Lynne Neagle AM: Okay, thank you. If we can just move on now to in-patient care, and if I can just ask you what the programme has been doing to address some of the challenges and opportunities we face in terms of CAMHS in-patient care, particularly in light of the restrictions that are in place in Abergele and Tŷ Llidiard.
Carol Shillabeer: Yes, thank you very much for that question. Again, quite a lot of progress has been made in the early part of the programme around in-patients, and you are very well aware of the challenges over the last year or 18 months in relation to both units. I think, certainly, there is some recovery in the position in north Wales, and the programme did a peer review visit to north Wales, which I think was very helpful. In terms of where the programme has been on this issue, there is some work under way, at quite an advanced stage, around the art of the possible around enhancing the scope of the services. This was quite a tricky thing to start off when you're in a position where, actually, there've been some restrictions, to then ask the service to think about going even further, but we really wanted to see what the art of the possible would be if we could attract the right workforce, get the right environment, et cetera, et cetera—so, that piece of work, the review of the specification about what could be possible. Clearly, we work very closely with Welsh Health Specialised Services Committee as the commissioner, so we don't commission that. We neither performance manage those environments. But, if I can just say, probably the most important part of moving forward now is the longer term work between health and social care in terms of having a much more integrated and joined up approach for children. We believe there would probably be about 100 children who have experienced care in multiple settings. We haven't got that mature approach in terms of these being joined-up teams; we've got social care and we've got healthcare. There is a growing appetite to do something different. There is a meeting with the children's commissioner on 9 July to explore that. I've previously had conversations with the chief inspector of Care Inspectorate Wales, for example, and we have now got, I think, a consensus growing that we need to do something very different for children and young people who are in this sort of need for the future. We also know that there've been some high-profile legal cases as well. So, we've got to move to that step now. It has been largely successful, the work that has taken place over recent years, but not without its key challenges.
Lynne Neagle AM: Thank you. And, just briefly on the new specification that WHSSC are developing, that will enable admissions at weekends and out of hours. How concerned should we be about that being a challenge, particularly in Abergele, where staffing has been a major issue?
Carol Shillabeer: Yes. I think we need to be very mindful of ensuring that the right workforce are in place before that gets implemented. The peer review highlighted the challenge of the physical environment, where the unit is, the challenge across north Wales of the workforce. These are issues well known by the health board, by the way, so it wasn't a surprise to them. But that dialogue about how do we ensure that we've got the right workforce, because that unit, potentially, could—you know, it's an isolated unit, and they’ve been risk-managing. They've been managing the types of young people that they can take bearing in mind the workforce that they've got available, and that's been entirely the right thing to do. But the downside of that is it's not as accessible as we would want.
Lynne Neagle AM: Okay, thank you. Hefin David has got some questions on workforce now.
Hefin David AM: Yes. With regard to the increased CAMHS posts that have been made available between 2016 and 2018—a 62 per cent increase in CAMHS posts—we know that there's likely to be labour market demand, high labour market demand, in those instances, so are the vacancy rates higher in Wales than elsewhere, given the increase in those posts to be filled?
Carol Shillabeer: So, you're absolutely right. There's been quite a lot of investment, and there have been quite a lot of new recruits coming to the service. We had in the early days a situation where we were largely robbing Peter to pay Paul, to be quite frank. So, as new services were being developed, people would move from one part of the system to the other. So, in the early days there was little net gain. That has improved slightly, but we're in a national context, particularly around nursing and around some specialties in medicine, of a national shortage, so this is not a quick fix. We are starting to see a greater diversity of workforce. So, if I can mention psychology assistants, for example, my own health board is employing more psychology assistants as part of a skill mix team, rather than going to where we might have been more traditionally based. We see some of that through the NHS benchmarking, particularly with England. They have more of that. We're perhaps a little bit—
Hefin David AM: More of what?
Carol Shillabeer: They have more skill mix in their workforce. We're catching up a bit more on that now.
Hefin David AM: Just to clarify there, what you're referring to—there are more nursing and medical staff in the Wales system and more psychological staff, experts, in the UK picture. Is that—?
Carol Shillabeer: In the England picture. So, England had a programme called IAPT, which is about psychological therapies, and had therefore looked at the skill mix. Some of that was—. We've chatted to colleagues in England, trying to learn—we're all trying to make improvements in this area, of course; it's a UK and international issue—what were their experiences of this psychological therapies approach. Because of their vacancies they had to skill mix, and because of the money that they had available—they didn't have as much of a cash injection as perhaps we've been able to secure. So, they skill mixed much earlier; we're skill mixing now. We're using different types of roles, for example. And if I can just make a plea, really, around recognising the input of the third sector—so, it doesn't always have to be an NHS-employed person to work in service provision, direct front-line service provision, and the third sector are offering a significant contribution in a number of areas of our services. And that is one that we will need to cultivate, because, to be quite frank, our recruitment challenges won't be solved overnight. We've recognised that the commissioning numbers for nursing and other professionals have gone up over recent times, but, with the training time, it's not a quick fix.
Hefin David AM: Does the workforce profile remain different, or are they starting to—?
Carol Shillabeer: They're starting to come together. There is a—graph 13 in terms of the CAMHS profile. Each year we do the NHS benchmarking, and we can see where we are compared to others, and I would expect over the next year or two that we see a bit more narrowing.
Hefin David AM: So, if you compare a child in Wales with a child in England in the last two years who's been through this, would they have had a different experience as a result, and different clinical advice as a result, or is there consistency despite the difference in workforce profile?
Carol Shillabeer: That's quite a big question. Hand on heart, could I tell you I absolutely know the detail of that? No, I couldn't. The practice in this area is guided by National Institute for Health and Care Excellence guidance, so it's pretty much guided. We would expect all of our practitioners to be able to work to NICE guidance. When you skill mix a team, you enable the right referrals to go to the right person, so you wouldn't necessarily have a child or young person with particularly complex needs—well, you would match them to the right practitioner for their needs. So, it does—. And we've seen some of that; if I just make reference to the panel approach in Gwent that's been developed, a multi-agency panel come together, a referral comes in, it's then about matching the right service and the right person to the needs that are being presented. So, we can be much more flexible in relation to that, and we have to be careful to use the right resource for the right person, because, if we've got a resource that is highly specialist, we want them to be dealing with those children and young people.
Hefin David AM: And one of the things you're able to do—because there's a lot about the labour market you can't control, but one of the things you can control is workforce development and ongoing workforce development. You've mentioned communities of practice. What other things are being done in addition, and how do the communities of practice work might be a good question, but what else is being done in order to upskill and develop and grow the existing workforce that is presented to you?
Carol Shillabeer: Thank you for that. So, there's a couple of things around—. I think there's a huge focus on staff retention now, not just in Wales but across the UK. So, we've got recruitment but we've got retention. What are the factors that affect retention? Actually, well-being, well-being at work—and you'll know that within 'A Healthier Wales' the focus on staff engagement, staff well-being, has been laid out—the ability to work well in teams and the culture of organisations and services, and, then, as you rightly say, training and development and career opportunities. So, the developments over the last few years have brought training opportunities and career development opportunities as well. I think the community of practice—it's something that has become a bit of a standard now across these areas—actually brings people together doing collective audit, doing collective reflection on service improvement, and being very clear about learning from one another. And, if you're a clinician, that gives you a lot of motivation to keep driving forward. So, I think we have the fundamental building blocks in place, but there is more to do around the environment in which our practitioners and our staff operate.
Hefin David AM: What about the Welsh language in the health board?
Carol Shillabeer: Thank you very much. There are two elements, if I may, just on that. In your report of last year you highlighted the need to do further work on the use of the Welsh language, and have we got enough Welsh language practitioners where we need them. We are doing that piece of work. I'm pleased to say that, over the last few years, I think all health boards have really stepped up in terms of being able to understand the levels of Welsh speaking amongst employed staff and where their Welsh-speaking communities are. We're particularly looking at it in terms of in-patient CAMHS and community intensive services, because, particularly when people are feeling at their most vulnerable, they would choose the language they wish to choose. So, we know we need to respond to that. So, we will be in a position to, by the end of this programme, provide that position statement on what happens next. I would also say, of course, we've got the Welsh language standards that we are all working on at the moment, and we've got a very clear programme of when we have to be compliant with those standards. So, that element is very high on the priority list.
Hefin David AM: Okay.

Summary: Carol Shillabeer answered Lynne Neagle's question by introducing the progress of the in-patient care programme and the challenge of the workforce. Carol personally recommended employing more psychology assistants as part of a skill mix team and indicated communities of practice to make the best use of the resource. Finally, as for the language, there was an agreement on the use of the Welsh language and the need for enough Welsh language practitioners to respond to vulnerable people.