, their parents and carers 
•	deliver a clear and coordinated approach to delivering children and young people’s mental health services. This must be easy to navigate for all children and young people, including those who are most vulnerable, to better meet their needs. This includes:
	ensuring there is a clear and measurable process for accessing all levels of service, making sure the referrals criteria and guidance are as clear as possible
	working with GPs, schools and others who may refer a child or young person to mental health services, to make sure that they understand how and when to refer someone
	making clear and accessible information available to children and young people and their parents and carers.

Background
1.	Improving mental health and wellbeing is a major public health challenge. In part, this is because the underlying issues tend to be complex and people’s needs can be different. Evidence suggests that mental health problems in childhood and adolescence have a significant impact on physical health, education and on the ability to find and sustain employment. Globally, mental illness is one of the leading causes of years lived with disability, and the life expectancy of people with serious mental health disorders is ten to 20 years lower than the general population.^,  In 2017, 64 suicides of 15 to 24-year-olds were registered in Scotland. The Scottish Government and the Convention of Scottish Local Authorities (COSLA) have identified mental wellbeing as one of six shared public health priorities for Scotland.
2.	Mental health problems cover a spectrum from wellbeing at one end, through to short-term periods of stress and anxiety which we all may experience during our lives, to severe and persistent diagnosable mental illness. Not all mental health issues require a medical response. All public services have an important role to play in supporting wellbeing and tackling the social and economic factors that contribute to mental health problems, including education, justice and housing. Children and young people can experience a range of mental health problems, including behavioural problems, attention deficit hyperactivity disorder (ADHD), depression, anxiety, eating disorders and self-harm. The most recent UK data, from 2004, estimated that one in ten children and young people aged five to 16 had a clinically diagnosable mental illness. 
3.	Some children and young people are more at risk of experiencing mental health problems than others (Exhibit 1). Poverty is a major contributor to mental ill health. This is a significant issue, between 2014-17, it is estimated that almost one in five children in Scotland were living in relative poverty. Scottish Government projections estimate that this will rise to 38 per cent by 2030/31.^, Adverse childhood experiences (ACEs) and trauma are also now recognised as key risk factors for mental ill health. ACEs are stressful events occurring in childhood, such as physical and emotional abuse and neglect. Those living in areas of higher deprivation are at greater risk of experiencing ACEs. Preventing and mitigating the impact of ACEs is a priority for the Scottish Government.
4.	There is no separate strategy for children and young people’s mental health. This is incorporated within the Scottish Government’s Mental Health Strategy 2017-2027, published in March 2017. The strategy aims to give the same priority to mental health as physical health. It highlights the importance of early intervention and prevention, stating that this should be central to both funding and activity. In relation to children and young people’s mental health, the strategy commits the Scottish Government to look across all four tiers of the current model of care (Exhibit 2), recognising the importance of specialist services but also the importance of intervening early. There is also a commitment to taking a human rights-based approach to improving mental health services.
About the audit 
5.	The aim of our audit was to establish how effectively children and young people’s mental health services are delivered and funded across Scotland. 
We set out to answer three key questions:
•	How effective are the funding and delivery of mental health and wellbeing services across Scotland in meeting the needs of children and young people?
•	What are the main factors supporting and impeding the delivery of children and young people’s mental health and wellbeing services, at both a national and local level?
•	How effectively is the Scottish Government providing strategic direction to support the improvement of outcomes for children and young people’s mental health and wellbeing?
6.	The audit looked across the whole system of children and young people’s mental health and wellbeing services, including services delivered by NHS boards, councils and their partners. The audit also looked at services to intervene early and help prevent mental health problems, such as work in schools to promote resilience and wellbeing. This report sets out many areas which need to be addressed, and highlights examples of organisations working together to redesign and improve services.
7.	This report is in four parts:
•	Part 1 considers how children and young people access mental health services
•	Part 2 examines the effectiveness of current services 
•	Part 3 considers the resources available
•	Part 4 outlines the policy and strategic direction.
8.	Our findings are based on reviewing documents, analysing performance and financial information, and interviews and focus groups. Appendix 1 summarises our audit methodology. Appendix 2 lists the members of our advisory group who provided help and advice throughout the audit.

Part 1
Accessing support
access to children and young people's mental health services varies across Scotland

The current system is complex and fragmented, making it difficult for children and young people to get the support they need
9.	Most children and young people’s mental health services are delivered through a four-tiered model of care, from early intervention and prevention through to more specialist support (Exhibit 2). Since this model was introduced, in 1995, the policy context and the way that services are delivered has changed, for example the introduction of Getting it Right for Every Child (GIRFEC) and health and social care integration. 
10.	Services are delivered by NHS boards, councils, the voluntary sector and the private sector. Many professionals are involved in delivering mental health services, but they are not all mental health specialists. Children and young people can seek help through a number of different routes, for example through their GP, school or social work services.
11.	Because services at different tiers are funded and provided by different organisations, this can lead to a lack of oversight of the whole system, and create boundaries between services to intervene early and specialist child and adolescent mental health services (CAMHS). This can mean that children and young people get bounced between services and professionals, adding to their anxiety, before they are able to access appropriate help. 
“It would be good if there was some explanation of what the service is about. Even just a picture so I can get an idea of what it will be like. It’s just an extra thing to get anxious about.”
Service user	
Children and young people experience a range of barriers to accessing mental health services 
Services to prevent and intervene early are patchy across Scotland
12.	Most tier one and two services, such as school counselling and primary mental health workers, are funded or provided by councils, integration authorities and the voluntary sector. The availability of these services varies between and within council areas, depending on local need and whether children and young people’s mental health and wellbeing services are recognised as a local priority. These decisions are being made in the overall context of financial challenges in the public sector alongside increasing demand. Support for mental health and wellbeing within schools also varies. It also depends on the allocation of additional funding streams, such as the Pupil Equity Fund, which is allocated directly to schools, and the Scottish Attainment Challenge Fund.
13.	Across the country, tier one and two services are not consistently available. While it is important that local areas have the flexibility to respond to local need, the level of variation raises questions about equity of access to services in different parts of Scotland. 
14.	Without a clear picture of what tier one and two services are available in local areas, it is difficult to identify where the gaps are. The full extent of demand for these services across Scotland is also unknown. This makes it difficult for local areas to plan and commission tier one and two services and to know what workforce they need. In Grampian, a multi-agency working group has looked at what tier one and two services are available, to identify gaps and areas for improving how services are delivered (Case study 1).

Case study 1
Grampian mapping exercise	
From November to December 2017, the Grampian Child and Adolescent Mental Wellbeing Working Group commissioned a mapping exercise to understand how services are delivered across tiers one and two in the health and social care partnerships within the board area.
The mapping exercise identified how these services were being delivered as well as highlighting areas of existing good practice, including:
•	initial assessment of mental health needs carried out by school nurses
•	the use of mindfulness groups in some schools
•	mental health training as commonplace for school staff and staff across agencies.
It also highlighted gaps which partners needed to address, including:
•	a need for equity in how tier one and two services are delivered across Grampian 
•	a need to increase the capacity of workers 
•	a gap in tier two services in some areas.
A multi-agency development session was held in April 2018 to identify and agree actions, including a review and refresh of the NHS Grampian CAMHS tiered model of service delivery, particularly for tiers one and two. The overall aim of the project is to improve multi-agency understanding, information sharing and consistency in the way children and young people are referred to local services.
Source: Audit Scotland

15.	A wide range of voluntary and private sector organisations provide mental health services for children and young people. These range from mental health promotion to support for those with severe and persistent mental health problems. Voluntary organisations often depend on short-term project-based funding, which makes it difficult to plan and sustain services. Young people do not always know where to go for support. A Scottish Youth Parliament survey found that:
•	74 per cent of respondents did not know what mental health information, support and services are available in their area
•	18 per cent of those who consider themselves to have experienced a mental health problem have never accessed services. 
16.	The survey also found that the stigma around mental health issues prevents children and young people from talking about their problems and seeking support and advice. Concerns about confidentiality, and fears that they will not be taken seriously, were also identified as barriers.
Criteria for accessing specialist services vary across Scotland 
17.	Children and young people with more severe and persistent mental health problems can be referred to specialist CAMHS. Thresholds for access to specialist care are high. To be accepted by specialist services, children and young people must be experiencing problems which seriously impair their day-to-day functioning, or be at risk of causing serious harm to themselves or others. 
18.	The referral criteria to CAMHS vary by NHS board (Appendix 3). For example, in some NHS boards, CAMHS are available to children and young people up to the age of 18; in others, CAMHS are only available to those over 16 if they are in full-time education. 
19.	The route to getting the help that children and young people need is not always as clear or as easy to understand as it should be. The Scottish Government’s CAMHS referral criteria guidance, from 2009, does not provide detailed information on who can make a referral. It only states that referrals ‘may be made by a person, team, service or organisation on behalf of a patient/client, or a patient/client may refer him/herself’. In practice, most NHS boards do not accept referrals directly from the young person or their parents or carers. According to the children and young people we spoke to, a referral to CAMHS should be made by someone they trust and feel comfortable speaking to.
“The GP told me that my guidance teacher should refer me to CAMHS but I didn’t like my guidance teacher and I had to speak to him a few times before he referred me.”
Service user	
Access to specialist support for vulnerable groups is limited 
20.	The need to improve models of service delivery for children and young people with learning disabilities and/or autism was recognised in both the current and the previous mental health strategies. In November 2017, the Scottish Government published a report which recommended that better community mental health services need to be developed for this group, alongside the creation of a national learning disability inpatient unit. The report found that between 2010 and 2014, at least 45 children and young people with a learning disability required specialist inpatient mental health care which is not available in Scotland. Receiving inpatient care far from home can place an additional burden on children, young people and their families. 
21.	The Scottish Government’s strategy for looked-after children notes the difficulties experienced by looked after children trying to access mental health services. Looked-after children may have experienced multiple adverse childhood experiences (ACEs). This can lead to a range of mental health difficulties, but they may not meet the threshold for access to specialist CAMHS. However, there is a lack of data on the numbers of looked-after children and young people accessing CAMHS.
The referrals process makes it too easy for children and young people to drop out of the system
22.	It is difficult for children and young people, their parents and carers, 
and professionals to understand how the referrals process works. Exhibit 3 shows an example of the CAMHS referral process, and highlights the points at which children and young people who are referred to specialist CAMHS can drop out of the system. For example, if their referral is rejected, or if it is accepted but they do not opt in to services, there is no routine monitoring of what then happens to them. That means it is not clear whether they are able to access alternative services, or whether they are referred to specialist CAMHS again at a later date. 
“I was sent a letter asking me to phone the hospital to say I wanted my appointment. I couldn’t manage to do this so I lost my referral.”
Service user	
23.	When referrals to specialist CAMHS are rejected, the CAMHS team may suggest alternative sources of support. Stakeholders have highlighted a reluctance on the part of some CAMHS professionals and GPs to signpost young people to voluntary sector services. This may be due to a lack of awareness of what is available. This can leave children and young people without support and unclear about what options might be available to them. The transition from child and adolescent to adult services is also widely recognised as an area where young people’s needs are not being met. Young people can too easily drop out of the system if services do not work together to support them while moving into adult services. The Scottish Youth Parliament has worked with young people to produce a transition care plan, launched in August 2018. This is designed to be used by young people and clinicians to improve the transition to adult services.
“You can end up back at square one when you move to adult services.”
Service user	

Part 2
Effectiveness of support for children and young people
Demand is rising and children and young people are waiting longer for treatment
Demand for specialist mental health services is increasing
24.	Between 2013/14 and 2017/18, the number of referrals to CAMHS in Scotland increased by 22 per cent, from 27,271 to 33,270 (Exhibit 4). All NHS boards, except NHS Shetland, received more referrals in 2017/18 than in 2013/14. The increase in referrals may reflect increasing awareness of mental health issues and a decline in stigma.
25.	Referrals may be rejected for various reasons including:
•	the child or young person does not meet the criteria for treatment. This can indicate a lack of understanding, clarity, or both, among referrers about whether a child or young person meets the criteria for specialist CAMHS 
•	a lack of tier one and two services for children and young people experiencing less severe mental health problems, meaning that referrers have limited alternative options
•	the referral does not contain enough information.
26.	National data on reasons for referral and rejection is not collected, making it difficult to understand the nature of demand for specialist CAMHS. Collecting this data would help to assess the level of referrals that are not suitable for CAMHS and indicate the number of children and young people who would benefit from lower level support and services. Locally, organisations need to work together to understand demand and ensure tier one and two services are available to meet the needs of those children and young people who do not need specialist CAMHS.
Children and young people are waiting longer for treatment
27.	Between 2013/14 and 2017/18, the average wait for a first treatment appointment increased from seven to 11 weeks. There is wide variation between NHS boards in the average time that children and young people wait for their first treatment appointment (Exhibit 5). 
28.	There is no clear link between the number of children and young people who have had a first treatment appointment and the average length of time they had to wait. There may be many reasons affecting how long a child or young person waits for treatment including:
•	the capacity of the team
•	the number of children and young people who need urgent treatment
•	the level of detail provided by the referrer.
29.	At the end of March 2018, 8,145 children and young people were waiting for treatment, up from 7,116 in March 2014. While children and young people are waiting for treatment, they may receive little or no support or advice. This means that their condition may deteriorate. Having appropriate support services in place is especially important in areas where there are longer than average waiting times. 
“GPs and teachers don’t always know what support to offer while you’re waiting for treatment.”
Service user	
Some NHS boards are struggling to meet the 18-week waiting time standard
30.	The Scottish Government’s standard is that at least 90 per cent of children and young people should receive treatment within 18 weeks of being referred to specialist CAMHS. The waiting time standard has not been met nationally since it was introduced in December 2014. In 2013/14, 15 per cent (2,182 children and young people) waited over 18 weeks, compared to 26 per cent (4,012) in 2017/18. There is also significant variation in performance against the standard between NHS boards (Exhibit 6).
“18 weeks is far too long for a child or young person to wait to receive treatment. That’s a whole school term.”
NHS manager	
31.	The performance of some boards has fluctuated. This may reflect a number of factors, including:
•	workforce capacity, for example if boards have struggled to fill vacancies 
•	changes to the referrals process, for example whether children and young people are offered an initial assessment appointment before the first treatment appointment
•	issues with data collection, for example migrating to new patient management systems.
32.	NHS Ayrshire and Arran improved performance between 2013/14 and 2015/16, and continued to meet the 18-week standard in 2016/17 and 2017/18. During this period, the number of children and young people starting treatment almost doubled, from 668 to 1,311 (Case study 2).

Case study 2
Ayrshire and Arran whole systems approach	
NHS Ayrshire and Arran is redesigning its CAMHS delivery to move towards a whole systems approach focused on the needs of children and young people. The approach involves:
•	improving routine data collection and making better use of the data to understand the challenges facing the system 
•	multi-agency collaboration 
•	more involvement of service users
•	implementing small-scale tests of change.
The new approach involves a range of pilot projects including:
•	Development of a multi-agency neurodevelopmental pathway to improve the assessment process for children, young people, and their families and carers. The pathway has now been rolled out across Ayrshire and Arran. 
•	Two teachers were seconded to the North Ayrshire CAMHS team to strengthen links between CAMHS and education staff and improve understanding of the referral process and the quality of referrals. 
•	Two CAMHS nurses have been co-located in Marr College, where they provide assessment and treatment to children and young people from the school and the cluster primary schools. This has improved engagement between the CAMHS team and school staff and families, leading to quicker assessments.
The challenge facing Ayrshire and Arran is in how to scale up successful projects, and to sustain improvements in the longer term, particularly those funded with non-recurrent funding.
Source: Audit Scotland

33.	Scottish Government guidance states that the clock stops when the patient starts treatment, but NHS boards interpret the standard in different ways. The distinction between assessment and treatment is not always clear for specialist mental health services, as assessment appointments ometimes include an element of treatment. Some of the variation in performance may also reflect issues with data quality or differences in referral thresholds (Appendix 3). Data is not collected nationally on waiting times for subsequent assessment or treatment following the initial treatment appointment. 
Data on performance and outcomes is limited
34.	Scrutiny of children and young people’s mental health services has focused on the waiting times for specialist CAMHS. Nationally, some wider performance data is published as part of the CAMHS balanced scorecard. The balanced scorecard was developed in 2008 to provide a core set of key performance indicators for all boards to use. It includes data on referrals, did not attend (DNA) rates, inpatient admissions and the community CAMHS workforce. The scorecard focuses on inputs and outputs rather than outcomes for children and young people, and provides limited information about the quality of services.
“Compliance with the [waiting times] target has become a huge focus. It’s been useful in focusing attention on how to do things differently, but once you’ve met the target I would question whether it is actually a good measure of success or progress.”
NHS manager	
35.	It is not possible to assess at a national level the outcomes for children and young people who access mental health services. Individual NHS boards may measure outcomes at a local level. NHS Greater Glasgow and Clyde, for example, has used a range of measures promoted by the Child Outcomes Research Consortium (CORC) to report quarterly on outcomes for children and young people accessing CAMHS since 2014. 
36.	The Scottish Government is developing quality indicators for mental health services. These will include measures across six quality dimensions: person-centred, safe, effective, efficient, equitable and timely. It is likely that NHS boards will be able to select which indicators they will report on, making national benchmarking difficult. There is no confirmed timescale for this work.
37.	Not all services and organisations have electronic systems which are fit for purpose so they can improve efficiency, share information and collect data on performance and outcomes. NHS Greater Glasgow and Clyde implemented an electronic record system shared across community children’s services in 2013/14. This system has helped to:
•	make information sharing easier and timelier between community children’s services as they all use and maintain a single record of an individual’s care history
•	make allocating appointments quicker and more efficient
•	make it easier for the NHS board and CAMHS teams to assess demand and capacity
•	identify areas for improvement. For example, analysing non-attendance at first CAMHS appointments by postcode to assess whether there is a link to deprivation.
ore needs to be done to understand how children and young people use unplanned and emergency care for mental health reasons
38.	Analysing pathways through mental health services demonstrates the different ways in which children and young people receive support. This can indicate where there are opportunities to intervene earlier to prevent a person’s condition worsening and avoid more intensive or emergency care. Data from 
one health and social care partnership shows that in 2015/16 to 2016/17, 
131 children and young people attended A&E on 297 occasions for mental health reasons, before attending outpatient CAMHS (Exhibit 7). Some of these attendances at A&E follow a call to NHS24 or a GP out-of-hours service. Data is not available on these individuals' use of in-house GP services. The use of emergency and unplanned care for mental health problems suggests that these children and young people are not getting appropriate mental health care and treatment until they reach crisis point. 
Continuity of care is at risk if organisations do not work together effectively
39.	Effective multi-agency working between specialist CAMHS, primary care, social work, schools and the voluntary sector is vital to ensuring that children and young people receive the right support at the right time. Young people told us about the importance of being able to build a relationship with a trusted person. Having some choice in who provides treatment is important so that a young person feels comfortable with those providing care. Young people also found it very frustrating repeating their histories to multiple professionals. 
“I feel I am always repeating my life story every time I meet a new doctor, which is difficult.”
Service user	
40.	In the Highland Council, the tier two primary mental health worker service works closely with NHS Highland CAMHS to help direct children and young people to the most appropriate source of support (Case study 3).

Case study 3
The Highland Council’s primary mental health worker service	
The Highland Council provides a tier two Primary Mental Health 
Worker (PMHW) service. NHS Highland has commissioned the service and the council has managed it since April 2012. PMHWs provide therapeutic support to children, young people and their parents/carers. They also provide consultation and training to professionals from universal services, including teachers and GPs. During 2016/17, they carried out 2,868 consultations, helping to build the capacity of staff to identify children and young people in need of support. 
The PMHW service consists of 11.2 whole-time members of staff 
(9.2 WTE funded by NHS Highland and a further two WTE funded by the Highland Council to focus on early years interventions).
The service has developed a triage process and the PMHW manager attends triage meetings with the tier three team twice a week. Where appropriate, children and young people can be ‘stepped up’ to tier three or ‘stepped down’ to tier two without losing their place on the waiting list. 
In 2016/17, mental health support was provided to 354 children and young people, with 70 per cent seen within six weeks of a service being requested. Assessment questionnaires showed that the children and young people seen between July 2016 and June 2017 showed significant improvements in their conditions.
Parent and pupil questionnaires in 2015/16 found that 78 per cent of young people and 95 per cent of parents felt that support from the PMHW ‘mostly’ or ‘completely’ helped improve their situation.
Source: Audit Scotland

Part 3
Resources
it is not clear how much is spent on children and young people's mental health

Mental health funding has primarily been used for specialist services
41.	The Scottish Government committed to spending more than £1 billion on all mental health services in 2017/18. It is unclear how much of this funding will be spent on children and young people’s mental health and wellbeing services.
42.	In December 2015, the Scottish Government announced £150 million additional funding over five years, up to 2019/20, to improve mental health services. In December 2016, the Scottish Government made a further commitment to spend £150 million over the five-year period 2017/18 to 2021/22, effectively extending its commitment to provide improvement funding by two years. These funding commitments include:
•	£10 million over two years to support new ways of improving mental health support in primary care 
•	£15 million over three years for the mental health innovation fund, which includes an allocation to all NHS boards to support increased access to CAMHS and develop new and innovative approaches to treatment
•	£4.8 million over four years to fund the MHAIST (Mental Health Access Improvement Support Team) programme, designed to improve access to CAMHS and psychological therapies
•	funding for the NHS Education for Scotland mental health programme, which is designed to enhance the supply and training of the CAMHS and psychological therapies workforce (£6.1 million in 2017/18).
43.	In December 2017, the Scottish Government announced a further £17 million of separate funding; £12 million to increase the mental health workforce and 
£5 million specifically to support CAMHS transformational change. On 
4 September 2018, the Scottish Government announced an investment of
£250 million for mental health services. This will include recruiting an additional 250 school nurses by 2020/22 expanding the availability of mental health first aid training for teachers, and developing community wellbeing services for 5 to 25-year-olds. 
44.	Some boards have chosen to focus additional funding on specialist CAMHS. For example:
•	NHS Lothian is using £0.5 million of innovation funding and £1.2 million of capacity building funding to fund temporary clinical posts to address the longest waits for specialist CAMHS between 2016/17 and 2019/20. The board has identified additional staffing as the improvement measure that will have the greatest impact on waiting times.
•	In NHS Ayrshire and Arran, innovation funding has been used to fund an additional two nursing posts for an intensive support team. The team was established to help reduce admissions to inpatient units by increasing community support for young people with acute needs.
It is not clear how improvements to service delivery through the use of non-recurrent funding will be sustained.
Poor data means it is not possible to identify total spending on CAMHS 
45.	The Scottish Government allocated £11.2 billion to the 14 territorial NHS boards in 2016/17. A summary of NHS spending is published annually by the Information Services Division (ISD) of National Services Scotland with support from the Scottish Government's health finance division. It is not possible to 
track all spending, but based on the spending summary, NHS boards spent £936.6 million on mental health in 2016/17. Available data on children and young people’s mental health shows that, between 2013/14 and 2016/17, spending increased by 11.9 per cent, in real terms, from £50.6 million to £56.6 million. Over this period, spending increased year on year, until a slight reduction of 0.6 per cent between 2015/16 and 2016/17.
46.	Children and young people’s mental health services represent a small proportion (six per cent in 2016/17) of mental health expenditure (Exhibit 8). Spending on CAMHS varies by NHS board but the summary does not capture all aspects of NHS CAMHS expenditure (Exhibit 9).
It is not possible to identify how much councils spend on children and young people’s mental health and wellbeing
47.	Council spending on children and young people’s mental health and wellbeing services is spread across education, children and families, and social work, and cannot be easily identified within budgets. Council spending includes, for example, counsellors and educational psychologists in schools. 
48.	NHS boards, councils and integration authorities need to better understand the balance of spending between different types of children’s services to identify where spending can be shifted towards early intervention initiatives. The Scottish Government is working with Community Planning Partnerships (CPPs) on the Realigning Children’s Services (RCS) programme, which is designed to support local improvement in the way children’s services are commissioned. It has been running since 2015, and includes:
•	improving sharing of data between different agencies
•	supporting CPPs to understand the availability of children’s services and the cost attached to these services, including early intervention and prevention
•	supporting CPPs to improve joint working and more effective commissioning of children’s services. 
49.	This programme has the potential to improve multi-agency working, but it is difficult to assess its impact so far. The Centre for Excellence for Looked After Children in Scotland (CELCIS) has been commissioned to carry out an evaluation of the RCS programme, which is due to be published in autumn 2018. 
There has been an increase in the specialist CAMHS workforce
50.	Nationally published workforce data focuses on NHS CAMHS employees. The specialist CAMHS workforce increased by 11 per cent between 31 March 2014 and 31 March 2018, from 917.5 to 1,014.4 WTE (Exhibit 10). Nursing and psychology make up 67 per cent of the workforce, as at March 2018. 
51.	Over the last ten years, CAMHS staff across all clinical groups aged 50 or over increased from 15 per cent to 24 per cent of the total workforce. Long-term workforce plans are required to ensure that the right size of workforce, with an appropriate skills mix, is in place to deliver services effectively.
More mental health training is needed for those who work with children and young people 
52.	Non-mental health specialists, such as teachers, school nurses, GPs and voluntary sector organisations, play a key role in supporting children and young people’s mental health and wellbeing. 
53.	A Scottish Association of Mental Health (SAMH) survey of over 3,000 school staff, including teachers, class room assistants and administrative staff, in 2017 found that:
•	66 per cent of teachers felt they did not have enough training in mental health for them to carry out their role properly
•	63 per cent of teachers said that mental health and wellbeing was not part of their initial training
•	45 per cent of teachers had never undertaken any training on mental health after qualification.
54.	Building the knowledge and skills of the full range of professionals who work with children and families is essential to increasing the capacity of the whole system to meet the needs of children and young people. However, they may need additional training and skills to be able to:
•	help build resilience and emotional wellbeing
•	identify mental health problems
•	intervene early to prevent problems worsening
•	refer children and young people to other appropriate services.
55.	The City of Edinburgh Council has developed a range of training courses for teachers, parents and carers to build skills and knowledge in promoting positive mental health (Case study 4).
Case study 4
The City of Edinburgh Council – Growing Confidence	
In response to a demand for training and improving the skills of teachers, parents and carers to promote positive mental health and wellbeing in pupils, the City of Edinburgh Council has developed a range of courses and materials. These consist of:
•	training and support for staff at all levels
•	resources for building resilience in primary school pupils
•	training for guidance and pupil support staff to deliver a Personal and Social Education (PSE) programme for S1/S2 classes on emotional wellbeing. This has also been delivered as a peer education programme where S5/S6 classes deliver to younger pupils
•	support for parents and carers through universal training courses.
Since 2008, 161 courses have been delivered to over 2,000 multi-agency staff. Ninety-eight per cent of participants report feeling much more confident to support the development of emotional wellbeing in children and young people that they work with including:
•	greater awareness of the reasons behind the behaviour (73 per cent)
•	more patient when listening and talking to children and young people (70 per cent)
•	85 per cent of participants reported the course had a positive effect on a personal level and were doing more to support their own emotional health and wellbeing.
The training and programmes are also being rolled out in Borders, East Lothian, Midlothian and West Lothian councils.
Source: Audit Scotland

56.	The Mental Health Strategy commits to reviewing PSE, counselling and pastoral support in schools, which is due to be completed by the end of 2018. The second stage of this work is a review of the delivery of PSE in schools carried out by Education Scotland. This will include looking at the availability and delivery of mental health promotion and counselling services in schools.
57.	In April 2018, the Chief Nursing Officer published a report on the revised role of school nurses. The school nurse role will now focus on ten priority areas, one of which is mental health and wellbeing. An evaluation of the early adoption of the refocused role in NHS Dumfries and Galloway and NHS Tayside found that additional training on mental health and wellbeing was required to enable school nurses to fulfil the new role. 
Part 4
Policy and strategic direction
organisations need to work together to bring about change

It is not clear how the Scottish Government’s mental health strategy will improve outcomes for children and young people
58.	The Scottish Government’s Mental Health Strategy 2017-2027 covers children and young people as well as adults. It identifies several areas where more work is needed to understand how the current system is working and what needs to change. The strategy contains 40 actions, 15 of which specifically relate to children and young people, but in some cases, these actions lack detail. For example, the strategy identifies the need for a multi-agency, whole system approach for the planning and delivery of all CAMHS, but it is not clear how and by when this will be done.
59.	The Mental Health Strategy includes an action to commission an audit of CAMHS rejected referrals, and to act upon its findings. SAMH and ISD carried out this work. A report was published in June 2018, and makes 29 recommendations for the Scottish Government, NHS boards and integration authorities, including recommendations on the need to improve the collection and publication of data on referrals. The Cabinet Secretary for Health and Sport accepted the recommendations in the report and announced an initial £5 million funding to reshape children and young people’s mental health services. This change will be led by a new task force, which will report to both Scottish Government and COSLA. 
60.	The strategy was initially intended to be produced jointly with COSLA, but COSLA did not endorse the strategy. Despite these initial difficulties, the Scottish Government and COSLA have agreed to work together, through their joint political leadership of health and social care integration, to support implementation of the strategy.
61.	An annual report on the strategy is due to be submitted to the Scottish Parliament’s Health and Sport Committee later in 2018 and a full progress review is due to be carried out in 2022. The strategy does not specify how outcomes will be measured, but the Scottish Government commits to developing a framework to ensure that data is fit for purpose. No timescale is specified for this. Without this it will be difficult to establish a baseline against which to measure progress.
Children and young people’s wellbeing is central to several Scottish Government policies
62.	Since the publication of the Christie Commission report on public service reform in 2011, the Scottish Government has identified preventative spending as a policy priority. This aims to better support people by shifting public spending to tackling problems before they arise. However, in many areas the public sector has found it difficult to do this while responding to more urgent and acute needs. It can be difficult to define what constitutes early intervention and prevention. Measuring the impact of early intervention and prevention services is also challenging, as improvements may not be evident in the short term. Where there are improvements they may not be easily attributable to preventative spending.
63.	Several key Scottish Government policies focus on the importance of prevention and on giving children the best start in life and enabling them to achieve their full potential. The Scottish Government also published its Suicide Prevention Action Plan in August 2018. This includes a commitment to consider the needs of children and young people in relation to all the actions. The different policy areas involved need to work together to take a coordinated approach to children and young people’s mental health and wellbeing. This should cover the full spectrum of need and make the connections between perinatal and maternal mental health, early years policy and children and young people’s mental health (Exhibit 11).
A step change is required in the way the public sector responds to the mental health needs of children and young people
64.	The current system is struggling to meet the needs of children and young people. The actions in the mental health strategy relating to children and young people focus on understanding the way the system works currently and its challenges, rather than meeting the needs of children and young people. The scale of the challenge means that the Scottish Government and COSLA need to be more ambitious and to review the system as a whole if it is to better meet demand and function in a more integrated and effective way. 
Effective leadership is needed both nationally and locally to provide a framework for change 
65.	If support for children and young people is to improve, the Scottish Government and COSLA need to support and empower councils, integration authorities, NHS boards and other partners to work collaboratively to change the way services are delivered. A major challenge in shifting spending on health and social care towards prevention is that money is locked into acute care and hospital provision. As highlighted in previous Audit Scotland reports, there can also be challenges in collaborative working and difficulties caused by perceptions about budgets belonging to organisations such as councils or NHS boards.
66.	To achieve the step change required the Scottish Government needs to work with COSLA, NHS boards, councils and integration authorities to set a clear framework for how the high-level priorities set out in the Mental Health Strategy will be achieved in practice by the organisations delivering services.
67.	 With the NHS and councils facing increasing financial pressures, and struggling to meet demand for reactive and crisis services, there is a need to consider how to deliver services differently. The Scottish Government could support this by reviewing alternative models of services delivery, such as the Thrive model currently being piloted in nine sites in England, and, where appropriate, working with local areas to pilot tests of change. 
68.	At a local level, health and social care integration has the potential to encourage a more coordinated approach to the planning of, and expenditure on, all mental health and wellbeing services for children and young people. However, this is only the case where children’s health and social care services are delegated to the integration authority. In 11 of the 31 integration authorities both children’s health and social care services are delegated. In a further eight only children’s health services are delegated. In 12 integration authorities children’s health and social care services remain the responsibility of the NHS boards and councils.
69.	Stakeholders have differing views about where specialist CAMHS is best placed. Some have highlighted the potential for a more integrated approach if they are managed within children’s services. Regardless of where specialist services are managed, effective partnership working between service areas and organisations is crucial to ensuring that children and young people’s individual needs are met and that the best outcome for them is achieved.
Local mental health and wellbeing strategies focus on adults 
70.	Some local mental health strategies, such as Fife Health and Social Care Partnership’s, cover all mental health services. Other areas' strategies, such as Angus Council's, focus solely on adult services. While a strategy does not in itself ensure that organisations prioritise children and young people’s mental health, the absence of any kind of mental health strategy may indicate that the mental health of children and young people is not always considered a local priority.
71.	Aberdeenshire Council has a mental health and wellbeing strategy specifically for children and young people (Case study 5). It is too early to see the impact of the strategy, and NHS Grampian continues to struggle to meet the 18-week waiting time standard. However, the strategy focuses on taking a child-centred approach to addressing children and young people’s mental health and wellbeing, and puts an organisational structure in place which encourages more effective partnership working.
Children’s services plans and other local strategies should have a stronger focus on children and young people’s mental health and wellbeing
72.	Under the Children and Young People (Scotland) Act 2014, all councils and their partner NHS boards are required to produce three-year children’s services plans. Statutory guidance states that these should plan for the provision of children’s services to support children at the earliest appropriate time, to prevent needs arising.
73.	Almost all children’s services plans refer to children’s mental health and wellbeing as a strategic priority, but with varying levels of detail, from brief mentions in some plans to specific mental health and wellbeing outcomes and actions in others. Whether local priorities for children and young people’s mental health and wellbeing services are set out in children’s services plans or mental health strategies, it is important that strategic planning of services takes place. This should involve all delivery partners and reflect an assessment of local need. 
74.	The Scottish Government has begun a six-month programme of engagement with CPPs which will focus on children’s services plans. This aims to identify the challenges faced by local areas in delivering children’s services, so that Scottish Government support can be better targeted.
Endnotes
1.	The global burden of mental, neurological and substance use disorders: An analysis from the Global Burden of Disease Study 2010, H. Whiteford et al., PLoS One. 2015; 10(2): e0116820.
2.	Risks of all-cause and suicide mortality in mental disorders: a meta-review, E. Chesney, G.M. Goodwin and S. Fazel, 
World Psychiatry, 2014 (13): 153–160.
3.	Suicide deaths registered in Scotland: Scotland overview 2017, ISD prepared on behalf of ScotPHO, 2018.
4.	Public Health Priorities for Scotland, Scottish Government and COSLA, 2018.
5.	Mental health of children and young people in Great Britain, 2004, Office of National Statistics, 2004.
6.	Poverty & Income Inequality in Scotland: 2014-17, Scottish Government, 2018.
7.	Tackling Child Poverty Delivery Plan – Forecasting Child Poverty in Scotland, Scottish Government, 2018.
8.	Polishing the Diamonds: Addressing adverse childhood experiences in Scotland, Scottish Public Health Network, 2016.
9.	Mental Health Strategy: 2017-2027, Scottish Government, 2017.
10.	This model was developed following a 1995 NHS review. Together We Stand: Commissioning, Role and Management of Child and Adolescent Mental Health Services, NHS Health Advisory Service, 1995.
11.	Our generation’s epidemic: Young people’s awareness and experience of mental health information, support and services, Scottish Youth Parliament, 2016.
12.	5 Year Survey of Need for Mental Health Inpatient Care for Children and Young People in Scotland with Learning Disability 
and/or Autism, Scottish Government, 2017.
13.	Getting It Right For Looked After Children And Young People Strategy, Scottish Government, 2015.
14.	Scotland's Budget: Draft Budget 2017-18, December 2016.
15.	Ibid.
16.	Scotland's Budget: Draft Budget 2018-19, December 2017.
17.	NHS in Scotland 2017 , Audit Scotland, 2017.
18.	The CPPs involved in the programme are Clackmannanshire, Dumfries and Galloway, Falkirk, Moray, North Lanarkshire, South Ayrshire, South Lanarkshire and West Lothian.
19.	Going to be well trained, SAMH, 2017.
20.	Paper 4, The school nursing role in integrated community nursing teams, Scottish Government, 2017.
21.	A Realist Evaluation of the Refocused School Nurse Role within Early Adopter Sites in Scotland: Main Report, Scottish Government, 2017.
22.	Mental Health Strategy: 2017-2027, Scottish Government, 2017.
23.	Rejected Referrals to Child and Adolescent Mental Health Services (CAMHS): A Qualitative and Quantitative Audit, Scottish Government, 2018.
24.	Commission on the Future Delivery of Public Services, Scottish Government, 2011.
25.	Scotland's Suicide Prevention Action Plan: Every Life Matters, Scottish Government, 2018.
26.	Health and social care integration , Audit Scotland, 2015; Changing models in health and social care , Audit Scotland. 2015.
27.	Statutory Guidance on Part 3 (Children's Services Planning) of the Children and Young People (Scotland) Act 2014, Scottish Government, 2016.

Appendix 1
Audit methodology
Our objective: How effectively are children and young people’s mental health services delivered and funded in Scotland?
Our audit questions:
•	How effective are the funding and delivery of mental health and wellbeing services across Scotland in meeting the needs of children and young people?
•	What are the main factors supporting and impeding the delivery of children and young people’s mental health and wellbeing services, at both a national and local level?
•	How effectively is the Scottish Government providing strategic direction to support the improvement of outcomes for children and young people’s mental health and wellbeing?
Our methodology:
•	Interviews, focus groups and analysis of documents in three case study areas – Ayrshire and Arran, Lothian and Grampian. We met with senior council officers, NHS senior managers, frontline staff, parents/carers and teachers.
•	Focus groups with children and young people. Our engagement with children and young people involved hearing about the services they use, listening to the difficulties faced when accessing services and asking for feedback on our work throughout the audit process. 
•	Interviews with senior staff in the Scottish Government, Convention of Scottish Local Authorities (COSLA), Healthcare Improvement Scotland, the Care Inspectorate, the Mental Welfare Commission and other national bodies, and with representatives from stakeholder organisations.
•	Analysis of national performance and workforce data published up to June 2018.
•	Analysis of financial data.^1
•	Reviewing of key documents, including the Scottish Government’s Mental Health Strategy 2017-2027.
Our conclusion
•	A step change is required in the way the public sector in Scotland responds to the mental health needs of children and young people.

Appendix 2
Advisory group members
Audit Scotland would like to thank members of the advisory group for their input and advice throughout the audit.
Member | Organisation
Gareth Adkins | Healthcare Improvement Scotland
Bernadette Cairns | The Highland Council
Laura Caven | Convention of Scottish Local Authorities
Marian Flynn | Centre for Excellence for Looked After Children in Scotland
John Froggatt | Scottish Government
Margo Fyfe | Mental Welfare Commission
Lorna Greene | Royal College of Nursing
Dorothy Hawthorn and Jonathon Hinds | Social Work Scotland
Carolyn Lochhead | Scottish Association for Mental Health
Elaine Lockhart | Royal College of Psychiatrists
Karen Martin | Carers Trust
Thomas McEachan and Laura Pasternak | Scottish Youth Parliament
Julie Metcalfe | NHS Greater Glasgow and Clyde
Barry Syme | Glasgow City Council
Judith Tait and Helen Happer | Care Inspectorate
Pete Whitehouse | Scottish Government
Amy Woodhouse | Children in Scotland

Note: Members sat in an advisory capacity only. The content and conclusions of this report are the sole responsibility of Audit Scotland.

Appendix 3
Overview of CAMHS referral criteria for each NHS board
NHS board | ^Age ^range | ^Who ^can ^refer | ^Process ^for ^urgent ^referrals

NHS Ayrshire and Arran

5-18 years old
0-5 is dealt with by community paediatrics unless exceptional circumstances and a clear MH disorder.

GP, social work and education services.
Referrer must have met the child or young person within five working days before making referral.

Not specified

NHS Borders

5-18 years old

Professional based within Children’s Services, who has met with the child or young person.

Urgent referrals assessed within five working days.
Emergency referrals assessed the same day.
These are usually carried out by a nurse and may require a psychiatrist.

NHS Dumfries and Galloway | Not specified | Someone who knows the child, young person or family/carer who may be able to offer some help in the first instance is preferable but if required the young person and families/carers are able to contact the team themselves. | Not specified
NHS Fife | Up to 18 years old | Professionals working with children and young people, who have met with the child/young person. | Committed to respond helpfully to requests for an urgent assessment and to provide, at the very least, same day telephone consultation to those seeking support and advice. They have provided direct telephone numbers for urgent assessments.

NHS Forth Valley

0–18th birthday
Up to 16 for those with learning disabilities

Any agency working with children (but all non-health referrers must inform the child or young person’s GP of the referral and complete Child’s Plan paperwork).
Must have met the child/young person first.

Responded to as appropriate, normally within four weeks. Children referred who are currently on the Child Protection Register will be prioritised, their referrals categorised as urgent, however the team will require access to all relevant assessments completed and the current Child Protection Care Plan.
Team may decide to expedite a referral due to level of need or risk.

NHS Grampian

0–18th birthday
Children with learning disabilities are seen up to school leaving age

Not specified

Urgent referrals are seen within one week.
Emergency referrals are seen within 24 hours.

NHS Greater Glasgow and Clyde

0–18th birthday

GP, hospital doctors, school, school nurse, educational psychologists, or social worker.

To be made via telephone contact.
On-call service is available during normal working hours. If a medical psychiatric response is specifically required and cannot be achieved within the team, the referral is passed to the emergency service Duty Child Psychiatrist.

NHS Highland

0 – 16 years old 
Up to 18 if in full-time education

Requests are accepted from ALL child care professionals.

Lists criteria when referrals are considered urgent.
If it is felt that child or young person requires an urgent mental health assessment then referrals should be discussed with a CAMHS Clinician prior to referral submission.
Referrals of an urgent nature outwith normal working hours and at weekends should be directed to A&E.

NHS Lanarkshire

0 – 16 years old
Up to 18 if in full-time education

Requests are accepted from a wide range of professionals working with children and young people.

Requests can be made over the telephone in this case, but must be followed by a written request.
If an urgent appointment is required, one will be offered as soon as possible within two weeks.
Where mental health problems present an immediate and significant risk of harm to a young person or others, they should be assessed by CAMHS by end of next 
working day.

NHS Lothian

0 – 18 years old

Professionals such as GPs, community child health, general medicine, social work, health visitors, schools, educational psychology and other voluntary or professional agencies.

Out-of-hours emergencies are advised to contact their GP in first instance.
The on-call duty doctor system for CAMHS should be used by professionals once they have seen the person, if a child or young person requires an immediate mental health assessment.

NHS Orkney | Up to 18 years old but can be older to allow for successful transition to adult services | Schools, social services, third sector, primary care, fellow professionals, educational psychology, paediatrics. | Urgent referrals come into the community mental health team during working hours. These are triaged on an individual basis and are responded to as soon as the initial triage dictates. This can mean within two hours. Emergency response is the responsibility of all mental health nurses in the team who are allocated duty slots between them. Out-of-hours emergency is triaged initially through the out-of-hours GP service or A&E and should specialist mental health assessment be required then on-call mental health nurse will provide this assessment. Additional support is coopted if required from the out of hours duty social work – particularly in younger children rota or the MHO rota. There are no on-site psychiatrists for any age group working locally.

NHS Shetland

0 – 16 years old 
Up to 18 if in full-time education

Not specified

Not specified

NHS Tayside | Up to 18 years old | Not specified | Not specified
NHS Western Isles | Not specified | Health professionals/education/social work. | Not specified

Note: Based on information available on the NHS boards' websites as at April 2018.