Child and Adolescent Mental Health and Wellbeing

– in the Scottish Parliament at 3:17 pm on 7 January 2010.

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Photo of Alasdair Morgan Alasdair Morgan Scottish National Party 3:17, 7 January 2010

The next item of business is a debate on motion S3M-5453, in the name of Christine Grahame, on the Health and Sport Committee's report, "Inquiry into child and adolescent mental health and well-being". This is a useful opportunity for me to point out to members that, unless an item of business has a specific time against it in the business bulletin, it is liable to start at any time after the previous item finishes, which—of course-is not time constrained. Members should take note of that and should be in their places.

I invite members who wish to speak in the debate to press their request-to-speak buttons. I call Christine Grahame to speak to and move the motion on behalf of the Health and Sport Committee. I point out that we are quite tight for time.

Photo of Christine Grahame Christine Grahame Scottish National Party

Thank you, Deputy Presiding Officer. Your rebuke is noted by me. I was en route and I apologise.

First, I take this opportunity to thank all who gave oral and written evidence to the Health and Sport Committee, which is listed in annex B of the report.

My colleagues on the committee unanimously took the view at the beginning of this parliamentary session that the committee should, as a priority, hold an inquiry into mental health. On behalf of the committee, I thank our clerking team and the Scottish Parliament information centre, who were very helpful.

While being mindful that the scatter-gun approach would get us nowhere and that mental health is such a wide and diverse area, we narrowed the inquiry down to child and adolescent mental health. Members will note from the title of our report that we broadened the term mental health to include wellbeing, in order, we thought, to reflect more accurately the range that mental health encompasses, from diagnoses of schizophrenia and bipolar disorder, for example, to people feeling depressed and low, having low self-esteem or being emotionally not well. I note that, in its briefing for the debate, Action for Children Scotland supports that broadening of the definition of mental health.

Very few committee reports set the heather alight, and this one will be no different. However, the inquiry and report should engage the attention of at least 25 per cent of the Scottish population, be they new mums, farmers, plumbers, teachers, politicians or the press—who are notably, but not unexpectedly, in absentia. Why should such people's attention be engaged? It is because one in four of us will, at one time or another, suffer from one or another form of mental illness, or our mental wellbeing will not be good, which will, of course, impact not only on ourselves but on our families, friends and colleagues and on our ability to work or even deal with day-to-day mundane matters. It costs society in terms of the loss of an individual's contribution in pounds, shillings and pence. It costs the national health service and the justice system, and it costs the individual in terms of enjoyment of his or her life.

So, where were we to start? The committee split into groups and made informal visits to various and varied projects, which are listed on page 2 of our report. After those visits, the remit of the inquiry was defined with a set of key questions. One was about identification: how do we recognise children and adolescents who are potentially at risk of developing mental health problems, and how can those problems be prevented? Another question related to obstacles: what gets in the way of identification of children and adolescents who have mental health problems, and can those obstacles be overcome?

Another question was about action: what is being done to aid early intervention when potential mental health problems are identified, and what else can be done? Another issue is access. Who can access the services and can on-going support be improved? Finally, with adolescents, are there particular problems around moving from child and adolescent mental health services to adult mental health services, and how can the process be improved?

It is frequently said that child and adolescent mental health services are the Cinderella service of the national health service, so the question for the committee in our report, which we published in June 2009, was whether that is the case. Despite the devotion and efforts of individuals in the statutory sector and the voluntary sector—which plays a particular role in such services—and despite the policy commitment of present and past Governments, the committee's overall view is that there is still a need for more drive in implementing policies, especially from national health service boards and local authorities. That is the general point.

I turn to specifics. Committee colleagues will no doubt highlight and develop the conclusions in our report, so I will refer to only a few of them, starting with the implementation of the child and adolescent mental health framework. An important question is this: who is in charge and where does the buck stop? First, I stress that the framework appears to be the right way to go. At no point in our evidence taking was there any suggestion that the framework needs to be improved or otherwise revised. The outstanding issue is the timescale in which the framework is being implemented. The committee's report recognises that progress has been made, but we state our concerns about who is taking ownership of its delivery. On that point, paragraph 25 of our report states:

"According to the Framework, 'responsibility for ensuring delivery of this Framework rests with both NHS and local authority Chief Executives'. There should, therefore, be no doubt about with whom the ownership and responsibility rests: these are the people who should be championing the Framework. Whilst it was evident that the Framework was a priority for the Scottish Government, as it had been for the previous administration, it appears that this sense of priority has not transferred more widely into the delivery of services and has not, therefore, translated into a momentum for effective implementation of the Framework. ... Whilst the Committee notes the Minister for Public Health and Sport's statement that 'there was nothing to suggest that any implementation activity was off-target', the Committee is concerned that 2015 is a very far-off target and that there may, therefore, be some complacency amongst those responsible for delivering the target. In the interim, NHS board annual reviews are unlikely to be an adequate monitoring mechanism for ensuring steady and consistent progress. The Committee recommends, therefore, that the Scottish Government establish further and more detailed interim targets"— just to keep people on the ball—

"and milestones by which implementation may be actively measured."

In the Scottish Government's response to the committee's report, the issue of interim targets and milestones is not picked up. Perhaps the Minister for Public Health and Sport can address that in her closing remarks. Given the apparently Cinderella status of CAMHS in the past, I am sure that the committee would welcome assurances that, in the difficult times that lie ahead, such services will not be deprioritised and become even more Cinderella-ish.

The early years are also important—the importance of identifying mental health problems in the under-fives was a continuing theme in the inquiry. I quote from our report:

"Dr Philip Wilson of the SNAP group"— the "SNAP" reference is to the Scottish needs assessment programme working group on child and adolescent mental health that was set up in 2000—

"also talked about the importance of work with this age group, stating that it is the group that should receive the most thought and the most resources. He spoke of the 'enormous blossoming in the evidence base on ways of identifying early in life the children who are going to follow a problematic and painful trajectory' and of a 'big increase in the evidence base on what works"— this puts the point in ordinary language—

"to stop the bad things happening'."

The evidence suggests that early neglect is the strongest predictor of later childhood mental ill health. Neglect can take many forms. The chief medical officer for Scotland examined attachment disorders and the effects of social and emotional deprivation in the context of his annual report, "Health in Scotland 2006", in which he highlighted the "huge influence" of pregnancy and the first years of life on the future mental health of the child and future adult. He wrote:

"Adverse events during this time can lead to irreversible problems for future ability to cope with everyday life and increase the probability of future poor mental and physical health. Such problems can then run on across generations. It is essential that we recognise the need to invest in the health of infants, young people and children as action by effective Child and Mental Health Services and other agencies can reap substantial long-term rewards for our future child and adult populations."

As I trailed earlier, the crux of whether statutory services can identify mental health problems in the very young is how those services are delivered. That key role was traditionally fulfilled by the health visiting profession, members of which would uncover such problems in the course of general unstigmatised interaction with families with young children. The key word is "unstigmatised".

In evidence, strong views were offered on the current state of the health visiting profession and, in particular, on the impact of the Scottish Government guidance "Health for All Children 4", which sets out the core programme of screening, surveillance and health promotion checks that every child should receive. The principle of Hall 4 is to have a universal service involving contact with all children, followed by a focusing in on the children who most need additional attention. However, witnesses told the committee of their concerns about the fact that babies often no longer see a health visitor after the first eight weeks of life. Mary Scanlon, in particular, pursued that issue in questioning. In addition, there has been a drastic drop in the number of health visitors. Fears were also aired that vital mental health and wellbeing assessments and interventions are being missed.

I have been told that because health visitors are no longer required to carry out universal checks on babies and toddlers, but instead target certain family groups, they sometimes encounter the hostile reaction that visiting social workers can encounter—most undeservedly—and may even be stopped on the doorstep. There remains a great deal of concern about the status of health visitors and, in particular, about the importance of keeping their link with health practices, as opposed to linking them to social work departments. The suggestion that the role that health visitors perform in child mental health could be fulfilled by social workers instead could be counterproductive from a public perception point of view, as I have demonstrated.

Although the committee recognises that it is difficult to achieve a balance between the targeted screening that is caused by inevitable limitations on resources and a universal approach, it considers that it is imperative to identify in the early years, through universal screening, mental health and wellbeing issues, in the child and the parents or carers that have not been recognised at the time of the child's birth, or in the first six to eight weeks of life. Furthermore, it is vital that standard health and developmental checks be carried out on every child at crucial stages of the early years.

In its response, the Scottish Government said that the revised additional guidance on Hall 4 to NHS boards that would be published in autumn 2009 would make it clear that what is set down in the Hall 4 guidance was the minimum number of contacts that a child should receive. It would be useful if the minister would set out what the current position is vis-à-vis the community health nurse role that is being piloted in Borders, Highland and Tayside.

I hope that our report demonstrates the commitment not just of the committee but of the Parliament to mental wellbeing, and our determination to put it on a par with physical wellbeing, given that they are two interacting sides of the human coin.

I move,

That the Parliament notes the conclusions and recommendations contained in the Health and Sport Committee's 7th Report, 2009 (Session 3): Report on the Inquiry into child and adolescent mental health and well-being (SP Paper 309).

Photo of Shona Robison Shona Robison Scottish National Party 3:29, 7 January 2010

Happy new year to all health colleagues.

I thank the committee very much for bringing the important issue of child and adolescent mental health services to the attention of Parliament. The committee's interest in the subject accords with the Scottish Government's commitment to improving the mental health and wellbeing of children and young people.

As Christine Grahame said, it is well recognised that a large part of the pattern for our future life is set during our earliest years—and even pre-birth. That is why we developed our early years framework, at the heart of which is parenting. We must ensure that parents have access to appropriate support to help them to understand their responsibilities, and so that they can develop the skills that are needed to provide a nurturing and stimulating home environment. The focus of the framework is on developing a prevention and early intervention approach in the early years that moves away from dealing with crises only when they arise.

The determining factors in securing good mental health are complex, but a good start in life even before a person is born must be a major factor. That is why good antenatal care is vital. For that reason, we are tackling antenatal inequalities and developing good care pathways for vulnerable families through building on the getting it right for every child approach.

I want to mention in particular the family nurse partnership project that NHS Lothian is taking forward. That approach has proved to have benefits for the most vulnerable families in the United States over the past 25 years, and I look forward to the same outcomes in Scotland.

However, we want to bring a greater focus to parenting skills and capacity, and to develop care pathways in order to ensure that parents with different types and levels of need are given the right kind of support. By creating a family-centred approach that builds capacity in communities, we can give families, parents and children the opportunity to find their own solutions using high-quality public services.

I want to talk about health visitors, and to respond to the question that Christine Grahame asked. I cannot place enough value on the role of health visitors, who provide a central and unique role in children's services by identifying and supporting children and families who are at risk. They are the lynchpin in the team approach that is necessary to ensure that the most vulnerable people receive the necessary support when they need it. They have responsibilities, including screening and surveillance responsibilities, by which they can potentially identify mental health problems at the earliest stage. The recently established modernising community nursing board will work with NHS boards and stakeholders to ensure that a modern approach to community nursing care is taken. In addition, the impact of the introduction of the new community health nurse role on both staff and patients in the three pilot sites will be evaluated and included in the final report, which we expect to receive in the summer. The evaluation and report will provide useful evidence that will contribute to the new board's work and future decision making. I assure Christine Grahame that I am happy to keep the Health and Sport Committee apprised of that development as we take forward decisions on the future of the community health nurse role.

Photo of Richard Simpson Richard Simpson Labour

I want to ask specifically about an issue that Christine Grahame rightly raised: that universal screening appears to end at eight weeks. That is not even the point at which post-natal depression maximises, which is 12 weeks. That seemed to the committee to be not a proper interpretation of Hall 4.

Photo of Shona Robison Shona Robison Scottish National Party

A new chief executive letter is about to be issued that will make it clear that there must be flexibility around the guidance. The guidance is simply guidance; it is about a minimum level of intervention. We will issue that letter soon, and it will provide the necessary reassurance that health visitors have their professional expertise and skills to draw on in making judgments. I hope that it will clarify matters.

I am pleased that the committee recognises the priority that we place on implementation of the mental health of children and young people's framework, which we are working towards full delivery of by 2015. Our aim is to ensure throughout Scotland equity of access to services that are designed to ensure that the right care and treatment are available at the right place and at the right time. We recognise that much more needs to be done, and we are continuing to work closely with NHS boards and their partners as they strive to implement the framework. The mental health delivery and services unit has just completed performance management reviews with each of the boards, and progress on the CAMHS agenda played a major part in the discussions. To respond to Christine Grahame's question, I would be happy to work with the Health and Sport Committee to consider how we can reassure it that progress is being made.

The best test of that progress is how many additional staff have been recruited. We expect a 15 to 20 per cent growth in the workforce, based on the two funding announcements that we have made. I would be happy to report to regularly the Health and Sport Committee on progress on that. That is a good measure of the progress that is being made towards delivery of the framework by 2015. I hope that the committee will be satisfied with that.

NHS boards have also been very much involved in establishing a waiting-time target for referral to treatment by specialist CAMHS, which will be effective from April 2010. By March 2013, no one will wait longer than 26 weeks, although some boards will achieve the target significantly earlier. It is important to remember that the target is directed at the longest waits, which do not represent the experience of all children. Of course, I hope that we can go beyond the 26-week target and meet the national waiting times standard. To achieve that target, NHS boards will need not only to increase capacity by growing the workforce, but to improve the efficiency of the current workforce. Boards must ensure that appropriate data-gathering systems are in place to monitor their performance, and we will support them in doing that through a three-month pilot that will start in January.

I have mentioned resources. We have started to address the shortfall in the specialist workforce by making available an additional £6.5 million to NHS boards over the next three years to enable them to increase the number of psychologists who are working in specialist CAMHS. We are also providing an additional £2 million on a recurring basis to accelerate the development of specialist child and adolescent mental health community services. That means that we will be spending an additional £5.5 million per year by 2011-12. We expect the workforce to be 15 to 20 per cent larger by 2012 on the basis of those funding announcements. It is, therefore, good news that recent CAMHS workforce statistics show an increase of 3 per cent—a small but positive step in the right direction. I am confident that those measures will build on what is already encouraging progress.

I want to touch on some of the other issues in the report, if time allows.

Photo of Shona Robison Shona Robison Scottish National Party

The promotion of mental health among infants, children and young people is one of our six strategic priorities that are set out in "Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011". It is an important element, given what I have said about early intervention. We all share a responsibility to ensure the good mental health and wellbeing of Scotland's children and young people: schools, working in partnership with social work, NHS boards and the voluntary sector, also play an important role in securing that outcome.

I could say a lot more, but time does not allow me to do so. I hope that I can pick up other issues in closing and in responding to members' issues. I reiterate my and the Scottish Government's commitment to improving the mental health and wellbeing of children and young people. That ambition is shared across the chamber. I hope that, by working together, we can make the improvements that are required.

Photo of Richard Simpson Richard Simpson Labour 3:38, 7 January 2010

I declare an interest as a fellow of the Royal College of Psychiatrists and a member of SAMH.

The whole area of children's services has been characterised over a long period—since the initial report in the 1980s—by a lack of any sense of urgency. Christine Grahame is right to draw attention to the committee's concerns about the fact that it is a Cinderella service that is still not being developed despite the provision of significant new funding by the Government, which I acknowledge. Concerns were expressed, particularly in the late 1990s, about the increasing prevalence of mental health problems among children and adolescents. The number of individuals who were suffering from a variety of conditions such as behavioural problems, hyperactivity, attention deficit hyperactivity disorder and autistic spectrum disorder increased significantly between 1974 and 1999. There has been a subsequent stabilisation since then, but the number is still around one in 10.

To see how stressed young people are and what little sense of mental health and wellbeing they have, we need look no further than a paper by Professor O'Connor of the University of Stirling that documents his study of 15 and 16-year-olds in Stirling and Glasgow. He found that 14 per cent of those children had self-harmed and that a further 14 per cent had had serious thoughts of self-harm. That is getting on for a third of all our children of that age, which is an absolutely frightening indictment of how we have dealt with the problem in the past.

There are factors that have changed significantly over that period. For example, we know that more than 100,000 children or thereabouts are growing up in households where there is a drug or alcohol problem. Given that 58,000 children are born in this country each year, that means that two years' worth of our children are being affected by that problem.

In his annual report last year, the chief medical officer, Harry Burns, drew attention to the issue of neglect. We have always identified the problems of domestic abuse, parental mental illness and so on, but neglect is poorly defined, even though we know that it has a serious physical and mental health consequence.

The report that we are debating marks the latest stage in the journey that children's mental health services have been on. The SNAP working group, to which Christine Grahame referred, began in 2000 and reported in 2003. It said that services were patchy; that links between CAMHS and wider services were limited; that there were significant and damaging delays in the diagnosis and treatment of early psychosis; that all four tiers of the services were working beyond reasonable capacity; that there was inadequacy in patient resources, including a severe lack of in-patient intensive care unit, forensic and learning disability services; that there was a lack of training, especially in tier 1; and, as Christine Grahame said, that young people were reluctant to be referred to the services.

The SNAP report led to the framework report, and the committee has quite rightly said that no one is suggesting that that framework is inadequate. Indeed, some progress has been made. For example, successive Governments have endeavoured to eliminate the inappropriate admission of children to adult units. However, 140 children are still being admitted annually to those units—that represents 140 lives that cannot be properly turned round, because those units are totally inappropriate for children. In its 2008 report, the Mental Welfare Commission welcomed the progress that has been made but said that the target of eliminating such admissions by 2011 was challenging. Indeed, that target will almost certainly not be met. The previous agreement between Government and the workforce was that we would have 56 beds for children who were in need of them, but I do not think that that will happen; perhaps the minister can tell me whether it will. The number of beds that is needed if we are to meet European standards is 20 per 1,000 children in the relevant group, which means that we should have 100 beds in Scotland. However, we will have only 48, or perhaps 56. There is a great need for more beds. We should certainly have a number of beds that is in the high 60s, or we will continue to have problems.

There is still no forensic unit and no learning disability service of any note, and the out-patient service is totally rudimentary. There are serious areas of long-term neglect that need to be addressed as an urgent priority.

I will not go into the area of staffing, except to say that the report indicates clearly that, in areas such as Lanarkshire, there are 4.5 CAMHS staff per 100,000 members of the population, whereas in most parts of England there are 20. However, I should say that Lanarkshire has done more than any other council area in terms of tier 1 training for its health visitors. There are eight CAMHS staff per 100,000 members of the population in Lothian and 13 in Dumfries. There are too many areas in Scotland in which even a 20 per cent increase will not make the necessary difference.

In the few seconds that I have left, I turn to prevention, which is the most difficult but probably the most important area. Unless we get the preventive side right, it will not be possible to turn things round. That means that we need health visitors to effect proper screening. We must deal with that in an appropriate manner. We must reduce and eliminate the fragmentation of services in primary care. We must increase the number of public health nurses. I welcomed the commitment in the Government's manifesto to do so, but there has since been a reduction in the number of school nurses.

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

I am afraid that the member is about to sit down—even though he may not know it.

Photo of Richard Simpson Richard Simpson Labour

Perhaps the minister can address the point that she was going to make when she sums up at the end of the debate.

To conclude—

Photo of Richard Simpson Richard Simpson Labour

The framework is excellent; the timing is wrong. We need greater urgency on this matter, which must become a higher priority.

Photo of Mary Scanlon Mary Scanlon Conservative 3:44, 7 January 2010

I am sorry to start the year on a negative note but, having listened carefully to the minister, I must say that I was disappointed in what she said. If there was one point that I wanted her to address, it was the one that Richard Simpson raised in his final minute and which is dealt with in paragraph 123 of the committee's report, which says:

"it is vitally important that there are standard health checks and developmental checks on every child at crucial stages of the early years."

Access and more money are all very good, but unless we identify those who need that service, I am afraid that they are pretty worthless.

We all knew that addressing mental health and development issues in childhood was a problem, but I for one was shocked at what the Health and Sport Committee uncovered. The report paints a harrowing picture of how poorly we understand and nurture young people in Scotland today. The concluding remarks in paragraph 149 state:

"Despite the commitment of ... Government" since 1999, and

"the existence of an agreed framework and the devotion, good work and admirable efforts of many individuals ... mental health and well-being" of young people

"seems not to have been a priority amongst those responsible for delivering the policy."

The starting point for the report is the four-tier model that is used for CAMHS. Unless those who are not mental health specialists—including general practitioners, health visitors, school nurses, teachers, social workers, nursery staff and parents—identify problems early in a child's development, there will be no referral to tiers 2, 3 or 4.

The committee was told that if the window of opportunity when a child is aged two or three is missed,

"the consequence can be life-long poor mental health."

The British Psychological Society Scottish division of educational psychologists confirmed that

"CAMHS are not geared up to deliver early intervention", and Dr Philip Wilson stated:

"We either pay for a service for young children or pay 10 times over later in life".

The British Psychological Society stated:

"There is considerable confusion at times about how to respond to self harm, aggressive or acting-out behaviours. It is also evident that young people who are withdrawn, depressed or struggling socially can often be missed."

The society went on to say that

"primary care health and education staff can be unclear and disconnected from the integrated children's services processes".

Just as worrying, the Scottish division of the Royal College of Psychiatrists stated that some professionals

"still deny the existence of disabling mental health disorders in children".

The SNAP report has been mentioned several times. In 2003, it stated that CAHMS were "patchy", the teams were under "heavy pressure", links were "limited" and there were

"delays in referrals and access."

It also stated that specialist services were "difficult to access", and that there were "long waiting times" and a "lack of training" in the wider non-specialist tier 1 network.

Seven years on, what has changed? The Scottish Executive report in 2005 credited the SNAP report with providing a

"strategic vision for the mental health of children"

—and yet Dr Graham Bryce confirmed that

"we have not found a mechanism to drive the implementation of the policy".

We have the policy, but we seem not to have moved any further towards implementing it. We are more than three years into the 10-year implementation plan, yet not one witness was able to give any indication of progress or interim goals achieved.

Just as worrying, as Christine Grahame mentioned, was the lack of clarity on priority and responsibility between local authorities and the NHS. The low priority that is given to child psychiatry in Scotland is reflected in the years-long—nearly 10 years, I believe—vacancy for the post of professor in Edinburgh. More teacher training is desperately needed, but, equally, far greater emphasis is needed on development issues for under-fives, on the health visitor role and on training for nursery staff. There has also been confusion with regard to in loco parentis, and the fact that what a teacher understood to be an accurate definition in fact meant the exact opposite.

As Christine Grahame said, the most compelling evidence was on the critical need for health visitors: not to give parents access and a number on a nursery wall, but to address before the age of two the early neglect and the lack of early relationships and secure attachments of a child, which we heard are

"powerful predictors of mental ill health."

We heard that it is possible to predict at the age of three as many as 70 per cent of those who will end up as in-patients in psychiatric hospitals or in prison. Professor Law stated that the majority of those with attachment disorders can be identified in the first five years of life.

I realise that I am running a bit short of time, Presiding Officer. I know from my family—

Photo of Mary Scanlon Mary Scanlon Conservative

I have only 10 seconds left.

My granddaughter received the measles, mumps and rubella jab at 15 months and her parents were told to bring her back at the age of five.

In conclusion, despite the estimate that 10 per cent of children have mental health issues and all the evidence that we heard about the lack of commitment, the lack of priority and the lack of funding—

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

I am afraid that the member is stretching my patience a little bit.

Photo of Mary Scanlon Mary Scanlon Conservative

The Governments of Wales and Northern Ireland have in place national strategies for school counselling and its implementation, backed by ring-fenced funding in every school.

Photo of Jamie Stone Jamie Stone Liberal Democrat 3:50, 7 January 2010

Clearly, not being a member of the committee presents me with a slight difficulty. As members know, I am more used to making a winding-up speech than an opening speech in such debates. That presents another difficulty in that I have to forge into new territory, if you like. Nevertheless, I acknowledge the work that the committee put in and I read its report with great interest.

The inquiry and last year's Audit Scotland review of mental health services highlighted significant waiting times for child and adolescent services as well as serious variations between different parts of the country. The waiting times were called "extensive" and "a travesty", and during the inquiry it was also reported that the time that it takes for someone to get an initial appointment can vary greatly depending on the condition. It was with great interest and some upset that I noted that last year's Audit Scotland report found that, in July 2008, 40 per cent of children in Highland waited more than 18 weeks for a first assessment by a community mental health team and some had been waiting for an out-patient appointment for more than a year.

The Government's new health improvement, efficiency, access and treatment—or HEAT—target sets out that by March 2013 no one will wait for more than 26 weeks from referral to treatment for specialist CAMHS. Although that is a step in the right direction, it illustrates the huge scale of the current problem. The fact that we are aiming for children to wait for less than 26 weeks demonstrates how far we have to travel to ensure that all children who need it are able to receive timely access to mental health services no matter where they live.

Photo of Shona Robison Shona Robison Scottish National Party

Does the member acknowledge that the vast majority of children are referred much more quickly than that? The HEAT target is designed to ensure that there is a backstop so that no child has to wait for the lengths of time that the member mentioned. As I said in my speech, we want to go beyond 26 weeks, but that was regarded by clinicians as a good and achievable target to make the required progress.

Photo of Jamie Stone Jamie Stone Liberal Democrat

I note what the minister says.

As I said just before the minister intervened, we need to ensure that children have timely access to mental health services no matter where they live. That is of enormous interest to me because of the constituency that I represent. I see Mary Scanlon nodding in agreement. The vast geography and distances that are involved in Caithness and Sutherland or Ross and Cromarty present a challenge. I was grateful to hear the minister speak of the health visitors, but I seek a reassurance in her summing up at the end of the debate that distance will be taken into account as the report's findings are brought to fruition in Government action. The challenge that the report presents is not insoluble, but it will require definite thought.

It is clear that a shortage of CAMHS professionals is having a huge impact on the availability of services. Given the waiting times that both I and the minister mentioned, it is perhaps telling that NHS Highland—along with seven other health boards, as far as I can see—have below the Scottish average for the number of staff who work in child and adolescent mental health services. In 2007, the figure stood at fewer than nine per 100,000 population. A 2006 national policy document stated that there should be 20 such members of staff per 100,000 population and that, if there were fewer, some aspects of the comprehensive service that is required would necessarily be missing.

In addition, a 2005 review of the workforce in Scotland estimated that twice as many staff would be needed to provide a comprehensive service and deliver Government policies. Although that is brought out in the report, the problem remains to be tackled. The acid test will be when we move on from the report to see what the minister and the Government can do. I am sure that the Health and Sport Committee will revisit the matter at a later date.

I am concerned that in its report the committee fears that the Government's plans to boost the workforce will not be sufficient to tackle the problem. As evidence to the committee suggested that most areas have nowhere near enough staff, we must have a more transparent process of workforce planning. We parliamentarians and people who have expressed concern about the matter need to look at the issue and be convinced that the solution is starting to be put in place.

Finally, there is a pressing need to destigmatise mental health problems. The inquiry illustrated that the stigma associated with poor mental health continues to be an obstacle to identification and treatment. Just yesterday, it was reported that a survey conducted by the see me campaign had found that no less than 58 per cent of people with poor mental health had been stigmatised in the past five years and that 47 per cent of them said that the stigma had come from their family and friends. I find that final point not just shocking but chilling. It is almost a betrayal. Surely the last thing that a child in such a position needs is to worry about the reactions of those who are dearest and closest to them. It is crucial that the stigma and myths surrounding mental health problems are tackled to ensure that children and young people feel able to talk to anyone about any problems, but particularly to their family and friends. Families should be able to seek help when they need it and parents should be willing to accept help for their children. Many adults do not dare to cross that threshold—we do not know why that is the case, but it does not happen as it should.

Photo of Ian McKee Ian McKee Scottish National Party 3:57, 7 January 2010

In the short time available to me I will concentrate on two matters that are covered in the committee's important report, which, sadly, received little publicity when it was first published.

A general point is to emphasise the need for NHS and local authority chief executives to take ownership of and responsibility for the framework developed by the then Scottish Executive in 2005 that was aimed at improving the mental health of children and adolescents—health that has been so sadly neglected over decades, even by those who now argue loudly for immediate action.

Although all seem to agree that the framework is evidence based and should be put into practice, it appeared in the evidence that was presented to the committee that the sense of priority accepted by successive Governments has not been transferred into the delivery of services. As but one example, Helen Eadie and I travelled to Lochgilphead to take evidence from a heroic and dedicated group of workers in the field to find that there were only four psychiatric CAMHS nurses covering a catchment area that includes 20 inhabited islands and a total population of around 90,000. Theoretically, the area should be served by 18 psychiatric nurses if an adequate service is to be provided. How much longer can we tolerate such neglect of our most vulnerable children?

It has been made clear that responsibility for implementing the framework lies on the shoulders of chief executives in the NHS and local authorities. I welcome the minister's statement that we will look further into that situation and see that they keep up to the mark.

I turn my attention to the role of schools in combating mental illness in adolescence, because a confused picture emerged in the evidence that was given to our committee. The background is that many mental health problems in young people present as inappropriate social or sexual behaviour. Such mental health problems can arise in early life and are often related to problems in the home, but they can be exacerbated by a subsequent inappropriate response. It is indeed a very confusing picture.

Some effects of those mental health problems can lead to physical problems such as an unwanted pregnancy, a sexually transmitted disease or self-harm. Often the teacher is the first person to pick up that something is amiss, so his or her role is vital in helping such youngsters. As Richard Simpson pointed out, the extent of the problem has been revealed in a recent paper by Professor Rory O'Connor at the University of Stirling, which showed that 14 per cent of adolescent respondents to a survey had self- harmed and about the same number had had thoughts of self-harm. A retrospective study in the area in which I worked as a GP showed even worse figures, so Professor O'Connor is definitely not overestimating the problem. The figures for unwanted teenage pregnancies and sexually transmitted diseases are as bad—they are a disgrace to Scotland.

However, we heard evidence that teacher training in these matters is patchy or even non-existent. There is considerable disagreement over the confidential nature of any communication between pupil and teacher, especially when it involves children under the age of 16. One experienced teacher—Heather Muir—explained that if she heard that a child was having under-age sex, she was under an obligation to report it to the social work department and possibly the parents.

A respected headteacher—Brian Cooklin—defined the phrase "in loco parentis" as meaning:

"we can do nothing without parental consent."—[Official Report, Health and Sport Committee, 25 March 2009; c 1721.]

That is important. I am not saying for a moment that a teacher should never disclose information given by a child—the interests of the child or even the greater community sometimes mean that that is the appropriate action—but a policy that makes disclosure mandatory can do harm, either directly or more subtly, by preventing children from coming forward for help. Doctors do not always have to disclose and nor should teachers always be required to do so.

In her evidence, the Minister for Public Health and Sport reassured the committee that it is not a criminal offence to fail to report a criminal offence. Now, of course, two under-age children who have sexual intercourse are both engaged in criminal activity. That is welcome—I do not mean the new law, but the fact that the teacher does not have to report the offence.

What we are concerned with here is not the letter of the law but what happens in schools. If we have headteachers interpreting the responsibility of a teacher to mean that parental consent is always required, some of our most vulnerable children will be very poorly served, because, sadly, the parents—or a parent—are often part of the problem, rather than the solution.

Clear guidance is required to help the ordinary classroom teacher deal with what is an incredibly complex and dangerous minefield of accepted practice. Backing is needed for classroom teachers who decide in good faith not to disclose. Perhaps a mentoring system for less-experienced teachers could help in that respect. We must realise that those who use judgment, rather than slavishly follow set-down rules, will sometimes get things wrong, which means that support from higher up is even more important.

The minister acknowledged to the Health and Sport Committee the problems in this field by saying:

"We can also reflect on whether more needs to be done to ensure that things are as clear and supportive as they can be for those on the front line who need to make such decisions. We should perhaps have a think about what more could be done."—[Official Report, Health and Sport Committee, 6 May 2009; c 1897.]

I agree with the minister and look forward to progress in this field.

Photo of Malcolm Chisholm Malcolm Chisholm Labour 4:03, 7 January 2010

As the committee's excellent report and the accompanying evidence make clear, there is a great deal of continuity in mental health policy from the previous Administration and from the Scottish Needs Assessment Programme report of 2003 in particular. Now, however, there is even stronger evidence about the supreme importance of the very early years for mental health, which is backed up by exciting new research about the effect of early family relationships on brain development.

As we head towards more difficult times for public expenditure, it is more important than ever that we identify the areas that are most important for the future of society and ensure that they are prioritised. I believe that the early years, and the first three years of life in particular, are such an area.

Evidence to the Health and Sport Committee certainly supported that point of view, especially the evidence given by Dr Philip Wilson on 25 March. He referred most strikingly to some work in the United States, which Mary Scanlon also mentioned, that suggested that it is possible to predict at the age of three as many as 70 per cent of children who will end up as in-patients in psychiatric hospitals or in prison. He also described the intensive home-visiting programme that was developed by David Olds in the United States, which I am pleased to say is now being taken up on a pilot basis by NHS Lothian, as the minister said.

Follow-up studies in the US indicated that children in vulnerable families who had received intensive home visiting from health visitors up to the age of two were, by the age of 15, half as likely to have psychological problems and half as likely to have been involved in the criminal justice system as similar children who were not in the programme. There is no more graphic illustration of the potential importance of health visiting, which was a major feature of the committee's report.

We should remember, however, that the example that I gave was targeted on vulnerable families, and I remind members that that was the thinking behind Hall 4, which was issued while I was a minister, as was the SNAP report. A good impulse was behind that, because we must have intensive rather than occasional home visiting if we are to support vulnerable families. That said, a clear danger is that children will be missed if not enough health visiting is undertaken, and it is generally agreed that the approach has swung too far the other way. It is important to find the middle ground—the minister recognised that in her speech, although people might feel that the balance needs to be redressed even further.

The committee's report and all members today have certainly acknowledged that health visitors are crucial in early identification. Equally, the report recognises that the task is not just for health visitors; we need a multi-agency strategy to address obstacles to early intervention. The committee made important recommendations about nursery schools and about training for the early years workforce across the board.

However, none of that can be at the expense of specialist CAMHS staff, not least because those staff train the wider early years workforce. I will focus on the staffing recommendation because it is clear that for many other issues, such as waiting times, staffing is the most crucial—but not the only—relevant element. The spotlight in the report is on the NHS and the figure of 20 specialist staff per 100,000 population, but we should remember the role of local authorities. In Edinburgh, several jointly funded posts were the result of changing children's services fund money. There are great concerns about the continuance of the local authority's contribution to those posts, and the fact that many of those staff in Lothian have temporary contracts is a particular concern.

A wider issue is council funding for mental health services in the voluntary sector. If we do not support the voluntary sector and other support services for mental health, the burden on CAMHS staff becomes all the greater. A superb project in my constituency that was funded by the fairer Scotland fund, called women supporting women, lost half its funding last year and is existing on a lesser service this year. That project has helped hundreds of women with young children in my constituency. Without that support, they and their children might well have had to access psychiatric services. We need to remember the wider funding situation, as well as the specific NHS money.

Of course, I welcome what the minister said about increased NHS funding for specialist CAMHS staff and the announcement a few weeks ago about clinical psychologists, but psychiatrists have told me that expanding the psychiatric workforce is an issue. The Government says that lots more psychiatrists are in training, but what guarantee do we have that they will obtain permanent posts? NHS boards must create the posts, which is a concern for some psychiatrists. The committee also raised the issue of research.

I should not really be mentioning the next subject just in my last 20 seconds, but it is clear that a key issue is the mental health improvement agenda. I note that SNAP's former chair, Graham Bryce, highlighted the failure to step up that programme, which must be central in the work against stigma, to which I know that the Government is strongly committed.

Photo of Michael Matheson Michael Matheson Scottish National Party 4:09, 7 January 2010

As a couple of members have said, mental health services are often called the Cinderella of our national health service. During the inquiry, I was struck by how CAMHS appear to be the Cinderella of the Cinderella service, as they are often simply not a priority.

During the inquiry, I had the pleasure, along with Ross Finnie—I said that I had the pleasure along with him, not the pleasure with him—of visiting the Barnardo's family placement service in Edinburgh, which is based at Haymarket. It is a specialist service that works with children and families who are often referred by a statutory service such as a CAMHS team or educational psychologist.

Over the course of the visit, I was struck by the real difficulty that children, young people and their families can have in accessing services. I am referring not to a difficulty in accessing services purely because of a lack of capacity in the existing infrastructure but to the failure at times to recognise that a child is presenting with symptoms of an emotional or mental health problem. We heard that getting past the first hurdle—establishing the need to refer a child to services—is a real difficulty.

Photo of Richard Simpson Richard Simpson Labour

Professor James Law of the Royal College of Speech and Language Therapists said that it was bad not only that the number of referrals from health visitors was down from 50 per cent to 15 per cent of all referrals but that referrals are now taking a year longer than they took five years ago. The point is important.

Photo of Michael Matheson Michael Matheson Scottish National Party

I recall the strong evidence that we received from Professor Law.

The visit emphasised for me the real need to ensure not only that adequate services are made available but that those who work with young people have the skills and training to allow them to identify issues at an early stage. Other members mentioned that. As Christine Grahame said, even the pre-school stage is important if we are to prevent problems from developing further down the line. Clearly, as we heard in evidence, early intervention is a key priority in trying to deal with the issue.

We have to recognise the challenges in trying to make early interventions at the pre-school stage. My children go to pre-school, and I am not sure how I would react if a nursery nurse were to tell me that my son was presenting with emotional problems. If pre-school staff are to take on this role, we need to recognise the dramatic change that it may make in their relationship with parents. It would be extremely important to ensure that we train staff not only to recognise things but to do so to a deep and meaningful degree. There may be a need for measures to be instigated in programmes that pre-school establishments have in place. Also, if we expect staff to pick up and highlight issues to parents, it is crucial that the correct infrastructure is put in place to support them.

Much has been said on the need for professionals to pick up on issues, but we cannot get away from the fact that the first port of call in picking up on any children's mental health issue is the child's parent or carer. We should not expect health visitors or anyone else always to have to pick up on these things; parents have that responsibility. I took from the inquiry the need to ensure that parents have a better understanding of the issues around attachment and the emotional problems that can arise as the child develops, so that they can take action to address them when possible.

The framework addresses many of the fundamental problems that the committee highlighted in our inquiry report. I recognise fully the minister's personal commitment to the issue and that the Government is taking forward implementation of the framework. Although local authorities and health boards have the responsibility to take forward the framework in their local areas, I am concerned by the evidence that we heard about who exactly is in the driving seat. I am conscious that health boards and local authorities have different priorities at times and that it can be difficult to get them to agree. We should look to take forward interim measures that allow us to see whether progress is being made. I note the minister's comments and that she will work with the committee to address the matter.

The committee's report provides a detailed and considered focus on some of the deficiencies that exist in services for children and adolescents who have mental health problems. It is clear that those deficiencies have developed over a considerable period, and it is fair to say that the minister has been dealt a difficult hand in trying to sort out many of the issues. The minister and the Government have given priority to the framework. We are travelling in the right direction, and I hope that we will continue to give priority to the framework in the future so that we can make real change.

Photo of Rhoda Grant Rhoda Grant Labour 4:15, 7 January 2010

The American declaration of independence declares that people have

"certain unalienable Rights" and

"that among these are Life, Liberty and the pursuit of Happiness."

Happiness is not attainable by those with poor mental health. We need to tackle that issue to enable children to grow up leading fulfilled and happy lives. We need to ensure that all our citizens have a right to good mental health, to help them with their pursuit of happiness. We need to start at a young age, to help young people to develop resilience and emotional wellbeing; Action for Children highlighted that issue in its submission to the Health and Sport Committee's inquiry.

The report's discussion of the consequences of poor mental health makes stark reading. Having inadequate services in place for children and young people who have mental health problems is inexcusable: the effect on their development and life chances is severe. Malcolm Chisholm talked about the American research that has been done into the issue. Our prison statistics show that the vast majority of prisoners have mental health problems. Our inability to deal with mental health issues at an early age creates problems for the future, as well as a cost to our society. However, the cost to the person who is affected is immeasurable.

Those who gave evidence to the committee made it clear that "The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care" was the right way forward; the problem was in its implementation. The Government is committed to implementing the framework by 2015. The long lead-in time means that work towards implementation of the framework is often patchy and inconsistent. The committee is keen that interim targets should be put in place, to ensure that progress is measured. That would also allow inconsistencies to be identified.

Waiting times are far too long. As we have heard, in Highland some people wait for more than a year for an out-patient appointment. That is unacceptable for an adult, but it is even more unacceptable for a child in its formative years. Each day, week or month that goes by without intervention makes that intervention more difficult and makes treatment longer.

In its report, the committee discussed the lack of research and the need to increase staffing levels to allow research time, as well as to cut waiting times and to increase service provision. Research is fundamental to improving the way in which treatment is offered. It is a false economy to reduce research in order to increase patient care—both are required.

Possibly the most unacceptable wait is for reports to the children's panel. When young people find themselves at a children's panel, they are already at crisis point. The panel needs to be able to react quickly and to intervene to address the situation in which that young person finds themselves. Waiting times of up to five months were quoted in evidence; that is too long for a young person who is already in crisis. Staffing levels directly affect service delivery, research work and the work of the children's panel. We therefore need more investment in the training and recruitment of professionals to increase the workforce.

The committee looked at the transition from CAMHS to adult services. It became obvious that the two services worked very differently and that many young people had difficulties with the transition. There were several aspects to the issue: the handover, the way of dealing with patients in the two services, and the way in which patients could be transferred. As we have already heard, children's services often use a broader definition of mental health that does not fit easily with adult service provision. Action for Children made the point that it is important to keep that wide definition within children's services, to allow for early intervention. It must be possible for professionals from both services to work together to draw up a single pathway that is geared to the needs of the individual.

In our casework, we often hear of families who feel abandoned when a child leaves school and falls into adult service provision. There is a lack of support and advice and a lack of protected workplaces or college places. The committee was frustrated by that issue and recommended the setting up of a transitional service to bridge the gap between young people's services and adult services.

We have been discussing for many years the effect of the stigma that is attached to mental health issues. I agree with Action for Children's statement that work needs to be carried out locally and nationally to deal with the issue. If we do not deal with it, those needing help will be reluctant to ask for it. It is therefore even more crucial to provide an immediate response to those who ask for help, given that they may already have suffered in silence for some time.

School counselling is one way of providing help in familiar settings, which helps to remove stigma. However, the British Association for Counselling and Psychotherapy tells us that Scotland is lagging behind:

"the Governments of Wales and Northern Ireland have in place national strategies for school counselling and its implementation, and provide ring fenced funding for the provision of these services in every secondary school".

We must ensure that we keep pace and provide these services to all children.

There are many other issues that have not been touched on in the report, including services to deaf people and tailored services for those who suffer from anorexia. Both groups need to travel out of Scotland for specialist care, which, at a time when people need the support of their families and friends, can only hamper their recovery. We need those services locally.

The committee's report is sound and well balanced. I therefore appeal to the Government to implement its recommendations.

Photo of Cathy Jamieson Cathy Jamieson Labour 4:21, 7 January 2010

Thank you, Presiding Officer, for giving me the opportunity to make a brief contribution to the debate.

I will focus on adolescents, but first I thank the committee for its report. The amount of work that was undertaken is very good. As has been said, the area is not necessarily one on which everyone focuses, but it is nonetheless very important, particularly as so many people come up against mental health problems at some stage in their lives.

I heard what the minister said about waiting times, on which Rhoda Grant also focused. Anyone would find it unacceptable when a child or adolescent member of their family who requires access to mental health services has to wait for a year or more. The minister mentioned the reduction in waiting times to 26 weeks, but for the person who requires access to the services, particularly if they are young, 26 weeks might as well be a lifetime, because that is what it will feel like.

Photo of Shona Robison Shona Robison Scottish National Party

Does the member recognise that this is the first time that any target has been set for child and adolescent mental health services? I do not want to sour the debate, but is it not a bit rich for her to criticise the situation that we find ourselves in when it could have been addressed a lot earlier had a target been set some time ago?

Photo of Cathy Jamieson Cathy Jamieson Labour

I am a bit disappointed that the minister has chosen to sour the debate, because I was making a point on behalf of the young people and families who are in the position that I described. I was not making a party-political point and I assure the minister that I would have made my point—indeed, I have made it—no matter who was in government. I hope that she takes my point in the spirit in which it is meant.

I know that some work has been done on the target of reducing the number of adolescents who end up in adult in-patient wards, but the report highlights that there is some way to go in that area.

Richard Simpson highlighted that issues remain around the lack of availability of forensic services for adolescents and Rhoda Grant highlighted issues around specialist services. Although I understand that there are now opportunities in some parts of Scotland for young people with anorexia to get access to specialist services, such provision is not universal across Scotland. In many cases, young people have to go to in-patient services outwith Scotland. We should be able to develop services here to provide for them.

There are also issues around looked-after children—Rhoda Grant referred to the length of time that it takes to get panel reports—and young people in secure accommodation. When we reviewed the need for secure accommodation and the number of secure beds in Scotland, we were particularly interested in what happened to young women who were in the children's hearings system, not necessarily because of offending behaviour but because of self-harm, for example. There was a clear wish at that stage to have a more joined-up approach between what was done in secure accommodation and what was provided by in-patient services. I am not sure that those things have been brought together.

It is important to ensure that all the good intentions match up on the ground. In the report, the committee talks about the value of drop-in services for adolescents. In the Doon valley in my constituency, there was a very successful pilot project in which a specialist mental health school nurse was provided to offer support to vulnerable young people in a disadvantaged area. The initiative was jointly funded by Ayrshire and Arran NHS Board and East Ayrshire Council. At the end of the pilot, although everyone—the headteacher of Doon academy, local general practitioners, the Zone youth project and young people themselves—said that it had been successful, people could not get their heads together to come up with a way of continuing to fund it. The project was lost, although it provided exactly the approach that the committee has recommended.

I welcome the debate. Thank you, Presiding Officer, for allowing me to speak.

Photo of Hugh O'Donnell Hugh O'Donnell Liberal Democrat 4:25, 7 January 2010

I congratulate the committee on its fascinating and important report. I am of a nervous disposition and I hesitate to contradict Christine Grahame, but I think that the report will set the heather alight if we continue to talk about it in the way in which most members have done.

Photo of Hugh O'Donnell Hugh O'Donnell Liberal Democrat

I took particular interest in the speeches by Dr McKee and Michael Matheson. Mr Matheson made a telling point about parents' abilities. It is regrettable that many parents of children who manifest the potential for mental ill health in their behaviour are themselves not capable of monitoring the situation. Dr Simpson talked about drug and alcohol abuse, which are always challenging issues. I have visited many educational facilities in my region of Central Scotland and I have found that many young people who have social, educational and emotional needs have chaotic social backgrounds. Certainly at primary school stage, people do not realise that a child's behaviour reflects the pressures, stresses and strains that they are under. The report highlighted that critical point.

The committee noted that the CAMHS team in the NHS Lanarkshire area is one of the teams that are under the most pressure, given the ratio of CAMHS staff per head of population. The health board has introduced a school counselling service—I think that Cathy Jamieson mentioned it—which provides a walk-in service to pupils in secondary schools. A charitable organisation provides a similar service to primary pupils in Edinburgh and the Lothians. The approach allows young people to access services in a less formal way. A young person who might be feeling a little under pressure and might have stuff going on at home can explore the issues in a situation that does not have the formal and perhaps intimidating nature of first contact with people who are perceived as mental health clinicians—a lot of that is to do with stigmatisation. The services work well. I ask the minister to consider the service that NHS Lanarkshire provides in secondary schools and consider whether the model can be successfully rolled out in other areas. It certainly seems to have proved successful in Lanarkshire.

The other issue that I will discuss is training, about which other members have spoken. Teacher training is a hobby-horse of mine. All too often, the pressures that the attainment and achievement agenda, the curriculum for excellence changes and the getting it right for every child changes bring about mean that teachers who have children who present with what appears to be bad behaviour—however we like to define that—do not necessarily have the training to realise that it is not bad behaviour for its own sake but possibly a manifestation of something deeper going on. Often, such children are excluded without being directed to the appropriate services.

It is my understanding that mental health training and special educational needs training are optional, not compulsory, parts of the current teacher training programme and that their delivery varies from teacher training institution to institution. I recognise that the minister will not necessarily be able to address that point, but perhaps the current review of teacher training will begin to address some of the issues. There is no doubt that, unless we address consistently throughout the country the needs of young people and adolescents with mental health issues and the challenges that they face, we create, or at least allow the continued creation of, individuals who will subsequently look for higher levels of service in adulthood, possibly in our justice system.

Photo of Jackson Carlaw Jackson Carlaw Conservative 4:31, 7 January 2010

As I was eager to hear the views of members from all parties in this debate, I will begin by commenting on points by which I have been particularly struck.

I congratulate Christine Grahame, who demonstrated her customary ability to detail comprehensively the range and scope of such reports. I say that notwithstanding the fact that in this instance the evidence presented and the conclusions reached are awkward.

Dr Richard Simpson developed those points from an informed career perspective, to which I defer. With almost shocking clarity, he drew our attention to some of the consequences of a long-term lack of urgency in implementation in CAMHS, even while he acknowledged the additional funding that has been made available.

I pay tribute to my colleague Mary Scanlon. Since I joined the Parliament, she has been keen to ensure at every turn that everybody on the Conservative side appreciates the underlying mental health problems that underpin many of the issues that we discuss almost weekly in the chamber. That passion is shared by others and came across in Cathy Jamieson's speech late on in the debate.

Jamie Stone ensured that we did not lose sight of the rural dimension. Ian McKee concentrated rightly on accountability and leadership in developing a service—an aim that has been agreed repeatedly as a policy objective but does not seem to be making progress. Michael Matheson and Hugh O'Donnell made a sensible point about training for pre-school and school staff on how to address and discuss with parents issues as they present.

I turn to the future of health visiting in Scotland and to the evidence of Dr Phil Wilson and others. For various reasons, the Conservatives have concluded that health visiting is descending into a shambles throughout large parts of Scotland. In his evidence, Dr Wilson said:

"catastrophic damage has been wrought to the health visiting profession."—[Official Report, Health and Sport Committee, 25 March 2009; c 1728.]

He went on to say that the number of health visitors is declining and that morale is at its lowest ever point. I know that the minister does not share that view because she said as much to me in the Parliament late last year, but I am afraid that I disagree with her.

I say to the minister, for whom I have some regard, that she cannot disguise the fact that, for all her espoused commitment, after nearly three years in government, there is the suggestion of what might be mistaken as an air of complacency—which I am sure is not intended—and of a reluctance to question whether the early evidence shows that the changes in health visiting that are now being put into effect are working towards or against the objectives that have been set. Moreover, as a result of many no doubt well-intentioned reviews, we seem to have 14 health boards progressing separate, if sometimes similar, approaches to health visiting in all its forms. I am witnessing, as are others—nowhere more so than in NHS Greater Glasgow and Clyde—what appears to be almost the disembowelling of a once effective and quietly magnificent service. Universality has ended, and such is the crisis in numbers, with many disaffected older health visitors leaving the profession, that even the hoped-for concentration of additional resource in areas of inequality has not been achieved.

The evidence that was presented to the committee was conclusive, it seemed to me, in identifying the need for health visitors to be involved with children for longer than the initial weeks after birth or even the first year, because problems often become apparent in the years after that. As Dr Richard Simpson pointed out, the Royal College of Speech and Language Therapists showed that referrals from health visitors—once a principal source of referrals—have collapsed. To borrow a phrase that I think I heard almost too much of earlier in the week, we cannot go on like this.

Scottish Conservatives have during this parliamentary session concentrated our thinking on the development of health visiting policy. We saw first that the changes had the potential to be catastrophic and we called for the appointment of an independent scrutiny panel in Glasgow ahead of the delivery of major service change. The Cabinet Secretary for Health and Wellbeing was wrong to conclude that that was unnecessary.

We now call for a national health visiting strategy. We believe that health visitors should be attached to GPs, that there should be a universal service and that health visitors should be engaged with children up to the age of five, but particularly in the first three years. We have identified that we would direct an additional £20 million into the development of the service in Scotland. We believe that that is a far greater priority for immediate health spending than, say, further reductions in prescription charges.

Let me be clear that, while maintaining a universal service, we would target additional resources into areas of inequality not by ending the service for others but by providing for additional health visitors in those communities. While we may differ on the means, I welcome the importance that Malcolm Chisholm placed on extended health visitor involvement and I look forward to seeing the results of the pilot in the Lothians that is based on the American experience.

We welcome the committee's report and the strength of feeling that is expressed in it. However, it perhaps sadly confirms that, while so many professionals strive to improve the position, we fail to match our appreciation of what needs to be done with the resource to make it happen. We need also to appreciate the associated stigmas that exist. Whereas a generation ago a cancer sufferer may have kept quiet—embarrassed to share the fact of their condition—in today's world that individual can talk openly about their cancer to a more understanding and knowledgeable world. However, who, suffering from a mental health condition, can step forward and speak of their condition in the same way and be sure that they will be met with equal understanding or knowledge? Far too few, I suggest. Surely that, above all else, tells us that we have a considerable amount still to do.

Photo of Richard Simpson Richard Simpson Labour 4:37, 7 January 2010

This has been a useful debate on a report that I hope will have some effect. In opening the debate, Christine Grahame almost summed it up by saying that the framework is there. Once again, we have the strategy and the policy; now we must drive forward the action. That is not a criticism of this Government but of us all, because we have failed as a Parliament to address the issue effectively over the first 10 years of our life.

Rhoda Grant referred to something that is very important, which is how we develop resilience in children. The first stage of that has got to be about attachment and bonding. Unless we get right that fundamental first step in the development of the individual, we simply build up problems that we have to patch and mend as we go along. This must not be a further instance whereby we have to deal with people being in prison at the age of 16, as Mary Scanlon said, or with unemployment, illiteracy and drug and alcohol addiction in young people, which all emerge in young adults with problems that we have failed to tackle in childhood.

There is obviously a balance to be struck between universal and focused services. Much of the debate has centred on that particular issue. The problem is how, with limited resources, we get that balance right. It is clear that we cannot identify, by the age of eight weeks, every child who might need help—that is simply not possible. We cannot identify every family that has problems, because they may develop problems at a later stage. There must therefore be a mechanism for allowing the sort of intensive support that exists in the programme being piloted in Edinburgh, to which Malcolm Chisholm referred, which is called the family nurse partnership. It is an intensive, two-year programme and we need that for our most vulnerable children.

At the two-year-old stage, we need the kind of nursery school for vulnerable children that was piloted in the NHS Ayrshire and Arran area. Unfortunately, that pilot was subsequently abandoned. Indeed, a theme that came through in our inquiry was that pilots were introduced and some effort was made by people to develop programmes that were subsequently, despite being apparently successfully, abandoned.

One theme that has perhaps not been sufficiently stressed in speeches so far is that of training. The training of teachers and pre-school teachers has been alluded to, but we also need a lot more training of primary care staff. Given that 30 per cent of general practitioners have no postgraduate experience in psychiatry, how do those people tackle mental health problems? Health visitors are also not always as well trained as they might be.

An interesting point is that England's National Academy for Parenting Practitioners—which I think is a wonderful initiative—is promoting evidence-based programmes in parenting. The parenting academy is now training commissioners of caring services for parents in every local authority and is training 3,500 practitioners in evidence-based training. However, the parenting academy's first report indicated that only about one in 100 of counselling or general support programmes in England are actually evidence based. Unless such programmes are evidence based, they will not produce change. Simple counselling is not enough; programmes need to be properly evidence based. That is why the programme in Edinburgh is really important.

Voluntary organisations have been mentioned, although perhaps only in passing. The committee felt that the voluntary sector was under huge pressure. With many contracts that previously lasted for three years now lasting for just one year and many services requiring to be retendered for, the sector is being put under huge pressure. The voluntary sector can make an important contribution. For example, a programme in Edinburgh that is run by the charity The Place2Be has excellent results in the counselling that it provides to children and in the support that it provides to teachers and parents through a variety of programmes. The charity provides most of the funding, yet its offer is not being taken up. The charity is looking for other local authority partners in Scotland but cannot find them, whereas there are 150 such partnerships in England. For a small amount of money, we could develop that sort of support for voluntary organisations.

Many of us have talked about the need for more resources and capacity, including physical capacity, given the lack of beds for dealing with those with learning disabilities and for forensic services. We are still admitting children to adult wards. We should say that that must finish by 2011. I hope that the Minister for Public Health and Sport will confirm that target, difficult though it might be to reach.

We need to identify the groups that will need help. As many speakers have mentioned, those include children under three, because identifying such children by that stage and applying the programmes to them provides the best rate of success. Our programme for corporate parenting does not stand up to much scrutiny. We are not very good at corporate parenting and our outcomes are very poor. In Denmark, the number of those from foster homes and care support who go on to university is 42 per cent, which is almost the figure that we achieve for the general population. In Scotland, the equivalent figure is 4 per cent. We are failing those people.

We need a comprehensive programme in which there is ownership, implementation and driving forward of the framework, which we all agree is necessary. We are able to identify some of the families that are at risk of mental illness, such as those with drug or alcohol-related problems, those in which the parents have learning disabilities, those in which the parents are homeless or refugees or in prison, those in which the children are involved in custody and access disputes, those in which there is neglect or abuse or domestic abuse and, as one speaker mentioned, those in which there are transition problems relating to local authority or corporate parenting. We can identify all those families and we should apply resources to them. We need to stop doing what we are not doing well and we need to do much more of what we know from the evidence base can be done. I commend the report.

Photo of Shona Robison Shona Robison Scottish National Party 4:44, 7 January 2010

I welcome the speeches that have been made during what has been an important debate. Members from across the political parties have shown their knowledge of the issues and their commitment to taking the issue forward.

Many have mentioned parenting, which is very much at the heart of the early years framework that I mentioned in my opening remarks. We will ensure that spending on CAMHS and implementing the CAMHS framework takes forward our work on parenting. In addition, we are looking closely at the role of nursing in the community to support new mothers, are ensuring that children's mental and emotional needs are identified and met in the school environment, and are considering the development of a core competency framework for the protection of children. I hope that all that reassures members that we are heading in the right direction.

I want to respond to some of the points that have been made during the debate. A number of members questioned whether the 15 to 20 per cent increase in the specialist workforce was adequate. It is certainly an extremely good start and represents encouraging progress towards our gold standard, which would be to have 24 whole-time equivalent CAMHS staff per 100,000 population.

While I am on the subject of the workforce, I should correct what Richard Simpson said about school nurse numbers. There has been a 20 per cent increase in the head count since 2007 and a 16 per cent increase in the number of whole-time equivalents. To pick up an issue that many members raised, we are focusing our attention on the need for a resource in schools to pick up issues at an early stage. We believe that the right way to take that forward is by having a team that includes staff with many skills, including mental health workers who have specific skills that they can bring to supporting the school environment. Our commitment to increasing health care capacity in that area is demonstrated by our provision of £7million over three years to do that. I believe that starting by focusing on the areas of highest deprivation is the right way to proceed.

Mary Scanlon analysed the extent of the problem, which we all acknowledge. What is important is that we put in place the right policies to ensure that those issues are addressed, and I believe that we have done that. I know that the critical issue of implementation has been raised, but I assure members that we will hold health boards to account. I suggest that the fact that we have set a HEAT target on that will focus the minds of senior managers in health boards more than anything else. We will use that to ensure that we drive forward the changes that require to be made in CAMHS.

Jamie Stone mentioned rurality and asked whether the increase in the number of specialist staff that is required in rural health board areas would occur. Of course it will. We will carry out monitoring to ensure that boards create the necessary posts—that is important—and recruit staff into them. I assure Jamie Stone that we will keep a close eye on that.

Photo of Mary Scanlon Mary Scanlon Conservative

I want to ask about implementation, which I raised in my speech. In paragraph 123 of its report, the committee asked the Government to ensure that

"there are standard health checks and developmental checks on every child at crucial stages of the early years."

Will that be done?

Photo of Shona Robison Shona Robison Scottish National Party

I will come on to that in a minute, when I discuss the review of health visitors, in response to Jackson Carlaw.

Ian McKee gave a well-informed speech, as always, in which he highlighted the complexities of appropriate disclosure, which is never a simple matter to deal with.

I welcome Malcolm Chisholm's support for the family nurse partnership, the evidence from which will tell us a lot about the way forward, particularly in supporting vulnerable families who require a more consistent and intensive level of support than can be provided at the moment, in many cases.

Michael Matheson made a strong point about how problems in the early years are responded to. He was right to highlight the fact that parental responsibility is crucial in that regard.

On exactly who is driving, I return to the point that I made earlier. We will hold the health boards to account at the highest level for delivering on workforce growth and the HEAT targets, all of which are clear and tangible measurements that we can ensure are taken forward.

Cathy Jamieson talked about out-of-area placements. I reassure members that out-of-area placements would happen in a very small number of cases in which there may be complex or comorbidity issues and in which finding the right environment in Scotland would be difficult. Of course, we take such an approach with cross-border issues in complex cases, but I would certainly expect mainstream cases to be accommodated in Scotland.

Photo of Shona Robison Shona Robison Scottish National Party

I am sorry, but I will have to move on; I am a bit short of time.

Hugh O'Donnell mentioned considering the counselling service that Lanarkshire NHS Board provides. I am happy to do that, but I think that the increased health care capacity in schools points the way forward, as schools can identify what the key issues are for them, and I would expect issues such as counselling to be taken on board in that process. I will get back to Hugh O'Donnell on the curriculum for excellence and teacher training issues, as I do not have the necessary information to hand.

I do not recognise the picture that Jackson Carlaw painted with his comments on health visitors, but I do not want to sound complacent in any way. We recognise that there are genuine concerns out there, which is why the cabinet secretary announced before Christmas that we will meet GPs and other interested parties in Glasgow to talk to them directly about their concerns. Jackson Carlaw talked about the situation in Glasgow, where health visitor numbers have increased since 2007 as a follow-up to the review. Nevertheless, there are genuine concerns there, which we will meet to discuss.

On the more general point of the community nursing review, as I said in my opening speech, I have always said that I am open-minded about the way forward for community nursing. However, things cannot stay set in aspic, particularly in light of the challenges that we and community nursing face and the recruitment difficulties that there are in getting young people to choose community nursing as a career option. We cannot stay as we are. Changes are required, but we have to take the workforce with us. I am happy to keep members informed about that.

Other points have been made, but I am under pressure of time. I will therefore respond in writing to members whose points I have not managed to come back to.

Photo of Trish Godman Trish Godman Labour

I call Ross Finnie to wind up on behalf of the Health and Sport Committee.

Photo of Ross Finnie Ross Finnie Liberal Democrat 4:52, 7 January 2010

It is right that members have been given time in the chamber to explore the Health and Sport Committee's important report, and the debate has been useful. However, I have some reflections. As a member of that committee and having listened to what has been said, I have been struck that we have almost had a repeat of the report. Certain members have greater concerns about certain elements and have been slightly angrier about matters not being progressed, but there has been consistency and coalescence around the fact that a framework exists that no one dissents from; the fact that we ought to focus on the key elements, particularly to do with the early years; and the fact that successive Governments have prioritised the issue. I do not think that any member has implied criticism of the minister in how things have been presented to her, but the report concluded that something is not right and that—regrettably—progress is not being made.

In his closing remarks, Richard Simpson said that he thought that we had failed to address the issue, but I am not entirely sure that I share his view. Surely our purpose as politicians is to identify problems, inquire into them and set policy directions; it is not necessarily for politicians to deliver on every aspect of policy. We sometimes make the mistake of thinking that, but our purpose as parliamentarians is to set policy directions.

Therefore, my reflection on behalf of the committee—I hope that its members will forgive me if I tread on toes that I should not tread on—is to suggest that neither we parliamentarians and committee members nor the current Government and its predecessor have managed to persuade the professionals who are engaged in the delivery of mental health services of the urgency that we politicians attach to the problem. We are not getting the buy-in that is required to meet the aspirations that members across the chamber appear to share. I therefore ask that, in talking about implementation, the minister urgently request her officials to look carefully at the way in which either we are failing to express the sense of urgency that we share or the professionals are failing to understand how we see the whole picture of mental health playing a much more vital role.

Malcolm Chisholm made the point that the identification of poor mental health in the early years must have huge ramifications for the costs and burdens on the Government of people subsequently presenting mental health difficulties in childhood, adolescence or adulthood. The cost to society of failing to deal with those problems at an earlier stage is that those burdens will continue.

Excellent points were made by many members, including Michael Matheson. For the avoidance of doubt, and for the Official Report, I say that I simply shared with him the pleasure of visiting the Barnardo's home. I hope that that will not be interpreted in any other way by those who inadvertently come upon the Official Report at a later stage. The point that he made emphasises the point that I am making. The committee was disappointed to discover that, despite all the efforts to raise the profile of mental health services, CAMHS remain the Cinderella of what continues to be a Cinderella service.

Michael Matheson went on to say that we have also failed to understand that parents do not want to recognise that their child might have such a disability. That is perfectly understandable, but it means that if a teacher or someone else raises the issue, there is an instant denial and there is no prospect of that child being referred to any element of the CAMHS framework. Michael Matheson was right to emphasise that difficulty. It is an aspect of implementation for which we are not criticising the Government per se; nevertheless, it must be addressed, as it is an impediment to progress in this vital area. The same question arises about how prepared or well trained the staff in teaching posts or elsewhere are to deal with people who react with that sense of denial. What preparation do they receive for that? Many members made the point that that issue has not been addressed particularly.

The report criticises targets, but we are not criticising the Government for setting them; we want to see how we can get to them. We say that interim targets might be helpful for those who have not necessarily understood the urgency that both the Government and the Parliament attach to the problem. I heard the minister's response on the HEAT target. Of course, 26 weeks is merely the outside figure and the overwhelming majority of cases appear to be dealt with in a shorter time. However, if that is the case, why do we not bring the target in? If only a minority of cases fail to meet the target and the overwhelming number are dealt with in a much shorter timeframe, does the Government really need to give the laggards a longer time period in which to come aboard?

The committee's report has helpfully and constructively raised issues to do with how we address mental health for children in a way that, I hope, will provide an additional framework that can be worked on. This is a continuing process, and the minister has engaged with the committee by saying that she will keep us apprised of developments. Our plea is that she do so on a regular basis in order that Parliament, through its committees, can be better informed as to how we take the matter forward.

All the speeches that we have heard today have been clear about the problems that can arise for people from an early age. We all know that the chief medical officer entirely shares that perspective, and we need to support him in his attempts to address those issues. The implications for society as a whole of failing to address those problems at the age of three and, perhaps, earlier, are grave.

This has been a constructive debate. The report was intended to be a constructive contribution, but it is also a contribution that, while recognising that we have a policy in place, calls for closer attention to be paid to why we continually fail to get a sense of urgency from those who are delivering on our behalf. Something is not right. Those at the coalface have not wholly bought into the process. That is the biggest lesson that we can learn from the report and from the debate.