1. Will the Minister provide an update on access to CAMHS inpatient care for high risk children and young people in Wales? 298

Thank you for the question. Hospitalisation is increasingly seen as a last resort and more young people now receive their care within their local community. To help meet the needs of young people who require in-patient care, we’ve invested £42 million in dedicated child and adolescent mental health service provision in Wales, leading to a reduction in those sent out of area.

The position on access was set out in my letter to the Chair of the Children, Young People and Education Committee on 25 February. A further update is due imminently to the Health, Social Care and Sport Committee, in response to the Chair of that committee’s letter of 7 March.

Thank you, Minister. I am deeply concerned that restrictions continue to be necessary at both CAMHS in-patient units in Wales, meaning that they are unable to care for young people who are at risk of suicide or self-harm. You will be aware that Healthcare Inspectorate Wales has again called for action on this in their report on services for children and young people, published just last week, and in doing so have emphasised that they’ve been raising these concerns since as long ago as 2013. My committee has been raising this with Welsh Government as far back as our ‘Mind over matter’ report last year.

I do understand that many more young people are now treated by teams in the community, but there are nevertheless those who do need admission to an in-patient unit. And it cannot be right that some of our most vulnerable young people have to be placed out of Wales, far more their families and support. It also raises serious questions about how we effectively ensure the quality and safety of such placements, which can be hundreds of miles away.

Minister, when can we expect our in-patient units to be in a position to admit young people at risk of suicide or self-harm? What assurances can you give in the meantime that there are robust and comprehensive processes in place for ensuring any out-of-Wales placements are safe and high quality? And, finally, given that predicting the risk of suicide is not an exact science, especially in a young person, what assurances can you give that a young patient who has not been identified as high risk will receive safe care in our CAMHS in-patient units?

Thank you for the follow-up questions. I do recognise the importance and the seriousness of this matter. Because we're not able to have full capacity, as we would otherwise want to, it's a combination of different factors in the north Wales unit compared to south Wales, but we think there are single figures of children and young people who have been placed outside of Wales because of those restrictions. So, single figures are small, but for each person there's a family and a context, and that's not the sort of care and the location of care that we want to be able to provide. It's not what the investment we've made and the capital is supposed to provide either.

On Tŷ Llidiard, specifically, that you mention, you'll be aware that we do need to make improvements to the physical estate. Part of that work has been completed; the rest of that work is due to be completed within the year 2019-20. I'll happily write to the Member and both committees that take an interest in this to give a clearer indication of when that work should be completed.

On your broader point about—. If you like, two slightly different points. One on how we assure ourselves about the quality of care out of area and out of country: that is a real challenge and that's a challenge for the commissioners and the framework that is provided and that's monitored through a quality assurance and improvement service. They undertake site audits and monitor performance, and the Welsh Health Specialised Services Committee receive regular monthly returns from the two Welsh units that are currently providing care.

So, again, I recognise the point you make that you cannot always tell if someone is having suicidal thoughts. So, the challenge is about making sure that the quality of care is appropriate. That's part of the challenge about why we're not admitting some people into those units now where that is a known risk. But that's why there is regular reporting back to WHSSC, to the quality team, whilst there is an escalation process in place. And that is an enhanced escalation process—that is not the normal way of operating because we do have concerns about our capacity to safely manage care. It is not the position that I or anyone else would want us to be in. I will provide the updates I've indicated to Members and specifically to the committees, and I'll outline in more detail in my letter that I will be sending to the health committee—I'll make sure a copy goes to the children and young people's committee, because I recognise both subject committees are maintaining a direct interest in this matter—and will continue to do so until we're in a different position.

Thank you, Minister, for your statement. I'm delighted that Lynne Neagle has brought this issue up once again in this Chamber this afternoon, because, as you will know, there is a child and adolescent mental health unit with in-patient capacity in my own constituency, in the town of Abergele. It was built almost 10 years ago now, back in 2009, with a capacity of 18 beds, which was to serve the north Wales area, and, unfortunately, those beds have never been fully occupied or fully opened, and we still face individuals being sent many hundreds of miles away from north Wales when only 12 of the beds are currently commissioned at our own flagship unit.

Now, I'm sure that more people could benefit from this facility if it were up to full capacity in terms of its bed use. I'm sure there would be people who would be sent in to north Wales from outside of the north Wales area as well in order to occupy those beds if they were available. And I wonder whether you could give us an update today on what action is being taken by the Betsi Cadwaladr University Health Board to make sure that there are sufficient beds in north Wales for the young people who might need in-patient facilities in our own region. I accept there will sometimes be specialist cases where there's a need for some very specialist provision that cannot be accommodated in one of these more generalised units. I understand and accept that that might be the case from time to time, but, clearly, there are young people who could benefit from these facilities in Wales who are currently being sent over the border to England. We can easily monitor the quality and effectiveness of the care. There isn't the problem with the commissioners having to face the challenge of monitoring something hundreds of miles away. This is within Wales, this is within the Betsi Cadwaladr University Health Board. So, can I ask, will you be working with the health board in north Wales to increase the in-patient capacity at Abergele and what work is being done within the health board to recruit, if necessary, the extra health professionals in order to man those additional beds, should you be planning to open them?

There are two points there that I think I should respond to. The first is the point about the numbers of beds that we have. We're at commissioned capacity in Tŷ Llidiard. We're below commissioned capacity—and, actually, we're commissioning 12 of those potential 18 beds—in north Wales. That's partly about the complexity and the space needed, but it is also, partly, about staff. And so there are 10 beds commissioned and in use, and they have been able to move up to 12; they had to move back down to 10, because of challenges about recruiting staff to work permanently in the facility, so I recognise that staffing is an issue. And resource isn't a problem—it's not that the health board are refusing to put staff in or holding open the vacancies; it's about our ability to recruit people into the service. And so we're operating 10 beds because it's safe to do so.

The further challenge then is, I guess, about the number of commissioned beds in any event. Actually, at present, the guidance from the Royal College of Psychiatrists actually shows that we are above the level of population to beds that they suggest we have across the country. But, in terms of reviewing our capacity, then of course we'll be informed by the level of need, and to see how many people could be served. Because, as I said, I recognise that, because we have not been able to safely staff all of the beds that we have commissioned, single figures of children and young people from Wales have gone out of the country when they could otherwise have been in those facilities within NHS Wales. So, it is a real issue for all of those children and young people and their families, and so, yes, I'm determined to provide an update that you and other Members will expect—and the undertakings I've given to Lynne Neagle about making sure that both subject committees are kept informed of progress.

Can I associate myself with everything that Lynne Neagle has said, and Darren Millar, about the seriousness of the situation? The Minister says that the current level of capacity reflects the level of what we would expect from population, but, clearly, it doesn't reflect the level of need, if we continually have, for that very small number of young people, accommodation facilities outside Wales. Given that the Minister has told us that we think we're talking in single figures here, is there more that the Minister can do to increase the capacity and to ensure that the capacity is in the correct locations, as well as being safely staffed? Does the Minister agree with me that young people should only be being treated with these serious conditions outside Wales if their condition requires it—if their condition is so unusual that we simply could not—not only that we cannot at present, but that we simply could not—meaningfully provide for that very particular need within our own country? And, accepting everything that he's said today, that he will take steps to try to address this, there is a slight sense that we have, as Lynne Neagle said, been raising these issues for a number of years. But, if we are still in a situation where young people are being treated outside Wales—even if we all accept that that isn't what we want to see—what further steps can the Minister take to ensure that young people being treated outside Wales are appropriately monitored, that we know that their care reaches the standards that we here in Wales expect, and that they are regularly visited by appropriate professionals, as well as by their families, to make sure that they are as safe and as comfortable and, I would say, as happy as they possibly can be?

I think there were two questions there. In relation to the second one, about the model and the quality of placements outside of Wales, I think I dealt with that in response to questions asked by Lynne Neagle in her supplementary. And I'll certainly be addressing that to provide a written level of detail to the two committees, as I've indicated in the undertakings I've given in response to Lynne Neagle's questions.

On your other question, about capacity and need, I'm happy to give her—and all Members—the assurance that my expectation is that we should put ourselves into a position where NHS Wales only helps to place children and young people outside of Wales where it's their need that drives that, rather than capacity. And so we will, of course, need to look at the capacity that we have and to see that that is matching need. The guidance—it is guidance, as opposed to a hard-and-fast rule from the royal college—suggests that we have sufficient capacity, if we're able to sufficiently staff those. And it's actually north Wales where there's more of an issue about appropriate staffing. We will then be able to—with the commissioned capacity in Tŷ Llidiard, we expect that staffing isn't going to be a concern—make sure that all those beds are properly and safely staffed. So, I'm happy to confirm that this is not a matter of simply tolerating forever and a day the fact that people are being placed outside of Wales when it's not their care needs that drive that placement.

Minister, I think that many Members in this Chamber would have dealt with often distressing cases involving this particular aspect of care and we're talking about some of the most vulnerable young people in society. I've had experience of cases where the treatment plan has not, really, been very successful after in-patient admission and, in fact, repeat admissions have occurred and this is very, very disruptive. Also, the way parents and carers are involved in the treatment plans can sometimes leave something to be desired. When patients are exhibiting these very distressing symptoms, we really do need to ensure that, when the patients leave in-patient care, they're still getting very specialist treatment—intensive treatment—and particularly that the diagnostic work that needs to be done is done effectively, because, sometimes, there's real doubt as to the best pathway for these often very troubled individuals under great distress.

I recognise completely the points that the Member makes. I, as a constituency Member, have had casework and met families who are in a very, very difficult position and haven't felt well supported by the system. So, we have not just put resource—financial resource and more staffing—into the broad CAMHS service, but, of course, this goes into our earlier prevention and intervention work, as well as not just the response to 'Mind over matter', but actually the point about what support is available, after admission, for those people who have been in in-patient care.

The Healthcare Inspectorate Wales thematic report—the positive news is that, overall, they found that young people had predominantly good experiences of care, with staff who were compassionate and providing dignified and person-centred care. But that highlights again that it's possible and it's also why there's such a need for improvement for those people where we don't think that has happened and why I know that you'll have seen, and other Members will have seen, examples of where families do not feel that that has happened. So, that's work that carries on, not just in conversations between the Government and health boards, but actually between the health service and people who are using the service to understand whether we're actually meeting our aspirations. 

If the Member has individual examples of where families do not believe that has happened, I would always be interested in receiving details of those to actually be able to take them up directly with that part of the health service.

In relation to the case of Claire Greaves—the tragic case—this was obviously a case of anorexia as well as personality disorder from an early age. My interest is in trying to understand, as part of the eating disorders review, whether you are considering a discussion, a wider discussion, about an eating disorders in-patient unit or units in Wales, not directly as a consequence of this, but as a consequence of the calls, over many years, by patients and carers.

When Mark Drakeford, the current First Minister, was the health Minister, he said that he was intent on repatriating many of the young people who were in units across the border, and it may be that we can discuss the level of care in this case or we may not, but what's important here is that we have a level of provision in this nation of ours whereby people are close enough to their loved ones so that they don't feel that they're in these types of positions. So, I'm wanting to understand what you can do to ensure that we have an open debate about the possibilities of this added dimension that wasn't included in the initial framework because of the way in which the framework was delivered on that regional hub basis. I think the time has come whereby we do really need to revisit that model, not only for this case in itself, but for other young people across Wales who are in the same position.

Again, I recognise this is a real and serious issue. We know that many children and young people who access the CAMHS service and are treated—that eating disorders are part of the reason why they're actually in the CAMHS service receiving a specialist service. We have money to repatriate more people, but we recognise that we haven't done as much as we would want to. That point I was making, in response to Helen Mary's question, is about need not capacity being the driver for where people are treated. I will publish the eating disorders report that Jacinta Tan and the team of people, including people with eating disorders, have contributed to, and there'll obviously be a response. And I'm more than happy to have an open debate about the provision that we have, how that matches the provision that we think we should have, and how we get to a different place. So, I'm entirely open-minded about what we could and should be doing, and, as I say, the report will be published, and I know that you and other Members will have questions to ask and comments to make that I hope will be helpful in taking a better way forward. 

Thank you very much, Minister. Thank you. The second topical question this afternoon is to be answered by the Minister for Economy and Transport. Helen Mary Jones.