The Review of Safeguards for Children and Young People Treated and Cared for by the NHS in Wales

"Too Serious a Thing"

"A child’s nature is too serious a thing to admit of its being regarded as a mere appendage of another being" (Charles Lamb)

Further copies of this document are available from : Family Health Branch Primary and Community Health Division National Assembly for Wales Cathays Park Cardiff CF10 3NQ Tel : 029 2082 5840 The National Assembly for Wales Internet Site : www.wales.gov.uk Contents Foreword 1.SETTING THE SCENE 1 Recommendations 4 2.THE HISTORICAL CONTEXT AND RECENT DEVELOPMENTS 6 IN THE NHS STRUCTURE 2.2 Background to the Review 6 2.9 The Structure of the NHS in Wales 7 2.12 Independent Contractors 8 2.13 Current Structure of Child Protection 8 in the NHS and Published Guidance 2.16 Children’s Commissioner 10 2.17 Cabinet Sub-Committee on Children and Young People 10 2.19 Recent Proposals 10 2.25 The Effect of Change 11 Recommendations 12 3 VULNERABLE PARTS OF THE NHS 13 3.11 Human Resources Policies 14 3.14 Paediatrics 14 3.17 Registered Children’s Nurses 15 3.18 Children’s Community Nurses 16 3.22 Prison Health Services 16 3.24 Use of Agency, Bank and Locum Staff 16 3.36 Recruitment of Staff from Abroad 19 3.38 Accident and Emergency Departments 19 3.43 Services for Young People who Use or Misuse Substances 20 3.47 Deliberate Self Harm (DSH) 22 3.49 Postmortem Examinations 22 3.50 Speech and Language Therapists 23 3.53 Radiologists and Radiographers 23 3.55 Play Specialists 23 3.56 School Nurses 24 3.60 Health Visitors 24 3.67 General Practitioners 26 3.78 Independent Dental Practice 28 3.81 Optometry 29 3.83 NHS Direct 29

i 3.89 Students 30 3.92 Transport 31 3.94 General Measures 31 3.98 Welsh Risk Management Standards 32 Recommendations 33 4. THE GWYNFA REVIEW 37 4.11 The Remit, Terms of Reference and Work of the Gwynfa 38 Group 4.16 Gwynfa 39 4.25 Cedar Court 40 4.27 The Allegations – The Nature of the Allegations 41 4.34 The Allegations against AB42 4.45 The Other Allegations 43 4.50 Responses to the Allegations – The Police Investigation 44 4.55 The Disciplinary Process 45 4.62 The Response of the NHS Trust then Responsible for Gwynfa 46 4.66 The Role of the Welsh Office Health Department 47 4.85 The Corporate Group 49 4.91 Subsequent Local Reviews 50 5. THE LESSONS OF GWYNFA 51 5.1 Introduction 51 5.3 Lessons for Policy 51 5.6 The Principles of Good Practice 51 5.13 The Professional Context 52 5.17 The Service Context 53 5.25 Lessons for Strategy – The All Wales CAMHS Strategy 54 5.30 Implementing the All Wales CAMHS Strategy 55 5.32 Post Abuse Services 55 5.35 The Role and Client Group of Psychiatric Inpatient Units for 56 Adolescents 5.42 Application of the Strategy to Developing Child 57 and Adolescent Mental Health Services in North Wales 5.46 Training and the Workforce 57 5.50 Lessons for Service Leadership and Management – Board 58 Accountability for Children in the NHS 5.53 Leading and Managing Directorates 58 5.59 Clinical Governance 59 5.65 Lessons for Operational Leadership and Management - 61 Avoiding Isolation

ii 5.76 Leadership and Management at the Service Delivery Level 62 5.81 Regulation 63 Recommendations 63 6.BUILDING REALITY FROM POLICY 67 6.3 Child Protection Policies and Procedures 67 6.8 Current Multi-Disciplinary Working 68 6.23 Information Sharing 72 Recommendations 74 7.OLD VIRTUES IN NEW STRUCTURES 76 7.2 Designated and Named Professionals in Child Protection 76 7.11 The Children’s Commissioner for Wales 78 Recommendations 79

8.CHILDREN IN NEED AND THOSE CARED FOR 80 AWAY FROM HOME 8.19 Secure Non-NHS Provision for Children 83 Recommendations 84 9.INFORMATICS: WARNINGS AND RECORDINGS 86 Recommendations 88 10.EMPLOYMENT: RECRUITMENT PROCEDURES: 89 TRAINING 10.4 Recruitment Procedures 89 10.13 Registration Bodies and Disciplinary Records 91 10.18 Agency, Bank Staff and Locums 91 10.20 Staff from Abroad 92 10.21 Induction Training 92 10.22 Board Members 92 10.25 Continuing Development of Staff 92 Recommendations 93 11.POLICE CHECKS 95 Recommendations 98 12.DISCRIMINATION, RIGHTS AND ADVOCACY 99 Recommendations 104 13. HOSPITAL BASED AND SPECIALISED 106 MEDICAL CARE FOR CHILDREN 13.1 Welsh Background 106 13.2 Learning from Bristol 106 13.3 Paediatric Services across Wales 107 iii 13.6 Tertiary Services 107 13.7 Admission of Children to Adult Wards 107 13.9 Adolescents 108 13.12 Physical Security of Hospital Based Services 108 13.13 Surgical Services for Children 109 13.14 Children with Profound and Multiple Disability 109 13.15 Services for Post Natal Mental Illness 110 13.16 Shared Care Model 110 13.17 Adaptation of ‘Learning from Bristol’ to Wales 110 Recommendations 111 14.CHILD AND ADOLESCENT MENTAL HEALTH 113 SERVICES (CAMHS) 14.5 Progress Made by the National Assembly for Wales 113 14.20 Improving Care and Accountability – Implementing the All 116 Wales Strategy 14.23 Commissioning the Service Developments 116 14.27 The Four Tier Strategic Framework 117 14.30 Developing the Contribution of Primary Care to Tier One 118 14.40 Admission of Young People to Wards for Adult Patients 119 14.44 Provision of Secure Services 120 14.47 Very Challenging Behaviour 120 14.52 Integrating Specialist CAMHS with Other Healthcare Services 121 14.61 Risks of Abuse in CAMHS 123 14.64 Appraisal and Mentoring 123 14.66 Workforce Development – Recruitment, Retention and Training 124 14.70 Nurses in CAMHS 124 14.72 Child Clinical Psychologists 125 14.73 Child and Adolescents Psychiatrists 125 14.74 Transfer of Staff 125 14.75 Therapy Mix 125 14.77 Positioning CAMHS in the NHS – The Issues 126 14.83 Managed Clinical Networks 127 14.86 The Mental Health Act 1983 127 14.88 Customer Research 128 Recommendations 128 15.AN ABUSE PROOF SERVICE? 130 15.6 Whistleblowing 130

iv 15.7 Assembly Responsibilities 131 15.10 Public Understanding 131 15.11 Priorities – "Nothing less than" 131 Recommendations 132 CARLILE REVIEW RECOMMENDATIONS 133 Putting Children at the Centre 133 Leading From the Front – Strategic Leadership and Management 134 Effective Structures in the NHS – Operational Leadership and 137 Management People Principles – Recruitment and Selection 140 People Principles – Education and Training 141 Achieving and Maintaining Standards – Clinical Practice and 143 Delivery Making the Difference – Quality Counts for the Safety of the 145 Child – Continuous Quality Improvement Sharing Information to Achieve Outcome 146 ANNEXES 147 Panel Membership 147 Terms of Reference 149 Guidance Issued to the NHS in Wales in Respect of 150 Child Protection Children’s Commissioner for Wales Initial Functions under the 154 Care Standards Act 2000 National Assembly Child Protection Committee (NACPC) 155 Terms of Reference Gwynfa Sub Group – Terms of Reference 156 Sub Group’s Working Methods Managerial Responsibility for Gwynfa 1974 – 2001 158 Caldicott in Context 159 Child and Adolescent Mental Health Services 170 and the Four Tier Strategic Concepts Written Submissions 173 Oral Witnesses 177 Review Site Visits 2001 179 School Visits and Public Meetings 2001 180 Bibliography 181 v FOREWORD BY JANE HUTT AM, ASSEMBLY MINISTER FOR HEALTH & SOCIAL SERVICES

I was shocked when I first heard about the allegations of abuse at Gwynfa, the former NHS inpatient clinic for children and young people with mental health problems. Young patients have the right to expect to be safe while in the care of the NHS. I was therefore anxious to ensure that consideration was given to the circumstances that had permitted the abuse to take place. I asked the Review Panel to consider the appropriate lessons from Gwynfa and the North Wales Child Abuse Inquiry generally and to make recommendations so that proper safeguards could be in place whenever and wherever a child had contact with the NHS. The Review Panel was asked to undertake a huge task as every child in Wales has contact with the NHS. I am grateful for the manner in which the Panel rose to the challenge and the co-operation offered by the NHS, local authorities and voluntary bodies. This demonstrates the importance that we all attach to the safety of our children. The result has been a thorough and complete consideration of the issues connected with the safety of our children when they are most vulnerable. What emerges from the report is a clear message that child protection is a matter for us all. It is important that proper safeguards are in place, of course, but the best safeguard is the constant vigilance of every member of staff, parent and adult. Those who perpetrate abuse are constantly looking for opportunities and we must be equally vigilant. The NHS has, however, an important role to play in both the prevention and detection of child abuse. This report outlines the ways in which it can best perform these roles. Some of the recommendations contained in the report will be reasonably simple to implement, and others that will require more planning. It is my intention that with colleagues in the NHS we will commence work on the execution of this task with enthusiasm with a view that at the end Wales will have a safe and secure NHS for all our children.

Jane Hutt AM

vi 1.SETTING THE SCENE

1.1 This Review was announced in September 2000 by the Minister of Health and Social Services in the National Assembly for Wales. The Review Panel was appointed by the Minister. The members and professions of the Panel are set out in Annex 1. 1.2 We were commissioned to review the safeguards for children, and to recommend any necessary changes of policy for the safety and protection of children in the NHS in Wales. Our primary function, therefore, is to review policy rather than events. The cohort of children within the Review’s remit is very large - every person under 18 years old who, within Wales, is in receipt of or liable to need National Health Service provision at any level; and every child from Wales whose healthcare is provided outside Wales as part of their NHS treatment. Although the review is exclusively aimed at NHS service provision in Wales, we expect independent providers of healthcare to subscribe to the same standards. These should, where possible, be enforced through inspection and registration mechanisms. 1.3 On the 30 June 2000 there were 705,179 children resident in Wales: they formed 23.9 percent of the country’s population. Almost every child receives almost all their healthcare through the NHS, albeit not always in NHS arrangements or establishments. Where provision is made under contract to the private sector, such provision falls within the range of our Review. 1.4 That the NHS provision for children should be safe from abuse and injury is self-evidently for the good of society, and a pre-requisite for the development of balanced and fit adults. 1.5 The historical background for the establishment of the Review is set out in Chapter Two. The root concerns behind its establishment arose from the evidence and conclusions of the North Wales Child Abuse Inquiry ‘Lost in Care’ chaired by Sir Ronald Waterhouse1. During the Waterhouse Inquiry, evidence was given by former clients of Gwynfa2, which was situated in Colwyn Bay and for many years provided inpatient psychiatric provision for children and adolescents with a mental disorder or mental health problems. As part of this Review’s process, the Minister asked us to examine the management processes at Gwynfa, and to use the conclusions of that examination as a case study to inform the Review as a whole. 1.6 Our terms of reference are set out in Annex 2. They are extremely broad. They include every entry by a child into the scope of the NHS. We have had to look at the full range of provision. By way of example only, this includes GP and other primary services such as accident and emergency departments, school nursing services in their currently diverse forms, hospital referrals of every kind, dentistry, optometry, hospices, facilities for children with disabilities, and the needs of ethnic and religious minorities. Because of the vastness of the range, and in order to complete our task within a reasonable time, we decided at an early stage that we should exclude from our work aspects of children’s safety arising from the physical condition of NHS premises and the plant and equipment contained in them. Nor have we considered safety in the sense of the clinical effectiveness of treatments: that subject has been covered extensively in ‘Learning from Bristol’, published in July 20013.

1 Waterhouse R, Clough M, le Fleming M, 2000, Return to an Address of the Honourable the House of Commons dated 15 February 2000 for the Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974, Lost in Care, HC 201, London: Stationery Office 2 See paragraphs 2.2-2.6 3 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol - the report of the public inquiry into children’s heart surgery at 1 the Bristol Royal Infirmary, 1984-1995, CM 5207, London: The Stationery Office 1.7 So far as economic issues are concerned, we have conducted no exact economic measurements of our proposals: they are based entirely on the merits of the factors we have considered, though we have attempted to use our combined experience to be thoroughly realistic as to what can be achieved by government given the very broadly consistent approach by successive governments to health economics. 1.8 Unlike the Waterhouse Inquiry, our terms of reference did not include the responsibility for examining individual cases of allegations of abuse. In our working programme we established an appropriate system for dealing fully, and outside this Review, with any such allegations as were brought to our notice. 1.9 Like Waterhouse, we have employed an evidential system of obtaining the information necessary to inform our conclusions. However, it has taken a different form, more suited to our purpose. We gathered evidence by four methods. First, we advertised for and received plentiful written responses from the public, professional and consumer bodies, NHS commissioners and providers and others. These revealed many excellent written policies, protocols and procedures: at an early stage we recognised the existence of multiple and synonymous documents of that kind. Similarly, we took account of the various government and Welsh Office documentation, issued over the years, advising on the care and protection of sick and disabled children. Second, in order to ascertain whether the written wisdom had been received and applied, we visited many establishments providing NHS treatment in Wales and a few in England. We were looking for factual illustrations of the extent of precautions to exclude abuse of children from the NHS. There are many examples of good practice. There were severe disappointments too: often these were places where one might have expected the awareness to be high of the possibility and potentially devastating consequences of child abuse, yet where hardly a thought had been given to the subject. Third, we visited schools and held public meetings, in an attempt to widen the range of the contributions to our process. As a result of the openness of the children and the excellent organisation by staff, the pupils of the large comprehensive schools that we visited provided some of our most valuable insights4. Fourth, we invited many of those who had made written submissions, and some others, to give oral evidence to sittings of groups of members of the Review panel on subjects of particular relevance, interest or concern. 1.10 The four forms of evidence gathering described in paragraph 1.9 have provided a full set of information from which to draw our conclusions. In our plenary sessions the Review Panel, which included a wide range of experts from across the relevant caring disciplines, has been able to reach firm conclusions based on a clear consensus. 1.11 As the Review developed, so did the sense of responsibility of its panel members. We came to realise that we were attempting to provide the Sylfaen, the foundation stone, for a complete revision of the protection of children from abuse in the NHS in Wales. We realised too that although good systems are a sound method of avoidance of child abuse, there is a considerable gulf between theory and everyday practice. Our overriding objective has developed into that of attempting to provide a Report that can act as a template for the managers and clinicians at every station of the NHS.

4 Alun School, Mold; St Cenydd’s, Caerphilly, Queen Elizabeth Cambria, Carmarthen

2 1.12 At the heart of our work is the need to recognise, understand and apply some fundamental human rights. We have been conscious throughout that recent changes have included the ‘Human Rights Act 1998,’ which incorporated the European Convention on Human Rights into our domestic law. This legislation has required anxious consideration in connection with sharing confidential information such as medical and local authority records about children: see Chapter 6. 1.13 Of especially fundamental importance is the UN Convention on the Rights of the Child5. This seminal document in the field of human rights is founded upon the proposition that childhood "is entitled to special care and assistance". Article 3 provides that States "undertake to ensure the child such protection and care as is necessary for his or her well-being … and shall take all appropriate legal and administrative measures". Most important, Article 19 provides that States "shall take all … measures to protect the child from all forms of physical or mental violence, injury or abuse … including sexual abuse"; and Article 20(1) provides: "A child temporarily or permanently deprived of his or her family environment, or in whose best interests cannot be allowed to remain in that environment, shall be entitled to special protection and assistance provided by the State.’’ 1.14 These rights form the basis of the guiding principles, requirements and guidelines set out in ‘The Health of Children in Wales’6 and covering hospital care in more detail, ‘Welfare of Children and Young People in Hospital’7 guidance which has, as yet, only been partly and unevenly implemented across Wales. In our view their full implementation would go a long way in ensuring the well being and protection of children and young people. Our recommendations add individual reinforcement to some of these guidelines. 1.15 Additional and specific provisions concerning health reinforce the general rights in the Convention. Matters relevant to mental health appear in Article 23. Article 24 recognises the right of the child to "the highest attainable standard of health". We must therefore look upon children receiving clinical care as the ‘owners’ of a wide range of fundamental rights enforceable not only as a matter of decency, nor merely as part of domestic law. The right of children not to be abused, or at least to be given special protection from abuse by the State, is a matter of international law and treaty obligation. International law has recognised that the nature of a child is too precious and serious to be appended to the rights of others. Indeed, we recognise the importance of health services not only in ensuring safety for children but also in enhancing their well being. Thus we have tried to ensure not only that our proposals will minimise bad practice but will promote good practice. A minimum target is to ensure that all children’s services reach an acceptable level. 1.16 It is imperative that the development of procedures to minimise bad practice do not themselves inhibit good practice. For example, one response to recognising that at times adults have assaulted children is to impose practices that reduce physical contact between child and adult. Demanding non tactile caring arguably is itself abusive: adults, in particular those caring for sick children, must be able physically to hold and comfort, but must do so in ways that treat children properly.

5 United Nations Convention on the rights of the child , 1989, General Assembly Resolution Document A/RES/44 6 The Welsh Office, January 1997, The Health of Children in Wales :The Welsh Office 7 The Welsh Office, 1991, Welfare of Children in Hospital :The Welsh Office 3 1.17 In our view, abuse is not only that directly given and received. In preparing our Report we have reflected that, in recent years, it has been realised that the negligent or incompetent failure to detect, warn of or prevent abuse can be seen as abusive in itself. 1.18 There is no scientific basis for measuring with anything approaching accuracy the number of children abused, whether in the NHS or elsewhere. There are numerous recorded events of children being abused and it is unfortunately certain that it may happen at any time; when it happens, it can be in the most unexpected places and by ostensibly the least likely persons; though the risk of it happening is low, the price in terms of the disturbance to lives and minds is high; and that there is a need for constant vigilance. We deal with the importance of whistleblowing in Chapter 15. 1.19 We have reminded ourselves that staff have rights too. We are conscious of the problem of false reporting, of the often more insidious risk of confabulation of serious allegations from minor circumstances, and of the stigma felt by staff even when cleared of untrue allegations. Employers owe their often ill- remunerated staff the duty to provide well-researched human resources policies to deal with these problems, and appropriate support in ensuring that in disciplinary procedures they have a fair hearing within a reasonable time of any allegations, in accordance with Article 6 of the ‘European Convention on Human Rights’. Staff recognise that, in any risk assessment, primacy will be given to the safety of the child: in making that assessment there must be a proper level of sensitivity to the vulnerability of staff. 1.20 We adopt the sense of purpose conveyed by the title and text of Lord Nolan’s recent report on child protection issues in the Roman Catholic Church ‘A Culture of Vigilance’8. This term implies ongoing awareness, training, monitoring and development of a subject regarded as important by the host organisation. If a culture of vigilance could be achieved, there would grow the motivation to implement training and procedures across the NHS in Wales to enhance the protection of children. 1.21 One aspect of such a protective strategy is clarification for children and families of what is to be expected from services. In later sections, we outline the implications, proposing publication of information on rights, expectations, standards and sources of advice. 1.22 Nobody should conceive of a credible organisation treating children’s health without the culture of vigilance. Our observation and evidence have led us to the conclusion that child protection does not receive a sufficiently high profile among all NHS practitioners and managers, and that there is a serious and discernible lack of consistency. Even as we set the scene for our Review, we were able to reach some basic conclusions.

Recommendations 1.23 We recommend that all staff having access to children should be trained to a full understanding of children’s rights and an appropriate level of awareness of the needs of children, and that they should be required by their employers, as a matter of specific contractual obligation, to respect and apply those rights rigorously. (Paras 1.13, 1.14, 1.15, 1.20)

8 Lord Nolan, 2001, Review on Child Protection in the Catholic Church in England and Wales, First Report, Catholic Bishops’ Conference of England and Wales 4 1.24 We recommend that a small number of accurate and comprehensive policies and protocols on child protection should be agreed on an All Wales basis as the recognised guide to good practice. These should be reviewed regularly and systematically. They should be disseminated in a routine and efficient way. (Paras 1.09, 1.22) 1.25 We recommend that all NHS service providers should develop improved human resources policies that include: systemic methods of investigating allegations of abuse; acceptance by staff and managers of timely and efficient disciplinary procedures (sometimes necessarily including suspension) as the means of investigating abuse and determining whether it has occurred; and the provision of proportionate advice and assistance to accused staff to deal with allegations and hearings. (Para 1.19)

5 2.THE HISTORICAL CONTEXT AND RECENT DEVELOPMENTS IN THE NHS STRUCTURE 2.1 This chapter looks at the reasons why the Review was set up. It examines the structure of the NHS and explains the current structure of child protection within the NHS and the guidance available to the NHS at the time the Review was taking evidence (February to July 2001). It comments on current policy initiatives and impending changes.

Background to the Review 2.2 The immediate background to the Review was the Tribunal of Inquiry into child abuse in North Wales. That Tribunal, which was chaired by Sir Ronald Waterhouse, was established in 1996. The report of the Tribunal ‘Lost in Care’ was published in February 20009. 2.3 The terms of reference of the Waterhouse Tribunal were to inquire into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974. Part of the methodology of the Tribunal was to seek out, by way of notices in newspapers and other publicity, children who had been abused while in the care of Gwynedd and Clwyd County Councils. In response to these notices, the Tribunal received allegations of abuse from children who had been patients at a NHS inpatient child and adolescent mental health unit in Colwyn Bay, North Wales. This unit was called Gwynfa and is described more fully in Chapters 4 and 5. Gwynfa, a NHS unit, fell outside the Tribunal’s terms of reference, though the issues raised were directly relevant. 2.4 The Tribunal was made aware by the NHS of other complaints that had been made from 1991 onwards directly to NHS bodies from former patients of Gwynfa and of the internal and police inquiries that had taken place. Notwithstanding the terms of reference referring to children in the care of the local authority, the Tribunal decided to take some evidence in respect of Gwynfa. The Tribunal received evidence from fourteen of the former patients of Gwynfa, of whom three gave oral evidence. 2.5 In March 1998, the Tribunal made a statement: "Each incident of abuse in relation to former patients of Gwynfa of which the health service bodies have been made aware, has been and will be the subject of close scrutiny by the relevant health service bodies in North Wales in conjunction with the Welsh Office, whether or not live evidence has been given to the Tribunal. The Tribunal has been assured that, if appropriate, action will be taken by way of disciplinary proceedings, referral to professional bodies, the police or by way of policy review". 2.6 ‘Lost in Care’ included a short chapter (chapter 20)10 on Gwynfa. The report contained 72 recommendations but none of these were specifically addressed to the NHS, although many of them could be read across to health settings from social service or educational settings.

9 Waterhouse R, Clough M, le Fleming M, 2000, Return to an Address of the Honourable the House of Commons dated 15 February 2000 for the Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974, Lost in Care, HC 201, London: Stationery Office 10 Waterhouse R, Clough M, le Fleming M, 2000, Return to an address of the Honourable the House of Commons dated 15 February 2000 for the Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 6 1974, Lost in Care, HC 201, London: Stationary Office, See Page 295 2.7 In response to the assurances that had been given to the Tribunal by the Welsh Office, action was taken on three fronts: • The then Secretary of State for Wales commissioned in June 1998 independent expert consultants Health Advisory Service (HAS 2000) to undertake an inspection of the two inpatient child and adolescent mental health units in Wales and of two adult psychiatric wards that occasionally admit children. A follow up inspection was commissioned in December 1999. Following this latter inspection, HAS 2000 concluded that there was considerable evidence that all agencies had worked hard and they were satisfied that adequate safeguards were then in place. • The Welsh Office took steps to ensure that the NHS was dealing properly with all outstanding allegations. • The Welsh Office issued ‘Welsh Health Circular (99)38’ in an effort to strengthen recruitment processes by commissioners and providers alike from the 1st April 1999. 2.8 Having received the Tribunal’s report ‘Lost In Care’ and the HAS 2000 report, the Assembly Minister for Health and Social Services determined that a thorough policy review was needed, to ensure that the highest standards of child protection apply in all parts of the NHS and she invited Lord Carlile to chair this Review.

The Structure of the NHS in Wales 2.9 The NHS in Wales has been subjected to repeated change and re-organisation over the last two decades and a further change is in prospect under ‘A Plan for the NHS with its Partners – Improving Health in Wales’12 published in February 2001. This plan proposes the abolition of health authorities, and the establishment of local health boards to replace local health groups but with expanded responsibilities. The implications of these changes for the protection of children are explored further throughout this Report. 2.10 The structure of the NHS set out here is as at the time when the Review was gathering evidence in 2001:

The National Assembly for Wales

The National Assembly for Wales has responsibility for health at a national level and for policy, resource allocation and performance management of the NHS. The Minister responsible for the NHS is the Minister for Health and Social Services. The management and administration is dealt with by the NHS Directorate led by the Director of the NHS Wales, and professional leadership is given by the Chief Medical Officer and the Chief Nursing Officer.

Health Authorities

Health authorities were formed as statutory corporate bodies. They are responsible for interpretation of policy through strategy. Their key role is to lead, shape and co-ordinate local health care systems. There are currently five health authorities in Wales and they commission health services in their area and have an important role in the protection and management of public health.

11 Welsh Office, 11 March 1999, Children’s Safeguards Review and ‘Choosing with Care’ 12 The National Assembly for Wales, A Plan for the NHS with its Partners – Improving Health in Wales, Cardiff : The National Assembly for Wales 7 NHS Trusts NHS trusts are statutory corporate bodies that provide health services to the public. There are 15 trusts that provide hospital and community services in their defined geographical area including 1 trust that provides ambulance services for the whole of Wales.

Local Health Groups Local health groups were established in 1999 and are formally sub-committees of health authorities. Local health groups are made up of a management board of 18 members and a smaller executive committee and are usually led by a GP chair. The responsible officer for the local health group is the general manager who is accountable to the health authority chief executive. The key roles of the local health groups in Wales are: • promoting health of the local population, in partnership with other agencies; • contributing to the Health Improvement Programme (HIP) to reflect the needs of the local community and then acting within this plan to improve health and health services; • developing and managing primary healthcare; • implementing a framework to support clinical governance within primary healthcare; • managing budgets such as those for drugs, GP staff and premises, which can be influenced locally; • integrating primary and community health services and working more closely with social services on planning and delivery; • commissioning secondary healthcare services from trusts in line with the HIP and monitoring trust performance against service agreements; and • consulting with the local community - LHGs are required to represent and to consult with the local population. 2.11 As relatively new bodies, the extent to which local health groups have fully taken on these roles has varied considerably.

Independent Contractors 2.12 All general practitioners, and the vast majority of dentists, pharmacists and optometrists are self-employed independent contractors, working under contract to the health authority and providing primary care services directly to the public.

Current Structure of Child Protection in the NHS and Published Guidance 2.13 There is an abundance of circulars, policies, guidance, protocols and other documents issued by the Welsh Office, the National Assembly and the various statutory bodies described above, which are responsible for their own areas. To a

8 greater or lesser extent each gives guidance to the NHS on child protection. Annex 3 sets out the guidance issued by the Welsh Office and the National Assembly as its successor. 2.14 Probably the two most important pieces of guidance are ‘Choosing with Care’13 and ‘Working Together’14. The former, is the report of the Committee of Inquiry into the selection, development and management of staff in children’s homes. This report was issued in 1992 and remains the current guidance in respect of recruitment, selection and appointment of staff. 2.15 ‘Working Together to Safeguard Children’, the most recent edition of which was published in September 200015, is aimed at all agencies and professionals who work with children. It sets out how agencies should work together to promote children’s welfare and to protect children from abuse and neglect. There are a number of key messages: • Social Services Departments are the lead agencies in matters of child protection and concerns over child welfare should be reported to them. • Each local authority area should have an area child protection committee (ACPC) which is an inter-agency forum for agreeing how the different services and professional groups should co-operate to safeguard children in their area. The local authority has the lead responsibility for the establishment of and effective functioning of the ACPC. • Each health authority should identify a designated paediatrician and a designated senior nurse with a health visiting qualification, to take a professional lead on all aspects of the health service contribution to safeguarding children. They should be a significant source of strategic advice and support when informing planning and policy. They are required to play an important role in promoting and influencing training, providing skilled professional involvement in child protection processes and participation in case reviews. • Each NHS Trust should identify a named doctor, a named nurse and, where relevant, a named midwife to take a professional lead within the Trust on child protection matters. The named professionals provide an important source of advice and expertise for fellow professionals and have a leading role in promoting good professional practice. • Local health groups, when they commission services, should have clear service standards for safeguarding children and promoting their welfare. • GPs should take part in child protection training and have regular updates as part of their postgraduate education programme. They should ensure their staff attend training and know when it is appropriate to refer a child to social services. • Nurses, midwives and school nurses must be provided with child protection training and have regular updates as part of their post registration educational programme. Supplementary guidance (Child Protection: Guidance for Senior Nurses, Health Visitors and Midwives) is available and will be updated.

13 Department of Hea1th, Chaired by Norman Warner , 1992, ‘Choosing with Care’ The Report of the Committee of Inquiry into the Selection, Development and Management of Staff in Children’s Homes, London: The Stationery Office 14 Welsh Office and others, 1991, Working Together under the Children Act 1989, A guide to arrangements for inter agency co-operation for the protection of children from abuse: London : HMSO 15 The National Assembly for Wales, 2000, Working Together to Safeguard Children – A Guide to Inter agency working to safeguard and promote the welfare of children, Cardiff: The National Assembly for Wales 9 Children’s Commissioner 2.16 The ‘Children’s Commissioner for Wales Act 2001’16 received the Royal Assent on the 11th May 2001, and the first Commissioner, Peter Clarke, is in post. Plainly, the role of the Children’s Commissioner for Wales will have an impact on all types of statutory children’s service. His scrutiny, capacity to criticise, and ability to develop cases will stimulate efforts on all fronts to ensure more effective child protection. The functions of the Children’s Commissioner are attached at Annex 4.

Cabinet Sub-Committee on Children and Young People 2.17 The formation of this new Cabinet sub-committee, with a core membership of the 4 relevant Cabinet Ministers, is designed to determine policy priorities, identify and pursue cross-cutting initiatives, and ensure that children and young people are given due priority in all Cabinet and Assembly policy-making. Its tasks for 2001-2002 include taking forward its work on children in need in the context of the ‘Children First’ timetable, focusing on special educational needs and out of school learning, and developing the framework for partnerships and extending entitlement. 2.18 We express the hope that the sub-committee will be influenced by the views of children, through Llais Ifanc and other means. If consulted carefully, agencies of this kind are often wise advisers.

Recent Proposals 2.19 During the preparation of this Review, events in the NHS have moved on apace. July 2001 saw the publication of ‘Learning from Bristol’: this is the report of the 3 year Inquiry arising from the deaths of children, connected with heart surgery in Bristol. Like this Review, its terms of reference allowed it to examine some broader issues of general application. The report is encyclopaedic in its scope. Whilst recognising that implementation of some of its recommendations will inevitably be selective and gradual, we support the report and urge the National Assembly to establish a programme of implementation for Wales as soon as possible. Some of its specific recommendations are referred to later in this report17. 2.20 July 2001 saw, too, the emergence of two important consultative documents from the National Assembly. These were ‘Improving Health in Wales – Structural Change in the NHS in Wales’18 and ‘Improving Health in Wales – The Future of Primary Care’19. While these are consultative only, they give a clear indication of the thrust of government thinking towards legislative changes in NHS policy for Wales: we have taken these consultative documents into account in the preparation of this Report and, in particular, our recommendations. 2.21 We recognise and support the National Assembly consultation proposals for simplifying management and organisation into two formal tiers, local and national. It will be seen that this fits tidily with our proposals. We note with equal

16 This amends Part V of The Care Standards Act, 2000, London : The Staionery Office, which established the Commissioner’s appointment and initial functions. 17 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary, 1984-1995; CM5207, The Stationery Office. In particular see chapter 13 18 The National Assembly for Wales, 2001, Consultation Document, Improving Health in Wales – Structural Change in the NHS in the NHS in Wales, Cardiff: The National Assembly for Wales 19 The National Assembly for Wales, 2001, Consultation Document, Improving Health in Wales – The Future of Primary Care, Cardiff : The National Assembly for Wales 10 approval the intention to introduce new, effective, unambiguous lines of accountability between the National Assembly, local health groups and NHS Trusts, and the need to create appropriate new arrangements for public health. 2.22 The proposals referred to mean that local health groups are likely to enjoy a changed function and responsibilities from 2003 onwards, and to be known as Local Health Boards. The local health boards will be a much-enriched development of local health groups, and their potential will be greater. Their coterminosity with local authority areas will enable them to develop the local health and social agenda in a way that may be unique to that area. The particular proposal that there be a pilot in Powys, involving a local health board to replace all the functions of the existing health authority and NHS trust, provides an especially interesting template for co-operation between services. In Powys, it is to be hoped that the local health board will feel vigorously empowered, in conjunction with other providers of services to children, to be flexible and unifying in moulding local services to local needs. 2.23 There will need to a major cultural change in the re-organised NHS if the recommendations of this report are to be implemented. This report requires the welfare of children to be out very firmly and centrally on the agenda. To convey our advice into a real and sustained difference will require major organisational development. 2.24 An important aspect of the proposed changes will be the development of strengthened partnership at national level. The Health and Well Being Partnership Council, to be chaired by the Minister, is proposed as the method of bringing together key players from the NHS, local government and the voluntary and independent sectors, together with staff, professional interests and patient representatives to ensure the overall direction and leadership of the new agenda for health and well-being. This proposal could only be for the benefit of children in the NHS, provided that child health and child protection are taken as specific agenda items regularly.

The Effect of Change 2.25 We understand the need for change from time to time in NHS structure and provision, and hope that the changes introduced as a result of primary legislation in the 2001-2 session of Parliament, and implemented by the National Assembly, will prove effective and successful. However, the Review Panel is unanimous in its view that we should make a plea for consolidation thereafter rather than yet more reform. Almost constant reconstruction of NHS structures and policies has occurred since 1974. It saps the intellectual and physical energies of managers, disrupts and disconnects networks, and runs the risk of demoralising clinicians and other staff. Few in the present age can make long-term assumptions about job security. But for the sake of children it is important, and for a few children vital, that well-considered policies and functions should have continuity. Constant change is the enemy of continuity. 2.26 Furthermore, the requirements to improve collaboration between agencies, partnership between departments and teamwork between individual practitioners all call for greater stability than has been the case in the statutory sector services in the last two decades. As we shall show later in this report, the answer to problems of collaborating across boundaries is not provided by re-organisation.

11 2.27 The recommendations in paragraphs 2.28-2.31 below are drawn from evidence of the way the present structures operate, and from our analysis of the consequences of the reforms currently taking place.

Recommendations 2.28 We recommend that, following the current round of reform, government policy towards the NHS in Wales should be founded on a presumption against further major change unless it is clearly necessary to improve clinical effectiveness and the safety of patients. (Paras 2.25, 2.26) 2.29 We recommend that the effect of the devolution of power to Wales, and the increase in democratic accountability consequent upon the creation of the National Assembly, should be taken fully into account in the formation of child protection policy. In the light of this, we recommend that ‘ownership’ of child protection policy should be seen as a national responsibility, though functionally devolved to the different parts of Wales. The reasoning behind policy and the force for its implementation should come from the National Assembly, which should be the foundation upon which robust child protection policies are laid. There should be an audit-capable consistency of approach and delivery at functional level. (Paras 2.20, 2.21, 2.22) 2.30 We recommend that the strategic management of child protection in the NHS in Wales should come from the National Assembly. (Para 2.24) 2.31 We recommend that civil servants implementing the recommendations of this report and any policy connected with child protection should be trained in child protection issues; that the National Assembly’s Child Protection Committee (NACPC) should develop transparent and formal links with the Cabinet Children’s Committee; and that links with Welsh education, social and police services should be a routine part of the consultative processes of all concerned in policy development and implementation in respect of child protection in the NHS. The Terms of Reference of the NACPC are attached at Annex 5. (Paras 2.17, 2.21)

12 3.VULNERABLE PARTS OF THE NHS

3.1 During our investigation we became aware that there are parts of the NHS in Wales with distinct vulnerabilities. Those vulnerabilities could put children at risk of abuse within the service, or of poor recognition of abuse by the service. 3.2 There are many and overlapping causes of weakness in NHS provision for children. A chronic issue is the shortage of trained staff. For example, on the 31 March 2001, there were vacancies for 5 consultant paediatricians in Wales, 29 speech and language therapists, and 69 physiotherapists. When vacancies of this kind are replicated across the statutory agencies, including social services and education, the seriousness of the consequent risks for children speaks for itself. 3.3 There are numerous reasons why children may be vulnerable to abuse within the NHS including: staff shortages; shortages of facilities; poor employment practices; children, parents and even staff being unaware of the risks; problems occurring between agencies both in sharing information and in collaborating. In some activities, which are a necessary part of health procedures, children are more vulnerable than in others. Examples of such events are: intimate examinations; situations of control and restraint; mental health therapeutic work involving close relationships with staff; procedures for visitors; the involvement of families in caring for their own and others’ children, especially when they stay overnight; bullying and assault by other children; and staff working on their own with individual children. 3.4 Other activities, such as horseplay with adolescents, have the potential to become inappropriately familiar or too rough. 3.5 In addition, some children are more vulnerable than others because they are younger, less able to tell adults of their concerns, physically less able to move away from unwanted contact, more isolated (with fewer visitors) or less likely to be believed because they themselves have learning disabilities or mental health problems. 3.6 Another critical aspect of understanding the background is that there are different types of risk: some are low level and frequent, such as giving children insufficient individual attention so that their views are not properly understood; others are high but rare, for example a staff member sexually assaulting a child. 3.7 We have already noted that establishing systems does not necessarily lead to sound practice. The culture or working style of the organisation is critical and it is imperative that all organisations in the NHS develop a style of openness in which explanations are given and questions are encouraged not only from children and parents, but also from other staff. The availability of information and the realisation that questioning is central to learning and development reduce the problems associated with secrecy and staff feeling inhibited from discussing their concerns about practice. 3.8 There is a shortage of facilities for different groups of children and young people and their family carers. In part, this lack is related to the difficulty of recruiting and retaining staff. There is also a shortage of facilities for certain day services, inpatient services and domiciliary support services. This is particularly the case for children with mental health problems. 3.9 Surgery and acute medical care are dealt with separately in Chapter 13, and child and adolescent mental health services in Chapters 4, 5 and 14. 13 3.10 From an early stage in our process, it became clear to us that one of the most acute shortages is in the field of nurses who have trained as registered children’s nurses. There is a demonstrable need to increase academic places for such children’s nurses, and to encourage mature nurses, including returnees to practice, to develop their skills and opportunities through such training. Of course, it would be futile to train more children’s nurses without developing opportunities and career paths for them as clinicians. These should not only be in the hospital setting. As will be seen below, we see an important and even a crucial role for a stronger school nurse service, and community children’s nursing service, membership of which should be dependent on possession of relevant higher qualifications and training. Many children require complex nursing and intervention both at home and at school.

Human Resources Policies 3.11 A glaring area of vulnerability arises from poor appointments procedures and inadequate focus by human resources professionals on child protection issues. Despite the directory nature and clarity of Welsh Health Circular WHC (99) 3820, this has been a misunderstood and even neglected subject. It is dealt with as a discrete issue in Chapter 10 below. 3.12 The heart of the matter lies in the recognition of child abuse. Staff shortages are likely to be an unwelcome but continuing reality for some years to come: they must never be accepted as an excuse for failing to spot an instance of child abuse. Sound human resources policies will ensure best value and appropriate knowledge at the time of appointment. Continuing professional development and efficient appraisal procedures and clinical supervision will provide more proficient staff in the right posts. None of this is of any use at all unless it contributes to the fast, accurate recognition of the signs of child abuse. Child protection should be a mentality rather than an issue. Further, it should be recognised that, in many instances, manual, secretarial and clerical staff can be at least as insightful as clinicians. The ability to recognise the signs of child abuse should be part of the mandatory and continuing training of all staff having contact with children. 3.13 In the following paragraphs, we discuss those parts of the work of the NHS in Wales, which, on the evidence collected during this review, we have identified as problem areas with scope for significant improvement.

Paediatrics 3.14 We consider that Wales is fortunate to enjoy such a varied and interesting group of specialist paediatricians. They range from the academically bold and conceptual to the intensely local and practical, sometimes combining all virtues. We observed that much best practice in child protection derives from the work of exceptional individuals, the ‘angels’ of child protection. Some of these ‘angels’ are paediatricians, some nurses, some social workers, and some are therapists in professions complementary to medicine. The challenge of infusing the practice of angels into the everyday mentality of everybody involved in the healthcare of children is formidable, not least because it is obstructed by overwork and shortage. The shortage of specialist paediatricians is a basic and unacceptable obstacle to their effectiveness.

20 See paragraph 2.7 14 3.15 On the 31st March 2001, there were 5 funded vacancies for consultant paediatricians in Wales. The employment of locum consultants presents problems of its own, and is never a satisfactory solution save in the very short term. We are satisfied that a significant contribution to the safety of children within and outwith the NHS is made by the existence of the corps of community paediatricians, whose experience fits them to spot abuse and intervene rapidly and sometimes quite informally, in a relaxed clinical context. 3.16 We understand that, during the course of our work on this review, the Royal College of Paediatrics and Child Health is reviewing its policies on the roles, training, deployment and designation of paediatricians. In particular, we believe the College is looking to bring together the presently separate appointments of community and hospital based paediatricians and make appointments to ‘Consultant Paediatric’ posts which will be based part in the acute sector and part in the community. This should help bridge the previous ‘artificial’ and unhelpful divide between the two areas. Such posts have already been created in Wales and are becoming more common. If this occurs, we envisage greater integration between the work and skills of community paediatricians, who have taken leading responsibilities for child protection, with the tasks of paediatricians who have taken roles in more intensive hospital care. Such a development could result in better integration of paediatric and child health services led by the needs of individual children and wider dissemination of knowledge of child protection. If so, we welcome this change in policy. However, we consider it vital that that the importance is fully recognised of the expertise in child protection that has been built up by community paediatricians.

Registered Children’s Nurses 3.17 The shortage of registered children’s nurses has already been mentioned in paragraph 3.10 above. Many nurses without a registered children’s nurse qualification nurse children and do so with exceptional skill. Some say that the skill is more important than the qualifications. While we accept that as a broad statement, no nurse has his or her skills diminished by the time spent developing them under high quality and specific training. There are good nursing colleges in Wales, and courses available in the North and the South, as well as in convenient English locations. The aim of having registered children’s nurses on duty at all times and in every children’s ward and accident and emergency department, minor injuries unit, and where appropriate out patient department is a realistic goal. This, already a requirement in Welsh Health Circular (91) 9721, was re-inforced following recommendations made by Sir Cecil Clothier in his report in 199122. In a letter to the NHS in 1994, District General Manager (94) 2623 the Director of the NHS in Wales asked the service to address those recommendations in the Clothier report falling within their remit. Of particular relevance to this Review is recommendation 10, in which Clothier recommended that the Department of Health take steps to ensure that its guide, The Welfare of Children in Hospital (WHC) (91) 9724 be closely observed. This advised Health Authorities and hospitals to take account of a number of standards which should form the basis of health service contracts for the provision of children’s services, and included the objective that "there be at least two RSCN’s (or nurses who have completed the Child Health branch of Project 2000) on duty 24 hours a day in all hospital

21 Welsh Office, 17 December 1991, The Welfare of Children and Young People in Hospital 22 Clothier C, MacDonald A, Shaw D, 1991, The Allitt Inquiry – Independent inquiry relating to the deaths and injured on the children’s ward at Grantham and Kesteven General Hospital during the period February to April 1991, HMSO 23 Welsh Office, 18 March 1994, Report of the Independent Inquiry relating to deaths and injuries on the Children’s ward at Grantham and Kesteven General Hospital during the period February to April 1991 ("The Allitt Inquiry") 24 Welsh Office, 17 December 1991, The Welfare of Children and Young People in Hospital 15 children’s departments and wards". We suspect that it also represents a sound investment towards the more effective recovery from illness by sick children, and the consequent reduction of the frequency and duration of hospital stays. Similarly, there should be adequate registered children’s nurses trained to work in the community. The reduction of frequency of admission can also be made possible through the development of community children’s nurses, and the school nursing service, for example the improved management of asthma by these nurses.

Children’s Community Nurses 3.18 Children’s Community Nursing (CCN) services have been established in England for over 20 years. The House of Commons Select Committee’s Inquiry into Services for Children in 1998 recommended that CCN services should be developed so that, children who require nursing care in the community setting receive that care from an appropriately qualified children’s nurse. 3.19 To date CCN services have been established within integrated child health services in Gwent and Bro Morgannwg, with the first CCN with a higher degree from the University of Wales College of Medicine. CCN teams complement existing primary care for children with complex needs in the community setting, however their development in Wales is disparate and slow, leading to lack of equity of access to currently recognised best practice. 3.20 Preliminary findings by Dr Nicola Eaton in a report due to be presented to the National Assembly this year suggest that where these services exist, parents and other professionals report on the success and importance of the service. 3.21 The recommendations in ‘Learning from Bristol’25 to implement effective managed clinical networks could well be enhanced by the development of CCN services to provide care as close to home as possible, especially for children who require tertiary care.

Prison Health Services 3.22 There are no women’s prisons in Wales and accordingly no mother and baby units. We were advised that the current provision of mother and baby units for England and Wales is 64 places. Admission is granted following multidisciplinary team consideration of ‘the best interests of the child’. 3.23 A formal partnership has been agreed between the Prison Service and the NHS by the Ministers at the Department of Health, National Assembly for Wales and the Home Office to secure better health care in prisons26. The partnership has been led since 1 April 2000 by two joint units namely the Prison Health Policy Unit and the Prison Health Taskforce. The results of our review have relevance for their work relating to the child protection standard in the prison mother and baby units.

Use of Agency, Bank and Locum Staff 3.24 Most NHS employers are careful in their choice of staff at all levels. Particular care is needed with staff working with children. In the rural parts of Wales it is rare for UK agencies to provide nurses. From the evidence we saw

25 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary, 1984 – 1995: CM 5207, London: The Stationery Office 16 26 The Prison Service and NHS Executive, HSC 1999/077, The Future Organisation of Prison Healthcare there is universal good practice in the choice of UK agencies where they are used in Wales. In all the situations of which we have been made aware we were satisfied that the agencies procedures for checking references and qualifications were a matter subject to both contract and scrutiny: there is no evidence in Wales of the inappropriate use of agencies. However, it is difficult to ensure that temporary staff are anything more than the best available from a limited choice, often to meet unexpected need. We are mindful of concerns about the use of agency nurses expressed in the Audit Commission’s report of September 2001 ‘Brief Encounters’27. There is disturbing evidence that the professional indemnity insurance provided by agencies for their nurses is limited so that, for example, they are not insured to give injections. Plainly, this type of restriction places extra burdens on regular staff which in turn impacts on child protection. We hope that there can be evolution towards a situation where when agency staff are employed, they will be suited to purpose and fully insured. 3.25 Bank staff tend to be ‘regular’ casual employees, often former full-time staff of the service concerned and known to them. Generally, there are few serious problems with bank staff, though the same principles apply on the issue of suitability for purpose. 3.26 Appointments of locums in the NHS from the medical profession may be relatively short-term (i.e. to cover staff absent due to sickness or to attend training events etc, or gaps arising after a doctor has left and before a replacement can start work) or longer-term (often covering posts to which suitable substantive appointments cannot be made). In practice, some short-term requirements for locums may extend into gaps that become long-term. These gaps may be filled with successions of short-term locums, remain as gaps in services or are filled by locums whose appointments are extended becoming effectively long-term. 3.27 It is difficult to see how occasional short-term and some longer-term gaps that generate requirements for locums can be entirely prevented. For example, consultants are required to give three months notice of their proposal to leave an NHS appointment but, in practice, reviewing internally a job description for a replacement, agreeing the job to be advertised with the bodies that must be consulted externally, conducting the public appointments procedures and awaiting arrival of the appointee takes around nine months. However, better planning, good human resources practice and longer lead-times between advertising posts that are to become vacant and the date on which the vacancies commence can reduce the problem. 3.28 Many long-term locum scenarios reflect more substantial recruitment and retention problems. Some jobs filled by locums are unpopular because the terms and conditions of service are unsatisfactory or because the jobs are too onerous and, effectively, undoable. All longer-term locum appointments should be reviewed as a matter of urgency by the responsible authorities to see if more should be done to make the posts attractive to substantive appointees. Inevitably, this will increase expenditure: however, it should increase efficiency and improve value. 3.29 In this context, it is evident that appointing locums to medical appointments can present problems. A change of doctor may be traumatic for patients, especially in those specialities in which doctor-patient relationships play a core part in the therapeutic process. Ensuring quality in situations in which

27 The Audit Commission, 2001, Brief Encounters: Getting the best from Temporary Nursing Staff, The Audit Commission 17 doctors are not necessarily required to submit themselves to the full scrutiny of a public appointments process is a challenge. If anything, moving in and out of temporary jobs and, potentially, working for a number of different employers in a relatively short period of time, (in which individuals are required to hit the ground running) demands additional skills above those needed by appointees who are able to take advantage of induction sessions, etc. In an ideal world, locum doctors would only act as such if they had extra qualifications and personal skills founded upon the need for versatile and speedy adaptation to temporary situations. Many locums are excellent but this is not universal. We are aware of a history of cases before the General Medical Council’s Conduct Committee in which locums have been found lacking in both skill and care. While this is not true of most locums, they all face the problem of low evaluation as compared with substantive appointees. 3.30 We recognise too the dilemma in which General Practitioners and Medical Directors may find themselves when presented with gaps in their medical staff complement. If locums are not engaged, more work is thrust upon the remaining staff who are already under pressure, with the accompanying risks of fatigue and all in the quality domain that may stem from this. There are also problems of continuity of care and uncertainties about the qualities of service that may arise from appointing locums and, as we have already concluded, long-term locum appointments may mask deeper problems in service provision and its quality. 3.31 However, there are ways in which these problems might be tackled. Currently, employers have much greater freedom in the ways in which they select and appoint locums than doctors to substantive posts. Our advice is that the Government should review its requirements and the procedures for appointing locums. We believe that appointments to all but the most short-term locum posts should be subject to similar levels of scrutiny as are substantive appointments. Locums should not be asked to take on tasks for which they are not trained and for which they are not able to demonstrate experience that is satisfactory or better. Great care should be exercised in identifying the skills of potential locums and then tailoring the jobs they are asked to take on to their capabilities. All employers must check references before any doctor starts work in a manner that is consistent with the principles set out in Chapter 10. 3.32 Often employers use employment agencies to recruit locums. We are firmly of the view that, where this occurs, employers should place especially stringent demands on the employment agencies for the quality assurance of all locum doctors. 3.33 The appraisal schemes that are now applicable to medical staff should be applied to locums in full measure. We realise that this may be practically very demanding on employers. Also, we are of the firm view that GMC Re-validation must be applied to locums. If anything, the importance of re-validation for doctors who occupy successive locum appointments is potentially greater than for doctors who occupy continuing substantive appointments, if they are to avoid the low evaluation that they may attract. Therefore, our opinion is that the Government and the GMC should prioritise the attention they are giving to finding ways to apply appraisal and GMC Re-validation to locums such that continuity of their development and the safety of the public is assured. 3.34 Many locum consultants are substantive specialist registrars (SpRs). As members of training schemes with a National Training Number, they may consider

18 up to a three month locum consultant appointment as within their training and as counting towards the experience they must have before award of a Certificate of Completion of Specialist Training, provided they remain in supervision and subject to the RITA appraisal scheme. In these circumstances, senior SpRs may find a locum appointment of very considerable benefit. We consider that the new Medical Education Standards Board should review appointments of trainees to locum consultant posts and appointments of locums to trainee posts not with a view to curtailing appropriate experience explicitly or implicitly (e.g. through creating processes that inherently hinder appointments), but with the intention of ensuring that the conditions are consistent and well applied and that appropriate safeguards are in place for the public and for the appointees. 3.35 Often, past consultants are invited to return from retirement to fill part or full-time locums. Their value to hard pressed services in the context of acknowledged current recruitment and retention problems should not be underestimated, but neither should the need to ensure currency of their capabilities and skills. For these reasons, we are certain that returning consultants should be subject to local appraisal schemes and have available to them all the benefits of an active programme of continuing professional development. The Medical Director of each Trust should ascertain that consultants returning from retirement are sufficiently up-to-date before appointments are made and that the job they occupy is adjusted, if necessary, to fit the capabilities and experience of the successful applicant.

Recruitment of Staff from Abroad 3.36 Some Welsh NHS trusts have embarked on a programme of recruiting staff from other countries. These include countries within the European Union such as Spain, Commonwealth countries such as South Africa, and also The Philippines. The attractions of The Philippines are that it trains substantial numbers of nurses to a good standard, that working in the UK is an attractive financial option for many young men and women from there, and that the staff recruited tend to be loyal and hard-working. There is no doubting the value and quality of many nurses from abroad, and they provide a speedy way of filling voids in the NHS. 3.37 In Chapter 10 below we set out our recommendations on checking references. Our view is that too much reliance is placed on references and checks by agencies based in The Philippines and some other countries: in most cases correct procedures are probably followed, but there is no satisfactory way of vetting this. Therefore, before any staff recruited from abroad are placed in jobs with unsupervised access to children, they should have completed a probationary period of at least 6 months’ continuous employment with the same UK employer, and should have been fully trained and counselled on the importance of child protection and child protection procedures. This would be a proportionate, non- discriminatory approach, and as adequate a substitute as one could achieve for the inability to verify fully references and past performance.

Accident and Emergency Departments 3.38 There is a diversity of A&E provision in Wales. In the cities and larger towns, there are extremely busy departments, in some cases with completely separate or distinctly separated areas for children. In smaller general hospitals, efforts are

19 made to provide separate rooms in which children can wait and be treated. In community hospitals in smaller towns there are minor injury units with books and toys to distract children, but no really separate facilities. 3.39 During one of our visits to a district general hospital we saw a child of about 3 years old, awaiting treatment for an unpleasant but minor injury. The child was waiting with his mother in a cold and draughty lobby between the outer and inner public entrances. Plainly the mother had decided that it was not in her son’s interest to be in the general waiting area beyond the 2 doors, as it contained a number of adults including elderly men in obviously frail condition, and others who might present other concerns. The mother was right to keep her child where he was in the circumstances, but those circumstances should never arise. 3.40 As refurbishment and new development occur, it should be a design criterion that wherever possible there should be separate entry, waiting areas and treatment areas for children. At the very least, separate waiting areas should be provided in all hospitals. We are aware of some current refurbishments and these should be re-examined to determine if it is possible to comply with this recommendation. 3.41 A&E departments should include in their duty rosters at all times nurses who are qualified in the treatment of children. Nurse practitioner posts should be developed as in Cardiff to further improve the quality of patient management, as recommended by the Audit Commission28. There should be access to a paediatrician at all times; if this latter point is impractical for community hospitals, telemedicine options should be explored. 3.42 We were told, when we visited the NHS services in one rural town, of the common problem of teenagers who drink to unconsciousness, and who arrive in distress at the local minor injuries unit. This information brought home to us several matters relating to risks taken by young people, their safety and healthcare services provided for them. First is the risk represented by substance misuse and second is the frequency of deliberate self-harm in adolescence. In these situations, and many others, hospital accident and emergency departments and minor injuries units are of key importance as places to which young people at risk of harm may go. But units of this kind have a wider and vital significance as points of entry to the healthcare system with which, cumulatively, young people, especially those in trouble, may have many contacts. The way in which young people are managed at these times is, in our opinion, critical. The staff of the unit we visited did not express much sympathy for young people in this predicament. Perhaps this is understandable to a degree though it is important that people who work in these units should be aware that young people who present in distress or after risky behaviours, particularly those who turn up repetitively, may be demonstrating underlying issues of physical or emotional abuse for which they are in need of attention.

Services for Young People who Use or Misuse Substances. 3.43 Our wider enquiries have revealed estimates of the possible involvement of young people in using and misusing substances. Obtaining accurate figures is difficult but there is no doubt of the extensive use of both drugs and alcohol by

28 The Audit Commission, Nov 1998, Update – Accident and Emergency services follow up.

20 even quite young adolescents. The worrying issues relate to patterns of alcohol consumption and the associations of substance misuse with a wide range of other health, education and social problems, probably stemming from social exclusion and deprivation. 3.44 The Government’s figures, now ageing, indicate a rapid rise in experience with drugs from about 12 years of age and that the peak time of use is in the teens and early 20s. Surveys show that around 50% of mid-teenagers report consumption of an illegal drug, most frequently cannabis. A substantial minority has used amphetamines, ecstasy, LSD or the so-called dance drugs. By comparison, alcohol is the substance most frequently used by young people. Again, accurate figures are hard to obtain, but the Government’s own sources indicate wide variations in the amount of alcohol consumed by young people. Many adolescents drink little, the majority consume modestly but a significant minority of mid-adolescents (5% of boys and 2% of girls) in Wales drink more than 15 units a week. Other surveys have shown that 5 to 10% of boys and girls aged 14 to 15 are drinking more than the levels recommended for adults. Also, there is evidence of widespread binge drinking and episodic drunkenness in 15 year olds. So, it appears that the pattern reported to us in our rural visit is not an isolated observation. In all likelihood, it is repeated in many towns and cities across Wales. 3.45 The surveys show that the extent of use and problems arising from it is greater in Wales than in any other country in Great Britain. Also, the pattern of substance misuse and its impacts are different in young people compared to adults. For example, high rates of co-existing (co-morbid) mental disorders are reported in young people (some report up to 90%) who misuse substances while only a tiny number becomes dependent. Repeated binge drinking (taking more than 5 drinks on the same occasion) is associated with raised rates of unprotected sexual intercourse. Also, research indicates that young people who misuse substances to the point of running risks to their health have much higher experiences of social exclusion and alienation and their families score more highly on indicators of social deprivation and abuse. (It is also worth reminding ourselves of the links between child abuse and alcohol misuse; some 20% of child abuse cases are associated with alcohol misuse by adults.) 3.46 The Government’s cross-departmental 10 year substance misuse strategy for the UK, published in ‘Tackling Drugs to Build a Better Britain’29 of 1998 focuses on people from 15 to 25 years of age. Similarly, the National Assembly for Wales’ strategy ‘Tackling Substance Misuse in Wales - A Partnership Approach’30 places emphasis on education and prevention work with children and young people. We concur with this focus on young people and are pleased that finance is being made available to implement these plans. Nonetheless, our perception is that the baseline level of education, prevention and treatment services for young people who misuse substances is very low and, although services are developing, particularly in the last two years, we are aware that the level of substance use and misuse by young people and the number seeking help is rising and that a major shortfall in services remains. We are, therefore, pleased that the National Assembly has identified services for young people who use and misuse substances as a priority in ‘Everybody’s Business’.31

29 Tackling Drugs to Build a Better Britain, 1998, London: The Staionery Office 30 The National Assembly for Wales, 2000, Tackling Substance Misuse in Wales – A Partnership Approach, Cardiff : The National Assembly for Wales 31 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business - Strategy Document, Cardiff: The National Assembly for Wales 21 Deliberate Self Harm (DSH) 3.47 One of the most frequent reasons for a young person’s admission to hospital is that of deliberate self-harm. For some years, it has been policy that young people who carry out acts of self harm should be admitted to a paediatric bed in hospital (in line with policy and the recommendations elsewhere in the Report) overnight, thereby enabling a full medical, social and psychiatric assessment to be made on the following day or later, depending on agreement as to when the immediate risk to life has resolved. In the experience of the practitioners who have advised us, most young people who harm themselves do so by taking tablets not prescribed for them in overdose and usually in a state of intoxication with alcohol. A full survey of deliberate self harm in young people and its management is contained in ‘Suicide Prevention: The Challenge Confronted’ from the NHS Health Advisory Service32. 3.48 We are aware that there is a risk to life arising from deliberate self harm not only immediately but in the longer term as a significant minority of young people repeat the act or kill themselves later. The factors most associated with a higher risk of later suicide are male gender, older age, high intent, psychosis or depression when examined and hopelessness. Therefore, a good assessment carried out after an episode of DSH could prove lifesaving. Many of the other young people who are not thought to present a serious risk of predictable repetition are found to have an array of other social, healthcare and risky lifestyle problems and a number come from chaotic families. All of these features render young people vulnerable and while we can understand why so many of them receive an unsympathetic reception on arrival in hospital, we encourage staff to think more widely about the risks to which young people who harm themselves may be drawing attention. We, therefore, support the policies of the Royal College of Psychiatrists contained in its document ‘Managing Deliberate Self Harm in Young People’33

Postmortem Examinations 3.49 A&E staff, including nurses who often carry a heavy level of responsibility in minor injury units, sometimes have to deal with the sudden and unexpected death of a young person. A postmortem examination is a routine consequence, and where the deceased is a child this is required to be carried out by a pathologist with special experience in child pathology. That this should be so is of understandable importance, given difficulties that can arise in ascertaining the cause of death of babies in particular: for example, Sudden Infant Death Syndrome is often very difficult to detect, but doing so or excluding it may be literally vital for other children in the family. It is paramount that the quality of autopsy is of the highest possible standard. Unfortunately there are relatively few pathologists with that special experience. As a result, the bodies of children are often transferred considerable distances shortly after death. This can cause immense distress for families, who may not arrive immediately at the hospital and wish to spend time beside their child. It is our view that it should be the general practice that postmortem examinations of children should take place in or as near as possible to the hospital where death has occurred or been certified. We accept that there will be exceptions for good reason, but exceptions they should be.

32 Williams R & Morgan HG (eds), Second Edition 1996, Suicide Prevention: The Challenge Confronted. A Manual of Guidance for the Purchasers and Providers of Mental Health Care. London: NHS Health Advisory Service. 22 33 The Audit Commission, Nov 1998, Update – Accident and Emergency services follow up. Speech and Language Therapists 3.50 We were impressed by the sensitivity and knowledge of speech and language therapists about child protection issues. Especially for children with learning disabilities or educational difficulties, speech and language therapists are in the front line in detecting abuse. In Wrexham, we found examples of therapists acting as key workers in appropriate cases. Their training and continuous professional development include child protection as a significant subject. Our concern is that there should be enough therapists to meet need throughout Wales. 3.51 While speech and language therapists are trained to recognise child abuse, and are accustomed to team work with other groups, they expressed concern that these attributes are not sufficiently evident in the approach of fellow- professionals to case conferences. With many others, they are critical of the lack of weight given to case conferences by GPs. This is dealt with below. They are concerned too about the clash between some views of confidentiality and the need for high levels of disclosure between the disciplines if children are to be protected satisfactorily. 3.52 Most Allied Health Professionals are professionally managed through adult directorates rather than children’s directorates. This can lead to lack of clarity as to the extent to which they are managed regarding children’s issues and whether they should be managed by Trust management or by professional line management within Trusts. A connected issue is that acute paediatric services are often covered by staff within the adult department, on rotation, rather than having designated paediatric professionals who have specialised training and acquired expertise in the paediatric field.

Radiologists and Radiographers 3.53 Radiological procedures can be frightening for younger children in particular. Knowledge and training of radiologists and radiographers in child protection appears patchy. The evidence we heard was that some radiographers may have no paediatric training at all, let alone a specific module on child protection. Such a module should be a short and robust component of training and continuous professional development, as with other clinicians. 3.54 Practices in radiology departments vary, but in some parents and children are separated on arrival at reception. With younger children, it would cause no difficulty if parents remained as close to their children as possible throughout the visit to the department whilst of course respecting the issue of safety from radiological hazard.

Play Specialists 3.55 During our hospital visits, nursing staff gave credit to the contribution made by play specialists to the work of ward teams. Qualified play specialists use play as a vehicle for preparing children for a variety of procedures, and in reducing stress and anxiety. They safeguard the child’s continued development and provide continuity for a child and parents in a changing staff situation. They have a key role in child protection, being in a prime position to see children playing-out their worries and fears, and noting relationships between child and parents, other

23 children and members of staff. Their skills are valuable in every area of the hospital where there are children. In common with other trained staff there is a gradual drift away into other employment sectors where their qualifications and skills are better valued. The NHS can ill afford to lose this valuable resource. In Cardiff a play specialist is specially trained to prepare and support children who are suspected to have been sexually abused, through the intimate and sensitive examinations. This should be developed in all units where children are having intimate examinations.

School Nurses 3.56 In most areas of Wales, school nurses are employed by the local NHS Trust, and have responsibility for a number of schools. However, in at least one area they are employees of the local authority and funding is found from the education budget. The former course seems much more satisfactory to the Review Panel. Where school nurses function well, they work within the primary health system but are employed by NHS Trusts. For many children, they are the first port of call for physical and mental health issues. The role of a good school nurse has developed far beyond the old notion of a school matron with a cabinet of ointments, unguents and sticking-plasters. A school nurse may be asked to deal with everything ranging from bruises and grazes to eating disorders, pregnancy and the discovery of cancer. 3.57 The Review was impressed by the dedication and sense of purpose of school nurses. We were less impressed by the variable knowledge of the presence of a school nurse, and of his or her potential, among pupils in schools. We were shocked by the under-valuation of their role by health organisations, the almost complete lack of a career path for them, and the relatively poor availability of training courses. We are aware that specialist pathways within the Degree in Community Health Studies have been developed recently and this first school nurse graduate should qualify in 2002 from the University of Glamorgan. We are convinced that, if ever there was an area of primary healthcare that can give demonstrable value for money by effective early intervention, this is it. Unfortunately, ambitious school nurses and those who realistically need to maximise their earning potential tend to move to other jobs in order to do so. 3.58 A programme in every Trust to ensure the constructive management of this part of the NHS would be beneficial. This should no longer be a Cinderella service. 3.59 We support the conclusions of the report ‘Recognising the Potential: A Review of Health Visiting and School Health Services in Wales.’34

Health Visitors 3.60 Health visitors are an extremely valuable and respected resource. The health visitor is the focus and voice for the youngest children at the primary care level and any future changes to the NHS should strengthen this role. Health visitors are required to visit all babies in the second week of life and these visits continue according to need. Health visitors provide key advice to parents, especially to those who are inexperienced and/or vulnerable. Part 8 reviews into serious injury or death of children have repeatedly stressed the need to meet

34 Professor Dame June Clark et al, April 2000, Review of health visiting and school nursing services in Wales, University of Wales Swansea 24 School of Health Science children within the home environment. If children are seen mostly in a clinic or surgery, the ways in which they are cared for and nurtured cannot be observed closely. Increasing the number of home visits in the first year of life can only be beneficial. We have noted too the report in ‘Evidence-Based Healthcare’ that home visiting improves parenting skills and decreases unintentional childhood injury amongst other matters.35 3.61 This is particularly important for those families with young children who have difficulty attending clinics because of access or transport problems, or because they find mainstream primary care services less than ‘user friendly’. This may be because they are linguistically or culturally different from most users or lead lifestyles others may stigmatise. This may include those who speak neither English nor Welsh, people who are unfamiliar with the pattern of UK primary care services, traditional travellers, new age travellers or homeless families in temporary or refuge accommodation. The important feature of services provided by health visitors is that they should reach out to all families to increase parenting skills and confidence and ensure the welfare of all children, especially the very young and most vulnerable. The balance between the needs of the child population and those of their families and vulnerable adults is one which is familiar to health visitors. They are able to deliver individual care while maintaining a wider perspective on the community in which they practice because their focus is on health rather than the care of the sick. 3.62 ‘Recognising the Potential’36 recommended that NHS Trusts, in conjunction with Health Authorities and local health groups, should review the public health function of health visitors. This role should be developed, to enable health visitors to make a greater contribution to child protection among vulnerable groups such as travellers, women in refuges, homeless families and asylum seekers. 3.63 Commissioning of health visiting seems likely to become the responsibility of local health groups in their post-reform guise as local health boards. Whichever are the responsible health bodies they should pay close attention to clinical supervision. Currently health visitors receive clinical supervision in child protection procedures. This should not be lost: it should be strengthened, and any risk of isolation from professional colleagues should be avoided. 3.64 We support the July 2001 consultation document37 that there should be development of opportunities for career progression for health visitors and all nurses in primary care; and that nurse, midwife and health visitor consultant posts should be created in primary care to ensure the recruitment and retention of top quality practitioners expert in clinical practice. Training should be structured accordingly. 3.65 ‘Sure Start’ is a locally based programme operating across Wales that focuses upon children under the age of 4 years old and their families. One of the aims of the scheme is to improve health through supporting parents in caring for children and promoting young children’s health and development. Sure Start is providing an opportunity for local authorities, health authorities and voluntary organisations to work together to establish partnership schemes. These include

35 Evidence-based Healthcare (2001) 5, 67-68, Harcourt Publishers Ltd; See Article ‘Home Visiting has many positive benefits but more evidence about cost effectiveness is needed’. Elkan R, Kendrick D, Hewitt M, Robinson JJA, Tolley K, Blair M, Dewey M, Williams D, Brummell K. The effectiveness of domicillary health visiting: a systematic review of international studies and a selective review of the British Literature. Health Technol Assess 2000; 4(13): 1-339. 36 Professor Dame June Clark et al, April 2000, Review of health visiting and school nursing services in Wales, University of Wales Swansea School of Health Science 37 The National Assembly for Wales, July 2001, Consultation document ‘Improving Health in Wales – The Future of Primary Care’, Cardiff : National Assembly for Wales, see page 34 25 offering parenting skills courses and provision of play opportunities for young children, as well as providing support for families with children with special needs. 3.66 The ‘Sure Start’ programme has developed promising initiatives in many areas in identifying vulnerable children at the beginning of their lives. For example, in Cardiff this is proving especially successful among ethnic minority families, whose languages and traditional roles may leave mothers seriously isolated. Evidence from ‘Sure Start’ highlighted the need for a consistent set of policies on the funding of trained interpreters independent of the clients involved. We are a little concerned that ‘Sure Start’ should not be an incidental cause of reduced availability of mainstream health visitors performing their traditional role. Both roles are part of a complementary service they must not be substitutes for each other.

General Practitioners 3.67 It is important and fair to begin this section on a note of concern and sympathy. It is a recognised problem that there is a real shortage of GPs in many areas of Wales, particularly in the Welsh valleys. Here there are a large number of single-handed practitioners who are coming up to retirement with little prospect of replacement. There were vacancies in Wales for 45.5 Whole Time Equivalent (WTE) GPs on the 1st October 1997: on the 1st March 2000 that number had risen to 73.75 WTE. Some of these are in economically disadvantaged places with high levels of social exclusion. The lack of GPs has a knock on effect on inappropriate use of emergency services and A&E departments and many secondary healthcare services and contributes toward specialist CAMHS waiting lists. 3.68 It is matter for government how it meets this shortfall, and beyond the limits of this Review’s terms of reference. Nevertheless it must be said that a shortage of primary health facilities and practitioners puts intolerable pressure on those in post. Overwork among GPs and their practice nurses is dangerous, and risks the continuation of abuse that might otherwise have been detected. In addition, the circumstances of general practice in some towns cause professional isolation, in itself an enemy of good practice. As against this, we acknowledge the excellence of some, who have recognised the destructive link between abuse and lifelong ill health. 3.69 The Government is already concerned about the shortage of GPs and has taken steps to increase undergraduate places in medical schools: this may be an effective way of dealing with the long term. In the short term, we feel sure that the National Assembly will wish to examine patterns of primary health care in an effort to discover quick and effective solutions to shortages. A more extensive use of the skills of nurses, and making available primary care in local hospitals for some sectors of the population at least, are ideas that might be developed further if acute shortages continue. 3.70 We recognise that some GPs are under intolerable pressure, and that early retirement and alternative careers are proving increasingly attractive. However, during the gathering of our evidence, we met many complaints about GPs founded not so much on work pressure as on lack of knowledge of child protection issues, or lack of appreciation of their importance.

26 3.71 A recurrent theme was that too few GPs attend case conferences called to discuss children who are already in the child protection loop. ‘Working Together 2000’38 says that because of their knowledge of children and families, GPs (together with other Primary Healthcare Team members) have an important role in all stages of child protection processes, from sharing information with social services when enquiries are being made about a child, to involvement in a child protection plan to safeguard a child. GPs should make available to child protection conferences relevant information about a child and family, whether or not they – or a member of the Primary Healthcare Team are able to attend. The presence of GPs, who often have lengthy medical records and considerable knowledge of the family concerned, can be a valuable resource in case conference discussions. Those who attend describe it as generally a useful experience, and one in the best interests of the child. However, there is clear evidence that there are two main inhibitions against attendance by GPs. The first is that case conferences are sometimes not arranged at times suited to GPs’ work patterns. The second is that, without adequate financial assistance to employ locum staff, it is economically and practically unrealistic to expect GPs to attend or even send their attached health visitors or practice nurses with a report. It is clear to us that the protection of children from abuse would be enhanced by measures on the part of government to make it economic for GPs to attend; and by efforts of those organising such conferences to arrange them at times and places accessible to them. 3.72 The Review Panel was very concerned by a visit to a practice in a rural town. The facilities we were shown were of a high standard, and the partner and practice manager we met were both personally impressive. However, there appeared to be very little knowledge of child protection procedures and almost no literature on the subject. No steps were taken to inform all the practice staff of concerns about child abuse. Doubtless, it would sometimes be recognised simply by the use of common sense, but in our view that will not suffice. We shall not identify the practice because it would be unfair to do so, having regard to the fact that it is clear to us that the same situation is widely replicated. That there is a great deal of sympathy for overworked GPs and their ancillary staff is beyond doubt, but this cannot be extended to the lack of knowledge and procedures for so basic an issue as child protection. 3.73 For all GPs it should be part of the revalidation and re-accreditation procedures to have been on a child protection course. Single-handed GPs in particular run the risk of becoming professionally isolated and unaware of new progress in child protection. Local Heath Groups and their successor bodies should be required to ensure that all single handed GPs keep up to date on child protection issues, through networking with similar practices and joint training initiatives; each practice should be required to produce evidence of its compliance with child protection procedures. 3.74 We hope that within not more than 6 months from the publication of this Report, every GP practice in Wales, in consultation with designated and named professionals, will prepare written basic protocols consistent with all Wales procedures for the recognition of child abuse and for dealing with it, and for complaints arising within the practice itself on child protection issues. Plenty of advice is available from colleagues in the local NHS health authority or trusts as to how best to achieve this. In every practice, there should be a nominated lead

38 The National Assembly for Wales, 2000, Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children, Cardiff : The National Assembly for Wales

27 GP on child protection issues, and, in the future, relevant information to help GPs update procedures should be made available via the Internet. Performance in this field, should be monitored by or on behalf of Local Health Boards. We would expect failure to follow this advice to be admissible evidence in future clinical negligence litigation. 3.75 We consider too, in accordance with evidence given to us on behalf of the Royal College of General Practitioners, that there should be a child protection component in GP training; and that continuing professional development co- ordinators should bring greater focus to bear on the subject. Further, lessons can often be learned by GPs from Part 8 Reviews: these should be disseminated more efficiently to GPs than is the case at present. 3.76 The July 2001 National Assembly consultation paper ‘Improving Health in Wales – The Future of Primary Care’39 has risen to some of the challenges indicated by our observations. The primary care system is the victim of poor, disjointed communications and an insufficient information technology platform. The recommendation that all GP practices, and all other primary care locations, must be connected to the central information network will, if effected, ensure that no GP has any reason to be unaware of developments in child protection practice. The same consultation rightly highlights40 the need to invest in restructuring professional training and the dissemination of best practice: this is to include providing support for isolated and overworked practitioners, by way of a variety of local and wider schemes to enhance their continuing professional development and service to patients. The establishment of resource centres by local health boards41, subject to the oversight and direction on child protection issues of the National Assembly based professionals, should boost the delivery and receipt of essential learning and good practice. 3.77 We were concerned to note that in neither of the General Medical Council documents ‘Good Medical Practice’42 and ‘Seeking Patients’ Consent: the ethical considerations’43 is there a separate section on the need of a doctor to inform himself of child protection issues as a requisite of competent practice. In both of these documents, difficult issues of consent are addressed very clearly, but on the assumption that child protection knowledge is second nature to all practitioners. On the basis of our experience, this review cannot accept that this is as a safe assumption, and we invite the GMC to revisit this point.

Independent Dental Practice 3.78 The evidence indicates that, whereas community salaried dentists are well versed in child protection issues, their colleagues in independent practice are less so. Occasionally, there have been criminal allegations of indecency against dentists, and we are sure that the profession would be the first to agree that many children feel vulnerable during dental treatment. 3.79 We had the benefit of very frank and factual evidence from the General Dental Council (GDC). It emerged that child protection is not part of the dentist’s training curriculum, though a review of the curriculum started in the spring of 2001. It is surprising that dentists, who necessarily see children at very closequarters, have no training in the recognition of non-accidental injury. Of course, as highly qualified clinicians many would recognise suspicious signs, but

39 The National Assembly for Wales, July 2001, Consultation document, Improving Health in Wales- The future of Primary Care, Cardiff: The National Assembly for Wales, see page 13 40 Ibid, see page 5 41 Ibid, see page 10 28 42 General Medical Council, 2nd edition, July 1998, Good Medical Practice, GMC Publications 43 General Medical Council, November 1998, Seeking patients’ consent: the ethical considerations, GMC Publications common sense is not sufficient on its own. At best, child protection training and practice among independent dentists is patchy and ad hoc. We regard this as an unsatisfactory situation. The GDC demonstrated a definite willingness to improve the situation, and we look forward to improving procedures rapidly and subject to similar scrutiny to that we recommend for GPs in paragraph 3.73 above. 3.80 GPs, like all registered medical practitioners, are subject to the relatively new performance review procedures of the General Medical Council: these enable the GMC to discipline and even erase the registration of medical practitioners who work below an acceptable standard of performance while falling short of serious professional misconduct. We were pleased to note that the GDC has recently been in negotiation with the Department of Health for primary legislation to introduce such a procedure for dentists. The Review believes that GPs and dentists who fail to introduce sufficient arrangements to deal with child protection issues, whether arising from outside their practices or within them, are likely in the future to fall foul of performance review procedures.

Optometry 3.81 It is certainly a matter for comfort that the National Assembly has appointed a part-time optometry adviser, who is also a member of the General Optical Council (GOC). The Review found his evidence valuable for its stark honesty, which confirmed the impression gained during one of our visits. He told us that there are no child protection safeguards either in the NHS or in private practice (where most spectacles are prescribed and fitted). It is self-evident that any optometrist who examines a child’s eyes in a darkened room is in a situation from which false and very occasionally true allegations of abuse can emerge. 3.82 Optometrists recognise that they now have to address child protection as an issue in their training and in the management of their practices. These are diverse, ranging from massive chains with sophisticated human resources policies to one-person, local practices. There is probably more diversity in the range of optometry provision than in any other clinical field. For small practices in particular, we are attracted by the view that local health groups/boards can play the leading part, in consultation with the GOC, in the development of clinical governance and protocols for optometrists.

NHS Direct 3.83 By March 2001, 25% or 75,000 of the telephone calls received by NHS Direct Wales were child-related. It is inevitable, even by the law of averages, that some calls will be from abused children, and from abusive adults holding parental responsibility concerned about injuries to a child but afraid to visit a clinician face-to-face. Dodging from hospital to hospital, GP to GP is common among abusers, and NHS Direct is likely to be adopted as part of this pattern. Plainly, it is desirable that there should be as many referrals to the NHS as possible of children who are or risk being abused. 3.84 NHS Direct Wales keeps its own database or register of families giving rise to concern. Onward referrals are made from this system to local intervention, though the system is still in its early stages and not apparently used in a particularly systematic way, according to our understanding of the evidence given. This requires improvement.

29 3.85 By March 2001, NHS Direct Wales was training its staff in child protection issues. However, only 20% of staff had any experience of children’s nursing in any form (and none at all with experience of child and adolescent mental health). If this continues, it means that there is no realistic possibility of a fully child-trained nurse being available on every shift. This is unsatisfactory, bearing in mind the growth in the importance of the service especially outside normal working hours. There should always be at least one appropriately qualified person on duty to deal with children’s issues. The Review Panel was told and accepts that calls can be stressful for staff, a point that emphasises the priority need for staff with such qualifications and for appropriate supervision and support. 3.86 We were surprised to discover that NHS Direct Wales cannot obtain access to local authority child protection registers. This should be remedied in order to enable telephone advice to be founded on as complete a history as can realistically be gained. A Child Protection Register is a central register which is maintained by each area covered by a social services department. It should list all children resident in that area (including those who have been placed there by another local authority or agency) who are considered to be at continuing risk of significant harm, and for whom there is a Child Protection Plan. The categories for registration are physical, emotional or sexual abuse or neglect.44 3.87 There is no doubt that NHS Direct has a useful part to play in the healthcare of the people of Wales. The present arrangement whereby it is run under contract by a NHS Trust is sensible and practical. What is needed is more attention to child protection issues, so that this new part of the service can be an effective point of entry to more effective healthcare for children who have been abused. 3.88 In addition to NHS Direct Wales, there are numerous telephone answering and nurse triage services run by GPs Out of Hours Co-operatives such as Cardiff Doctors on Call (CADOC), and East Cardiff Co-operative in Cardiff (ECCO). These organisations take emergency calls from patients, process them through a nursing triaging system and decide (before the doctor is consulted) if the call can be dealt with by telephone advice, a visit to the Centre, or a house call (the doctor visiting may not be the family GP). These decisions are largely taken by the nurse, using computer-led decision making software. Although the individual doctors working in these systems need to make sure they are up to date with child protection procedures, the organisations that employ the receptionists and nurses also need to make sure that they have written child protection procedure protocols and provide training for their staff on this issue. In time, NHS Direct may take over this work, but not for the foreseeable future.

Students 3.89 The Review Panel has experience of problems raised by undergraduate medical schools and other clinical teaching professionals as to the competence of qualifying students. We received representations on one such case. The issue arises with students who are academically able, have no disciplinary findings against them, but in the view of teachers are unsuited to clinical practice, We consider it unsatisfactory that there appears to be no solution hitherto for this rare but real difficulty.

44 The Child Protection Register is defined in Working Together 2000 at page 64 Chapter 5, paragraphs 5.100-5.102 inclusive.

30 3.90 In these cases, full regard has to be had to the student’s rights, especially as they present a richly litigious prospect that should be avoided by due process if at all possible. A decision to exclude a student from a course would probably be held by the courts to affect a student’s ‘civil rights and obligations’ as they are described in European Convention on Human Rights, Article 6. It is an extremely serious step. 3.91 Other professions, such as social work, have recognised that, exceptionally, information or events may come to light, which appear to question the suitability of a student for practice. This can arise in cases of behaviour damaging or dangerous to service users, other students, or staff, or behaviour presenting an unacceptable risk to self and others. Recognising its duty to protect future users, the training programme reserves the right to recommend any action deemed necessary or appropriate, including the termination of a student’s place on the course. This principle should be extended to the training of all health professionals. In such circumstances, the procedures adopted will have regard to fair and due process, including the student’s right to challenge evidence and to appeal.

Transport 3.92 Especially in rural areas, there is understandable concern about non- ambulance travel arrangements for children who have to be delivered to hospitals and clinics. The Review has been informed of concerns expressed from time to time as a result of taxi drivers making innuendoes and using inappropriate and suggestive language to young passengers, especially adolescent females. The Welsh Ambulance Services NHS Trust is to be commended for the development of its own safeguard and Welfare of Children Policy. The implementation of this policy now requires the training needs of staff to be assessed and met. In line with other providers there needs to be safe recruitment policies. Child protection should be given a high profile within the organisation. 3.93 For the purposes of employee checks (dealt with in Chapter 10), drivers for contracted taxi firms are generally included. However, there is some evidence that advice given to staff by their own employers is insufficient for a small minority of drivers. The introduction of short, NHS-led training sessions would help to drive the necessary points home, and need not be a large cost to the NHS.

General Measures 3.94 There are a number of ways in which general procedures can minimise the likelihood of abuse. Management and staff should consider the particular circumstances of the work in their section to consider which risks appertain to their work and simple steps to minimise them. For example, in one day centre for children a window has been put into a washroom/toilet area so that staff on their own with children know that anyone might see them at any time. Ideally there should always be another staff member around when intimate care practices are taking place. We are not prescribing solutions but stressing that it is essential that all sets of circumstances should be scrutinised by the staff within them.

31 3.95 As a matter of general principle, in all settings there should be written publicised procedures. In one centre, there were some powerful statements in booklets and on the walls about the centrality of children in the life of the place. In addition, in all settings there should be packs of material information for children and families. The material within the pack may vary from place to place but should contain guidance for children as to what they can expect in terms of handling and treatment, the nature of intimate examinations or intimate physical care, and where and how they can expect to be touched and handled. Rights and complaints procedures including contact details for helplines and advocates should also be included. Similarly staff should have available to them handbooks which, in relation to the topics central to this review, provide the range of information reasonably necessary for successful practice. 3.96 Although physical restraint of children by staff is rare in NHS settings, there are settings where this is appropriate. There should be clear guidelines as to the use of such restraint and all instances of restraint should be recorded. 3.97 Families are far more involved in caring for children in hospitals than previously, and restrictions on visiting hours are few. There are occasions when staff may suspect that parents are abusing their own child, or someone else's child. There must be clear guidelines for staff as to the action they should take in these circumstances. The involvement of parents with other people's children is complicated. In many ways it is beneficial for parents to be interested in and concerned for children other than their own, particularly recognising that some children receive very few visitors. However, we consider that staff would have to be very confident of their oversight of any such contact before allowing it.

Welsh Risk Management Standards 3.98 The National Assembly for Wales, in partnership with the Welsh Risk Pool45, has developed and implemented a single compendium of guidance on risk management for the NHS in Wales, the Welsh Risk Management Standards (WRMS)46. The WRMS now support the process of continuous self-assessment introduced with Controls Assurance and is helping organisations within NHS Wales in: • Reducing risk exposure through more effective targeting of resources to address key risk areas; • Improving economy, efficiency and effectiveness resulting from a reduction in the frequency and/or severity of incidents, complaints, claims, staff absence and other loss; • Demonstrating compliance with applicable laws and regulations • Enhancing its reputation through public disclosure of achievements in meeting objectives and managing risk; and • Increasing public confidence in the quality of services provided.

45 The Welsh Risk Pool administers the arrangements between health authorities and trusts to share the costs of large compensation awards. This is done by each trust and health authority making a contribution to the Risk Pool based on its turnover and claims history. The contributions are set so that they cover the full estimated cost of claims above an excess level. The Welsh Risk Pool has recently expanded its role from cost sharing arrangements into improving risk management and spreading good practice. 46 The WRMS document combined the Welsh Risk Pool standards with Controls Assurance standards to support health bodies’ in risk management, and to advance internal control beyond financial control, to cover wider organisational controls and risk management, as featured in the Turnbull report. The first set of WRMS was issued in March 2000.

32 3.99 Risk management is closely linked to Corporate Governance47. Corporate Governance is an evolutionary process, and in the context of risk management, following consultation with stakeholders, individual standards within the WRMS document have been revised and updated to achieve improvements. Further additional standards are also being developed. To this end a Welsh Risk Management Standards Review Group48 has been established to ensure that the standards are as up-to-date and relevant as possible, and that NHS practices within the scope of risk management are assessed properly. Additionally a Risk Managers’ Network Forum has also been established, which has representatives from every health body in Wales, the Welsh Risk Pool and the Assembly. This forum draws together practitioners from the service in Wales and enables them to share experiences, learn lessons and disseminate good practice. The group is currently reviewing established WRMS with the aim of amending them, where necessary, to ensure the safeguards for children and young people treated and cared for by the NHS in Wales is incorporated into the standards. One of the outcomes of this review may be the need for a separate WRMS for children and young people as well as the need to make revisions to existing standards. Recommendations that have emerged from the Bristol Royal Infirmary Public Enquiry are also being considered by the review group.

Recommendations 3.100 We recommend that urgent measures be pursued to increase college places for registered children’s nurses including the encouragement of mature nurses to develop their skills and opportunities through such training. (Para 3.10) 3.101 We recommend that the ability to recognise the signs of sexual, physical and emotional child abuse should form part of the mandatory and continuing training of all staff having contact with children. (Para 3.12) 3.102 We recommend that measures be taken to secure a sufficient number of paediatricians to meet the needs of Welsh children, so that paediatric medicine can function without a ‘ration’ mentality. (Paras 3.14, 3.15) 3.103 We recommend that the NHS should recognise fully the value of the expertise that has been developed by community paediatricians in ensuring the safety of children, and that the target should be for every community in Wales to enjoy a paediatric service in which this expertise is appropriately represented and available. At present, this means that there should be an appropriate balance between hospital and community paediatric and child health services. In the future, if these two branches of paediatrics were brought closer together, the functions required of an integrated paediatric and child health service should be kept under review. Either way, a proper balance of community and hospital based expertise and functions must be maintained and the posts required must be funded. (Para 3.16) 3.104 We recommend, as already required by DGM (94) 26, that there should be a registered children’s nurse on duty at all times in every children’s ward and staff trained and experienced in the care and treatment of children available at all times in accident and emergency department and minor injuries unit, and in outpatient departments where children are seen. (Para 3.17)

47 Corporate Governance is the system by which bodies are managed and controlled. In health bodies this refers to the responsibilities of the organisation’s Board and senior officers. Corporate governance in the NHS in Wales includes the development of a framework of corporate accountability and the development of a controls assurance approach based on worldwide best practice on internal controls, including risk management.48 The Standards Review Group has been formed to act as the central point for the continuous review and revision of the Standards, and is designed to support the risk management process. The group is made up of representatives and the various stakeholder organisations and meets every 6 weeks to continuously review existing WRMS and to consider any new standards for addition 33 to the set. It is the aim of the group to develop ‘a one stop shop’ for all standards applicable to the NHS in Wales. A network of contacts both within the Assembly and NHS Wales has been established and are consulted as part of the reviewing process. 3.105 We recommend that career pathways for registered children’s nurses should be appropriate to care for children in community and school settings. (Para 3.17- 3.21, 3.56-3.59) 3.106 We recommend that the formal partnership between the prison service and the NHS is used to promulgate the improvements in child protection identified in this review. (Paras 3.22 - 3.23) 3.107 We recommend that where agency nursing staff are employed, they should be suited to purpose and fully insured to carry out all role appropriate functions. (Para 3.24) 3.108 We recommend that no locum doctor should start work without a full and proper check having been carried out on his/her references, in accordance with good human resources practice. (Para 3.31) 3.109 We recommend that all NHS employers should place especially stringent contractual terms on employment agencies for the quality assurance of locum doctors. (Para 3.32) 3.110 We recommend that before staff recruited directly from abroad are placed in jobs with unsupervised access to children they should have completed at least a 6 months continuous probationary period with the same UK employer, and should have been fully trained and counselled on the importance of child protection and child protection measures. (Para 3.37) 3.111 We recommend that, as refurbishment and new development occur, it should be a design criterion that accident and emergency departments and minor injury units and outpatient departments should have separate entrances, waiting areas and treatment areas for children. At the very least, there should be separate waiting areas. (Para 3.40) 3.112 We recommend that staff working in accident and emergency and minor injury units are trained to recognise that teenagers presenting with substance misuse or deliberate self harm may be demonstrating underlying illness or physical or emotional abuse for which they need attention. (Paras 3.43-3.48) 3.113 We recommend that postmortem examinations of children should be conducted by paediatric pathologists and should take place as near as possible to the place where death has occurred or been certified. We recommend that where possible the Paediatric Pathologist should obtain a full clinical history from a Consultant Paediatrician before confirming the cause of death. All parents should be fully informed at all stages and in detail of the postmortem procedures that are being followed including the removal and examination of organs. (Para 3.49) 3.114 We recommend that all allied health professionals should be given clear information as to their lines of management and professional direction. (Para 3.52) 3.115 We recommend that all allied health professionals working in the paediatric field wherever possible have permanently designated paediatrics posts and be trained in child protection issues. (Para 3.52) 3.116 We recommend that radiologists and radiographers who deal with children should be trained in child protection issues. (Para 3.53)

34 3.117 We recommend that it should be the practice in radiology areas for parents to remain with their children to the greatest extent possible. (Para 3.54) 3.118 We recommend that the employment of play specialists should be developed widely, and that they be supported in their training and their qualifications be duly acknowledged. (Para 3.55) 3.119 We recommend that all school nurses should be employed within the NHS, and seen clearly as a valued part of the primary care system and the recommendations contained in ‘Recognising the Potential: A Review of Health Visiting and School Health Services in Wales’49 should be implemented. (Paras 3.56-3.59) 3.120 We recommend that every NHS Trust should review the provision and management of the school nurse service, with the aim of providing an attractive career structure and a more effective service. (Paras 3.56-3.59) 3.121 We recommend that every NHS Trust should review the provision and development of children’s community nursing services, to reduce hospital admissions and manage continuing care in the home setting. (Paras 3.17-3.21) 3.122 We recommend community children’s nurse teams be developed as part of the integrated child health services to meet the needs of children who could be managed in the community setting. (Paras 3.17-3.21) 3.123 We recommend an All Wales strategy to develop managed networks for children’s community nursing to best use resources. (Para 3.21) 3.124 We recommend that NHS organisations should review the public health function of health visitors, to enable them to make a greater contribution to child protection among vulnerable groups in the community. (Para 3.62) 3.125 We recommend that nurse, midwife and health visitor consultant posts should be created in primary care settings. (Para 3.64) 3.126 We recommend that a consistent set of policies should be developed on the funding of trained interpreters independent of the clients for ethnic minority communities. (Para 3.66) 3.127 We recommend the provision of increased payments to enable GPs to attend case conferences, and the timing and location of case conferences should be more sensitive to the particular circumstances of GPs; and that at the very least it should be mandatory to send a report. (Para 3.71) 3.128 We recommend that Local Health Groups and their successor bodies should be required to ensure that all single handed GP’s keep up to date on child protection issues through networking with similar practices and joint training initiatives: each practice should be required to provide evidence of child protection procedures. (Para 3.73) 3.129 We recommend that, within 6 months of the publication of this Report, every GP practice in Wales should have written basic procedures for dealing with child protection issues; and that there should be a nominated lead practitioner in each practice on child protection issues. (Para 3.74)

49 Professor Dame June Clark et al, April 2000, Review of health visiting and school nursing services in Wales, University of Wales Swansea School of Health Science. 35 3.130 We recommend that information concerning child protection issues should become readily available to GPs via the Internet. (Para 3.74) 3.131 We recommend that local health boards should monitor the performance of GPs in relation to child protection as an element of clinical governance. (Para 3.74) 3.132 We recommend that there should be a child protection component in GP training, and that continuing professional development co-ordinators should bring greater focus to bear on child protection. (Para 3.75) 3.133 We recommend that the General Medical Council should consider amending ‘Good Medical Practice’ by adding a separate section reminding doctors of the need to inform themselves of child protection issues as a prerequisite of competent practice. We recommend the General Dental Council to consider taking corresponding steps. (Para 3.77) 3.134 We recommend that GPs and general dental practitioners who fail to introduce sufficient arrangements to deal with child protection issues should be regarded by their registration bodies as failing appropriate tests of good performance. (Para 3.80) 3.135 We recommend that all optometry practices should develop written child protection procedures and relevant training, and that connected aspects of clinical governance should be provided or led by local health boards and as with all other primary care staff they should be police checked before they can work with children. (Para 3.82) 3.136 We recommend that NHS Direct Wales should always have on duty at least one appropriately qualified person to deal with children’s issues. (Para 3.85) 3.137 We recommend that NHS Direct Wales should be enabled to gain access to local authority child protection registers. (Para 3.86) 3.138 We recommend that all GP out of hour’s services have written child protection protocols and provide training for their staff on this issue. (Para 3.88) 3.139 We recommend that an independent procedure should be established to enable just determination of situations in which a teaching institution wishes to exclude a student whom it considers to be of a personality or character unsuited to clinical practice. (Paras 3.89-3.91) 3.140 We recommend that local health boards should lead self-financing training sessions for taxi and minibus drivers from the private sector used to transport children for NHS purposes. (Para 3.92, 3.93) 3.141 We recommend that the Welsh Risk Management Standards are amended to take account of the recommendations of this report. (Para 3.99)

36 4.THE GWYNFA REVIEW

4.1 Gwynfa, in Colwyn Bay, was for 36 years (from 1961 to 1997) the NHS child and adolescent psychiatric inpatient unit for patients mainly from the North Wales area. 4.2 During the early 1990s, at much the same time as allegations of abuse in children’s homes in North Wales were arising, allegations of abuse perpetrated by staff upon former patients of Gwynfa began to emerge. 4.3 Cumulatively, allegations of a substantial number of incidents of abuse were made by the possible victims during the 1990s. Most related to their care at Gwynfa many years before. They arose by a variety of routes. A very small number were made spontaneously to staff in the service or came to light in the course of clinical practice. 4.4 Others arose from the police investigation launched at the request of the responsible NHS authorities in North Wales. The police investigation and three NHS internal investigations were carried out across the 1990s. A number of cases were referred to the Crown Prosecution Service (CPS), which decided to pursue prosecution in one case. Subsequently, a former member of staff of Gwynfa was convicted of rape. 4.5 Other possible victims came forward as a result of the work of the Tribunal chaired by Sir Ronald Waterhouse. As we have seen, Sir Ronald’s terms of reference were interpreted as limiting his remit to children in the care of the state. Gwynfa was an NHS facility that admitted many young people who had not been in the care of the state as well as some who had. Perhaps this might not have been perceived when the Tribunal’s terms of reference were set. Consequently, the chapter in his report relating to Gwynfa is brief. 4.6 Waterhouse did take evidence in 1997 from staff and former staff of Gwynfa and from young people who had been patients there. This gave rise to many more allegations. It is now evident from all sources that the alleged incidents spanned a period of around 18 years. 4.7 Later, the CPS decided not to charge any other staff member against whom allegations had been made and so no other convictions have occurred. A small number of the complaints were pursued by or on behalf of the victims in civil litigation. Subsequently, most were struck out. 4.8 Since 1997, three reviews, each with a different focus, have been undertaken. a. Late in 1997, the Welsh Office agreed with North Wales Health Authority and the Clwydian Community Care NHS Trust that they would jointly establish a Corporate Group to review the allegations relating to staff at Gwynfa. b. In 1998, the Health Advisory Service HAS 2000 was appointed to create standards for inpatient services for adolescents in Wales and to review the present facilities against them. c. Since 1999, the Conwy and Denbighshire NHS Trust, which manages the present adolescent psychiatric inpatient unit, Cedar Court, has carried out a further investigation to determine whether there were any disciplinary

37 actions outstanding that should be taken with regard to the allegations. This has led to another former member of staff having his employment by the NHS terminated. 4.9 Sir Ronald Waterhouse acknowledged that the situation in which his Tribunal found itself left an unsatisfactory position as regards alleged abuse within the NHS in North Wales. He was keen that these matters should be pursued and, in due course, the National Assembly for Wales agreed that further action was required to look into matters within the NHS and to ensure that all reasonable action had been taken to deal with the complaints. 4.10 Our terms of reference include provision for a further retrospective consideration of matters relating to Gwynfa. The intention was that we should use this work as a study from which to identify and feed into the wider work of the review recommendations for protecting and safeguarding children and young people cared for by the NHS in Wales. A group selected from the Review Panel has carried out this task.

The Remit, Terms of Reference and Work of the Gwynfa Group 4.11 The term ‘Gwynfa Group’ refers to the three members of the Review Panel selected to pursue enquiries based on events that allegedly occurred between the 1970s and the mid 1990s. The members of the group, working in close conjunction with the Chair of the Review, Lord Carlile, were: • Professor Richard Williams (Chair); • Miss Marion Bull; • Ms Ruth Henke. 4.12 Scrutiny of the terms of reference at Annex 6 shows that the task facing us was not to mount a retrospective inquiry into what took place at Gwynfa. Rather, the Group was required to extract, from the allegations and the actions taken in response to them by professionals and managers at all levels from the frontline of the clinical service to the Welsh Office, lessons that should impact on the National Assembly, its Health Department, the NHS and professional practice. Additionally, we were tasked with advising this Review as a whole as to whether there are any matters evident to us on the basis of our work that have not yet been satisfactorily resolved. 4.13 We began our work early in 2001 and a more detailed description of our working methods is also at Annex 6. The core of the work was an office-based review of relevant papers held by the responsible authorities. We negotiated access to papers relating to Gwynfa held by: a. The NHS Directorate within the former Welsh Office, now National Assembly for Wales; b. The North Wales Health Authority; c. The former Clwydian Community Health NHS Trust (the responsibilities of that Trust in respect of the child and adolescent psychiatric service were assumed by the Conwy and Denbighshire NHS Trust in 1999);

38 d. The present Conwy and Denbighshire NHS Trust; e. The minutes of the meetings of the management group within Gwynfa and, more recently, its replacement Cedar Court; and f. The statements of the alleged victims made to the Waterhouse Tribunal of Inquiry. 4.14 In February 2001, two members of the group visited Cedar Court in the company of other members of the Panel when it visited North Wales. Similarly, one visited the Hergest Unit, one of the two adult mental illness units in North Wales that admits adolescents who have a serious psychiatric disorder, at Ysbyty Gwynedd in Bangor. 4.15 After our initial scrutiny of the papers, we decided to seek clarification on a range of matters and so took oral evidence from a selection of informants (see Table 1 in Annex 6) during June and July 2001

Gwynfa 4.16 Gwynfa opened in 1961 to serve the whole of the North Wales area. From 1974, it was funded by the Clwyd and Gwynedd Health Authorities, run by the former and was intended to provide inpatient services for children and adolescents in North Wales who required them. In 1996, the health authorities were amalgamated becoming the North Wales Health Authority. 4.17 When Gwynfa was opened, hospital units throughout Wales were run by hospital management committees that were responsible to the Welsh Hospital Board. In 1972, a review of NHS and local authority services led to the establishment from 1974 of Area Health Authorities charged with strategic determination of the pattern of local services for defined populations and their operational management. Most had a number of subordinate districts each headed by a district management team. In the early 1980s, the district tier was removed. 4.18 In the mid 1980s, general management was introduced into the NHS, which, generally, clarified management responsibilities for healthcare. Subsequently, there have been a number of policy-driven changes in the structure of the NHS in Wales. These included separating purchasing and commissioning of services from their operational management consequent on the NHS and Community Care Act 1990. Broadly, this legislation gave responsibility for strategic matters, and for commissioning and purchasing services to the new health authorities and responsibility for providing and managing specialist health services to NHS Trusts which grew in number rapidly in the first half of the 1990s. The health services in North Wales were fully involved in this scenario, which created a fast-moving context of demanding change throughout the NHS.

. 39 4.19 Consequently, responsibility for commissioning and operating Gwynfa has passed through the hands of a number of responsible bodies and management structures in the period covered by our review (see Table 2 in Annex 7). The allegations summarised here and the management responses to them are to be seen against this background. The most recent change came in 1999, after NHS Trust reconfiguration. 4.20 The papers read by the group suggest that for a lengthy period Gwynfa was something of an outpost from the main centre of specialist psychiatric services at the North Wales Hospital in Denbigh. It was at a geographical distance from other psychiatric services and at an even greater distance from other mental health services of similar type and role. 4.21 During its first 20 years, the specialist medical contribution to Gwynfa was provided severally by the consultant child and adolescent psychiatrists who worked in North Wales. In 1981, the Clwyd Health Authority appointed a single doctor to the new role of consultant in clinical charge of the unit. We believe that, hitherto, the more dispersed nature of consultant involvement had left the main thrust of day-to-day management with the senior nurse on site. 4.22 Even with hindsight, it is difficult to provide an accurate and balanced impression of matters as they were managerially so many years ago. Nevertheless, all that we have heard and read suggests that the involvement of the wider NHS management and professional structures in Gwynfa was reactive to the turn of events rather than active and planned throughout most of the 1970s and well into the 1980s. 4.23 The papers provided by the consultant in clinical charge, record his attempts from appointment to gain greater managerial and professional interest in Gwynfa and to move its culture forward by promoting education and learning for the staff of all disciplines and, thereby, to reduce their isolation from contemporary opinion within their field. Nonetheless, if the accounts of staff present at the time are accurate, their environment was more one of having to justify recurrently what they did against possible closure, rather than service development. 4.24 Creation of the mental health unit within Clwyd Health Authority in the mid 1980s brought more active management involvement in Gwynfa. This culminated in its relocation to more suitable premises, an achievement that was delivered more through local action than strategic planning, and in the face of some resistance.

Cedar Court 4.25 In 1997, the premises of the unit at Gwynfa were closed and its work was transferred to another location in Colwyn Bay. Although Cedar Court, the new premises, is distinct from Gwynfa in many ways, a significant number of the staff, including some key personnel, transferred from one to the other. There is therefore continuity from Gwynfa to the present unit. 4.26 Today, Cedar Court is managed within the Children’s Services Directorate of the generic Conwy and Denbighshire NHS Trust. We are of the opinion that Cedar Court is now at the centre of consideration within that directorate’s activities and no longer managerially so isolated.

40 The Allegations The Nature of the Allegations 4.27 Earlier, we have identified the origins of the allegations. The North Wales Tribunal took statements in 1996 and 1997 from a number of former Gwynfa patients. They remain in the custody of the Tribunal and so the Counsel to the Review took steps to secure revelation of the relevant statements. This resulted in the Gwynfa Group being allowed privileged and limited access to relevant papers. For these reasons, we are unable to reveal any detail of their content. Some of them are of neutral content with respect to Gwynfa, some are in praise of care received at Gwynfa while others detail allegations of sexual and physical abuse or of what the group has considered to be rough handling. 4.28 We have also seen a number of the statements generated by the police investigations conducted in the early 1990’s and a number of letters before action written on behalf of former patients. 4.29 We are aware that 32 former patients have made complaints of abuse against at least 17 members of staff at Gwynfa. The allegations range from claims that members of staff failed to intervene to prevent patients being bullied by other patients through allegations of rough handling, excessive chastisement and inappropriate sexual horseplay against staff, to allegations that staff members seriously physically and sexually assaulted patients. The latter include allegations of rape and buggery. One additional complainant alleged that a member of staff at Gwynfa failed to act upon a disclosure of serious intrafamilial abuse and thereby failed to protect them. The staff concerned were nurses, nursing assistants and catering staff. 4.30 All of the 33 complainants were voluntary patients. Twenty-two were children in care (voluntary or involuntary) at the time of their placement at Gwynfa. The period covered by the allegations was extensive. All but two fell in the period 1968 to 1986. 4.31 We understand that, during the mid to late 1980’s, various safeguards and procedures were introduced which aimed to improve the standard of care and protection available to patients at Gwynfa. While we see these as positive steps forward that were to be encouraged, with hindsight it can be seen that they were insufficient. 4.32 Only one person, referred to arbitrarily as ‘AB’ in our account, has been convicted of any offence arising out of the Gwynfa allegations. One other member of staff against whom allegations were made has been the subject of internal disciplinary processes resulting in his dismissal from employment in the NHS. 4.33 It is not for us to judge whether or not any of the allegations made were true. However, we believe that the ways in which the allegations were made and handled at the time and the subsequent responses provide an informative study from which the NHS (and other statutory bodies) might learn. The account that follows concentrates upon areas open to criticism.

41 The Allegations against AB 4.34 We now know that in 1991, AB, a nursing assistant at Gwynfa, raped a female patient on two occasions when she accompanied him to a private house. He was convicted of those offences in March 1997. 4.35 In the summer of 1991, complaints were made by both residents and members of staff to the managers at Gwynfa about AB’s inappropriate behaviour with a particular female patient. At first, AB was counselled about his conduct. A little later, a love letter from him to the patient was found in her laundry. There were no allegations of rape made in this period. AB was suspended promptly while the matter was investigated. He tendered his resignation, which was accepted, during his interview and the disciplinary process did not proceed further. 4.36 In summary, in 1991, when AB was employed at Gwynfa and his victim was resident there, there had been evidence of an improper sexual association although there was no claim or evidence of rape prior to 1996. We believe that the child protection procedures should have been followed in 1991 in response to the allegations made by the patients and staff and in response to the love letter. Instead, the matter was investigated with the victim in a clinical interview. We think that this action was wholly inappropriate because the letter disclosed matters that suggested the possibility of a sexual relationship between a patient and a member of staff of the hospital where she was being treated. In law, if such a relationship were proven, it would amount to a breach of S128 of the Mental Health Act 1959. 4.37 The offences of which AB was convicted were based upon formal statements of complaint made by his victim in January 1996. By then, she had ceased to be a patient at Gwynfa long since and AB no longer worked there. 4.38 We consider that this case highlights the vulnerable nature of patients in units such as Gwynfa and the trust they placed in the staff that care for them. It emphasises the need for rigorous child protection procedures50 to ensure, in so far as is possible, that such an offence could not occur in the future. 4.39 While it is far from clear that, had action been taken under the procedures that prevailed at the time, an earlier revelation of rape might have occurred, this situation has reminded us of the key importance of ensuring that all staff are offered initial training and continuing updates in child protection matters and that the mechanisms for using the procedures are explicit, easy to use and well known. 4.40 At this point, we raise concern about the promulgation of policy and guidance from the Welsh Office and National Assembly for Wales to the NHS. Over the years, sometimes acting in conjunction with departments in England and elsewhere, the Welsh Office and the National Assembly for Wales has issued guidance relating to a wide variety of matters including child protection. Many of the documents, particularly Working Together on child protection procedures, are laudable and highly appropriate. Government has kept policies and its guidance for practice under review in this particular area and reissued it in 2000. We see weight in the argument that the guidance in Working Together should be issued to the NHS under similar statutory provision to those that apply to the social services departments of local authorities.51

50 Mental Health Act Commission, 2001. Ninth Biennial Report. London: The Stationery Office 51 S 7(1) Local Authority and Social Services Act 1970 42 4.41 What is less clear is the efficiency with which policy and guidance on practice has reached the frontline of services. Inevitably, there is a lag between issuing guidance and its implementation but, on the basis of our work, we believe that there is a need to review methods of transmission of important guidance and to agree with the service timetables for implementation and the necessary training that stems from it. There also needs to be explicit channels for the services and practitioners within them to provide active feedback about the appropriateness of the guidance and any adjustments thought necessary. 4.42 Given the standards at the time, we consider that it could have been arguable that AB should have been allowed to resign in 1991. But what is without doubt is that this case illustrates the unsatisfactory nature of such a termination of a disciplinary process with child protection implications. AB’s resignation halted the disciplinary process and so there were no findings recorded against him in his personnel record. As an untrained nursing assistant, there was no mechanism for his registration with a professional regulatory organisation to which allegations could have been referred. So, there was no record of the allegations against him in a professional context either. Both of these circumstances left a real risk that any subsequent employer would be unaware of the allegations and the possible risk posed to children. Hopefully, unsatisfactory situations of the kind that we have discovered will be reduced by adherence to the procedures required by the ‘Protection of Children Act 1999’52 (POCA). 4.43 Our opinion is that this matter raises governance and procedural issues for not only children’s services but also for universities and other centres of professional education. Our wider inquiries revealed that the problem of dealing with and recording satisfactorily allegations of misconduct relates to all ‘unqualified’ staff who work in the statutory and non-statutory sector services. Significantly, it is also a challenge to all of the universities and other higher educational bodies that are responsible for training students of the professions because learners are not eligible for professional registration before qualification. We advise that this is a matter that must be actively resolved by all the appropriate bodies. They are likely to require advice from lawyers expert in child protection and the law relating to children and as well as employment law. 4.44 We have come to the view that those responding to the allegations which led to AB’s later conviction took undue comfort from the fact that his offences occurred away from Gwynfa. We must emphasise that the geographical location of an offence in no way mitigates the abusive nature of a sexually inappropriate relationship between a psychiatric patient (formal or informal) and a member of staff.

The Other Allegations 4.45 We stress that the majority of the allegations are unproven. Nonetheless, we were particularly concerned to consider how opportunities might be maximised to enable young people in the care of the NHS to disclose past abuse elsewhere or to share any current concerns they might have about their safety. 4.46 Children may prefer not to disclose sensitive matters of this kind to staff who are caring for them and this raises the importance of balancing privacy, safety and transparency of relationships between children, parents and the staff

52 Protection of Children Act 1999 (POCA) London : The Stationery Office

43 of our services with providing children access to advocates and with free telephone contacts with external agencies with which they might feel comfortable. 4.47 The information we reviewed plainly indicates that some members of staff brought considerable and commendable concern to bear about the children and, indeed, worked hard to secure their best interests. Nevertheless, there might also have been circumstances for periods in the history of Gwynfa when this was not necessarily consistently the case for all children throughout the 24 hours of the day. 4.48 Although we have concentrated, so far, on abusive incidents substantiated by legal action, we are also particularly concerned by allegations relating to the way in which a number of other children were cared for. Not amounting to frank misuse, some of the other allegations concern what we have here termed ‘rough handling’. If any were true, it seems to us that some children were not treated in a way that was consistent with what are now requirements of the Children Act 1989 and the UN Convention on the Rights of the Child and did not receive a standard of care commensurate with that expected for children within other NHS facilities for children with physical ill health. 4.49 Thus, we take this opportunity to remind all of the need for active and continuing vigilance about the way in which children are cared for and treated and the requirement for all services to place their needs first. This demands open, supportive, learning organisations that encourage reflective practice and a continuing focus on: the rights of children; providing advocacy services; providing services in a child-friendly manner and striving to hear the voices and opinions of children in all that is done for and about them.

Responses to the Allegations The Police Investigation 4.50 In August 1991, the North Wales police launched a major investigation into allegations of abuse in children’s homes in North Wales. In September 1991, a former patient of Gwynfa appeared in a television documentary alleging publicly that he had been abused while resident at Gwynfa. We were unable to find evidence that the responsible health authorities took action to investigate adequately the allegations or to secure the safety of any child who might be in the care of any alleged perpetrator. This Review is firmly of the view that allegations of this nature must be taken seriously, and proper steps must be taken to co-operate both with any police investigation and to secure the safety of any children with whom those under investigation may have contact. 4.51 However, the allegations made in the TV documentary were investigated by the police as part of their on-going investigation and, in the early months of 1992, they took statements from the complainant and a number of other former patients of Gwynfa. 4.52 The police met with a representative of the relevant health authority in February 1992 to outline the police enquiry and seek access to records (including staff rotas, record books and the medical files of patients) held by Gwynfa believing that sight of these documents was necessary if the police were to complete their enquiries into allegations made about Gwynfa. We note with

44 concern that, while this request was repeated on a number of occasions by the police, access to the required documents was not given until April 1993, some 14 months after the initial request. During the intervening months, further historical complaints were made by other former patients of Gwynfa. 4.53 We have considered the reasons for the delay put forward but have concluded that the change in stance occurred only after informal advice was offered by an official in the Welsh Office. We accept that those considering whether or not to allow access to the police had to grapple with complex issues of ethics and legality, but feel compelled to state that, in our opinion, the delay was unnecessary and unhelpful. While it continued, the investigation into very serious allegations was hampered and children might have been at risk. 4.54 We have concluded that the delay was caused by a failure to appreciate two significant factors. First, no one appears to have understood the distinction between confidential and non-confidential written material. Not all documents held by a health body are confidential (e.g. staff rotas). Second, there appears to have been a failure to comprehend that the confidentiality attached to documents, such as patients’ records, is not absolute. We raise this to avoid the possibility of the subsequent ‘Caldicott Report’53 being misunderstood with the risk of its recommendations becoming obstacles to disclosure rather than positively informing procedures for regulating disclosure where necessary and when it is justified.

The Disciplinary Process 4.55 By mid 1993, the police investigation into one member of staff had been concluded and the CPS decided not to prosecute. The police then gave one senior manager and a non-executive director of the recently established Trust that now managed Gwynfa access limited to sight only of some of the statements of complaint they had taken referring to this individual. 4.56 The police felt unable to make wider disclosure without the consent of the complainants and not all gave theirs. The net effect was that the Trust’s knowledge was restricted to awareness of the contents of a selection of statements rather than it receiving evidence it could use for any disciplinary process. Evidently, it is not only the NHS that experiences problems with disclosing confidential information. At the time, it is apparent that the police did not appreciate that the privilege attaching to these documents was not absolute. With the benefit of later case law54, our opinion now is that they could have disclosed statements without consent of their makers if the public interest had justified it. 4.57 We believe that this incident shows that the Trust was placed in an invidious position by being given access to information without the ability to use it. Limited disclosure hampered the disciplinary process which, of necessity, was based only on those statements that the police had consent to disclose and they did not give the complete picture. 4.58 An internal disciplinary process was conducted in the autumn of 1993. At its close, the employee, who had been suspended during the investigation, was free to return to work. He was re-deployed within the Trust because the investigation had raised issues that would have made it difficult for him to return to Gwynfa. 53 The Caldicott Committee: Report on the review of patient-identifiable information – December 1997: Department of Health: London. 54 Woolgar v Chief Constable of Sussex Police (2000). 1 WLR 25. 45 4.59 With hindsight and judged against current standards, we have concerns about the process employed. It took the form of an investigation rather than a hearing. This caused the complainants to be re-interviewed but did not provide an internal tribunal to test the allegations. In our opinion, there was no need for the complainants to be re-interviewed as a decision could have been made on the previous papers as to whether or not there were reasonable grounds to suspect that the allegations were founded. We think that this process was unfair to both the complainants and the accused since it provided no opportunity for a fair hearing. 4.60 The option of re-deployment, while practical, also fudged the issues. We are concerned that, upon re-deployment, those with immediate management responsibility were told that there was nothing (other than inexperience working with adults) that might affect this person’s work. This was consistent with the allegations not being substantiated, but it resulted in someone, who had been the subject of various serious allegations about children, working with vulnerable adults without his immediate superiors being alerted to any relevant areas of concern. We hope that adherence to the provisions of POCA will prevent such an unsatisfactory situation arising in the future. We believe it important that the reasons for taking any disciplinary proceedings; the nature of the proceedings adopted and the outcome of the proceedings should always be clearly noted on the personnel file of an employee. 4.61 In 1998, the same employee was the subject of new complaints of serious abuse from the time when he worked at Gwynfa. The police investigated the allegations and they decided in early 1999 to take no further action. The Trust with responsibility for Cedar Court decided to hold a disciplinary hearing and that internal Tribunal found that there were reasonable grounds to suspect that the allegations were true and dismissed the member of staff. In the summer of 1999, the Trust formally referred this member of staff to the United Kingdom Central Council for Nurses, Midwives and Health Visitors (UKCC). The procedures of that body are still current at the time of writing.

The Response of the NHS Trust then Responsible for Gwynfa 4.62 In autumn 1996 and in response to the establishment of the North Wales Inquiry, the Clwydian Community Care NHS Trust appointed a retired former Director of Public Health Nursing of the Clwyd Health Authority to provide a report for the Trust Board before the end of the year. 4.63 Her terms of reference required her to review the results of previous inquiries, produce an analysis of all allegations made by then that involved the Trust, forecast the areas likely to be covered by the North Wales Inquiry and recommend actions to be taken by the Trust. 4.64 The task was achieved against a tight timescale. She recommended that the Trust be represented at the Inquiry and provision of support for staff at Gwynfa. Later, her report was used by senior officers of the Trust to brief officials for the Welsh Office. 4.65 We recognise now that there were some inaccuracies, for example relating to certain dates and the precise number of allegations in that report. These are understandable when the volume of work is considered against the time available. They were corrected by the Corporate Group later (see below).

46 The Role of the Welsh Office Health Department 4.66 The Welsh Office first became formally aware of the allegations about staff at Gwynfa in 1993 when the Clwydian Community Care NHS Trust informed officials of the suspension of the staff member following allegations of abuse. The Welsh Office advised the Trust to follow the procedures in ‘Working Together.’ 4.67 There was no further involvement of the Welsh Office until 1996 when a copy of the report described in paragraph 4.63 was received from the Trust. The terms of reference of the Waterhouse Tribunal that were attached drew the focus of that inquiry to the attention of the Director of the Welsh Office Health Department who had not been personally involved previously. In response, the Director set up a team, led by a secondee from the NHS, to work directly to him. This team provided the health input for the Tribunal and monitored the Gwynfa situation. 4.68 However, it appears in retrospect that little consideration was given to the training or support requirements of staff who necessarily had to deal with sensitive and potentially traumatic material. So, we take this opportunity to draw attention to the potential impact not only on professionals but also on managers including those at a distance from events that may stem from their intervention with situations in which others may have suffered abuse. There is now evidence of the considerable demands and the potentially heavy toll of working with these matters. 4.69 By mid 1997, it became clear that the Tribunal was not going to cover the NHS in any detail and the Welsh Office set about agreeing a chronology of allegations with the NHS. 4.70 During the course of this work, concerns were expressed by Welsh Office officials to the responsible NHS authorities in North Wales that none of the allegations had been referred to the UKCC. The Chief Nursing Officer of the Welsh Office referred all nurses against whom allegations had been made to the UKCC. 4.71 We have looked into this issue. We found a view, which appears to have been held widely at that time, that there had to be sufficient evidence to satisfy the criminal standard of proof before a referral could be made to the UKCC. In our opinion, the documents we saw from the UKCC for the mid 1990s relating to the thresholds for reporting potential incidents to that body were ambiguous55. Our review has left us clear that, while the criminal standard has to be met before a person can be removed or suspended from the register, that does not mean that it must be satisfied before a referral is made to the UKCC. 4.72 The professional regulatory bodies for the various professions should, in our opinion, work to common reporting thresholds. The NHS Plan for England56 announced that there will be a UK Council of Health Regulators for formal co-ordination of the work of the eight independent regulatory bodies currently covering the healthcare professions. The Bristol inquiry57 has recommended that a single body, which it calls the Council for the Regulation of Healthcare Professionals, should be charged with co-ordinating and integrating the professional regulatory bodies. In August 2001, the Department of Health

55 United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996. Reporting misconduct – information for employers and managers. London: UKCC.. 56 Department of Health, 2001, The NHS Plan – A Plan for Investment, A Plan for Reform, CM 4818-1. London: The Stationery Office 57 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995, CM 5207, London: The Stationery Office. 47 published a consultation document58 on the functions, responsibilities and accountability of such a new UK Council. We consider it appropriate that the new Council should have the power to ensure that the separate professional regulatory bodies issue common advice. This guidance should also be included within any new appraisal and regulatory system for NHS managers. 4.73 The new council should be invited to give particular consideration to how it handles evidence from children. 4.74 We believe that the regulatory bodies should recognise that an acquittal in criminal proceedings does not necessarily mean in absolute terms that the accused person did not commit the alleged acts . It may still be possible to prove the allegations on the balance of probabilities (the civil standard) and, in some situations, it may be enough to prove on balance of probabilities that there are grounds to believe or suspect that the accused person has committed the alleged offences. 4.75 Similarly, we consider it important that the regulatory bodies should consider the desirability of admitting hearsay evidence in matters concerning the welfare of children60. 4.76 The advice in paragraphs 4.74 and 4.75 is addressed to the regulatory bodies. However, the same matters should be considered by the human resources departments in all children’s agencies, including the NHS, as they may be responsible for advising on or conducting disciplinary investigations and hearings relating to the behaviour and conduct of the staff they employ. 4.77 We make this recommendation because we believe that there was not only at Gwynfa but also in the minds of senior managers in the responsible authorities, a lack of clarity about how best to proceed when investigating, on the first three occasions, disciplinary matters regarding the behaviour and conduct of staff. 4.78 In order to avoid the possibility of similar uncertainties arising elsewhere in the future, we believe that there is a need for human resources guidance to be issued by the National Assembly for Wales to the responsible authorities relating to the conduct of staff generally and with particular regard to children. 4.79 In particular, we would like to see guidance prepared and disseminated on procedures for dealing with cases of child abuse, allegedly committed by NHS staff. It may be necessary to remind personnel in the NHS of the existence of Paragraph 298 in Part X of the Memorandum to the Mental Health Act 198361 62. 4.80 The Welsh Office also required a report on Gwynfa to be compiled by a Corporate Group comprising the Chief Executives of the Trust and the Health Authority and two non-executives directors from each body. 4.81 Following receipt of the Corporate Group report, there was much correspondence and some meetings between the NHS and the Welsh Office. It seems to us that some of the exchanges were sharp and, at times, acrimonious. In our opinion, the variety of roles of the Health Department within Government

58 Department of Health, 2001, Modernising Regulation in the Health Professions, London: Department of Health. 59 R v Swindon Borough Council and another ex p S (2001). LGR 318. 60 Hearsay evidence is admissible in civil proceedings by virtue of the Civil Evidence Act 1995 and in proceedings concerning the upbringing, maintenance and welfare of children by virtue of the Children (Admissibility of Hearsay Evidence) Order 1993. 61 Department of Health and Welsh Office, 1998. Mental Health Act 1983 explanatory memorandum on parts I, II, III, IV, V, VI, VIII and X of the Act and associated Schedules, and on the Health (Hospital Guardianship and Consent to Treatment) Regulations 1983. London: The Stationery Office.. 62 Hospital managers have a duty under subparagraph (d) to ensure, as far is practicable, that a detained patient understands that the Secretary of State for Wales or the National Assembly for Wales has a duty under section 120 of the Mental Health Act 1983 to investigate complaints made by detained patients, regarding matters ocurring whilst being detained, which he considers have not been satisfactorily dealt with by the managers of the hospital 48 and uncertainty about lines of accountability between it and the boards of the health authorities and trusts contributed to misunderstandings amounting to mutual mistrust on occasions. We also think that it is possible to misconstrue the demanding nature of the matters under consideration and their impact on key people despite their distance from the individuals who were involved. 4.82 After the work of the Tribunal in North Wales was complete, and before publication of its findings, a programme of action was agreed between the Welsh Office, North Wales Health Authority and Clwydian Community Care NHS Trust. The intention was to establish standards for adolescent psychiatric inpatient care, wherever it is provided, and to review the performance of the facilities in Wales that admitted under 18 year olds. In 1998, the Welsh Office set up an internal Recommendations Group to look at the lessons to be learned and this formed the basis for an all Wales expert workshop that met in the autumn of that year. Its papers have contributed to the lessons that we have identified. 4.83 In February 1998, the Secretary of State (who subsequently became First Secretary of the National Assembly for Wales) commissioned HAS 2000 to conduct a review of residential child and adolescent psychiatric services in Wales. This included an inspection of Cedar Court which had replaced Gwynfa by then. The HAS 2000 report was published in December 1998 and this led to a programme of action required for each of the units to meet the designated standards. Compliance visits were made by professional officials from the National Assembly and the account of the follow-up inspection, conducted by HAS 2000 in November 1999, was published in July 2000. 4.84 In December 1998, the Welsh Office sought the opinion of Counsel on how to deal with the issues surrounding Gwynfa.

The Corporate Group 4.85 By December 1997, the North Wales Health Authority, Clwydian Community Care NHS Trust and Welsh Office had obtained a significant amount of information about allegations made by former patients at Gwynfa. The Corporate Group began its work in January 1998 and reported to the Welsh Office in May and to the boards of the Health Authority and Trust in June. It reviewed each allegation, the action taken and considered whether it would be appropriate to refer any for further investigation to the police, social services department, regulatory bodies or the employer to invoke disciplinary procedures. The Corporate Group also determined whether any of the policies and procedures pertaining to the management response to the emerging allegations should be reviewed in the light of experience. 4.86 The process included detailed reviews of all the information available to the Health Authority and Trust. We have reviewed that Group’s papers. The volume of correspondence, notes of meetings and video links demonstrate the considerable effort expended to achieve a common understanding with the Welsh Office, the extent of the allegations, the surrounding events, and subsequent action taken. There was also a substantial contribution of legal advice from the Trust and Health Authority’s solicitors and the Legal Department at the Welsh Office.

49 4.87 The report of the Corporate Group concluded that, with the exception of one suspended member of staff then being investigated by the police, all appropriate action had been taken in relation to the listed allegations. In addition, the report noted that, with the benefit of hindsight, certain information clearly possessed a significance that could not have been appreciated at an earlier stage. The summary of the report concludes that it found no evidence to justify criticism of officers or the Health Authority and Trust 4.88 That report highlights that it would have been beneficial in assessing the position of the Health Authority and Trust if the police had been able to share more openly the information they were gathering at the time. 4.89 With the benefit of hindsight, several informants commented to us that the work of the Corporate Group would have been made easier if the Welsh Office had been part of it and there had been greater clarity at the time about relationships between the NHS and the health department in the Welsh Office. It appears to us that including independent advisers would have enhanced the objectivity of the exercise. 4.90 The policy issues identified for further attention included matters relating to central guidance, sharing information between the NHS and the Welsh Office and developing procedures to ensure that employers are aware of the previous employment history of staff engaged in a caring role particularly when those staff are not under the supervision of a professional body.

Subsequent Local Reviews 4.91 In April 1999, the Conwy and Denbighshire NHS Trust assumed responsibility for Cedar Court on Trust reconfiguration. In our opinion, objectivity (for the scrutiny of past actions) was gained when, in May 1999, this Trust’s board, which had previously been uninvolved appointed a Gwynfa Review Team, chaired by a non-executive director, to review the report of the Corporate Group and the actions taken by the bodies that were formerly responsible for the management of Gwynfa and Cedar Court in response to all the allegations. That team concurred with the earlier conclusions of the Corporate Group. 4.92 In parallel with other quality assurance activities, the Trust has adopted a general policy of an annual review of compliance with child protection procedures. 4.93 Subsequently, the Chief Executive of the Trust has told us that he considers that all actions that should properly have been taken have been and that he is satisfied that the service provided by Cedar Court meets the child protection standards set by his trust. On the basis of our own examination of the circumstances, we concur.

50 5. THE LESSONS OF GWYNFA

Introduction 5.1 In this chapter, we turn to some of the wider issues raised for the Gwynfa Group in the course of our work. Inevitably, we identify some issues that are considered at greater depth elsewhere in this report, but we draw attention to them because they frame significant lessons that arose from our work. 5.2 At intervals, we refer to the recent All Wales Strategy for Child and Adolescent Mental Health Services, ‘Everybody’s Business’63. That initiative was given additional impetus by concern about child and adolescent mental health services (CAMHS) in Wales, and by the North Wales Inquiry.

Lessons for Policy 5.3 Many of the wider lessons stem from putting Gwynfa into its historical, management and professional contexts. Therefore, we begin by reviewing policy and service developments over its lifetime. 5.4 The forty years from 1961, when Gwynfa opened, to the present have seen rapid changes and developments in the philosophy of care for psychiatric patients and in the potential capability of CAMHS. By comparison, progress in developing good and effective services on the ground for young people across the UK has been much slower and this has opened growing gaps between potential and practice that reflect deficiencies in policy, strategy, service provision, the workforce, training and resources. Not least, there continue to be mismatches between: public and professional expectations; resources and levels and complexity of need in the population of children and young people; and quality of training of staff, and the numbers of them who are capable of responding64 65. 5.5 The situation at Gwynfa must be seen against this wider backdrop not to reduce the weight of responsibility on anybody but to stress the importance of learning the wider lessons for the benefit of children and young people cared for throughout Wales and the UK.

The Principles of Good Practice 5.6 When Gwynfa opened, the Mental Health Act of 1959 was in the process of implementation. That legislation was ground-breaking in that it put, for the first time in England and Wales, admission of patients to psychiatric units onto the same footing as all other NHS provision. In effect, it brought psychiatric care fully into the NHS. Since then, the Mental Health Act 1983 and the White Paper of 200066 (that is likely to lead to a new Mental Health Act) have reaffirmed these principles. 5.7 In 1969, the report of the inquiry, chaired by Geoffrey Howe QC, into Ely Hospital in Cardiff was published as a White Paper67. It received wide publicity and achieved considerable impact on the NHS. The problem of professional

63 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales. 64 Audit Commission, 1999. Children in Mind – a report on child and adolescent mental health services. London, Audit Commission. 65 NHS Health Advisory Service, 1995. Together We Stand. London: HMSO. 66 Secretary of State for Health, 2000. Reforming the Mental Health Act. Part I: the new legal framework. Cm 5016-1. London: The Stationery Office. 67 Department of Health and Social Services, 1969. Report of the committee of inquiry into allegations of ill-treatment of patients and other irregularities at the Ely Hospital, Cardiff. London: HMSO. 51 isolation was identified in its conclusions and Howe recommended a system of regular visiting and inspection. This gave rise to the formation of the Hospital Advisory Service (later the NHS Health Advisory Service), which became a vehicle for change and service development68. 5.8 ‘The Children Act 1989’ reformed, and for the first time consolidated most public and private law relating to children and young people. It too was ground breaking in that Section 1 brought together in summary the factors to be taken into account when considering the welfare of a child. It came into force in 1991 at about the same time as the UN Convention on the Rights of the Child which stated similar values and principles, was adopted in the United Kingdom. 5.9 The outcome of our work reinforces the vital importance of applying these principles, developed in Chapters 8 and 14, and in the recent CAMHS Strategy69 consistently wherever and whenever childcare is practised. Healthcare services for children must be child-centred and we agree completely with the principles laid out in ‘Everybody’s Business’. 5.10 In particular, our review of Gwynfa reinforces our opinion that it is important that national level guidance should be issued on managing of children and young people in inpatient units in the NHS. In particular, the guidance should include clear advice, based on acknowledged principles, about the freedom of children and young people to leave hospital premises on their own and the role of NHS staff and the responsibilities they hold for the safety and welfare of children in their care. 5.11 Section 85 of the ‘Children Act 1989’, requires hospitals to notify local authorities of any child who has been or is likely to be in hospital continuously for more than three months70. We believe that the intentions were to ensure that: children receive appropriate assessment of their social and welfare needs; the best interests of the children are at the forefront of decision-making about their absence from home and contact with familiar adults and peers; and young people in hospital have access to independent visiting, if needed. 5.12 We consider that it is now appropriate that local authorities and the NHS should agree common standards of childcare and extend the application of S 85. This might be promoted by the Director of the NHS in Wales agreeing with the Chief Inspector of the Social Services Inspectorate for Wales that the NHS would reduce voluntarily the qualifying period for S 85 to one month irrespective of whether or not young people have weekend leave. However, a change of this kind would only be meaningful and appropriate if the local authorities were in a position to form partnerships with the NHS in agreeing standards of childcare to be applied regardless of the agency responsible for the children’s care. We recognise that this will have staffing, resource and financial implications for the Social Services Departments as well as the NHS.

The Professional Context 5.13 Within the lifetime of Gwynfa not only were legal, management and ethical concepts in the public sector changing rapidly, but developments were taking place in parallel in the philosophy and practice of child and adolescent psychiatry.

68 The NHS Health Advisory Service (HAS) was a Non-departmental Public Body (NDPB) and its Directors reported to the Secretaries of State for Health and Wales. In 1997, the HAS was wound up by the Government of the time. It wad replaced by a consulting body, Health Advisory Service (HAS) 2000, run by a consortium of professional and managerial bodies. 69 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales 70 S85(1) Where a child is provided with accommodation in any Health Authority, Special Health Authority National Health Service Trust or 52 local education authority (the ‘accommodating authority’) – a) for a consecutive period of least three months; or b) with the intention, on the part of that authority, of accommodating him from that period, the accommodating authority shall notify the responsible authority. 5.14 Child and adolescent psychiatry did not emerge until around the 1920s and formal specialist training in it for doctors was not defined before the 1960s. Thus, Gwynfa was opened before formal training leading to consultant appointments began. Inevitably, the first consultants in child and adolescent psychiatry were drawn from backgrounds of training in other specialties within psychiatry. Since then, the number of established training and consultant posts has expanded progressively though, strikingly, not until very recently has there been a real endeavour to link the development of posts to estimates of the distribution of need in the child and adolescent population. 5.15 Progress has been particularly rapid and welcome in academia. Starting from recent beginnings (there were few, if any, academic posts in child and adolescent psychiatry prior to the 1960s), almost all medical schools now have departments or sections within them of child and adolescent psychiatry, child psychology and nursing. This has propelled research, and has encouraged much closer consideration of the distinctive roles of mental health practitioners drawn from the range of differing disciplines who work with young people as well as progressive developments in their training. 5.16 It is evident that rapid developments have been made with: • Understanding psychiatric disorder as it impacts on young people71 72; • Recognising the nature of the risk factors, including abuse and misuse, that may contribute to individuals developing diagnosable disorders; and • Developing more potent capability for intervention. These positive developments have brought their own pressures for service provision and staffing.

The Service Context 5.17 Outpatient clinics (many were formerly called child guidance clinics) delivering child and adolescent mental health services have developed gradually from the 1920s through to the present day. 5.18 Most of the present inpatient psychiatric units for younger people were developed in the late 1960s and early 1970s in the wake of concern about the need for purpose-designed accommodation that enabled young people not to share facilities with adults73. Widely-held concerns of this kind persist74. 5.19 Nonetheless, pressure on resources, staff numbers and finance brought a reduction in the pace of developments from the mid 1970s. By then only an incomplete array of inpatient services had been developed and this situation has persisted and worsened since then. Pressure on the existing inpatient services grew in the 1980’s and 1990’s. They were a soft target and many former inpatient units have closed in an unplanned way to use the resources they represent differently and only sometimes for the benefit of young psychiatric patients in the immediate locality. 5.20 Consequently, the number of psychiatric beds for young people has reduced compared with the already unsatisfactory circumstances of 1980. Today,

71 The papers published in Vol 1(eds Green J, Yule B) and Vol 2 (eds Taylor E, Green J) of Research and Innovation on the Road to Modern Child Psychiatry, 2001 (London: Gaskell and ACPP) provide a number of sentinel papers from just one source. 72 The papers published in volume 179 (published in August 2001) and Volume 180 of the British Journal of Psychiatry (published in September 2001) provide examples of current progress. 73 H.M. (64) 4. 8 January 1964. In-patient Accommodation for Mentally Ill and Seriously Maladjusted Children and Adolescents. Ministry of Health. 74 Biennial Reports of the Mental Health Act Commission in 1997, 1999 and 2001. London : The Stationery Office 53 the number of beds in Wales per 1000 of the population is lower than in any of the English regions. 5.21 Our Review shows that, in the past, the client group of Gwynfa included children of diverse ages and needs being treated within the same unit. It appears to us, in the light of present thinking, that many of its young people might have been more appropriately treated and cared for in other resources, had they been available. This suggests to us strong evidence that the range and volume of CAMHS in North Wales was and remains inadequate. 5.22 Until recently, there has been a vacuum in policy relating directly to the mental health services for children and young people. Inevitably as a result, strategy for the NHS and guidance from the centre on service commissioning and delivery have also been largely absent leaving the responsible agencies to afford such priority and resources to CAMHS as might be locally determined. 5.23 In 1989, the Strategy for Wales for Mental Illness Services75, produced at the instigation of the Secretary of State for Wales, recognised children and adolescents as client groups in a generic policy for mental health services. The NHS Health Advisory Service reported in 1995 at the behest of the Secretaries of State for Health and Wales and the recommendations in ‘Together We Stand’76 have guided developments in the UK since then. In 2001, the National Assembly for Wales launched ‘Everybody’s Business’77. 5.24 We are left with a clear sense that mental healthcare of children and adolescents must be embedded organically within policy for the NHS in Wales and that the National Assembly for Wales has a key role in leading developments.

Lessons for Strategy The All Wales CAMHS Strategy 5.25 Much of what we have to say about strategy arising from retrospective review of Gwynfa is entirely consistent with the approach in and content of ‘Everybody’s Business’. 5.26 Elsewhere in this report, we will observe that it is all too easy for the sometimes uncomfortable needs of young people with mental health problems and disorders to be overlooked. We derived a strong sense that this may well have applied, at intervals at least, to Gwynfa. 5.27 It appears to us that little was known of the existence and role of Gwynfa outside its immediate vicinity in North Wales or outside the more specialised professional circles. Our reading and the oral evidence suggests that the requirement for the unit had to be substantiated episodically and repeatedly over an extended period and that there was no continuing plan for its support and investment in it. By all accounts, matters improved from the mid 1980s with the formation of the mental health unit based on the North Wales Hospital when the investment of senior managerial support for Gwynfa appears to have become more real. However, we do not see this as amounting to a strategic plan for CAMHS within which inpatient services had a clearly acknowledged place. 5.28 We support the four tier strategic framework for CAMHS that is now policy

75 Welsh Office, 1989. Mental illness services - a strategy for Wales. Cardiff: Welsh Office. 76 NHS Health Advisory Service, 1995. Together We Stand. London: HMSO. 77 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: 54 The National Assembly for Wales in Wales as we consider that the experiences of Gwynfa clearly show the necessity for such a coherent framework. 5.29 We agree that the most specialised services should be commissioned on an all Wales basis but we are clear that all residential child and adolescent mental health services within the NHS should be part of a wider network of child and adolescent mental health services in the localities they serve.

Implementing the All Wales CAMHS Strategy 5.30 We consider it vital that there should be evident lines of responsibility and accountability for the development of mental health services for young people that are informed by the national strategy and traceable from the National Assembly for Wales through the NHS bodies locally to frontline service provision. We believe that the Director of the NHS in Wales has a key role to play in initiating this process and there should be clear lines of accountability for implementation to the Local Health Boards and NHS Trusts in order to ensure implementation of ‘Everybody’s Business’. 5.31 So we endorse the organisational relationship between the Assembly’s NHS Directorate and NHS bodies set out in ‘Improving Health in Wales - Structural changes in the NHS in Wales’78, which proposes a direct line of accountability between the NHS and the Assembly.

Post Abuse Services 5.32 Our review also provides a keen reminder of the importance of providing timely access to multi-agency, multi-disciplinary packages of care and therapy services for the sufferers of abuse be it physical, sexual or emotional abuse or the result of neglect. Although services were made available to witnesses and attendees at the Waterhouse Tribunal, we remain unclear as to what routine services of this kind were and are available in North Wales but the accounts provided to us plainly indicate paucity of such services generally. We believe there is urgency to review the adequacy in Wales of therapeutic services for sufferers of abuse in the light of the current knowledge, skills and thinking on this topic and encourage the Minister for Health and Social Services to set this as a high priority within the agenda created by the All Wales CAMHS Strategy. 5.33 While there is a growing literature on post-abuse services, considerable uncertainty on best practice flowing from it remains and the present evidence is incomplete. For example, we are aware that there is a current debate about the advisability or otherwise of contemporary psychological de-briefing of victims with respect to the immediate and longer-term impact of interventions of this kind. Therefore, we wish to see a review of the evidence for best practice in responding to the psychological aspects of abuse before commitments are made to service models and their contents. 5.34 Similarly, we draw attention to the impact on professionals and managers that may stem from their intervention with all children and young people in need, including particularly those who have suffered abuse. There is now abundant evidence of the considerable demands and heavy toll that working with children and their families in these circumstances can bring to bear. Therefore, we

78 The National Assembly for Wales, 2001. Consultation Document, Improving Health in Wales - Structural Change in the NHS in Wales, Cardiff: The National Assembly for Wales. 55 consider that plans for post-abuse services should take into account, the training, resources and continuing support needed by all who deliver them.

The Role and Client Group of Psychiatric Inpatient Units for Adolescents 5.35 Reading the annual reports of Gwynfa/Cedar Court spanning the majority of the last 20 years and the minutes of the unit’s management group provides a picture of the evolution of the unit and its role. 5.36 In our opinion, there can be no doubt about the enormous challenge of the work Gwynfa took on. A number of young people who came forward during the inquiries in North Wales have recorded their thanks to its staff for the great value to them of their work. Many of the young people admitted appear to the group to have been among the neediest young people in the population. A considerable number appear to have had severe learning difficulties amounting to real disability, traumatic backgrounds including their experience of family breakdown and abuse, as well as very challenging behaviour. While, in all probability, few showed evidence of severe psychiatric disorder, if by that one means the kinds of mood and psychotic disorder that are at the centre of concern of most psychiatric services for adults, this should not be taken to suggest that the children admitted lacked serious problems that put their current and future mental health at risk. 5.37 But, our opinion is that, for many years - perhaps the first 25 - the clients of Gwynfa had much in common with the young people who were admitted to and cared for by children’s facilities provided by the local authority social services departments and special education units of the time. Research79, as experience, shows that there are many overlaps: and distinctions between psychiatric disorder and other problems affecting young people are, in many practical senses, unhelpful. Current policy is still endeavouring to promote better collaboration and partnership across agency and service boundaries. Yet, after our review, we were not able to see how admission criteria operated in the first 20 years of Gwynfa’s activities. However when viewed against evolving opinion in the period, such a finding might not have been unusual. 5.38 Gwynfa, and more recently Cedar Court, have slowly shifted towards a changed client group. In the past, Gwynfa admitted both children and adolescents whereas, now, it concentrates on admitting adolescents. While most of the patients admitted have substantial emotional and behavioural problems, the proportion of those with serious disorder has risen slowly. Nevertheless a significant number of adolescents with the most demanding disorders still have to be admitted to adult mental illness services in North Wales. 5.39 It seems to us that these circumstances at Gwynfa illustrate well the national debate that lasted from the late 1970s until publication of ‘Together We Stand’ about the priorities for use of the limited inpatient facilities that were available80. 5.40 On one side were the proponents of very specialised psychiatric services taking on the majority of young people in need whose problems are often manifest in disruptive behaviour while, on the other, was a view that these services should concentrate, first, on those young people with severe established

79 Office for National Statistics, 1999. Mental health of children and adolescents, ONS(99)409. London: Government Statistical Service. 80 Williams R, Skeldon I, 1992. Mental health services for adolescents, pp 137-160, a chapter in Youth Policy in the 1990s, eds Coleman J, 56 Warren C, ISBN 0 415 05835X. Routledge. psychiatric disorder. Gradually, this second view has gained greater currency. In parallel, concern about taking children away from their families has increased the reluctance of professionals to admit children under ten. 5.41 The All Wales Strategy recommends that there should be a review of the role, client groups and adequacy of day and inpatient psychiatric services for children and adolescents in Wales. We agree strongly.

Application of the Strategy to Developing Child and Adolescent Mental Health Services in North Wales 5.42 Application of the four tier strategic framework to the circumstances in North Wales produces clear evidence of significant under-resourcing of CAMHS. It is our firm opinion that the services need to be substantially developed. We believe that there is a strong case for developing the scope of the present outpatient facilities, creating new day patient services at a number of places in North Wales while also retaining child and adolescent inpatient services for the whole of North Wales. We believe that this will reduce the need for families to travel a significant distance to find a suitably specialised service. Also, geography might be reduced as a factor influencing decisions to seek admission of some children and adolescents. 5.43 During the course of our work, we visited one of the two adult mental health units in North Wales used to provide inpatient provision for the adolescents with more serious disorders. While the staff there work hard to provide sensitively for young people in acute need, we can see a clear case for developing more appropriate inpatient facilities for young people with severe disorders. 5.44 Developing adequate day patient facilities for adolescents across North Wales could provide a primary benefit of allowing some of the present client group of Cedar Court to be treated by a specialist service nearer to home and on a non-residential basis. A secondary impact would be that the role and client group of the present inpatient unit could then be adjusted to enable it to take on a greater number of children with more serious psychiatric disorders. This would require reconsideration of the suitability of the present premises and an increase in staffing levels and expansion of the range of staff competencies. 5.45 It is important to stress that we cannot advise such a development without enhancements of provision elsewhere in the current system and the services provided by the local authorities and especially without continuing inpatient provision and more staff. Neither can we envisage this development removing the need for some particularly problematic young people being treated outside North Wales though we hope that such a development might reduce this requirement.

Training and the Workforce 5.46 Nationally, there are major workforce problems to be tackled in the field. We recognise the contemporary pressures on generating sufficient well-trained staff in all disciplines to meet present establishments let alone expansion and we agree with the All Wales Strategy that workforce planning and development is the

57 key to development of CAMHS. 5.47 The demand for professionals in all of the relevant disciplines continues to rise but the numbers of them leaving training schemes continues to lag behind both the numbers of vacancies and the potential to develop new posts. In particular, this report has already marked the inadequacy of standards for training and managing nurses. We consider these issues as the impact of psychiatric nursing in more depth in Chapter 14 on CAMHS. 5.48 Staying up-to-date demands endeavour, support from peers and service managers and good professional and institutional communications. It is threatened by isolation, lack of resource, unsympathetic and ill-informed management and absence of leadership. 5.49 In our opinion, the service provided by Gwynfa has faced many of these pressures both from within and without. In this, its isolation, to which we return later, cannot have helped.

Lessons for Service Leadership and Management Board Accountability for Children in the NHS 5.50 As a consequence of the work we have done to review retrospectively matters in North Wales, we are concerned to ensure that the Chairs and Chief Executives of the statutory agencies in the NHS are charged with clear and accountable responsibilities for the welfare, care and treatment of children in the NHS. 5.51 In chapter 10, we recommend that an identified member of each board should have a particular responsibility for children and the way in which they are cared for within local services. One of the key observations arising from our scrutiny of the Gwynfa papers is that board members, including executives and non-executives, should undergo particular training and advice to discharge these responsibilities effectively. 5.52 With this in mind, we believe that it is important that members of statutory boards, managers of services and the clinical professions should all have competent professional and legal advice readily available to them. This means that all boards should appoint professional and legal advisers who can demonstrate the relevant knowledge and competence.

Leading and Managing Directorates 5.53 Good leadership and expert management are vital throughout the NHS and especially within services for children. Both require continuing training and reflective practice. Our review emphasises the need to strengthen leadership and middle and clinical management in the NHS. All clinical managers and leaders should be skilled in service, professional management and leadership. Like the Bristol inquiry into the children’s cardiac services81, we regard a professional approach to raising the quality of leadership and management at service and operational levels as vital. 5.54 Most of healthcare requires teamwork. Teams need to be well managed and they depend on empowering leadership for success. Leaders are people of

81 Kennedy I, Howard R, Jarman B, Maclean M, 2001. Learning from Bristol – the report of the public inquiry into children’s heart surgery at 58 the Bristol Royal Infirmary 1984-1995. CM 5207(1). London: The Stationery Office. clear vision with the ability to communicate, to attract allegiance and to inspire sharing. They require a blend of enthusiasm, commitment, openness, consistency, integrity and passion that engenders the trust that inspires colleagues to collaborative work towards agreed goals82. Picking the right people to turn visions into plans and carry them forward is a key function of senior staff83. Managing demands the capacity to predict the staff and resource consequences of longer- term intentions, and the ability to plan towards identified goals while maintaining current services and their quality. 5.55 The distinction between leadership and management and the importance of both is well made by the following quotation from a senior nurse manager in the NHS. "It is the function of leaders to ensure that the staff want to go on the journey and do so with enthusiasm and commitment. It is the role of managers to ensure that staff are fully-equipped for the journey and that the full range of relevant factors has been taken into account when planning the route."84 5.56 Paucity of training and lack of time for managerial duties in the middle and lower management levels of NHS services have emerged as features at Gwynfa. In our opinion, the present management arrangements for Cedar Court are much improved, but problems remain mainly relating to the time afforded to the clinical director for his duties. 5.57 Our review of Gwynfa led us to our more general convictions about middle professional and service management in the NHS. As a consequence, we advise most strongly that adequate training, time to do the job and support be made available to clinicians who take on management and leadership responsibilities at directorate level. It is vital that clinical managers and clinical directors who have continuing professional responsibilities within clinical services be given sufficient protected time away from their clinical duties to enable them to manage their directorates effectively. Only in this way is it realistic to expect them to sustain the close contact with the services and staff for which they are responsible and which we consider core to effective clinical leadership. 5.58 Our opinion is that all managers, including clinical service managers and clinical directors, must undertake continuing professional development in knowledge and skills pertinent to management, leadership and effective communication. Thus, continuing leadership and management development should be the parallel of the continuing professional development (CPD) that is now a vital part of maintaining and developing professional practice. Our findings, independently derived, are consistent with a similar recommendation made in the Kennedy Report into the problems in Bristol.

Clinical Governance 5.59 Our view is that clinical governance structures running from the Directorate of the NHS in the National Assembly through the responsible boards to the point of service delivery should be required to have a focus on children and young people. They should intensify their scrutiny of the quality of care, the adequacy of caring environments, and procedures for managing allegations of abuse.

82 Horder J, 2000. Leadership in a multiprofessional context, Medical Education, 34:203-205. 83 Handy C, 1999. Picture framing. Pages 73-76 in Thoughts for the Day. London: Arrow. 84 Muth Z, Williams R, 1995. With Care in Mind Secure : A review for the special Hospital Service Authority of the services provided by Ashworth Hospital. London : NHS Health Advisory Service 59 5.60 Any child’s disclosure of misuse or an untoward event must be taken seriously. Neither immaturity nor a history of behaviour or psychiatric disorders renders a child’s disclosure incredible: each case must be judged singly and carefully on its merits. We are certain that all safeguards and standards that apply to children who are physically sick must apply equally to those with mental health problems and disorders or learning disabilities. 5.61 Similarly, we believe that there is a need to ensure that there is a system in place to investigate appropriately circumstances in which untoward events occur. Our observation is that, in the past, the lack of procedures of this kind has resulted in lack of clarity about what to do when they occur and a reactive and piecemeal approach. Inevitably, in our observation, such a situation contributed to tensions between the Welsh Office and the responsible authorities in North Wales over how the allegations made in respect of certain staff at Gwynfa were handled. We are firmly of the view that problems of this sort need to be avoided in the future. 5.62 Inevitably, this will require systems to be set in place for more effective communications across the responsible divisions, branches and sections within the National Assembly for Wales. Consideration is required to overcome the ‘silo mentality’ that can stop information being shared within the Assembly. Presently, the NHS is moving towards managed clinical networks (MCNs) as a means of putting patients and the services they need at the centre of service design and functional management. They have the advantage of avoiding larger scale re-structuring. Originally a Scottish concept, MCNs were defined as ‘ linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing professional and Health Board boundaries, to ensure equitable provision of high quality effective services’85. Since 1999, further thinking and experience with MCNs has taken place. We conclude that the concept could well be extended to Wales with the benefit to ensuring delivery of multi-sector, multi-agency, multi-disciplinary services. We believe that the Assembly should seriously consider this approach and its evaluation in a variety of trial projects bearing in mind that it would avoid further re-structuring of public sector services. Furthermore, we believe that the Assembly should consider the Scottish experience with MCNs when reviewing and re-designing its own internal systems. 5.63 It is important that all NHS Trusts and other healthcare providers should have robust mechanisms for recording and learning from untoward events. Systems for this purpose are becoming commonplace throughout the NHS and most responsible authorities consider them a key part of their clinical governance agenda. In February 2000, the Tilt Report86 recommended that untoward incidents should be categorised according to the seriousness of outcome and in accordance with the Mental Health Act Commission’s classification system87. We see this system as being applicable to untoward events involving children because it deals with a wide spectrum of circumstances including possible psychological sequelae. We commend its adoption by healthcare services for children. 5.64 We observed during the course of our visits through the NHS in Wales, that there is a variety of mechanisms, some more detailed and demanding than others

85 Scottish Executive, Department of Health, NHS MEL (1999)10, Introduction of Managed Clinical Networks within the NHS in Scotland, Edinburgh: Scottish Executive 86 Department of Health, 2000. Report of the Review of Security at the High Security Hospitals. London: The Stationery Office. 60 87 Mental Health Act Commission, 2001. Ninth Biennial Report. London: The Stationery Office. relating to learning from untoward events. We recognise that there are risks of both under- and over-reporting. In some circumstances, having too low a threshold for the definition of an untoward event runs the risk of large numbers of events being reported and there being insufficient managerial and professional time to pursue each and learn the lessons for healthcare delivery. This brings home to us the vital importance of not only reporting untoward events but also having an effective system for reviewing those reports, extracting the lessons and then disseminating remedial activities within the service. There is a balance to be struck; simply reporting is not enough. We are clear that sensitivity to the needs and circumstances of children and young people must be built into the systems as they are developed and applied and the systems for reporting and learning from untoward events should themselves be open to audit.

Lessons for Operational Leadership and Management Avoiding Isolation 5.65 Oral and written descriptions of Gwynfa suggest to us that its staff saw it as being at the forefront of psychiatric developments. Opened in 1961, at a time when units of this kind were uncommon and prior to debate in Parliament in 1964 about the need to preferentially admit minors to purpose-styled accommodation, that might well have been the case then, but, in our opinion, such a view may have prevailed too long. We formed an impression that Gwynfa became an isolated unit managerially and professionally. 5.66 We believe that Gwynfa’s isolation, evident geographically, did not derive from a single source. It reflects the wider issue of general background disinterest in CAMHS at policy, strategic and service levels. It seems likely to us that, in North Wales, through at least the first half of the period we reviewed, the management of Gwynfa and its staff was substantially left to people on site and that one individual had disproportionate powers and responsibilities. Indeed, we were shown a letter of which limited notice was taken alleging elements of such a scenario from as far back as 1979. 5.67 At times in Gwynfa’s history, endeavours were made to challenge the drift towards isolation. For example, after the appointment of the sole consultant in clinical charge, there is evidence from the management papers that greater efforts were made locally to review the assessment and therapeutic practices used by the Gwynfa and the standard of its provenance. However, it appears that, until the mid 1980s, it lacked inclusion within a more active form of management and the papers suggest to us that gaining external interest in Gwynfa and support for it was an uphill struggle. 5.68 We note from the papers that the day nursing staff working at Gwynfa were rostered on two separate shifts and that, once a member of staff had been allocated to a shift, they usually remained on that shift unless there was a particular reason why they should change. Thus, for substantial periods, the composition of those two groups remained unchanged. In our opinion, such a circumstance, while leading to stability, could also lead to a group ethos of complacency and uncritical attitudes. 5.69 In summary, we suspect that, despite the best efforts of certain staff, Gwynfa was professionally, geographically and managerially isolated. We think

61 that this could have reflected both the preferences of other staff in Gwynfa and inactivity in the wider healthcare system. We think that this may have contributed to lack of critical appraisal, to ineffective mentoring, to an absence of awareness of child protection procedures, and to the denial of priority for service development and resources. 5.70 Thereafter, and with the implementation of general management in the NHS, Gwynfa appeared to have a clearer place within the overall picture of NHS management at the time. Now, the present unit, Cedar Court, appears to be central to the consideration of the child health directorate within which it is managed. However, we stress the importance to staff in all services of their receiving visits from Trust Board members and directors of professions and that such visits should have acknowledged purposes and a thematic approach. 5.71 We are left with the view that, generally, units of the kind represented by Gwynfa may be at risk of similar circumstances. We reiterate the gist of Howe’s advice from 1969; professional, managerial and geographical isolation must be recognised as key risks for specialised services. 5.72 We think it vitally important that all services should be enabled to put into effect the important principles and remedies identified as key to maintaining quality. They relate to the attitudes and roles of staff within CAMHS and create a substantial agenda for the senior managers of healthcare agencies. 5.73 We take continuing training and peer referencing to be the norm that must be included within the overt rather than the hidden costs of providing psychiatric care. 5.74 All staff should have colleagues to whom they can turn. Even the best professionals need support, for discussion when making difficult decisions, and to share practice. Active support for continuing professional development is vital. Staff have to be released from their duties in order to undertake training. This means that the staff complement of all CAMHS, including especially day and inpatient units, must be sufficient and allowances must be made within the establishment for professional development. 5.75 The opportunity for staff to mix with others outside their own unit, to exchange experience and to remain in the flow of contemporary practice is also key. To this end, we consider it important that all senior staff of all disciplines working in day and inpatient units should have responsibilities in the wider services elsewhere. Particularly, we believe that there is no place for a solo consultant working in residential psychiatric units.

Leadership and Management at the Service Delivery Level 5.76 Earlier, we have stated our opinion on the importance of ensuring that there is continuity of management relationships that are led by policy and clear strategic, communication and accountability frameworks from the office of the Director of the NHS in Wales, through to the frontline of services. What we have said about good leadership and sound management applies at the operational level too and supervision, appraisal, mentoring and good communications are key to this. 5.77 In the case of Gwynfa, there appears to have been no clarity about the

62 nature of the managerial relationships on site for much of the first 25 years of its existence and the management context in which it fitted appeared to be largely re-active to the energies and endeavours of staff from within Gwynfa. In the present day Cedar Court, there appears to be a clearer framework linking the unit to the Trust board through the office of Clinical Director for Children’s Services. 5.78 However, we consider there are relationships that still require further clarification within the service provided by Cedar Court. For example, it was unclear to us what the management relationships are intended to be between the most senior nurse, the consultant in clinical charge, those responsible for the support services and the staff within the external management tiers to which Gwynfa and Cedar Court have related over a period of years. Therefore, we state here our conviction as to the principles. 5.79 All staff within any service should be able to identify who is in charge. They should know the span of their own responsibilities and their route of reporting and accountability through to board level. In particular, we consider that it is vitally important there should be one identified person, be it professional or manager, who is in overall charge of each inpatient service. This means that one identified person should be acknowledged as in charge of the operation of the unit, including all the functions delivered in it by all of the separate departments and elements of service, professional groupings, and supporting facilities management enterprises that make up the unit. Also, it should be clear who is in operational charge of each service at each site and who is in charge of the site overall. 5.80 None of this is intended to reduce the importance of professional supervision and parallel mechanisms for continuing professional development. This may need to be separate for very good reasons, who is responsible for what must be explicit, and mechanisms for harmonising professional development processes with operational management must be in place and understood. Thus, the relationships between, for example, professional heads of service, heads of constituent services and facilities managers with the person operationally in charge of a unit must be clear. Similarly, the relationships between the clinical director, the person in charge of the unit and the heads of its constituent services on site should be clear, so that it is apparent how accountability and responsibilities flow between them and their junior members of staff.

Regulation 5.81 Child and adolescent mental health units often have as much in common with residential child care facilities as they do with hospitals. For this reason we believe it would be appropriate for the Care Standards Inspectorate for Wales to inspect these facilities. This will ensure that the same standards of child welfare and protection operate in them as in comparable residential child care facilities.

Recommendations 5.82 We recommend that guidance is issued to the NHS that makes it clear how best to harmonise the procedures on child protection, untoward incidents, clinical governance and discipline in cases of alleged abuse. (Paras 4.38, 4.39 and 4.40)

63 5.83 We recommend that hospitals have clear policies and procedures setting out the duties placed on employers and staff for ensuring the safety of children in their care when outside NHS premises that balance children’s freedom to leave hospital premises on their own. (Paras 4.38, 4.39, 4.45, 4.48 and 5.10) 5.84 We recommend that the guidance in ‘Working Together’ should be issued to the NHS under similar statutory provisions to those which apply to the social services departments of local authorities. This may require primary legislation. (Para 4.40) 5.85 We recommend that the National Assembly for Wales should review its methods of transmission of important guidance and agrees with the NHS a timescale, the resources and training required for implementation and feedback pathways in each instance. (Para 4.41) 5.86 We recommend that the National Assembly for Wales should ensure that the NHS, all agencies responsible for children, educational establishments, and any other bodies responsible for training staff, professional or otherwise, who come into contact with children, issue competent personnel guidance on disciplinary and performance processes and proper recording of them. The advice should include guidance on disclosure of confidential information and of all relevant health records, the timing, thresholds and mechanism of referral to statutory regulatory bodies, and the impact of POCA and the Care Standards Act 2000. (Paras 4.42, 4.43 4.58 to 4.60, 4.76 to 4.79 and 4.90) 5.87 We recommend that all the safeguards and standards that apply to children who are physically sick apply to those with mental health problems and disorders or disabilities. (Paras 4.48 and 5.59) 5.88 We recommend that the reasons for taking any disciplinary proceedings; the nature of the proceedings and the outcome of the proceedings should always be clearly noted on the personnel file of the individual. (Para 4.60) 5.89 We recommend that systems are set in place for more effective communications across the responsible divisions, branches and sections within the National Assembly for Wales and we commend a client group approach. (Paras 4.67, 4.89 and 5.61) 5.90 We recommend that all relevant organisations should review the training, supervision and support of all staff who deal with sensitive and potentially traumatic material. (Paras 4.68, 4.81 and 5.34) 5.91 We recommend that the National Assembly for Wales and the NHS should agree a structure and process for managing serious untoward incidents and events and the role that the National Assembly will play. (Paras 4.70, 4.78, 4.79, 4.89, 4.90, 5.30 and 5.62) 5.92 We recommend that prospective training programmes be established for any staff in the NHS Directorate in the Assembly who are likely to deal with abuse. (Paras 4.68, 4.81 and 5.34) 5.93 We recommend the UKCC and its successor review the current information for employers and managers and to give consideration to how it receives evidence from children in their processes for conducting investigations and hearings relating to professional conduct in cases of alleged child abuse. (Paras 4.73 to 4.75)

64 5.94 We recommend that procedures for investigating and responding to allegations made by children and their families against NHS staff should be balanced and fair and recognise the differing positions of children and families. Guidance be reviewed on procedures for dealing with complaints against NHS staff relating to children. (Paras 4.90 and 5.60) 5.95 We recommend that the Director of the NHS in Wales should take action to secure the same high standards of childcare in all statutory provision regardless of agency and agrees with the Chief Inspector of the Social Services Inspectorate for Wales that the NHS will reduce voluntarily the qualifying period for S 85 to one month irrespective of whether or not young people have weekend leave. (Para 5.12 and 12.14) 5.96 We recommend that the new lines of accountability between the Director of the NHS in Wales and the NHS should include responsibilities for implementing ‘Everybody’s Business.’ (Para 5.30) 5.97 We recommend that the National Assembly for Wales should review urgently the adequacy in Wales of therapeutic services for sufferers of abuse in the light of the current knowledge, skills and thinking on this topic and encourage the Minister for Health and Social Services to set this as a high priority within the agenda created by the All Wales CAMHS Strategy. (Paras 5.32 to 5.34) 5.98 We recommend that the standards for training and managing nurses developed by the All Wales CAMHS Nursing Forum be used as the basis for seeking agreed UK-wide training standards for nurses working in CAMHS. (Paras 5.46 and 5.47) 5.99 We recommend that all NHS bodies (especially Trusts) should appoint professional and legal advisors who are members of the children’s panel and who are familiar with the children’s services that the NHS body provides. They should advise and train the board and subordinate managers and practioners on lawful and appropriate delivery of care and treatment of children. (Paras 5.51 and 5.52) 5.100 We recommend that all clinical directors, managers and operational level leaders should have leadership and management training and a requirement to undertake CPD in these areas. (Paras 5.53, 5.55 to 5.58) 5.101 We recommend that all clinical directors, managers and operational level leaders should have sufficient protected time away from their continuing professional responsibilities in order that they can be expected to perform their management and leadership duties well. (Para 5.57) 5.102 We recommend that all NHS Trusts and other healthcare providers should have robust but realistic mechanisms for recording and learning from untoward events that are sensitive to the needs and circumstances of children and young people and open to audit. (Paras 5.59, to 5.64) 5.103 We recommend that measures be taken to avoid isolation of the child and adolescent mental health services and, particularly of day care and inpatient units. (Paras 5.65 to 5.75) They should include ensuring that: a) Each unit is linked to a network of outpatient services in the area it serves (notwithstanding the requirement of the All Wales CAMHS Strategy that these services should be commissioned on an All Wales basis with which we wholly concur);

65 b) All senior staff of all disciplines in day and inpatient units should have duties elsewhere that take them away from the unit for a part of each week; c) Some staff whose duties are primarily elsewhere should have part-time duties in inpatient units; d) No consultant works as the sole consultant to a specialised unit; e) There is a consultant in clinical charge for each unit who has clear contractual requirements for explicit leadership and managerial responsibilities that pertain to his or her post; f) The appointment of consultant in clinical charge should be rotated between two or more consultants over a period of years in a way that balances stability with openness to new ideas and new emphases; g) Professional mentoring and supervision are available; h) Every member of staff has a personal development plan, funded CPD and is appraised annually; and i) Non-executive directors and directors of the professions as well as responsible directorate and trust board level managers make regular and purposeful thematic visits. 5.104 We recommend that the standards for nursing should include appropriate levels of nurse provision on paediatric and children’s psychiatric units and clear recommendations on how nursing staff should be led and managed. (Para 5.68) 5.105 We recommend that all units in the NHS should have management arrangements in which who is in charge and the lines of communication between the person in charge and their superior managers and subordinates are clear. (Para 5.79) 5.106 We recommend that the Care Standards Inspectorate for Wales should be given responsibility for regulating and inspecting all NHS child and adolescent mental health inpatient units following the same principles as those for residential child care facilities. (Para 5.81)

66 6. BUILDING REALITY FROM POLICY

6.1 Our process is a review of policy. We were not set up as a ‘think tank’ to devise a completely new, ‘blue sky’ approach to the provision of safe NHS services for children. We do not start with a completely clean sheet of paper. 6.2 This Review cannot be a useful process unless it reports on the service as we saw it during our evidence-based inquiry and on changes we can reasonably anticipate developing from known government policy. In performing a review we believe that we can assist in the development of new and improved standards applicable to that policy and founded upon a culture of vigilance. We see the need for a defined approach, which can be used as a realistic template against which any future policies and practices can be judged.

Child Protection Policies and Procedures 6.3 As already observed earlier in this Report, there are many well conceived child protection policies available, in Wales and elsewhere. They come in different styles and forms. One example of a readable and accessible format is the Great Ormond Street Hospital pamphlet ‘Child Protection Policy and Procedures’88, which is printed in a pocket book format; it contains a particularly clear section89 dealing in an honest and factual way with possible abuse by hospital staff. Another good example can be found in the detailed child protection policies and procedures of the Bro Morgannwg NHS Trust, including their ‘Children’s Charter’, all of which follow the South Wales Police area Child Protection Procedures: their work is founded upon close co-operation on a wide South Wales geographical front including nearby Area Child Protection Committees (ACPCs), and includes development of a link with other partners to formulate All Wales Inter-Agency Child Protection Procedures. 6.4 The examples given in paragraph 6.3 are of high quality. So are many others the Review has seen, from all over Wales and elsewhere. Yet in the face of all the excellent policies and protocols, published in their different ways, something important is missing. That something is neither knowledge nor experience. It is the gelling agent that will provide universality and certainty to the well-honed learning and documentation. 6.5 In Chapter 2 we have recommended that ‘ownership’ of child protection policy should be seen as a national responsibility, though functionally devolved to different parts of Wales. We believe that one of the advantages of devolution on the Welsh scale is that it is feasible for that ownership to be expressed in a single set of policies and charters to be devised and published by the All Wales NHS Child Protection Service (see chapter 7), and administered at the national and local level through the co-operation of ACPCs and the NHS commissioners and providers. The production of a single set would have many advantages. Not least, staff moving from one Welsh employer to another would be familiar with child protection policies and procedures common to both. A further advantage would be that the public would be more likely to develop awareness of a standardised and national policy, published nationally and distributed locally. Awareness should be enhanced by the government’s access to the full range of sophisticated methods for the dissemination of information to the public. In addition, clinical

88 Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, August 2000, Child Protection Policy and Procedures 89 Ibid. see pages 53-58. 67 audit of standards used on an all Wales basis should be reasonably straightforward. 6.6 Some NHS facilities, for example specialist CAMHS services, may well need individual child protection documentation because of their special nature. These should be devised in conjunction with the All Wales NHS Child Protection Service designated to produce national standards and publications. 6.7 Because of the availability of existing policies and protocols, we believe that a national child protection set of documents could be produced relatively quickly. We would regard a year from the publication of this Report as a reasonable on stream period.

Current Multi-Disciplinary Working 6.8 There are a number of examples of good practice. Generally the ACPCs are working encouragingly, to the extent that they provide a forum for inter- disciplinary discussion, and inform the production of local written policies. There are many less formal arrangements in Wales, particularly forms of co-operation between local authority social services departments and parts of the NHS: for example, some accident and emergency departments are able to obtain access to child protection registers by the use of password-limited computer systems. Why others do not have the same facilities is a matter of concern. 6.9 Standards were set as long ago as 1991 in ‘Working Together’, which is subtitled as ‘a guide to arrangements for inter-agency co-operation for the protection of children from abuse’90. In ‘Working Together’ its recommendations were not rocket science. The preface to the 1991 edition noted that it consolidates previous guidance on procedures for the protection of children, as well as recommending developments to make them more effective. Those recommendations have been honed over time. The most recent edition of Working Together was issued in September 2000. It emphasises that promoting a child’s well being and protecting a child from harm is the shared responsibility of all statutory agencies – social services, education, police and health. At paragraph 1.10 it states: " Promoting children’s well being and safeguarding them from significant harm depends crucially upon effective information sharing, collaboration and understanding between agencies and professionals" At paragraph 1.13 it states: " For those children who are suffering, or at risk of suffering significant harm, joint working is essential to safeguard children and where necessary to bring to justice the perpetrators of crimes against children. All agencies and professionals should: be alert to potential indicators of abuse or neglect; be alert to the risks which individual abusers, or potential abusers, may pose to children; share and help analyse information so that an informed assessment can be made of the child’s needs and circumstances; contribute to whatever actions are needed to safeguard the child and promote his or her welfare; regularly review the outcomes for the child against specific shared objectives; and work co-operatively with parents unless this is inconsistent with the need in order to promote children’s health and development".

90 Welsh Office and others, 1991, Working Together under the Children Act 1989, A Guide to arrangements for Inter agency co-operation for the protection of children from abuse : London : HMSO 68 At paragraph 3.19 it states: " The involvement of health professionals is important at all stages of work with children and families: recognising children in need of support and/or safeguarding, and parents who may need extra help in bringing up their children; contributing to enquiries about a child and family; assessing the needs of children and the capacity of parents to meet their children’s needs; planning and support to vulnerable children and families; participating in child protection conferences; planning support for children at risk of significant harm; providing therapeutic help to abused children and parents under stress(e.g. mental illness); playing a part through, the child protection plan, in safeguarding children from significant harm and contributing to case reviews. There will always be a need for close co- operation with other agencies, including any other health professional involved" 6.10 Despite the clear evidence of successful and productive work by ACPCs, this Review has considerable doubts as to the effectiveness of many existing joint working arrangements. Managed networks, if they are to be effective, must be a relationship between all the relevant disciplines, not just the health parts. There will be some cases in which the sharing of information and co-operation are crucial between the social services and health, others requiring close liaison between education and health, yet others in which the police and the probation service should be involved in conjunction with health. Flexibility to make these permutations is of paramount importance. 6.11 Health and social care have always depended on teamwork. The opportunities for more effective collaboration are now more extensive. High technology and rapid advances in all disciplines, accompanied by an explosion of researched information and the Internet are the engines of change. In the UK, emphasis of partnership and inter-agency working has been a feature of virtually all guidance published in the last twenty years to stimulate development of children’s drug misuse, healthcare and criminal justice services91. Health needs highlight social needs and vice versa92. Similar statements can be made about relationships between education issues and health and social welfare factors93. Perhaps it is not surprising that work across boundaries between organisations is problematic at times; children’s problems and behaviour do not fall neatly into health, education or social services boxes. Even if they did, no one professional discipline can now contain the knowledge and skills required. 6.12 Unfortunately evidence of gaps and failures in communications and recommendations about the importance of co-operation and partnership between statutory agencies can be found in report after report but remains unacted upon. For example, evidence to this review was given that in Wales reports on Part 8 reviews relating to problems in child protection cite communication failures as a key feature in their findings. 6.13 The Review has been left with the impression that there is a good level of co-operation between the disciplines, but that this could be improved. The sharing of information retained in information systems (including the child protection register) is discussed later in this chapter. Solutions to the challenge of effective working together on a consistent basis remain elusive. We can see that achieving the desired outcomes may be problematic, especially when staff and agencies feel under pressure. However, such pressure cannot be allowed to

91 Christian J, Givarry E, 1999, Specialist Services: The need for multi – agency partnership. Drug and Alcohol Dependence, 55, 265-274 92 Bullock R, & Little M, 1999, The Interface between social and health services for children and adolescent persons. Current Opinion in Pyschiatry, 12, 421-424 93 Meltzer H, Gatward R , for Office of National Statistics 2000, Mental Health of Children and Adolescents in Great Britain. ISBN 0 11 621373 6. London: The Stationary Office 69 conceal remediable problems or inhibit effective solutions. The current levels of co-operation might be improved for some geographical areas by closer working arrangements, possibly even to the extent of combining day-to-day operational services to discharge parts of local authority responsibilities together with parts of the responsibility of the NHS. In the past, despite there being successful models of practice of this kind (e.g. some of the former child protection guidance clinics), these arrangements have not been favoured by senior managers on both sides on the grounds that they have managerial weaknesses, may reduce the coherence of teams within individual agencies and because they might involve complex human resources and line managerial responsibility problems for joint staff working practices, differing salary scales and pension arrangements. 6.14 However, these problems have to be faced on if the result will enhance child protection. Agencies must be ever ready to work collaboratively, never permitting fault lines to develop between them. The recently developed concept of Managed Clinical Networks that we define in Chapter 5 shows that there are relatively straightforward ways of removing managerial and administrative blocks to collaboration that stop short of re-structuring services or parts of agencies. Where these are insufficient, the potential of the ‘new flexibilities’ introduced by the Health Act 1999 provides formal mechanisms for resolving these problems. Recent research into collaboration in the statutory and non-statutory sectors has identified the factors that impinge on effective co-operation. For example, protocols have been devised in the UK that describe the requirements for effective partnerships. The main contents are summarised by Christian & Gilvarry: ‘A jointly agreed statement is essential. The statement should spell out the contribution, which each partner will make, specifying the financial and human resources to be made available. The values, expectations, and priorities of each agency should also be defined as well as the information requirements (e.g. service activity finance), mechanisms for accountability and arrangements for monitoring and evaluation’.94 6.15 Under the Health Act 1999 section 31, the government and Parliament recognised the limited extent of existing joint working arrangements. The ‘new flexibilities’ were introduced, with the purpose of encouraging, facilitating and providing a variety of arrangements for the improvement of delivery of health-related and local authority functions. The prescription includes arrangements for the discharge by NHS bodies of local authority functions, and vice-versa. It is legislation that would enable an NHS Trust to manage and run the social services provision in an area, or enable a local authority to manage and run the CAMHS services, were such dispositions to be thought desirable and in the public interest. To local authority elected members in particular, the new flexibilities may have little superficial appeal, on the understandable basis that devolving local authority functions out of council control dilutes democratic accountability and transparency. On the other hand, councillors will have to face up to decisions about new flexibilities if it is in the interest of children and the community at large. Turf wars between different parts of the public service cannot be allowed to obstruct or dilute potential improvements in child protection 6.16 On the 11th October 2000, the National Assembly’s Health and Social Services Committee95 considered draft guidance covering the use by NHS bodies and local authorities of powers under section 31 to improve joint working. Assembly Members were advised that powers under the Health Act 1999 have

94 Christian J, Givarry E, 1999, Specialist Services: The need for multi-agency partnership. Drug and Alcohol Dependence, 55, 265-274 95 The National Assembly for Wales, Health and Social Services Committee, 11 October 2000, Flexibilities under section 31 of the Health Act 70 1999 [HSS-17-00] been transferred to the National Assembly and delegated to the Assembly Minister for Health and Social Services. In her foreword to the draft guidance the Welsh Health Minister Jane Hutt AM, said: "There is already much close working and innovation in Wales in designing and providing services in ways which span health and local authority responsibilities. Many of these developments actively involve the voluntary and independent sectors. The Assembly is keen to support and encourage the development of such partnerships. I want to see NHS bodies and local authorities exploit these new opportunities vigorously. I want them to think innovatively and imaginatively about how services could be provided outside the traditional organisational constraints." 6.17 We agree with the Minister that there is no limit to the size of potential partnerships, or the number of partners. English and Welsh NHS bodies and local authorities can combine in partnership arrangements. There is a menu of acceptable arrangements, embracing lead and collaborative commissioning, pooled funding, integrated provision and contracting out to the private sector. The new flexibilities are explicitly founded on the belief that extensive use of the new partnerships will make a substantial contribution to continually rising standards within the existing quality frameworks for NHS and local government services. 6.18 The July 2001 consultation ‘Improving Health in Wales – The Future of Primary Care Services’ has recognised96 that the evolution of local health groups into local health boards provides the opportunity to lead the development of "seamless multi-sector services", bringing together colleagues in the NHS with those in local government and the voluntary and independent sectors. We support that aim. 6.19 We support too the view97 that no health professional should be able to operate in isolation or to develop idiosyncratic practice outside a formal review mechanism. The development of primary care resource centres would be an admirable initiative, to provide a centre for sharing ideas and practice of clinical governance activities locally and the place where all staff can access support and continuing professional development. Among the practices that we have found and would regard as idiosyncratic in the contemporary health world is that of any clinician performing any physical examination of a child without a chaperoning system, save in emergencies. 6.20 Very little more than tentative work has been done outside the National Assembly itself to identify real opportunities to put flesh on the skeleton of the new flexibilities within Wales. This Review considers that every NHS body and each local authority should be giving anxious consideration to the potential of the new flexibilities, to identify any areas in which they might become relevant. It will be clear from Chapter 2 above that we are less than enthusiastic about constant or repeated structural reorganisation. The present phase of already announced reorganisation should be combined with the establishment of any managed arrangements to be evolved out of section 31 the 1999 Act. The kind of joint enterprise that might be considered urgently could include the pooling of housing, social services, education and NHS functions concerned with mentally ill and disordered children in large rural areas, where resources are thinly spread yet sometimes unnecessarily duplicated.

96 The National Assembly for Wales, July 2001, Consultation Document, Improving Health in Wales – The Future of Primary Care, Cardiff : The National Assembly for Wales, see page 11 97 Ibid, see page 23 71 6.21 In this context the proposals contained in the July 2001 National Assembly consultative documents98 offer considerable scope. Local health boards are urged in the consultation document concerning structural change to form consortia to develop joint service plans. The project for a unitary health structure in Powys could lead to that county piloting a wider co-operative framework across children’s services. We recommend that consideration be given to this. The role of the proposed new NHS Directorate should catalyse national policies towards appropriate joint working arrangements. 6.22 It is widely recognised that such shared responsibilities are dependent on partnership and negotiation. Typically partnerships work well when individual staff collaborate effectively. However, it is imperative that sound practice is not reliant solely on individual staff who manage to steer their way through complexities. There must be good organisational systems in place which will ensure that the structures as well as individuals lead to effective practice. In the same way there must be clear systems in place within organisations so that sound practice is not dependent on the competence of an individual who may not always be around.

Information Sharing 6.23 This vexed subject is of prime importance in the battle against child abuse wherever it occurs. Those concerned with the welfare of a child need to know all relevant information, if they are to provide managed and co-ordinated care to an individual. On the other hand, the gratuitous sharing of confidential information can be embarrassing, demeaning and unlawful. There is a complex of legislation, together with common law duties such as the duty of confidence, to be faced in order to understand the limits upon sharing of information, though we consider that it can be reduced to some simple and useful conclusions that still are not readily recognised by many professionals. 6.24 The main statutory provisions to be considered are: Access to Health Records Act 1990 Computer Misuse Act 1990 Human Fertilisation and Embryology Act 1990 NHS Venereal Diseases Regulations and Directions 1974 and 1991 Data Protection Act 1998 Crime and Disorder Act 1998 Human Rights Act 1998

6.25 Among the rights and fundamental freedoms incorporated into our domestic law under the Human Rights Act 1998 is Article 8, which is headed ‘Right to respect for private and family life’. It provides: 1 Everyone has the right to respect for his private and family life, his home and his correspondence. 2 There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.

98 The National Assembly for Wales, July 2001, Consultation Documents, Improving Health in Wales – The Future of Primary Care, and Improving Health in Wales – Structural Change in the NHS in Wales. Cardiff: The National Assembly for Wales 72 6.26 The exception is plainly one of the key provisions to be understood in decoding the principles applicable to the sharing of information by professionals and their employing bodies. 6.27 The Caldicott Committee’s ‘Report on the review of patient-identifiable information’99 considered in detail the use of records and the protection and use of patient information. From that report emerged the ‘Caldicott Guardian’ system, whereby a senior person is nominated in each health organisation to act as a guardian, responsible for safeguarding the confidentiality of patient information: this person is normally a health professional at consultant grade. This Review does not in any way question the Caldicott solution and system. What we do seek to achieve is better understanding of it. 6.28 Caldicott’s Appendix 12100 provides data mapping for particular purposes. This includes a Table showing flows of information in a child protection case where the mother has mental health problems. It is clear that, unsurprisingly, Caldicott envisaged a flow of information on an inter-disciplinary front and a multi-agency basis in such cases. ‘The Data Protection Act 1998’ provides the framework of law that is a pre-requisite of national compliance with ECHR Article 8 (cited above), albeit with the specific exclusion of health, education and social work101. Also material is ‘S115 Crime and Disorder Act 1998’ which allows any person, who apart from this section would not be able to disclose the information, to disclose that information to any relevant authority (the definition of relevant authority includes a local authority, the Chief Constable, a health authority etc) where that disclosure is "necessary or expedient for the purposes of the Act". 6.29 Nothing in Caldicott or in any other document or decision known to this Review contradicts the principle that in child protection work the degree of confidentiality will be governed by the paramount need to protect the child. In ‘Working Together’102 at paragraph 7.27 it is stated: "Research and experience have shown repeatedly that keeping children safe from harm requires professionals and others to share information: about a child’s health and development and exposure to possible harm; about a parent who may need help to, or may not be able to care for a child adequately and safely; and about those who may pose a risk of harm to a child. Often, it is only when information from a number of sources has been shared and is then put together that it becomes clear that a child is at risk of or is suffering harm". At paragraph 7.28 it is stated: "Those providing services to adults and children will be concerned about the need to balance their duties to protect children from harm and their general duty towards their patient or service user. Some professionals and staff face the added dimension of being involved in caring for, or supporting, more than one family member – the abused child, siblings, an alleged abuser. Where there are concerns that a child is, or may be at risk of significant harm, however, the needs of that child must come first. In these circumstances, the overriding objective must be to safeguard the child. In addition, there is a need for all agencies to hold information securely

99 NHS Executive, 1997, The Caldicott Report – Report on the review of patient-identifiable information. Department of Health 100 Ibid, see Appendix 12, Methodology for considering data flows 101 Data Protection Act, 1998, see section 30 102 The National Assembly for Wales, 2000, Working Together to safeguard children – A guide to Inter agency working to safeguard and promote the welfare of children, Cardiff: The National Assembly 73 6.30 There can be derived a simple principle of which all should be aware if working in the child protection field in Wales. If a child is the suspected victim of sexual, physical or emotional abuse, all professionals dealing with the educational, social or health needs of the child should have reasonable access to relevant information. This means that for example, subject to secure password safeguards, accident and emergency staff in the NHS should be able to gain access to the local authority child protection register (and anything that may replace the register in the future); and that social services should, on reasonable request, be given access to relevant parts of a child’s and its parent’s health records, provided that disclosure is for the protection of the child’s physical or mental health. To allow this kind of exchange of information is within the perspective of the ‘Human Rights Act 1998’. 6.31 It follows reasonably from the above that there needs to be a renewed effort to disseminate clear understanding of what the law is, as many professionals are on the side of caution and against disclosure even if they would like to disclose. It is no use holding large amounts of potentially useful information if it cannot be shared in order to protect the child’s health. The NHS in Wales should work to develop systems to enable sharing of information relevant to child protection: this information is held by local authorities, GPs, hospitals, police, and those holding the disciplinary records of professionals such as the GMC, the UKCC for nurses, and the CPSM for professions supplementary to medicine. For example, if there were concerns that a child may be the object of abusive intentions by a doctor, the revelation by the GMC that the doctor was suspended in the past for an inappropriate sexual relationship with a patient is surely relevant, and must be capable of disclosure in the interests of the child (and possibly too for the prevention of crime). The same applies to all professional bodies. 6.32 At Annex 8 is a detailed explanation of the law relating to confidentiality, entitled ‘Caldicott in context’ We hope that this will assist managers and clinicians to understand the law more accurately than in the past. 6.33 Adult mental health and substance misuse services should note that confidentiality does not mean the invisibility of children. Where disclosures are made to mental health or psychology services concerning historical abuse, they should be followed through with social services and the Trust Named Doctor or Nurse. Mental illness in a parent does not necessarily have an adverse impact on a child. However, recent reviews of child deaths show that of 100 deaths where child abuse and neglect had been a factor in death, associated parental mental illness was present in one third of the reported cases. Mental health service users should be assessed for dependent children and the named health visitor informed where there are children under five.103

Recommendations 6.34 We recommend that all agencies must be enabled to discharge their statutory responsibilities through receiving the inputs they require from other agencies. This is likely to require enhanced support to SSDs and LEAs from primary and secondary healthcare services and vice versa. (Para 6.11)

103 Research carried out by Dr Adrian Falkov, Consultant Child Psychiatrist, Lambeth Healthcare NHS Trust 1996, See Reder P, Duncan S, Lost Innocents – A Follow up study of Fatal Child Abuse, page 48, second paragraph 74 6.35 We recommend that, within a year of the publication of this Report, a Welsh national child protection set of documents be produced, containing policies, protocols, standards and publications appropriate to every NHS setting. (Paras 6.4, 6.5, 6.7) 6.36 We recommend that every NHS organisation and each local authority should consider urgently ways of improving services to children, taking into account the opportunities offered via the new flexibilities envisaged under the ‘Health Act 1999, section 31’. (Paras 6.20, 6.21) 6.37 We recommend that all working in the field of child protection recognise that the degree of confidentiality in each case should be governed by the need to protect the child, so that all professionals dealing with the educational, social or health needs of a suspected victim of abuse should have reasonable access to relevant information. (Paras 6.29, 6.30) 6.38 We recommend that, subject to secure password safeguards, accident and emergency, outpatient and minor injury unit staff should be able to gain access to local authority child protection registers; and that social services should on reasonable request be given access to the relevant parts of a child’s health records provided that disclosure is for the protection of the child’s physical or mental health. (Para 6.30)

75 7. OLD VIRTUES IN NEW STRUCTURES

7.1 There are a number of important components of the existing system of provision for child protection in Wales that this Review would like to see retained and enhanced following the current round of health service reform. Some are discussed in this chapter.

Designated and Named Professionals in Child Protection 7.2 The deployment, as outlined in ‘Working Together’104, of designated professionals working for the Health Authorities and named professionals working for NHS Trusts has become an important part of child protection provision. Where they are in post, they should provide expertise, consistency, training, advice and pastoral guidance to colleagues and organisations. They are a resource of considerable potential and actual growing value. These posts must be adequately funded. Currently in Wales they are not. 7.3 We are concerned by the clear evidence that NHS bodies are not unanimous in their valuation of the designated and named professionals system. For example, in July 2001, there were 2 vacancies for designated doctors at health authority level, and 1 vacancy for named doctors at Trust level. Some individuals are expected to act as both designated and named professionals within the present health service structures. This could be a potential cause of conflict of interest and should be phased out as quickly as possible. Further, the amount of protected time for this important work varied considerably, save that there was almost no variation in what we found to be the shocking fact that only a single Trust has allocated protected time to its named doctor. We do however recognise the problems in workforce that can lead to difficulties in recruiting candidates of suitable experience to fill these important roles. However it is our view that, as a matter of urgency, all unfilled posts should be filled. We consider that substantial protected time is needed for these roles to be performed fully; designated professionals should not have less than six sessions each; that is a minimum commitment of three whole days per week. This minimum number of sessions will need to be reviewed as a result of the proposed changes to the NHS in Wales and the support that will be required for the Local Health Boards. Fragmentation following removal of the Health Authorities will lead to an increased workload for designated professionals. Where geography makes it impossible for the professionals to fulfil their roles adequately, an additional person should be appointed. Several designated professionals are due for retirement in the coming year. It is essential that new appointments are made to these posts. The Assembly should authorise Health Authorities to view these posts as being an exception to the embargo on all new permanent Health Authority appointments between now and April 2003. We hope that these aims can be achieved within six months of the publication of the report. 7.4 Each trust should have a named doctor, named nurse, and a named midwife, who take the overview for child protection within the trust. These roles are important and should not be viewed as an ‘add on’ to management or clinical roles. Additional protected time is required to fulfil this important strategic function. We propose that each trust evaluate the time needed for the named professionals, within six months of publication of this report. This should be done in collaboration with the designated professionals. Care should be taken where

104 The National Assembly for Wales, 2000, Working Together to Safeguard Children – A Guide to Inter agency working to safeguard and promote the welfare of children, Cardiff: The National Assembly for Wales 76 such posts have a managerial responsibility, or other clinical responsibilities (e.g. named nurses also acting as clinical nurse specialists/child protection) that this is not allowed to impede the named child protection function. These roles are pivotal in ensuring the Trusts discharge fully their obligation for child protection both within the Trusts and within the multi-agency remit. Designated and named professional time should take account of the size of the population covered, and other factors such as deprivation and rural factors. 7.5 The deployment of designated professionals in the context of NHS reorganisation is part of a broader Public Health Review chaired by the Chief Medical Officer for Wales. The designated professionals’ role are functionally public health activities and as such they can be defined as public health professionals who should be incorporated into the future public health arrangements for Wales. In our Review, and presumably in other forums, there is tension between those who believe that the designated doctors and nurses should be placed at local health groups/local health boards level, and those who argue that they should provide a strategic overview at national level. The designated professionals are certainly a scant resource and should be deployed to optimum effect. 7.6 If the child protection system is to work, it must be rationally and systematically organised to produce the best possible outcomes. After a careful assessment of differing views we agree with the All Wales Designated Doctors and Nurses Group (AWDDN), which proposed that all designated and named professionals should be part of an all Wales managed network accountable to a Director. The roles of the designated professionals and of the named professionals will remain exactly as they are at present, as described in ‘Working Together’.105 Named professionals will continue to be based within Trusts but will be professionally accountable for their child protection function to the Director. The Director would receive authority from the National Assembly via an all Wales public health body: to deal with the strategy and policy in this way would ensure universally good standards of practice, and make the work involved more publicly accountable. We see no difficulty in some staff being answerable to the Director for their child protection function, and to their local employer for other functions, as long as the time for child protection functions is ring-fenced and has primacy in the interests of children in Wales. 7.7 To that end, and in order to secure the best quality child protection service for Wales, we support the establishment of an All Wales NHS Child Protection Service, with a dedicated management group having few competing demands. The management lines would be a matter for detailed negotiation, but quality assurance responsibilities should be clear from the outset. The best setting for the Service would be as part of an all Wales public health body. Failing the establishment of such a body then an alternative arrangement would be for the Director to be accountable to a host trust similar to models already in existence for Breast Test Wales and Cervical Screening Wales. The Service would be the body responsible for the implementation of the objectives described in the conclusions to Chapter 2 above. Policies and protocols should cover all elements of the programme and should be mandatory, clearly documented and reviewed on a regular basis. The Director of the Service should be a consultant in public health medicine and should have significant experience in children’s policy. The Director should manage the Service’s budget. The Director should prepare an annual report to the National Assembly’s Health and Social Services Committee.

105 The National Assembly for Wales, 2000, Working Together to Safeguard Children – A Guide to Inter agency working to safeguard and promote the welfare of children, Cardiff: The National Assembly for Wales 77 7.8 The Review believes that the Service described would match up to the aspirations contained in the recent National Assembly consultation papers of a direct line of accountability between the Assembly and the local health boards and NHS trusts. 7.9 As part of his or her role the Director of the Service should chair an all Wales group consisting of all the designated and named professionals within the country. The group should act as the centre for training initiatives and for information distribution throughout the Welsh NHS. Outside interests connected with child protection should be capable of co-option to the group. Area groups should follow the same pattern, along the lines of existing informal bodies such as the Bro Taf Health Authority Professional Advisory Forum, the North Wales Designated and Named Professionals Group and Iechyd Morgannwg’s Child Protection Advisory Group. 7.10 The named professionals should continue to lead child protection procedures at NHS trust level, as now, though as part of the national structure described. The roles and responsibilities of the designated and named professionals would remain the same as outlined in ‘Working Together’.106

The Children’s Commissioner for Wales 7.11 The Children’s Commissioner is the first to be appointed for any country or region of the United Kingdom, and is underpinned by primary legislation. He has already become an established presence, though his activities are still in the development stage and his budget is limited107. His legal powers are circumscribed consistent with the powers given to British Ombudsmen including the Parliamentary Commissioner and also local government commissioners. However, it is likely that the Children’s Commissioner will develop considerable influence from his powers to obtain responses, make recommendations, and ‘name and shame’. The targets of his praise and criticism are likely to be many and various. They will certainly include NHS facilities, and equally certainly will take account of child protection. 7.12 It is important that there should be some clarity about the Commissioner’s role in relation to NHS matters. He and the NHS are partners in the sense of having the shared objective of ensuring that healthcare is in itself a non-abusive experience, and one that has the best chance of dealing with abuse arising elsewhere. 7.13 It is our view that this would best be achieved by the designation as Children’s Commissioner Liaison Officer of a person functioning within each health organisation. The role would be part-time, and would require routinely a small amount of protected time each week to keep abreast of the Commissioner’s activities and to maintain whatever contacts and correspondence were necessary. This role could usefully be given to a manager responsible for children’s services, or to one of the named clinicians.

106 The National Assembly for Wales, 2000, Working Together to Safeguard Children – A Guide to Inter agency working to safeguard and promote the welfare of children, Cardiff: The National Assembly for Wales 107 Peter Clarke, formerly Director of Childline Wales, took up his position on the 1 March 2001. His budget for the fiscal year 2001-2002, in which he set up his office, was £800,000. 78 Recommendations 7.14 We recommend that, within 6 months of publication of this Report, all designated and named professionals should be allowed protected time to perform their given functions. (Para 7.3) 7.15 We recommend that re-appointment into designated professionals’ posts should be an exception to the embargo on new Health Authority appointments between now and April 2003. (Para 7.3) 7.16 We recommend that all designated and named professionals should, for the child protection part of their work, be managed by an All Wales NHS Child Protection Service. This Service should be ultimately accountable to the National Assembly, with a dedicated management group having few competing priorities. There should be a Director of the Service, a consultant in public health medicine. The Director should be required to prepare an annual report on child protection for the National Assembly. (Para 7.7) 7.17 We recommend that the Director of the All Wales NHS Child Protection Service should chair a group consisting of all the designated professionals in the country, together with co-opted members from outside interests connected with child protection. This group should act as the centre for training initiatives and for information distribution throughout the Welsh NHS. Area groups chaired by designated professionals should follow the same pattern. (Para 7.9) 7.18 We recommend that named professionals should continue to lead child protection procedures at trust and local health boards level. (Para 7.10) 7.19 We recommend that in every NHS organisation there should be designated a suitable person to act as liaison with the Children’s Commissioner for Wales. A small amount of protected time should be provided to facilitate this role. (Para 7.13)

79 8. CHILDREN IN NEED AND THOSE CARED FOR AWAY FROM HOME.

8.1 This chapter demands repetition of Article 20 of the UN Convention on the Rights of the Child: "A child temporarily or permanently deprived of his or her family environment, or in whose best interests cannot be allowed to remain in that environment, shall be entitled to special protection and assistance provided by the State." 8.2 The Waterhouse report ‘Lost in Care’ is not the only terrible indictment of the neglect and lack of insight that can befall children who are removed from their own homes108. Many children within the care system are placed away from home. Many other children have to be cared for away from home by reason of their own health needs. We recognise that the NHS has responsibility for the healthcare of all children, including those in the care system. We also recognise that being hospitalised for a short period may be traumatic for any child. However this chapter is specific to that group of children who, for whatever reason (health, social or educational) live away from their families for what are often considerable periods. We consider these children to be especially vulnerable109. 8.3 The problem is extensive. On the 31 March 2000, there were 3574 looked after children, in the care of Welsh local authorities, resident in Wales. Regrettably, statistics for children from Wales being looked after in England are not available. Welsh children being looked after in Wales are often placed across county and health organisation boundaries. Children living away from home are in 3 main settings: school; those placed in alternative care by local authorities; and hospital. 8.4 At the same time as this Review was hearing evidence, the National Assembly set up another policy review, under the chair of Adrianne Jones, looking at ‘Improving Placement Choice and Stability for children and young people who are looked after’. Their work is complementary to this Review and entirely consistent with it. 8.5 ‘People Like Us’110, produced by an expert team chaired by Sir William Utting, is a document of profound importance for good practice with looked after children. Like this Review, Utting emphasised above all the need for all agencies to collaborate. The report has made a significant contribution to government policy since its publication. The ‘Quality Protects Programme’ was launched in its wake in England and the ‘Children First Programme’ in Wales in April 1999. However, the work programme posed by Utting remains incomplete. Nothing this Review says should be seen as anything other than encouragement towards further incorporation of the proposals contained in ‘People Like Us’ into law and practice.

108 Inquiries to date have included Hughes, 1985, Report of the Committee of Inquiry into Children’s Homes and Hostels, Belfast; Kahan and Levy, 1991, The Pindown Experience and the Protection of Children, Report of the Staffordshire child care Inquiry; Williams and McCreadie, 1992, Ty Mawr Community Home Inquiry; Kirkwood, 1993, The Leicestershire Inquiry; Brannan et al, 1993, The Castle Hill Report; Ward (Paedophile ‘led a career of abuse’, The Guardian, 8th March 1997); Marshall et al,1999, The Report of the Edinburgh Inquiry into the Abuse and Protection of Children in Care. 109 A useful summary of developments in the UK is the presentation by Andrew Kendrick to the International Society for Prevention of Child Abuse and Neglect, Durban, 3-6 September 2000 (www.personal.dundee.ac.uk/~ajkendri/specprot.htm) 110 Utting, W, Department of Health and Welsh Office, 1997, ‘People Like Us’ The Report of the Review of The Safeguards for Children Living Away from Home, London: The Stationery Office 80 8.6 Many looked after children have experienced abuse. Some have been dragged into a spiral of abuse and have become young abusers themselves. It is essential for them and for the wider community that they should be followed by the health system, and a full range of services consistent with their needs offered to them. 8.7 Young people looked after by the local authority, particularly those who have been cared for in this way for some time, run greater risks than other children of becoming involved in problematic life styles, including prostitution and drug taking. They are more likely than their peers to commit suicide. They are less successful in education and are likely to make less use of health services, whether through their own (and their family's) neglect or because less attention is given to their needs. This makes the role of the NHS in their lives all the more important, including advice on contraception, disease prevention and health promotion and access to an appropriately full range of diagnostic services. 8.8 It might be thought that there are routine ways for the NHS of tracking looked after children. There are not. It is likely that they are merely temporary residents with GPs, thus incomplete records may be available for the time being in assessing their health needs. Even where there are systems in place, they do not work effectively in all cases. For example, in the area covered by Gwent Health Authority, there is a high quality of provision of paediatric child health input from consultant level, and real expertise in fostering, adoption, issues of child protection, and the needs of looked after children. There are 5 unitary authorities, with 4 ACPCs. Despite the paediatric excellence, there is no integrated agreement or policy for looked after children, and the level of co-operation varies as between different unitary local authorities. This is not a situation peculiar to Gwent, and it does cause frustration to those who have to deal on an immediate and sometimes-critical basis with the health needs of looked after children. There are real concerns that there should be a uniform and more effective approach. There should be specific training in the needs of looked after children for interested professional groups such as teachers and health professionals, and school governors. 8.9 The Review was able to identify a problem originally described some 30 years ago by Professor Tudor Hart now of the University of Glamorgan as ‘inverse care law’111 : put simply, this alarming proposition suggests that there is likely to be less effective healthcare provided for those in greatest need. This applies powerfully to looked after children who often have inadequate access to key services such as speech and language therapy, counselling and family based respite care. If true, the inverse care law is the starkest illustration from the NHS of the problem of social exclusion, which has received continuing and close attention from UK central government since 1997. 8.10 The Review believes that Wales must try to improve access to good quality NHS care for the most socially excluded children. These include looked after children, though not to the exclusion of all others by any means. The same observations apply to children from black and ethnic minority communities and asylum seekers in Cardiff and elsewhere: we were able to identify from our evidence a particular level of exclusion among the Somali community in the capital city.

111 Hart J T, The Inverse care law. The Lancet 1971; 405-12 81 8.11 Barriers to achieving better health among looked after children are considerable, not least because they are all too often moving targets. Some primary healthcare facilities are difficult to access, there is a poor exchange of inter-agency information, records are not always maintained as fully as is desirable, advocacy skills are often under-developed, and inter-professional co- ordination is often not ideal between the various health and social care workers and the organisations that employ them. In particular, we believe that solutions must be found that ensure reliable access for looked after children to primary healthcare, as this is the avenue to specialist service in the UK. 8.12 Lessons are being learned. The Review was able to observe the work of a pilot study undertaken throughout the Caerphilly area into the health care of looked after children. That study has produced useful lessons, and well- considered draft joint policy and protocols. The potential of health visitors in identifying the health needs of looked after children emerged as a strong issue from our evidence. Peer education of foster carers is a practice well worth developing. 8.13 In its report, ‘Learning the Lessons’ 112, the Joint Review Team of the Audit Commission and Social Services Inspectorate for Wales observed that Welsh local authorities’ baseline spending on children’s social services was 33 per cent lower than that in similar councils in England. The National Assembly’s ‘Children First programme’ has provided valuable additional ring fenced revenue funding for local authorities’ children’s services, based on management action plans linked to specific outcomes, including those relating to the health of looked after children and children in need. These are reviewed annually. The involvement of health service professionals in drawing up management action plans appears to have been patchy and ‘Children First’ funding has been used primarily to improve the basic provision of social services departments’ work with children. However, there are some imaginative examples of joint commissioning using ‘Children First’ funding. One authority commissioned an independent health visitor to conduct a review of how the health care needs of looked after children are being met. 8.14 A considerable amount of wisdom on this subject can be derived from the report of an expert workshop held in 1998 and arising from the Waterhouse Inquiry113. The workshop concluded that co-operation between the major agencies should be improved to ensure that information is pooled and services co- ordinated. We agree. We agree too that individuals should be given responsibility for co-ordinating health services for looked after children, using the designated and named professionals as the instrument for the preparation and implementation of this information system. They would be expected to maintain good working contacts with named individuals in other agencies. Inspection arrangements between different types of establishment should be rationalised (as is envisaged by ‘section 31, Care Standards Act 2000’114, a part of the Act not yet in force when we were taking our evidence). 8.15 Health professionals play an important role in ensuring that looked after children receive the health services that they require to promote their health and development. It is important that there is a clear strategic lead for the provision of health services and local inter-agency working for this vulnerable group. This will include developing links with other agencies, particularly with local authority

112 The National Assembly for Wales, The Audit Commission, 2000, Learning the Lessons from Joint Reviews of Social Services in Wales, 1999/2000, Audit Commission Publications 113 Welsh Office, Expert Workshop Chaired by Miss Marion Bull, Chief Nursing Officer, North Wales Child Abuse Inquiry ‘Lessons for the NHS’, Hensol Castle Conference Centre, 29th September 1998. The report of this workshop provided extensive material for this chapter, and deserves full acknowledgement. 114 Care Standards Act 2000, London : The Stationery Office 82 children’s services in planning services and ensuring that they are delivered effectively. We consider that there need to be identified senior paediatricians and senior nurses (designated professionals) to take a lead on all aspects of health care for looked after children. They will play an important role promoting and influencing relevant training and providing professional advice to other professionals and local authority children’s services. Their roles should always be explicitly defined in their job descriptions and should allow sufficient time for them to fulfil their duties. Consideration will need to be given as to whether this role should be linked with the designated professionals for child protection and the structures we are proposing in chapter 7. 8.16 NHS organisations in Wales have responded to the recommendations of ‘Lost in Care’. A good example is the very detailed response by the North Wales Health Authority115, which includes strengthening of their existing Child Protection Service Specification. It incorporates too the strengthening of complaints procedures, with each NHS body to identify a senior person with specific responsibility for handling cases of professional abuse. We support this approach. 8.17 With regard specifically to health records, one cannot over-estimate the advantages for diagnosis and treatment of as complete a written medical history as is possible. To this end, the emergence of a ‘virtual clinic’, a mechanism to bring together all health documentation for the child, to aid production of a personal child health record unifying all health information, for looked after children is the appropriate aspiration: this would enable the whole of their healthcare situation to be monitored, without the necessity of repeated examinations and questioning, which many adolescents find stigmatising and intrusive. Children can distrust systems that they perceive to be hostile to their needs. There is a need to make them feel included, to give them ‘ownership’ of their own health, if we are to discourage a negative attitude to the well-meant and well-thought approaches of professionals. 8.18 The interests of this client group would best be achieved by the further development by the proposed all Wales management group of standard clinical indicators for the health of looked after children. In addition, tracking and sustaining their health could best be achieved by the design and use of a standard data set. Most important, whenever a NHS contact occurs with anybody whom it is believed falls within the category of looked after children, in the absence of evidence that the status of the child is already known to health professionals the all Wales group should be informed, so that a co-ordinated approach can be arranged.

Secure Non-NHS Provision for Children 8.19 There is a single secure non-NHS unit for children in Wales, the Hillside Unit at Neath. At the time of our visit, it was housing eighteen boys and girls between 14 and 17 years old; fourteen from the youth justice system and four from the care system116. We were impressed by the clarity of thought on health issues by management and staff there, particularly as they function in a far from perfect health structure for such a unit. Most of the youth justice children are serving indeterminate or long terms under ‘sections 90-91, Powers of Criminal Courts Act 2000’117 (formerly ‘section 53, Children and Young Persons Act 1933’). Hillside is run by the local authority, under arrangements with the Youth Justice Board. By definition, all the residents there are looked after children; most are very troubled.

115 North Wales Health Authority Response and Action Plan – November 2000 116 S25 Children Act 1989 117 Powers of Criminal Courts Act, 2000, London : The Stationery Office 83 8.20 The view of local government officers offered to the Review is that, despite its obvious and sometimes very public importance in dealing with some of the most disturbed adolescents in the UK, Hillside is run on a shoestring. The evidence contained too the assertion that linkages with specialist CAMHS structures and provision are tenuous, and that Home Office policy input is weak. 8.21 The Review received strong representations that the absence of non-NHS secure provision in North Wales leads to children from that region being sent far from home (to Hillside or one of the 29 secure units in England) if they need or are required to fall within the secure system. We recognise the problem identified, but also the lack of critical mass in North Wales to justify a secure establishment there. We suggest that this matter be kept under consideration, in consultation with potential partners in Northwest England and the West Midlands. In the long term, a secure unit in North Wales may be justified. 8.22 The Review was concerned that there appeared to be no clear procedure for ensuring that the health needs of children at Hillside are dealt with on a specific as opposed to generic basis. The Unit is obliged to deal with medical requirements via the conventional primary care system. There is no doubt that the local GP practice providing services to Hillside does as well as possibly it can: however, it was a matter of surprise to the Review that the general practitioners and dentists visiting Hillside are not police checked. There is no justification for this exception to the universal rule we recommend in Chapter 11. 8.23 Some of the client group housed at Hillside suffer from psychological problems and are themselves victims of abuse and/or serious neglect. Direct access to secondary psychiatric/psychological services could prove advantageous, as could a direct input of community paediatric services. The provision of services to Hillside and any similar unit established in Wales in the future should be determined by direct negotiation with the NHS Directorate of the National Assembly. In this regard, we are mindful of the Health Ministers policy in ‘Everybody’s Business’. It is that a very specialised Forensic CAMHS service, be developed for Wales. We envisage Tiers 2 and 3 of that service will provide liaison services to Hillside. 8.24 In summary, our view of the safety of NHS patients within the secure system is that it could be much improved by a new strategy, which is likely to have to come from central government and/or the National Assembly. There are potentially very serious consequences of overlooking the small cohort of secured children: they may well be more vulnerable to institutional abuse than others, and if the NHS fails them the patterns of behaviour that have led them to places such as Hillside are less likely to be broken.

Recommendations 8.25 We recommend that it is essential that looked after children can be identified by the NHS, wherever they are. (Para 8.8) 8.26 We recommend that there should be specific training in the needs of looked after children for all interested professional groups such as teachers and health professionals, and school governors. (Para 8.8)

84 8.27 We recommend that priority should be given to improving access to good quality healthcare for the most socially excluded groups of children, including assylum seekers and children from black and ethnic minority communities. (Para 8.10) 8.28 We recommend that inspection arrangements between different types of establishment should be rationalised, to produce more consistent standards. (Para 8.14) 8.29 We recommend that designated professionals should be appointed in each area to take a strategic lead in the provision of health services for looked after children. (Para 8.15) 8.30 We recommend that NHS complaints procedures should be strengthened, with each NHS body to identify a senior person with specific responsibility for handling cases of professional abuse. (Para 8.16) 8.31 We recommend that the quality and information for children in need contained in medical records be improved, with a view to the emergence of a ‘virtual clinic’ to develop a personal health record unifying all health information. This would be especially valuable for looked after children. (Para 8.17) 8.32 We recommend that standard clinical indicators should be further developed for looked after children, together with a co-ordinated approach to the collation of information. (Para 8.18) 8.33 We recommend that the arrangements for healthcare at the Hillside Unit and any other non-NHS secure unit opened in Wales should include direct access to secondary psychiatric, psychological and paediatric services. (Paras 8.22, 8.23)

85 9. INFORMATICS: WARNING AND RECORDING

9.1 The technology revolution has already proved beneficial to clinical knowledge and treatment. Research is now conducted commonly by clinical scientists working in partnership from around the globe. More locally, organisations such as the Institute of Rural Health (based in Mid Wales) have pioneered telemedicine projects, which have brought secondary and tertiary diagnosis and treatment closer to areas remote from centres of excellence. In the report ‘Monitoring the Health of our Nation’s Children’ 118 it is correctly stated: "Information keeping is critical to the delivery of a high quality, effective child health service" 9.2 A reason additional to those given in that report is that information keeping of quality and detail can be an effective tool in the detection of child abuse wherever arising. That there is no standard data set or format for monitoring or evaluating child health and child protection means that technology is being underused in areas in which it might well increase the safety of children. Subject to appropriate data gateways for protecting confidential information from those who do not need to know, the sharing of the collected data among those with a legitimate interest in the safety of individual children is a proper goal. We believe that steps could be taken quickly in Wales to reach that goal. 9.3 One of the issues discussed in ‘Monitoring the Health of our Nation’s Children’ is the development and implementation of a ‘safety net’ geographically based computer record to handle data: • to include those GP practices which have not achieved the desired level of computerisation • to pick up those children who, because of living in chaotic families, homeless or travelling families, are rarely registered with a GP • to link community and hospital based data to create the Electronic Health Record at primary care level119 9.4 This Review supports the development of the data set proposed in that report. Further, we consider that serious consideration should be given to linking a geographically based health record of that kind, for Wales, with child protection information kept by local authorities social services departments. In time this could usefully be expanded to include information relevant to child protection issues from education authorities and schools. 9.5 There is a Welsh component to the available learning and material on informatics in the NHS. Adrian Savill, of the Centre for Health Informatics at the University of Wales (at the UCW colleges at Swansea and Aberystwyth), has been seconded to the National Assembly to advise on telemedicine policy, and has made a particular study of available Welsh databases. He provided this Review with written and oral evidence. 9.6 There is already an established child health computer system in use in Wales. This is the National Child Health System, which has operated in all NHS Trusts and their predecessors for nearly 20 years. It is one of the oldest operational computer systems in use in healthcare. Every child in Wales is on this database, though there have been few resources for its development in recent

118 Child Health Informatics Consortium and the Royal College of Paediatrics and Child Health, May 2000 Monitoring the Health of our Nation’s Children 86 119 Ibid. see paragraph 4.4 years. A successor is now in development for the whole of the UK: this is the Community Child Health System 2000 (CCHS). We were informed that contemporaneous work is being carried out on the GP Foundation Project, which, if fully developed, would give GPs what amounts to their own dedicated computer network. 9.7 It should be remembered that there are already approximately 80 video- conferencing suites in health establishments and local government in Wales. These provide the potential for video case conferences, which ought to enable a wider range of professionals to participate. 9.8 The CCHS should rectify some of the deficiencies in the National Child Health System, notably difficulty in data analysis, lack of line access, lack of local control, and difficulty of interface with other relevant systems. However, under present plans, there will be areas in which the lack of an all Wales co-ordinated approach would continue to cause problems, notably because of differing codes and schedules being used by different trusts, and inconsistent use of the system. This may be overcome by the work currently being done on a common dataset for the child health system in the child health information requirements project 2 (CHIRP 2).120 9.9 Whatever steps are taken towards the improvement of informatics in the NHS in Wales, health visitors and others likely to be placed in the position of contributor of information should receive training in the creation and analysis of data: the absence for the most part of such training compounds the view many have of feeding the system but getting nothing out of it. In Scotland, all health visitors are being issued with laptop computers, and corresponding training is being given. 9.10 All staff involved in the care of children require training and periodic evaluation of their skills in the use of databases, both data intervention and search and retrieval processes. 9.11 Lack of resources has precluded useful and obvious developments such as the installation of online access to the National Child Health System. Such access could for example: • Identify child ‘hospital hoppers’ (often in itself an indicator of abuse); • Provide an all-Wales information system; • Reduce the number of unnecessary treatments. 9.12 The Review notes that local authority social services departments all keep child protection registers, and that many are developing better and revised systems for child protection. There is the danger of parallel and largely autonomous systems, unable to communicate with each other, being created by different organisations with parallel and even synonymous interests. For this to occur would be neither operationally nor economically effective: most important, it would do less than might be achieved in the enrichment of child protection. Giving controlled access to the National Child Health System and any successor, for input and output purposes, to local authority social services departments would prove more effective than creating a range of systems with their inherent problems of compatibility and accessibility. There may be a need to amend the National Child Health System somewhat, to incorporate additional data items required by social services, but we were advised that this is well within the scope of the system.

120 CHIRP 2 is a National Assembly project looking at standard data set for CCHS 87 9.13 Subject to appropriate confidential, security and ethical guidelines being followed, the amended national system could be used on an all-Wales basis to, for example: • Allow controlled access online and off-line to differing professional groups; • Maintain records of a child’s accident and emergency attendances wherever they occur; • Schedule sets of screenings and health assessments for looked-after children (e.g. one every time a child enters and leaves a care institution); • Create alerts from a subset of indicators, or ‘landmarks’, consistent with possible abuse. 9.14 The evidence indicated that technology presents fewer problems than breaking down the barriers between health and other relevant public bodies. These barriers must be pulled down, to achieve a system of informatics with the maximum potential for the protection of children. 9.15 We have concluded that the National Assembly should give energetic consideration to establishing an all Wales health database, which, for child protection purposes, should be accessible to other disciplines, subject to access controls. Research should be conducted towards the inclusion in the database of the child protection registers of Welsh local authorities, together with such other material as ought to be shared with the purpose of detecting and ending child abuse. In addition, the National Assembly should support the developments proposed in ‘Monitoring the Health of our Nation’s Children’,121 with the medium- term aim of a single controlled database for all aspects. 9.16 These suggestions are consistent with the National Assembly consultation of July 2001, which proposes an all Wales national database and data warehouse: we suggest that the information in that kind of system should be wider and deeper than may have been envisaged hitherto, in the interests of integrated and networked child protection.

Recommendations 9.17 We recommend that the National Assembly’s proposed National Plan for Information Management and Technology takes further account of the recommendations of this report. (Para 9.8) 9.18 We recommend that the previously recommended development of a NHS data set forming an electronic health record at primary care level be expedited; and the development of a Welsh data set, in which primary health care records could be linked with local authority held child protection information. (Paras 9.3, 9.4) 9.19 We recommend that all potential contributors of child protection data should receive training in the creation and analysis of such data. (Para 9.9) 9.20 We recommend that the potential use of a single system or compatible data systems capable of acquiring, exchanging and sharing information between he NHS and local authority social services departments should be explored. The development of an all Wales health and child protection database would be in the interests of children. (Paras 9.15, 9.16)

121 Child Health Informatics Consortium and the Royal College of Paediatrics and Child Health, May 2000 Monitoring the Health of our Nation’s Children 88 10. EMPLOYMENT: RECRUITMENT PROCEDURES: TRAINING

10.1 In Chapter 3 above, we have discussed the shortage of suitably qualified staff in key disciplines in the NHS. We recognise that, in present structures, it is impossible to employ only those with the relevant specialist qualifications in all circumstances, though hopefully nobody would disagree that it should be the aim of training and recruitment policy. In this chapter, we concentrate on what is at least an equally important issue, that of how recruitment takes place into jobs involving contact with children. The recommendations made at the end of this chapter require no legislation. They should be effected immediately where they are not already in place. 10.2 The connected matter of police checking procedures is dealt with in Chapter 11. 10.3 The objective of recruitment in the context of our Review is clear. It is the employment of the most suitable staff available to provide safely for the health needs of children. To that end, in every part of the NHS, whether clinical, secretarial or manual, rigorous recruitment procedures should be followed even where there are staff shortages.

Recruitment Procedures 10.4 A considerable amount of attention has been given to human resources policies in the NHS. The seminal document in the present context is ‘Choosing with Care’122, published as long ago as 1992. Although the terms of reference of that report related to children’s homes, during the course of our inquiry there was unanimity of evidence that similar processes should be used when choosing staff to work with children in the NHS. Having said that, this Review was alarmed by the revelation that some who supported and even espoused what were generally referred to as ‘Warner Principles’ had plainly never read ‘Choosing with Care’, or had completely forgotten what they had read. Lip service is no service to the safety of children, if there follows an increased risk of abuse by those employed. 10.5 In particular, more than one NHS body told us that it was consistent with ‘Warner Principles’ that interviewing panels should only be made aware of references following interview of the candidate; and that it was appropriate to make job offers subject to references. We have seen these practices displayed as paradigms of human resources practice. They are not. For completeness, it is necessary to remind readers of this Report what ‘Choosing with Care’ did recommend. 10.6 Recommendation 16 stated: "Employers should use preliminary interviews as a standard part of establishing a fuller picture of the character and attitudes of shortlisted candidates for all posts in children’s homes." The report suggested that an employer could be regarded as negligent in not using a preliminary interview, to explore many of the sensitive personal issues affecting suitability for work in children’s homes. The purpose of a preliminary

122 Department of health, Chaired by Norman Warner, 1992, ‘Choosing with Care’ The Report of the Committee of Inquiry into the Selection, Development and Management of Staff in Children’s Homes, London: The Stationery Office 89 interview is to look at whether a candidate has a propensity to form a sexual relationship with children and young people. This is a difficult subject to probe properly other than in an informal setting.123 10.7 The same report condemned the reliance solely on written references, without follow-up124. It stated: "Prospective new employers should take the initiative in obtaining information about candidates from previous employers or line managers before interview. Previous employers have the information that enables a new employer to form a rounded picture of a candidate’s strengths and weaknesses, and this information should be sought by letter and telephone. Information obtained by telephone is often more accurate and revealing, and to forbid the obtaining of it by this means through some misguided view of equal opportunities policies is simply to neglect the interests and safety of children." 10.8 In our view telephone discussions with referees should be the norm; and written records should be kept of such conversations. Warner recommended that candidates should be asked to reveal details of all employment, including dates; that candidates should be told that approaches may be made to previous employers for full details, including any disciplinary offences; and that references should only be supplied by persons with direct knowledge and experience of the candidate. Candidates should be required to provide a full working life history, including employment outside the NHS and periods out of employment. They should be required to declare all cautions and convictions, and told that failure to do so will lead to immediate dismissal on discovery. 10.9 This means that more time is needed to check previous employment records. Telephone inquiries and informal networks will have to become respectable with those employers who until now have remained opposed to their use125. 10.10 This Review shares the opinion of ‘Choosing with Care’ that giving references is a very serious and responsible function. Just as a malicious or deliberately inaccurate reference may in some circumstances be defamatory, equally, an untrue or misleading reference that conceals something material to the prospective new employer’s interests may well be a serious breach of discipline by the referee. 10.11 Consistent with ‘Choosing with Care’, we believe that there should be training of members of interview panels, and that membership should always include a person who is independent of the department of which the new employee would become a member. 10.12 We consider that reference checks and interviewing procedures should be applied strictly and universally for all posts having any prospect of lone contact with children. This means that the principles should apply to many parts of the NHS where such matters have barely been considered: they should certainly apply to all GPs and practice nurses, hospital doctors and nurses, dentists, optometrists, speech and language therapists, occupational therapists, physiotherapists, radiographers, psychologists and dieticians and to whichever disciplines fall within these general objectives. Additionally, any person offered a job must provide certificates and qualifications and separate proof of identity.

123 Ibid Paragraphs 4.37-4.39 124 Ibid Paragraph 4-43 90 125 Ibid Paragraph 4-49 Registration Bodies and Disciplinary Records 10.13 Whenever a new, professionally qualified member of staff is appointed, it is accepted practice that their registration is checked with their professional registration body. Registration is a prerequisite of practice; therefore employment is impossible without registration. 10.14 During evidence sessions, the Review learned that it never has been the practice for registration bodies to be asked if there have been professional disciplinary findings against the prospective employee. Equally, it has not been the practice of registration bodies to provide such information. Only if the registration is affected currently - by erasure, suspension or conditions imposed on practice – is the prospective employer told. While the current practice plainly is necessary, we consider that more could and should be done. 10.15 A simple illustration based on real cases will suffice as explanation. A highly qualified psychiatrist applies for a post as a consultant. A check with the GMC reveals that he is registered currently, without conditions. Taken alone, that information reveals him to be suitable for consideration for appointment. However, within the past 5 years, he has been disciplined by the GMC’s professional conduct committee and found guilty of serious professional misconduct consisting of a sexual relationship with a suggestible young female adult, resulting in suspension from practice for a year. If that knowledge was in the hands of the prospective employer, it is very much less likely that they would employ the consultant as part of their CAMHS team, where the potential exists for treating vulnerable adolescents. 10.16 Would there be anything unfair or discriminatory in the routine disclosure of disciplinary matters by registration bodies? We think not. Indeed, there is a strong moral obligation on any job applicant to disclose relevant history, which would include the example given in the previous paragraph. Asking the registration body is therefore nothing more than verification. Nor would there be any difficulty in the provision of the information, as the registration bodies all keep records of disciplinary findings. 10.17 We conclude that it should be the responsibility of all prospective employers to enquire of registration bodies as to an applicant’s current registration status and also as to any disciplinary findings in the past. Correspondingly, it should be the duty of the registration body to make such information available. In our view, there should be no time limit on any verdicts founded upon sexual impropriety or professional incompetence: a time limit of 10 years on findings of financial misconduct would be appropriate.

Agency, Bank Staff and Locums 10.18 In paragraphs 3.24-3.35 above, we set out concerns about the employment of agency and bank staff, and locums. Contractual and verifiable standards should be imposed upon agencies to ensure that the standards and requirements set out earlier in this chapter are met in relation to all agency and locum staff. 10.19 Bank staff are direct casual employees of NHS organisations. Many remain in bank employment for many years or even permanently. Their recruitment should be no different from that of their permanently employed colleagues.

91 Staff from Abroad 10.20 In paragraph 3.36-3.37 above there is discussion of the now common practice of recruiting nurses and others from abroad. In every such case, attempts should be made to contact and obtain material information from their employers and registration bodies. Contractual and verifiable arrangements with the recruitment agencies working in this field should make it possible in most cases to pursue references by telephone in exactly the way recommended for UK based staff. However, this course may not be totally reliable in all cases. Therefore, we consider it a wise and non-discriminatory precaution that staff recruited from abroad should face the additional requirements set out in paragraph 3.37.

Induction Training 10.21 Generally induction training in the NHS in Wales is provided as a standard practice, and covers relevant issues. One of the routine matters that should be included in all induction courses is a basic component emphasising the primacy of child protection, and the importance and procedure of reporting any suspect incidents or conduct.

Board Members 10.22 Board members of NHS organisations, including non-executives, should receive training in the same way as others. While non-executive board members will have limited contact with patients, training is needed to enable them to meet their corporate responsibility with a commensurate level of knowledge. 10.23 In some NHS organisations, a board member has the specific responsibility of reporting to the board on child protection issues. An executive member usually does this. This is a sound approach, and we consider that it should be universal and part of board routine on at least a quarterly basis. 10.24 In addition, we consider that it would be a valuable practice for a non- executive director in each NHS organisation to hold the responsibility for child protection procedures, and to report to the board at least twice yearly on the effectiveness and resourcing of those procedures. This course would move child protection up the corporate agenda to reflect its fundamental importance.

Continuing Development of Staff 10.25 The evidence received suggests a patchy recognition of the need for continuing training and development of staff. Some are required by their professions to maintain a level of post-graduate education. Others have no such requirement. All NHS organisations in Wales recognise and to a varying extent make provision, and some of that provision includes a child protection component. While we are opposed to standardisation between what may be very diverse functions and places, we consider that all staff having contact with children should have a child protection component in their continuing training. For those who are in clinical contact with children, especially clinicians who work on a one to one basis with them, continuing professional development should contain a strong element of professionally devised child protection material.

92 10.26 Continuing professional development should be designed to inspire staff to higher quality of work and increased aspirations. This can be achieved in several ways. One is to encourage them to take part-time study for improved and more specialist qualifications. This is a potentially productive way of bridging part of the qualifications and skills shortage, as local connections and the likelihood of promotion will retain loyalty after qualification. Another way is to increase the sense of the level of responsibility held by staff, by continuing leadership and management development. This approach to training often leads staff to re- evaluate their work and to draw greater satisfaction from it. A connected aspect of training is the development of the ‘one up two down’ principle: this is designed to give every employee a good working knowledge of the responsibilities and functions of their immediate manager one line up, and of the two grades below themselves. The consequence of application of the ‘one up two down’ principle should be more flexible as well as more knowledgeable NHS employees. 10.27 In all professional groups that work with children there should be a robust clinical supervision structure. This has been reported for many years as one of the most effective mechanisms of reflecting on therapeutic relationships between the professional and the client. The primary purpose of supervision is to protect the best interest of the client. Supervision performs three main functions. First it gives support for the individual to focus on the difficulties of the job and to adopt appropriate coping strategies. Second, continuing professional development provides the opportunity to learn from reflection and the experience of the supervisor. Third it helps us to manage our work more effectively, challenging recurring patterns and entrenched ideas.

Recommendations 10.28 We recommend that in every part of the NHS, whether for clinical staff or others, rigorous recruitment procedures based on sound human resources practice should be followed. (Para 10.3) 10.29 We recommend that it should be the invariable practice for written references to be followed up by telephone conversations with referees. (Para 10.9) 10.30 We recommend that giving a misleading reference should be regarded as a serious breach of discipline. (Para 10.10) 10.31 We recommend that employment practices consistent with ‘Choosing with Care’ should be applied universally in the NHS. (Paras 10.11,10.12) 10.32 We recommend that registration bodies should include with registration information details of all adverse disciplinary findings recorded by them. (Para 10.14) 10.33 We recommend that for the employment of staff from abroad, wherever possible attempts should always be made to follow the same recruitment procedures as for UK staff. (Para 10.20) 10.34 We recommend that induction training for all NHS staff should include a suitably tailored child protection component. (Para 10.21) 10.35 We recommend that all board members of NHS organisations should

93 receive child protection training; and that both an executive and a non-executive member of the boards of NHS bodies should hold responsibility for child protection issues, with regular reporting to the full board as part of their function. (Paras 10.22, 10.23, 10.24) 10.36 We recommend that staff should be encouraged to obtain further qualifications, and to receive continuing leadership and management development. (Para 10.26) 10.37 We recommend that staff should be trained in the ‘one up two down’ principle, to ensure deeper knowledge of the areas in which they are employed, and better and more flexible skills. (Para 10.26)

94 11. POLICE CHECKS

11.1 Close attention was given to police checks in ‘Choosing with Care’126. As was pointed out, police checks are only one means of scrutiny, and have their limitations. Generally they reveal only convictions, though recent developments discussed below will broaden their scope usefully. Knowledge of the presence of criminal convictions for sexual offences plainly will be of considerable value to a prospective employer. The absence of convictions is no more than that, and cannot be taken of itself as being anything more than the absence of a negative. Home Office advice suggests that only a small percentage, certainly fewer than 10%, of sexual offences result in a report let alone conviction. Experience of the cases in which guilty pleas have been entered in North Wales, Merseyside (‘Operation Care’) and Cheshire show that many offences were discovered decades after they were committed, and that, on the whole, offenders were of otherwise good character. 11.2 ‘Choosing with Care’ described the problems associated with contemporary police checking procedures. Many of those problems have persisted, especially the delays inherent in the system. It is to be hoped that the new system now being introduced will be free of most of the pitfalls associated with its predecessor. One of the worst was delay. Another was the inconsistency of information provided by different forces: some included basic conviction information, while others have been prepared to include cases where there was a decision not to prosecute but, nevertheless, there remained issues of concern. 11.3 This Review was assisted by evidence from Mr R Wright, Head of the Criminal Records Section at the Home Office. The availability of routine police checks for employment purposes has been limited, mainly to those in public sector posts that afford substantial unsupervised access to children. The police have never been resourced to carry out such work, and the demands for checks have increased exponentially, especially after Warner and Waterhouse. The efficiency of checking procedures has been limited by competing policing priorities, and by the absence of any ring-fenced funding. For some years, guidance on police checks of NHS employees has been that in ‘NHS Executive Guideline HSG (94) and WHC (94) 61’127 128. However, it became recognised by the Home Office that the arrangements for police checks on people working with children or other vulnerable persons was not comprehensive. Following consultation, a White Paper was issued in June 1996129. This paved the way for new legislative provisions in the ‘Police Act 1997’.130 11.4 While recognising that there will sometimes be urgency in filling clinical and other posts, we reiterate Warner’s Recommendations 25 and 26: "Employers should only offer appointments after completing police checks; checks against Central Government lists (and any lists of approved practitioners that may be established in future); and verification of birth certificates and educational/professional qualifications; and should allow no unsupervised access to children before completion of all checks."

126 Ibid Paragraphs 5.8-5.30 127 NHS Executive, Health Service Guideline, September 1994, Protection of Children: Disclosure to NHS employers of criminal background of those with access to children. Department of Health 128 Welsh Office, October 1994, Protection of Children: Disclosure to NHS employers of criminal background to those with access to children 129 Home Office, June 1996, On the Record: The Governments Proposals for access to criminal records for employment and related purposes in England and Wales; Cm 3308; London HMSO 130 As amended by the Care Standards Act 2000 95 "Employers should designate people at a level above the manager of the appointee as ‘designated appointing officers’ who should take final responsibility for all appointments; oversee all stages of the appointment process; and ensure that all checks are made." 11.5 ‘The Police Act 1997’ offers the promise of a more comprehensive and informative police checking system. Part V of the Act defines a new framework for disclosures to be made, on application by the individual subject of a check. It provides for three levels of disclosure, according to the circumstances of the case: • Criminal conviction certificates: these are for the generality of cases in which no special circumstances arise. These certificates will contain convictions which are held centrally on the Police National Computer (PNC) and which are not spent under the terms of the ‘Rehabilitation of Offenders Act 1974’; • Criminal record certificates: these include people in sensitive posts, including working with under-18s and other vulnerable persons. The ‘Exceptions Order’ under the Rehabilitation of Offenders Act covers such positions: this means that employers are entitled to ask for information about spent convictions. Certificates will show unspent and spent convictions, cautions, reprimands and warnings recorded on the PNC. Where the position involves working with under-18s or vulnerable adults, certificates will show too whether the applicant appears on a list maintained by the Department for Education and Skills, of people barred from working in schools, or by the Department of Health, of people considered unsuitable to work with children or vulnerable adults. In the past, there have been two government lists maintained separately from police records. Thus, the Criminal Records Beureau (CRB) is described as a one-stop shop arrangement made with the co-operation of the departments concerned. • Enhanced criminal record certificates: these relate to a subset of people covered by the ‘Exceptions Order’ who are in positions of special sensitivity, including people who are regularly involved in caring for, training, supervising or being in sole charge of under-18s or vulnerable adults. In these cases, in addition to information available on criminal record certificates, there will be included relevant information held in local police records. This will incorporate information about cases that were not pursued to trial, but left reasonable cause for concern. Pending investigations and prosecutions may be disclosed, depending upon relevance. Regulations, together with a ‘Code of Practice’ published on the 26th April 2001, deal with issues such as fees, forms and the distribution and use of certificates. 11.6 The (CRB), set up via a public/private partnership with the human resources consultancy Capita, has been established to run this certificating system. One of its aims will be to move reasonably quickly from a largely paper exercise to a mainly electronic operation: if effective, this will reduce delays and comply with good NHS recruiting practice. 11.7 An important aspect of the CRB is that it will be self-financing by means of the charges it makes for disclosures. After representations by charitable bodies the government announced on the 6th February 2001 that the two higher-level

96 types of disclosure would be issued free to volunteers. The controversy as to who should pay for disclosure certificates is outside the terms of reference of this Review. 11.8 The CRB will operate in England and Wales, with a detailed interface with similar arrangements in Scotland. The arrangements for Northern Ireland are still under consideration. Arrangements under which people can obtain information for employment purposes operate in many other countries, often through the police or a local civic authority. The CRB is not empowered under the ‘Police Act 1997’ to conduct enquiries of authorities outside the United Kingdom. This is something upon which the NHS may wish to make future representations. However, work is being undertaken to build up information about contact points in other countries, for the benefit of the CRB’s clients. 11.9 It is to be hoped that, once the regrettable and repeated delays in bringing the CRB fully into operation are overcome, there will be a sea change in the availability of information. What will be provided will hopefully appear more quickly, and will be more relevant and complete. The CRB’s ‘ideal scenario’ (as it was described to us) would involve a call centre, where there would operate a process leading to expeditious provision of the certificate. This is essential if the CRB is to provide a useful process for the employment of locum doctors, supply teachers etc. The 1997 Act contains an appeal mechanism for anyone wishing to challenge the data revealed about them. 11.10 The Review is encouraged by the hope that the CRB checking procedures will make much more available the discovery of material effectively disqualifying applicants from some forms of employment. The procedures should be used consistently and rigorously by all NHS organisations in Wales. We hope that the government and the National Assembly will keep a close watch on the efficient development of the CRB service. 11.11 There are restrictions upon the private organisations able to apply for the full range of certificates. This may impact on the NHS in so far as it contracts work out to the private sector. However, the CRB is making arrangements whereby user groups consisting of smaller organisations could obtain certificates. The method of implementation is far less important than the result: nobody should be allowed to work with children in or for the NHS unless they have undergone the checking procedure and certification at the appropriate level. 11.12 Our enquiries revealed a number of problems and/or inconsistencies with applying the present procedures in the NHS. Many existing staff in the NHS in Wales have been police checked, but by no means all. Also, while, it is common practice for professionals who are to have substantial contact with children to be police checked, policies and practice on checking many other people who work in the NHS in contact with children, including managers, clerical and administrative and ancillary workers, are much less clear. Additionally, in many cases where checks are required, appointments are offered before the checks are carried out and in circumstances in which how any positive findings are to be handled has not been made clear. We also came across situations in which certain staff are police checked repeatedly sometimes after only intervals of months since the last. This appears to be particularly the case for specialist medical trainees who may be police checked as they move between arms of the same training scheme in adjacent Trusts and while in the same employment.

97 11.13 We accept that there may be objections on principle to existing employees submitting to checks that were never considered necessary or required before. However, the Review considers it as important to remove from sensitive positions those who would not now be acceptable to protect children from unsuitable new employees. Therefore, we advise that all staff working in contact with children should be police checked as soon as is compatible with the establishment and development of the CRB.

Recommendations 11.14 We recommend that appointments in the NHS or the contractor professions offering NHS services should only be offered after the completion of police, professional and personal checks, and that no staff should be allowed unsupervised access to children before completion of all checks. (Para 11.4) 11.15 We recommend that every NHS employer should designate an officer at senior management level who will make decisions about whether an appointment should be made in cases where a previous conviction or other relevant information is disclosed following a Criminal Records Check. The reasons for any such decision should be clearly recorded. (Para 11.4) 11.16 We recommend that every NHS employer should have designated appointment officers above the level of appointees, to ensure that correct recruitment policies have been followed in each case. (Para 11.4) 11.17 We recommend that the National Assembly should give full support to the development by the new Criminal Records Bureau of a call centre providing in a speedy and efficient way certificates required by NHS employers in Wales. (Paras 11.9, 11.10 ) 11.18 We recommend that all existing NHS staff in Wales whose work brings them into contact with children should be police checked as soon as is compatible with the establishment and development of the Criminal Records Bureau. (Para 11.12) 11.19 We recommend that, in the interval before the new CRB system is in place, attention be directed by employers in the NHS and the universities to resolving the most evident irregularities and inconsistencies in the present system. (Para 11.12)

98 12. DISCRIMINATION, RIGHTS AND ADVOCACY

12.1 Among the reasons for the historic and unimpeded abuse of children in institutional settings is the failure to listen to what they wanted to say. Probably there was an even deeper failure, that of not even considering the need to listen. Discrimination in society comes in many forms. Ageism is a common and justified target of anti-discrimination measures and campaigns. Most elderly people can speak out for themselves, yet they may remain heavily discriminated against. Children are often more vulnerable. The very young lack the capacity and experience to express their concerns. Adolescent children are marked by traditional concepts of exaggeration, moodiness and anti-authority attitudes. Research shows that these attitudes and especially anti-authority attitudes are exaggerated and frequently false stereotypes. Most adolescents experience greater moodiness but are compliant and responsible young people. Nevertheless, all children tend to be disbelieved when they complain about the apparently respectable and often respected professionals with whom they have contact whether in health, education or social services: this is an inevitable conclusion from those historic child abuse cases in which there is evidence of contemporary complaints, but of almost no consequent action. 12.2 For some children other features compound their weak position as self- advocates. A greater proportion of children than elderly adults come from ethnic minorities. Some children have learning difficulties and disabilities across a wide range: they tend to be less aware of their own rights than adults with similar characteristics. Children with speech and language difficulties face manifest communications challenges unless they are empowered by good quality therapy, together with interpretation and associated skills. Even the most stable children, when in hospital, suffer not only illness but also the dislocation of their normally secure support mechanisms. Staff in the NHS should always recognise that, even when all that is involved is an elementary examination or inoculation, they appear to be figures of considerable authority. Naturally parents tend to support this convention of confidence in clinicians: it is part of the upbringing of most contemporary parents, and in many instances is justified by experience of good doctors. 12.3 One of the key safeguards against discrimination against children in the NHS is a sound system of advocacy (using that term in a completely non-legal sense). Children’s advocates can act as proponent, gatekeeper, mentor and whistleblower. To do so, they must be competent, independent, trained, accessible and informed. 12.4 The Review received evidence from and about some of the advocacy services available in Wales. Details of how to access many of these services have long been available publicly, in the pamphlet ‘Patient’s Charter: Services for children and young people in Wales’131. This document describes itself as "a charter for children". It is a worthy but dull publication targeted on parents. We doubt that more than an infinitesimal proportion of families in Wales is aware of its existence: better and more up to date methods should be sought for the dissemination of what may be crucial information for children and families in dire straits. True though it is that the majority of NHS facilities in Wales contain some information about how to access crisis services, this Review considers that a

131 Welsh Office, March 1996, Patient’s Charter : Services for children and young people in Wales, Produced for the Welsh Office by the Central Office of Information 3/96 WOFF J02-6034 99 uniform principle needs to be established by an analogy with statutory requirements to post certain types of information at workplaces. Every NHS establishment in its foyers, public waiting areas and resource areas where children may be expected as clients should be required to exhibit a prominent notice containing information about how to contact a representative selection of crisis and advice organisations and advocacy services. However, posters and leaflets are only a small part of the armoury of measures available. 12.5 At the Review’s public meeting at Mold on the 27th February 2001 an experienced voluntary sector advocate expressed concern about what is often perceived as the lack of independence of the complaints procedure in the NHS: she told the Review that children often feel that their voices are not heard. A representative from Save the Children told us that there had been much improvement in social services complaints procedures since the publication of ‘Lost in Care’, but less so in the NHS: an example was given of a complaint made against a GP, with the response that the complaint should be referred to the GP’s own practice manager. The clear message was that advocacy services when available could offer a considerable measure of independence, and improve the quality of complaints. Above all, properly trained advocates can raise the understanding that children and their families have of the treatments being offered, and can remove what may be fundamental misunderstandings between clinicians and patients of all ages. The essence of good children’s advocacy services is that they are partisan in that they are designed to assist children to say what the children want to say. 12.6 The Review received evidence from the Children’s Society Cymru. We regret their recently announced decision to withdraw from Wales as they currently provide advocacy services for children in 13 of the 22 local authority areas. Their advice was that advocacy is not about saying what’s best for a child, but rather it is about enabling a child to to come to informed decisions about matters which are affecting their lives. This involves a process of: • Assisting children to understand what has happened/is happening to them; • Clarifying options available to them; • Clarifying the consequences of each option; • Supporting them in conveying their views in what usually are adult dominated situations. 12.7 The link between the existence of the rights referred to in Chapter 1 above and the safeguarding of those rights will for some children depend on the availability of advocacy services. The Children’s Society report ‘The Last Rung of the Ladder’ 132 examined the use of advocacy by children and young people within the child protection system in South-East Wales. Children offered these remarks: "Advocates helped us take our points to social services and the police". "With a bit of help from my advocate I was able to write my letter of complaint myself." "My advocate explained to me I had the right to use the complaints system." "I wanted to speak for myself in the meeting about my complaint but I was frightened of forgetting the important things. It was great just to have my advocate there to prompt me."

132 Wyllie, 1999, The Last Rung of the Ladder, The Children’s Society 100 Those comments show the advantages of advocacy for articulate children. A number of studies and reports have identified the particular importance of advocacy for children with communication or other difficulties133. 12.8 The HAS 2000 report ‘CAMHS Residential Units in Wales – A Review of Safeguards and Standards of Care’134, in specifying the criteria and standards for child and adolescent mental health inpatient care in Wales, included access to independent advocacy services as one of their requirements. Other supportive material emerges from many sources, including the North Wales Health Authority’s response to Waterhouse. 12.9 In ‘Learning from Bristol’ 135 the following appears: "A further feature of a patient-centred health service which respects patients' needs is the provision of support to patients and relatives by the NHS. We regard this as of very great importance. It should not be limited to the time actually spent in hospital but should extend to the time before admission and after discharge. We recognise that difficult questions arise as to the proper, and indeed effective, reach of the hospital, given its resources. Thus, we do not see the provision of the sort of support referred to here as being the exclusive responsibility of the hospital. A period in hospital is only one element along a continuum of care. Rather, we argue for the development of a more integrated approach to the provision of support services, whereby the respective roles of the hospital, the GP and local primary care team, the local Social Services Department and the various volunteer organisations are clarified and organised around the needs of the patient. We were struck by a strong theme which emerged consistently from parents' evidence in Phase One: that they felt abandoned, both in the hospital and later, after the discharge, or the death of their child. Very often, their need for support was closely linked to a need for information about their child's care, particularly when a child had died. Support is a subtle and complex process. It requires skill. Some patients may reject it. For others, it is a lifeline. What matters is that the hospital (with other organisations) has a system whereby information which addresses the needs of parents and patients on leaving hospital is communicated swiftly and that efforts are made to integrate a process of continuing care and support. To meet these needs for an integrated system of support, a hospital must have a well-developed system and a well-trained group of professionals whose task it is to provide counselling and support and to make the links to the various other forms of support (such as that provided by voluntary and social services) which patients may need. (We use the generic term support to include counselling, while conscious of the fact that counselling is distinct and calls for different training and skills.) The support which may be required is wide ranging. ……Crucially, this wide- ranging set of needs must not be regarded as an optional `add-on', to be provided solely by untrained volunteers or untrained administrative staff; or in an `ad hoc' way by healthcare professionals, according to whether they happen to be available at the time. It is integral to care and should be regarded as such. It is what patients (and others) are entitled to……. Many families find emotional and social support from others who themselves have gone through similar experiences. They value the exchange of information and mutual understanding which such support groups offer, often long after they

133 Morris, 1998, Still Missing? Volume 2 Disabled Children and the Children Act, The Who Cares Trust; Morris, 1998, Accessing Human Rights, Barnados 134 Health Advisory Service, 2000, December 1998, Child and adolescent mental health services in residential units in Wales ‘ A review of safeguards and standards of care, The Welsh Office 135 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 -1995. CM 5207, London: The Stationery Office. See page 293 101 or their child left hospital. It is not necessary for each and every hospital to create such groups; what matters is that such groups, wherever they develop, particularly in the voluntary sector, are supported, and that means funded, as an important part of the healthcare process. Within the hospital, patients and families need to be told that such support exists and how to call upon it. Equally, healthcare professionals must be made aware and must be active in directing patients towards it. The proposed Patient Advocacy and Liaison Services could play an important role here; it is vital that these services are visible within each trust, that staff are familiar with what they can offer, and that these services are properly funded. NHS Direct and NHS Direct Online can and should also serve as a gateway to such groups." 12.10 This Review is in accord with ‘Learning from Bristol’ that NHS procedures should play a key role in providing and funding information systems. As in Bristol, in Wales too, voluntary sector success is notable, though not altogether welcomed in all the parts of the NHS to which we have enjoyed access. We believe that the independence of the sector gives it the credibility necessary to achieve the aims and effects described earlier in this chapter. The Children’s Society (including the successful Swansea, Neath and Port Talbot Advocacy Project), The Association for the Welfare of Children in Hospital, Children in Wales, Voices from Care and the Cardiff Child Advocacy Services were among those who provided us with compelling evidence to this effect. Articulate teenagers who were clients of the Harvey Jones Unit in Cardiff, which provides for a client group suffering from serious mental illness, spoke of the value and clear independence of the regularly available advocacy service: one of the advocates working there suggested that advocacy can be even more effective if advocates are permitted to go round the establishment, rather than waiting surgery-style in a designated room for clients to approach them. 12.11 It is generally accepted, and certainly right that all advocates and those having access to the organisation and records of advocacy services should be police checked. 12.12 The Review has concluded that children’s advocacy services are one of the most valuable resources in the safeguarding of children within the NHS. It is an imperative that in every NHS organisation there should be established a system for ensuring the availability of advocacy services to all children receiving in- patient treatment. We consider that access should be facilitated by the availability of free advocacy phone numbers. 12.13 It should not be assumed for a moment that the thrust of our views is directed solely at the CAMHS sector, important though that consideration is. The Bristol experience has shown how children may not be safeguarded fully in surgical and acute medical wards. The long-term patient, whatever the illness, runs the risk of becoming isolated from many of the normal incidents of life – school friends, school itself, group activities including sport, shopping, and the other aspects of daily life outside hospital. 12.14 For long-term patients, we believe that it would be productive towards co- operation between child-centred agencies if there was a strict and effective requirement that they communicate. In our view, as already stated in para 5.12 if a child remains under treatment as an inpatient for more than 28 days there should be a system for the child’s school, if relevant the local education authority and social services to be informed and to liase with the hospital to ensure continuity of education and family. 102 12.15 Sufficient funding arrangements should be put in place to guarantee the availability of advocacy. Whilst we would encourage strongly the provision within the NHS of improvements in advice, counselling and complaints procedures as recommended in ‘Learning from Bristol’, we are sure that advocacy of the nature we have described will only be seen to be truly independent if it comes from outside the NHS. The characteristics of the voluntary and charitable sector suit it ideally to this role; not least because we accept that in some circumstances the work of an advocate can be extremely stressful, and the voluntary sector may provide a range of people of wide experience whose skills can be deployed successfully in the best interests of clients. Advocates should generally be provided with facilities to see in-patients in private, and also to introduce themselves in wards and explain their roles direct to patients and their families. 12.16 A similar universality and quality of arrangements should be made available for children who are not inpatients. Notices in NHS facilities, readily available leaflets, and other conventional means of distributing public information could best achieve this. We would like to see the production of a refreshed ‘Children’s Charter’ in 2 forms, one aimed at parents like the last, and another targeted at the older range of children to read for themselves. 12.17 For children with sensory disabilities or difficulties in communication, each NHS organisation should have a list available of advocacy services that are able to provide specialised skills. Similar problems may arise for children from ethnic minorities and the children of asylum seekers. If such skills are not available, arrangements should be in place to enable confidential interpretation to enable advocates to understand clients’ needs and concerns. Some advocates may, for example require training in British Sign Language136. Otherwise, this may involve employing personnel from the independent sector when required. Expensive though this might prove from time to time, it needs to be done. 12.18 Advocacy is but one, albeit important method of ensuring children’s rights in the interests of their safety in the NHS. Another is to establish that each NHS organisation has an efficient system of recording critical incidents. In addition, consistent with ‘Learning from Bristol’ 137, tape-recording facilities should be provided by the NHS to enable those with parental responsibility, advocates and Gillick competent138 children to make a tape recording of a discussion with a healthcare professional when a serious complaint is being discussed and time should be given for questions to be asked by or on behalf of the child in any such discussions. 12.19 The protections offered by the measures recommended in this chapter will be strengthened by the provision for staff of legal advice independent of management where issues surrounding abuse are raised. For some staff this advice is available readily via their professional bodies and trade unions. NHS organisations should regard it as their responsibility to provide for at least initial advice in cases where no such arrangements exist. In addition, those advising management, whether as in-house legal advisers or from firms of solicitors or the Bar, should only be engaged once the organisation has satisfied itself that they have the knowledge and expertise to deal with child protection issues as they arise.

136 Williams R and Muth Z (eds), 1998, Forging New Channels – Commissioning and Providing Mental Health Services for People who are Deaf, ISBN 095259871 X. London: The British Society for Mental Health and Deafness 137 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 – 1995 CM 5207, London: The Stationery Office. Recommendation 10, page 439 138 A child is Gillick competent if, whatever his or her age, he or she has sufficient understanding and intelligence to be able to make up his or her own mind on the matter requiring decision. 103 12.20 The current complaints procedure was introduced in April 1996 following the report of the ‘Wilson Review’139, and the subsequent Government response, ‘Acting on Complaints’140. In collaboration with the Department of Health, the NHS Executive in England, the Scottish Executive and the Northern Ireland Department of Health, the National Assembly for Wales commissioned a study and evaluation of the effectiveness of the revised complaints procedure. The resultant report was received in March 2001 containing 27 recommendations on which the National Assembly is presently consulting stakeholders. It is however a matter of concern to the Review Panel that nowhere in the report is there any reference to the complaints procedure for children and young people. There is no doubt that one of the most effective safeguards is an effective and responsive complaint procedure that is easily accessible to children, young people and their parents or carers. We therefore recommend that the National Assembly for Wales should develop a complaint procedure specifically for children and young people and their families, that is accessible and child friendly. 12.21 The Waterhouse report ‘Lost in Care’ 141 recommended that every social services department appointed a children’s complaints officer who would act in the best interests of the child and on receiving a complaint would see the affected child. We consider that this should be extended to all NHS Trusts and local health boards.

Recommendations 12.22 We recommend that there should be competent, independent, trained, accessible, informed and funded children’s advocates available to all children in the NHS. (Para 12.3) 12.23 We recommend that every NHS establishment should display prominently in foyers, waiting areas and resource areas notices containing information about how to contact a representative selection of crisis and advice organisations and advocacy services. (Para 4.46 and 12.4) 12.24 We recommend that all children’s advocates and those running advocacy organisations should be police checked. (Para 12.11) 12.25 We recommend that advocates should generally be allowed to see children in private, and also to introduce themselves in wards and explain their roles direct to patients and families. (Para 12.15) 12.26 We recommend that the National Assembly should produce and disseminate effectively two new NHS ‘children’s charters’, one aimed at parents and the other at the older range of children themselves. (Para 12.16) 12.27 We recommend that advocacy services should always be made available for children with communication, language or sensory difficulties and disabilities. (Para 12.17) 12.28 We recommend that critical incident recording should be enhanced; and that tape-recording facilities should be made available to enable those with parental responsibility, advocates and Gillick competent children to make a recording of a discussion with a healthcare professional when a serious complaint is being discussed. (Para 12.18)

139 The Report of the Review Committee on NHS Complaints Procedures, chaired by Professor Alan Wilson: Being Heard, 1994: Department of Health 140 The Government’s Proposals in Response to Being Heard: Acting on Complaints, 1995: Department of Health 141 Waterhouse R, Clough M, le Fleming M, 2000, Return to an Address of the Honourable the House of Commons dated 15 February 2000 for the Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 104 1974, Lost in Care, HC 201, London: Stationery Office 12.29 We recommend that provision should be made for staff to obtain independent legal advice independent of management where issues surrounding abuse are made, in the absence of such advice being available via trade unions and professional bodies. (Para 12.19) 12.30 We recommend that the National Assembly for Wales should develop a complaint procedure specifically for children and young people and their families, that is accessible and child friendly. (Para 12.20) 12.31 We recommend that legal advisers to management should only be engaged once the organisation has satisfied itself that they have the knowledge and expertise to deal with child protection issues as they arise. (Para 12.19) 12.32 We recommend that all NHS Trusts and Local Health Boards should appoint a children’s complaints officer to act in the best interests of the child. (Para 12.20)

105 13. HOSPITAL BASED AND SPECIALISED MEDICAL CARE FOR CHILDREN

Welsh Background 13.1 This chapter is concerned with the provision of hospital based and specialised services including elective and other surgery (which may be inpatient or day surgery), acute admissions to medical wards, maternity services, and ‘hospital at home’ services. Hospital services for children in Wales are provided via the network of Teaching and District General Hospitals. Some tertiary hospital and specialist services are provided at specialist children’s hospitals in England. Using the maxim that parental vigilance is a major safeguard for children, due regard must be given to the problems of visiting sick children who are inpatients in hospitals in places such as London, Liverpool, Birmingham and Bristol. Parental visiting should be encouraged by appropriate facilities (such as overnight stay) for children in hospitals distant from home. It is worthwhile noting that the Association for the Welfare of Sick Children in Hospital (AWCH) has for many years advocated that reimbursement of travel expenses be part of a total care- package. AWCH operates a travel and emergency fund to help families finding it financially difficult to visit.

Learning from Bristol 13.2 The Bristol Report included142 the following, which we fully support : "We start with what seems to be a difficulty on the part of policy-makers and health service managers fully and consistently to accept or acknowledge that the healthcare needs of children and young people are different from those of adults. It seems so obvious that it hardly needs to be said: just as children differ from adults in terms of their physiological, psychological, intellectual and emotional development, so they differ in their healthcare needs. They experience and see the world differently. Children are in a constant state of growth and development which creates particular needs and demands which are of a different order from those affecting adult patients. Their relative physical and emotional immaturity, in comparison with adults, has implications for both the treatment which they receive and the physical environment in which they are cared for. Children communicate their thoughts and feelings in a very different way from adults. Effective communication with children as patients (often through a combination of play, one-to-one interaction, and by communication with parents) is seen by professionals involved in paediatric healthcare as crucial to the child's physical and psychological wellbeing. Thus the ability of staff to care appropriately for children is crucial. Skills, understanding and knowledge are required which are different from those of staff who mostly care for adults. There is still a continuing lack of recognition of the need for the holistic, child- centred approach to the care and treatment of children which has been advocated for the past 40 years. Children's needs are ordinarily expressed through their parents, who are usually the primary providers of their care. But there are also important differences between children and their families. Their interests do not always coincide.

142 Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 – 1995 CM 5207, London: The Stationery Office. Chapter 29, page 419 106 Equally, children are different at various stages of development: infancy, childhood and adolescence. Thus, although as a group they are different from adults, children and young people cannot be seen as a homogeneous group. In short, a child-centred approach to healthcare is complex."

Paediatric Services across Wales 13.3 The Review heard evidence of the proposals for the planned new Children’s Hospital for Wales, on the site of the University Hospital of Wales in Cardiff. We were impressed by the proposals, which would provide much improved facilities to replace existing buildings and to build and develop new ones to allow a new state of the art Children’s Hospital to emerge, staffed and equipped for the 21st century. We consider it important that, in the interests of children from areas distant from Cardiff, the initiative is linked with National Assembly workforce and service planning to ensure the development of managed clinical networks and clinical information technology. This would ensure existing or better levels of provision of tertiary services and specialist expertise throughout Wales, delivered as close to home as possible for the child. 13.4 The National Assembly should review the configuration of hospital based paediatric service provision in order for high standards to be maintained, and to avoid duplication of functions (clinical and organisational) between any 2 hospitals situated within close proximity, for example, in the Swansea area. 13.5 We found the concept of the single Paediatric and Child Health Directorate operated at the Withybush Hospital, Haverfordwest to be impressive. It’s disciplined and co-operative approach gives children a good prospect of access to the range of services they really need, and to appropriate tertiary referrals at the earliest possible stage. In the same hospital there had been established a drop-in centre for staff: with a resource centre this is proving a good means of learning and working through employees’ concerns. It provides a safe haven for trust staff who might want to be whistleblowers concerning suspected child abuse within the service. For a large rural area the Withybush approach offers a service combining the desirability of treating inpatient children as near as possible to home with the merits of clinical specialisation when it is needed.

Tertiary Services 13.6 A review of children’s tertiary services is being carried out at the same time as this Review. This will determine which tertiary services are sustainable within Wales and which will be provided either in partnership with England or in England. The Review members believe that the future commissioners of these services should ensure that English providers comply with the recommendations of this report.

Admission of Children to Adult Wards 13.7 Children admitted to adult wards can find the experience upsetting and intimidating, especially if the ward contains very sick and often elderly patients displaying distressing symptoms. Nursing and other staff on adult wards may have no expertise in the care of children, and will not have gone through the appropriate employment checks or training in child protection. This is explored further in relation to CAMHS at paragraph 14.40.

107 13.8 As a basic principle, sick children should always be nursed in children’s wards, even if this means some increased inconvenience for their families in terms of travel. If in exceptional circumstances children are in adult wards, in accordance with current practice they should be nursed in a side room with appropriately trained and qualified nursing and support staff and all the facilities they should receive in a children’s ward; access by other patients (or their visitors) should be refused. Children should be removed from adult to children’s wards as soon as possible. Whilst they remain on an adult ward the nursing and medical management of these children should be in partnership with staff from the Child Health team.

Adolescents 13.9 Evidence was given by several professionals of a need for separate inpatient facilities for adolescents. Young girls requiring obstetric or gynaecology services are often on adult wards; women with fertility problems complain about being on wards with young girls undergoing terminations, and this is likely to lead to negative interactions, even if inadvertent. Many adolescent boys and girls have an understandable wish for privacy and confidentiality that recognises their approach to adulthood, and feel reduced by placement with much younger children. This was emphasised to the Review by some of the school pupils consulted. A further reason for this view is that adolescents can be disruptive and potentially abusive towards younger and weaker children and conversely young children can be very distressing to adolescents as they often cry for long periods. The goal of quality including separate adolescent provision is a proper one: it should be explored by policy makers, and considered actively by management in all hospitals in an effort to improve this situation. 13.10 There is evidence of hospitals in England being unwilling to accept seriously ill adolescents either in children’s or adult wards from Wales. This is objectionable: each hospital providing acute facilities for Welsh under 18s should be required to agree a policy for the placement of adolescents. 13.11 Adolescents using maternity (and gynaecological) services should have the same consideration as other adolescents using the NHS and be subject of an individual care plan. We were reminded of the value of the additional safeguards for the newborn provided through the continuity of care in an integrated (hospital/community) midwifery service which is firmly linked to primary care services. We are of the view that adolescents requiring maternity and gynaecological services benefit from the effective and sensitive interaction between primary and secondary care services.

Physical Security of Hospital Based Services 13.12 Maternity Services warrant a particular mention here. The very nature of maternity services demands a care environment providing a high standard of safety and security for the newborn. During our visit to Ysbyty Glan Clwyd, we heard how the incident of the abduction of a baby 7 years previously had led to a full review of child protection and security arrangements. The willingness of staff to share the traumatic experience and the lessons learned are a valuable stimulus for action in other parts of Wales. Despite a full array of security aids now in place, staff at Glan Clwyd remain alert to the potential risk and emphasise

108 the importance of constant vigilance in maintaining security in busy clinical areas. We were informed that the Trust has a general policy of an annual review of compliance with child protection procedures, including reports of regular exercises (called ‘code pink’) when mock scenarios are played out without the knowledge of staff to test the effectiveness of security in vulnerable parts of the hospital. In general terms, we recommend that access by members of staff and visitors to hospital wards nursing children must be controlled by adequate security measures. In particular we recommend that the standards advocated by the Association for the Welfare of Children in Hospital, in their publication ‘Health Services for Children and Young People’ be audited in every hospital on a regular basis143. This includes routine identification of staff and controlled access to wards, control over access by visitors, security baby tags and specific arrangements for adolescent facilities and children on adult wards. Appropriate arrangements must be in place to ensure that emergency teams can gain access and that other genuine visitors (such as wider family and friends, advocacy workers, chaplaincy and religious representatives) are identified and given appropriate access.

Surgical Services for Children 13.13 Surgery may be provided as an inpatient or as a day case in a range of settings (medical and dental). The Review recommends that the common principles of appropriately trained and qualified staff, and child friendly facilities be provided for all surgical interventions on children. In particular, the protection of children at vulnerable stages in the process can be promoted with policies such as parents accompanying children to the anaesthetic room and registered children’s nurses working in the recovery area (with or without involvement of parents). Play specialists should work proactively with children to prepare them for surgery and to help with post-operative recovery.

Children with Profound and Multiple Disability 13.14 These children may require ‘hospital at home’ services with specialist packages of care, such as for a ventilator dependent child, relying on teams of nurses to provide 24 hour life supporting and intimate care. Whilst such care packages give some very disabled children the chance of a life outside hospital premises, the risk to the child requires determined professional measures. Risks may include professional isolation of staff, with limited professional development; and enmeshment with the family; or there may be excessive use of bank nursing to staff 24 hour shifts. Any of these may produce greater risks of abuse or neglect for very vulnerable children; such packages of care must have documented regular review by senior child protection staff in the provider unit. The development of community children’s nursing teams will enable children at home who have complex needs to access appropriately qualified registered children’s nurses. The care and management plan of these children should be co- ordinated by a registered children’s nurse preferably with a specialist community children’s nursing higher degree.

143 Hogg C, 1996, Health Services for children and young people – A guide for commissioners and providers, NAWCH/Action for sick children 109 Services for Post Natal Mental Illness 13.15 Most areas of Wales are developing integrated services to support and treat psychiatrically ill mothers at home with their babies rather than admit them to hospital. In South Wales, Bro Taf Health Authority was the main provider of mother and baby services, before the closure of Sully Hospital in November 1999. Figures show that there were 26 admissions to the mother and baby unit between January 1998 and November 1999. Accurate figures are not currently available for the whole of Wales, as admissions over the years have only included one or two other psychiatric units which have tended to be in single rooms on ordinary acute admission wards. Consideration needs to be given to commissioning a feasibility study of all interested agencies to establish whether such a therapeutic resource should be available in Wales.

Shared Care Model 13.16 The children and young people cancer service based in Cardiff is an excellent example of a shared care model. The consultant tertiary team consists of consultants, play specialists, specialist nurses, social workers (who access geographical boundaries), and support staff. The success of this family centred management is due to well established shared care clinics in Swansea and Carmarthen, and geographically allotted specialist nurses and social workers; who work alongside local child health departments as well as primary care providers. There is in place a system of link professionals who are regularly updated. Families have extensive parent and child held records that contain certain contact numbers, and disease information. The ability to maintain local links with excellent information sharing reduces the risk of abuse to this vulnerable group. Good quality parental accommodation has been provide by LATCH144 which is the main partner charity to the service, enabling parents and whole families to reside near the sick child. The geographically based specialist nurses can co-ordinate and manage terminal care at home as approximately 20 children will die from cancer each year in South and Mid Wales.

Adaptation of ‘Learning from Bristol’ to Wales 13.17 The quotation in 13.2 above is merely a part of the very strong justification contained in ‘Learning from Bristol’ of its recommendation that children’s acute hospital services should ideally be located in a children’s hospital, which should be physically as close as possible to an acute general hospital. This model offers the prospect of supporting many of the underlying principles of children’s health care services for better outcomes in the future.145 The Philadelphia Children’s Hospital in the USA operates a system whereby children’s hospitals take over the running of the children’s acute and community services throughout a geographical area.146 This Review considers that the proposals for a Children’s Hospital for Wales have developed in a form that could be made to fall neatly within the Philadelphia style concept. The Review recommends that research should be commissioned by the National Assembly into the effectiveness of such a system we suggest that consideration be given to providing the resources for a pilot project of the kind envisaged.

144 Llandough Aims to Treat Children with Cancer and Leukaemia with Hope (LATCH). The charity is based at Llandough Hospital, Penarth, South Wales. 145 Ibid see page 459, recommendation 178 146 Ibid see page 459, recommendation 180 110 13.18 We consider that Wales should be consistent with the thrust of the Bristol report, and that arrangements across the Welsh border into England will remain a crucial part of children’s care for the foreseeable future. We support the other recommendations made in ‘Learning from Bristol’ in so far as they relate to the planning of the future of children’s healthcare services and the staffing of services. 13.19 The terms of reference of the Bristol Inquiry referred to securing high quality care across the NHS. We hope that it is safe to assume that the National Assembly will accept its conclusions to at least the same extent as the Department of Health. How they are implemented is outside our scope. However, we do wish to emphasise two important conclusions arising out of Bristol. The first is that clinician managers must not only prove their competence to manage or become managers as a pre-requisite of appointment, but must in every case be allowed sufficient protected time in the form of allocated sessions to carry out their managerial role. The second is that a National Director for Children’s Healthcare Services should be appointed for Wales. His/her job would be to promote quality in clinical healthcare services provided for children. The National Director would focus strongly on planning, training and staffing issues, and should be required to provide an annual report to the National Assembly on the state of children’s health services in Wales.

Recommendations 13.20 We recommend that commissioners of tertiary services from English providers ensure compliance by those providers of the recommendations of this report. (Para 13.6) 13.21 We recommend that sick children should be placed in children’s wards whenever possible. If in adult wards, they should be nursed in a side room and access should be refused to other patients who are not their close relatives. Children should be removed from adult to children’s wards as soon as possible. While on the adult ward children should have the same access to parents, qualified staff and facilities that they should have on a children’s ward. Total management should be overseen by the paediatric team. (Para 13.8) 13.22 We recommend that the goal of separate adolescent provision from children and adults should be explored by policy makers and considered actively by management in all hospitals. (Para 13.9) 13.23 We recommend that each hospital in England providing acute facilities for Welsh children should be required to agree a policy for the placements of adolescents. (Para 13.10) 13.24 We recommend that the standards advocated by the Association for the Welfare of Children in Hospital are audited in every hospital on a regular basis. (Para 13.12) 13.25 We recommend that all trust and local health boards undertake an annual review of safeguards for children based on an audit of compliance with child protection procedures. This information should be made available to the Director of the All Wales NHS Child Protection Unit to identify training needs and assist with monitoring the implementation of Child Protection Policy in the NHS in Wales. (Para 13.12)

111 13.26 We recommend that a study is conducted with all interested agencies into the feasibility of establishing a residential therapeutic facility for mothers and babies in Wales. (Para 13.15) 13.27 We recommend that consideration should be given to a pilot project in Cardiff whereby the children’s services of the University Hospital would take over the running of children’s acute and community services throughout the Cardiff city and county area, building on the example of the Philadelphia Children’s Hospital in the USA. (Para 13.17) 13.28 We recommend that clinician managers should be able to prove their competence to manage, and should be given protected time for allocated sessions to carry out their managerial role. (Para 13.19) 13.29 We recommend that a National Director of Children’s Healthcare Services be appointed for Wales, to promote improvements in clinical healthcare services provided for children. (Para 13.19)

112 14. CHILD AND ADOLESCENT MENTAL HEALTH SERVICES [CAMHS]

14.1 This is an extremely difficult area. Working with children and young people who have mental health problems, disorders and illnesses is stretching and stressful. They form a group of troubled, distressed, sick and occasionally disruptive young people and, all too often, it can be convenient for the public and their representatives to feel uncomfortable and forget them. There is little political capital in spending large sums of money on children’s mental health, as opposed to neonatal care, cancer and other important and rather more emotive areas of child health. However, elected politicians and the public need to realise the extent and effect of the problem. 14.2 While precise data are elusive, it is estimated that more than 40% of children and young people have recognisable risk factors indicative of possible mental health problems and disorders; and that up to 25% have a disorder147. A recent population survey showed that 10% of children in Wales had one of only three disorders studied148. 14.3 Adult psychiatric units contain many patients who might have led regular and healthy lives had more effective treatment been provided in their youth. In a small number of disturbing cases, failures to diagnose and treat childhood mental illness has resulted in extreme criminal acts including murder and child abuse, and in suicide. There is increasing evidence of the success of properly resourced intervention and of its potentially long-term positive impacts and financial savings. 14.4 As part of our terms of reference, the Review was asked to carry out a management review of the circumstances of the former Gwynfa residential unit. The purpose of that task was to provide us with a case study of real events, albeit historic, showing how the combination of underachieving management procedures and a small number of abusive events can lead to disastrous consequences and a loss in the credibility of CAMHS provision. Chapters 4 and 5 above contain the relevant history, and management lessons that we believe can be learned from Gwynfa. This chapter is concerned with wider policy issues that arise from the Gwynfa review as well as the visits and evidence taken by the Panel.

Progress Made by the National Assembly for Wales 14.5 The National Assembly has already taken steps to address this problem. The report ‘Everybody’s Business’ 149, by the Advisory Group on Child and Adolescent Mental Health Services chaired by Dr Jennifer Lloyd, produced a complete analysis of the problems facing CAMHS in Wales. Its consultation document made a wide range of recommendations. Rightly the Advisory Group commenced its work with the conviction that Wales needs a comprehensive CAMHS strategy, child-centred, quality assured, and universal in its availability for all children in Wales. Like this Review, members of that group found the task of assessing and invigorating the disparate parts of the CAMHS service very complex.

147 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business - Strategy Document, Cardiff: The National Assembly for Wales. 148 Office for National Statistics, 1999, Mental health of children and adolescents, ONS(99)409. London: Government Statistical Service. 149 Ibid, see para 14.2 113 They identified the link between poor mental health and other forms of social exclusion, and in their recommendations they defined new principles needed to underpin a modern and effective CAMHS service. We support those recommendations. 14.6 For CAMHS, as with other services, our terms of reference are much narrower: we have concentrated on risks to the safety of children while clients of CAMHS. While we do not seek to replicate the work represented by ‘Everybody’s Business’,150 we do consider it appropriate to reiterate the importance of designing and delivering services that are child-centred. 14.7 In particular, this requires that all NHS agencies, including the authorities that are responsible for designing and commissioning as well as those that deliver healthcare to children, should be holistic, flexible and centred on professional practice which, regardless of discipline, must: a. view each child as a developing person in his or her own context; b. view problems from a perspective of the way in which children experience them; c. empower good parenting; d. include a focus on prevention and health promotion; e. develop relationships that aid young people in tackling their problems; f. be realistic. 14.8 We believe that there is a continuing requirement to change attitudes and perceptions about the needs of children with mental health problems and disorders in society generally, as well as among the medical, nursing and other professions and, indeed, among children and young people themselves. 14.9 Challenges to collaboration are key in CAMHS. In ‘Together We Stand’151 the Health Advisory Service (HAS 2000) emphasises authorities, local authority social services departments, the NHS and the voluntary sector are essential joint and several contributors to effective CAMHS. While HAS 2000 did find some pairs of the major agencies working effectively together and some good bilateral relationships, nowhere in its field did it find all of the major agencies in effective collaboration. 14.10 Injunctions to agencies to jointly plan, commission and deliver services are found in all recent reports of standing152. Analysis of recent policy relating to designing, commissioning and delivering CAMHS identified that one of six common themes that are regarded as core to development in the UK is multi- agency ownership of the CAMHS concept153. This means that achieving shared multi-agency ownership of a broad approach to improving children’s mental health. However, experience indicates that long delays occur all too often in arranging for children to be assessed when they are referred by one agency to the other. This reflects serious shortages of facilities, professionals and training in health, social and education services.

150 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business - Strategy Document, Cardiff: The National Assembly for Wales. 151 The NHS Health Advisory Service, 1995. Together We Stand - the commissioning, role and management of child and adolescent mental health services. London: HMSO. 152 For example, Audit Commission, 1999, Children in Mind – a report on child and adolescent mental health services. London: Audit Commission 153 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, 114 Cardiff: The National Assembly for Wales 14.11 Ideally, when there are concerns about the mental health of a child, a professional skilled in mental healthcare, working together with a social worker or teacher or a member of the education support staff as appropriate, should be able to provide rapid assessment. Following assessment, the mental health professional may determine that an adolescent has not a treatable mental illness, yet it may be clear to all that the young person needs a therapeutic regime. The severe shortage of child and adolescent psychiatric nurses inhibits this process, so that there are real problems about speed of assessment and the treatment available after assessment. 14.12 Similar observations can be made about responses to referrals made by the NHS to the education support services and social services departments. We are aware that we are highlighting areas in which there are acknowledged problems and that there are no easy answers. Nevertheless, we think it essential that the authorities that are responsible for health services, the local education authorities, the social services departments and agencies in the non-statutory sector should plan collaboratively so that they develop new resources and share existing skills to provide the best care for young people. 14.13 Lack of co-operation, which leads to children being passed between the agencies or neglected, appears to stem from many sources including over-tasking of the staff of current services resulting in individual agencies resorting to defining their own priorities unilaterally. The problems are compounded for young people with combinations of learning disabilities, education difficulties mental health problems and problems arising from substance misuse. 14.14 They are most evident when the problems presented by young people do not fit the models and concepts adopted by the agencies to which they are referred and when there are gaps in communications that allow the agencies to make assumptions about the roles of the others. 14.15 For example, there is evidence that referrals within the healthcare system to specialist CAMHS may not identify the full reasons for referral, lack clarity about the expectations of what is requested or are unrealistic about what can be delivered154. This research indicates that referrals are often made to specialist CAMHS when other family members and professionals experience worry or a feeling of being burdened by a young person. 14.16 Experience shows that, frequently, single agencies may define a problem as lying in the zone of responsibility of another agency but this may not be accepted by the agency receiving such a referral or enquiry. This leads to mutual frustration and the care of children falling into gaps between the agencies. 14.17 Evidently, an accurate view of the core functions of the different organisations should be clear to all. The social services departments are concerned with social care and not psychiatric assessment or psychiatric nursing, both of which are NHS responsibilities. Similarly, the role of the NHS is not primarily assessment of social welfare and education needs or provision of education support services or social care. However, definitions of this kind do not prevent individual agencies coming to view that a child’s problems lie primarily in the area of responsibility of another. For example, social services departments may have a different conception of what is mental disorder than might the education and specialist CAMHS. This is particularly liable to occur when young people present seriously challenging problems.

154 Rawlinson S, Williams R, (2000). The primary/secondary care interface in child and adolescent mental health services: the relevance of burden. Current Opinion in Psychiatry 2000; 13 389-395. 115 14.18 The local education authorities, specialist CAMHS, social services departments, child health services and primary healthcare may each hold, and operate on the basis of disparate views about each other’s roles if there is not recurrent and active continuing negotiation between key players in each department or agency. 14.19 Active negotiation needs to be accompanied by agreements to work together in a planned way to fill gaps between the agencies that are discovered in the course of discussion rather than adopting the forlorn alternative of one agency unilaterally reframing a young person’s problem into the zone of another agency. This includes agreements about the ways in which referrals are made and provision of opportunities for discussion of them. The tipping points that should trigger a change of lead responsibility between teams, departments and agencies need to be identified in general terms and as care plans for individual young people are drawn up.

Improving Care and Accountability - Implementing the All Wales Strategy 14.20 It is important to remedy the gap at policy level. We concur with the prominence that CAMHS are now receiving and are pleased to see that the National Assembly for Wales proposes, in its confirmed strategy, to enact the recommendations of the Advisory Group. We regard it as extremely important that the plan in ‘Everybody’s Business’155 be seen through from policy into implementation and we urge the Minister for Health and Social Services to ensure that this occurs. 14.21 Implementation of the strategy in full will strengthen against the risks of child protection failures not only CAMHS but also those services with which they relate as partners. Implementation is a core component of the safeguards we recommend. 14.22 As the Advisory Group made clear, this will require a financial commitment measured in a number of millions. We consider that would represent good value and a saving in the long-term when measured against the cost of additional medical, social, education and criminal justice interventions. The National Assembly for Wales should not forget, when assessing cost-benefit, that the price of keeping a single patient in acute psychiatric care can exceed £150,000 per year at 2001 prices.

Commissioning the Service Developments 14.23 Therefore, with ‘Everybody’s Business’ 156, we believe that it is essential to establish a multi-disciplinary group under the auspices of the National Assembly to ensure that the patient-centred multi-disciplinary approach is implemented in full. 14.24 The challenges to commissioning CAMHS that are presented to the responsible health and local authorities are less tangible than the current problems in service delivery. It appears to us that few of the responsible agencies have yet afforded sufficient priority to CAMHS or developed the information and knowledge bases or the skills required to commission services that reflect the

155 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales 156 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, 116 Cardiff: The National Assembly for Wales. Page 29 paragraph 5.2 needs of the children and adolescents of Wales. Maintaining priority for CAMHS, which require long-term approaches and wider cross-sector conceptions of health gain and financing can be difficult when viewed against the shorter-term targets often set for the NHS. 14.25 The roles and activities of all the agencies should be better integrated around a shared strategic framework that is child centred. CAMHS at all levels are not only the business of the NHS. They are and, in the future, should be commissioned and provided by the statutory education, health and social services and by the non-statutory voluntary and independent sectors. Within that network, each child’s care should be integrated through a case-specific, shared framework for multi-disciplinary assessment and intervention in which the lead agency can vary from child to child according to the exigencies of the case. 14.26 We are convinced that the Four Tier Strategic Concept that is now policy in Wales meets the requirement for a framework around which more effective co- operation and planning can be developed.

The Four Tier Strategic Framework 14.27 For ease of reference, we reproduce a description of the Four Tier Strategic Framework as adopted in Wales at Annex 9157. This approach was intended "to integrate the many elements of a truly comprehensive service for children, adolescents and young people into an understandable whole" and "through encouraging the development of service networks, to support those working with children, young people and families so that they are enabled in their work, and their skills are increased" 158. It’s other intentions, were to match the level of specialisation offered to individuals to the complexity of their ascertained needs, to bring together the various sectors involved in CAMHS through a new service language (it dovetails with, for example, the educational Code of Practice) and better balance demand on the various components of CAMHS. The Four Tier model is strategic. It is evident that it’s authors intended that it should focus on the needs of, and service functions required by children and adolescents rather than on structures. We see this approach as child-centred. 14.28 We can see why it is that the CAMHS Advisory Group recommended incorporation of the Four Tier Strategic Framework into Welsh healthcare policy in ‘Everybody’s Business’. We strongly support that advice and the subsequent policy. In our opinion, use of the Four Tier approach should enable the NHS, both at the centre and locally to analyse gaps in service functions and key partnerships. We note that the Minister for Health and Social Services has adopted it as policy in Wales. Here, we use it as a convenient basis for further recommendations. 14.29 As we have said earlier, it is not our intention to repeat the work and advice of the CAMHS Advisory Group though we do draw attention to some key matters that arose from our Review. For example, we support very strongly the emphasis given by ‘Everybody’s Business’ to developing a coherent first-line response in better integrated, resourced and understood and more accessible Tier 1 services. We agree that Tiers 2 and 3 require considerable development and, in Chapter 5 as in this chapter, provide recommendations on the need to review and develop Tier 4 services in the NHS. We are pleased to see that the Minister for Health and Social Services has accepted and developed the Advisory group’s

157 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales, page 25. 158 From paragraph 163 on page 59 of Together We Stand. 117 recommendations into the Welsh policy for the NHS. The new strategy, also named ‘Everybody’s Business,’ has been issued as joint health, education and social services guidance.

Developing the Contribution of Primary Care to Tier One 14.30 We agree with ‘Everybody’s Business,’ with regard to how it envisages that the NHS components of CAMHS should be commissioned by the re-organised NHS. 14.31 Within healthcare, we see Local Health Boards (LHBs) as being responsible for commissioning Tier 1. However, we must bear closely in mind the small size of specialist CAMHS in the NHS, the geographical areas they cover, the specialisation of Tiers 2, 3 and 4, and the huge agenda of change and development envisaged in ‘Everybody’s Business.’ 159 We must remember too the requirement for effective interfaces with the National CAMHS Implementation Group as well as the demands of other agendas that will face LHBs. Our firm opinion is that commissioning specialist CAMHS should not be a LHB responsibility. Rather, we see great advantages to ensuring continuity of presently fragile services and delivering the agenda for change in constructing commissioning arrangements for Tiers 2 and 3 in the NHS at a regional level which brings together a number of LHBs. We agree with ‘Everybody’s Business,’ that Tier 4 services should be commissioned on an all Wales basis. 14.32 ‘Everybody’s Business,’ considers that it is not appropriate that so many young people are referred to the more specialised services (at Tiers 2, 3 and 4) without effective prior assessment and intervention in Tier 1. Part of the reason for the present overwhelming level of demand on specialist NHS CAMHS relates to rising levels of need, but also to limitations on their present resources, which are insufficient for the assigned role of the specialist services. However, there is also evidence that insufficient resources, staff and training in the non-specialist CAMHS at Tier 1 are causing more cases to be referred to the specialist services than is either appropriate or necessary. In other words, Tier 1 requires considerable development to achieve the intended pattern of services and we are clear that it requires more staff, support, and training if it is to be a real part of an integrated system of CAMHS. We think that all in primary care and first contact services could develop to achieve this. 14.33 General practitioners are a vital element but they, as other disciplines, lack training and confidence in this work. Like them, we see school nurses, health visitors and practice nurses as vital assets. Presently, they are involved informally and to differing degrees in mental healthcare but they could become a more potent and recognisable part of Tier 1 CAMHS without threat to their identity as primary care practitioners. 14.34 But there are also other sources of relevant expertise available to Tier 1. For example, during our work, we found that 50% of medical practices in the UK have access to a designated counsellor, whose role is to enable the articulation of difficulties, including abuse, and to encourage the development of strategies to cope with such difficulties. Referrals are made through GPs and other members of the primary care team.

159 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales. 118 14.35 While the involvement of counsellors by some GPs in Wales may have arisen, especially in rural areas, out of their increasing frustration with patchy specialist CAMHS that are not able to cope with the rising demand, our reaction is to see this as a spur to development of Tier 1. There is some evidence that both GPs and patients like the skills-mix approach, the lack of stigmatising context160, the more limited waiting times and the financial savings161. 14.36 This group of therapists in primary care is trained to postgraduate standard. This is a highly-skilled and distinct professional group, regulated by national bodies162. Provided they are also trained to work with children and young people and fall within the safeguards, we believe that the value of this service is beyond doubt. Furthermore, its availability at Tier 1 is a distinctive bonus. 14.37 The service should be evaluated fully by the NHS Directorate in Wales, with a view to its being consolidated fully into CAMHS strategy and provision while retaining it’s place as a primary care resource. 14.38 In other words, if the outcome of the evaluation was positive, the view of this Review is that the psychological therapy provided by counsellors should be integrated into Tier 1 as a skilled resource alongside the other disciplines. In that way, the therapists would benefit from the training and support and access to specialist CAMHS that should be provided by primary mental health workers outputted from Tier 2 and become a part of a systemic approach to service delivery. For the services, the prospect of an increase in provision in this manner has the potential to provide a high added-value and cost effective addition to present Tier 1 CAMHS that could improve its accessibility and capability throughout Wales. 14.39 This is also consistent with the approach taken in ‘Everybody’s Business,’ 163 which sees the specialist CAMHS as concentrating on those young people with more serious problems demanding a specialised approach. The All Wales strategy anticipates among many commitments that there should be a substantial increase in what might be called, in broad terms, ‘psychological services’. Some of these are required to augment Tier 1 and others to develop specialist CAMHS at Tiers 2, 3 and 4. Included in this development are the purposeful, planned and managed deployments of increased psychological skills through the distinctive contributions of: trained counsellors; staff who are trained to provide psychological support to children, young people and families as well as to practitioners; clinical child psychologists and educational psychologists, as well as services provided by psychology assistants and technicians working to qualified psychologists.

Admission of Young People to Wards for Adult Patients 14.40 As we recognise in Chapter 4, a matter of ever-active concern in CAMHS provision is the use of adult wards for children and young people who present as emergency admissions, or are in an area of Wales where separate facilities are not available. This is not a problem peculiar to CAMHS services, but can be particularly serious in the mental health field.

160 Rogers IC (1996) Loosening the Bond in Mental Health Review. 161 Powys Local Health Group, 2000. Figures from Powys Local Health Group for activity in 1999. Professional Counselling and Psychotherapy, Guidelines and Protocols: Defining Psychological Therapy in Primary Care. 162 Association for Counsellors and Psychotherapists in Primary Care.. 163 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales 119 14.41 As a general principle, whenever possible children and adolescents should not be placed in adult wards save when it cannot be avoided, and even then in a side room with appropriately qualified and experienced nurses. Staff who are not police checked or trained in child protection procedures should not have any involvement with this group of patients when they are in adult wards. Our findings and the principles derived from them resonate with the recurrent concerns and recommendations of the Mental Health Act Commission164. 14.42 The HAS 2000 report ‘Child and Adolescent Mental Health Services Residential Units Wales: A Review of Safeguards and Standards of Care: Follow Up Inspection’ 165 though positive about improvements in some respects, leaves the reader without reassurance that any real progress is being made towards provision to meet the critical mass of seriously mentally ill children within Wales. 14.43 There is a particular shortage of inpatient psychiatric provision throughout Wales. Even in the areas in which there is a unit (one in North Wales and one in South Wales), demand outstrips supply and the number of dedicated inpatient places per head of population is lower than in any comparable area in England. Neither does a comprehensive psychiatric inpatient service exist in Wales. Due to pressure on places, their premises, their staffing and training, the two units have to be restrictive of the patients they admit, the circumstances and urgency in which they can respond and the kinds of problems with which they deal. In these circumstances we are pleased to see confirmed as policy the steps that the Minister for Health and Social Services proposes to take to commission Tier 4 CAMHS, including inpatient services, on an all Wales basis.

Provision of Secure Services 14.44 In Chapter 8 above166, we discuss secure provision in general. The Hillside Unit, described there, is essentially a criminal justice facility now supervised under the auspices of the Youth Justice Board. A minority of young people are now admitted there by the local authorities. 14.45 Consistent with our recommendations in that chapter, and with those in ‘Everybody’s Business’167, we consider that progress should be made urgently towards creating within Wales specialised forensic mental health service resources for adolescents, outside adult mental health provision, for children presenting with the most challenging disorders and illnesses falling outside the criminal justice system, and those who present in emergencies. 14.46 We see these new forensic CAMHS as pending not only highly specialised inpatient facilities, but also very specialised outpatient liaison and consultative services. The latter could and should be developed more to support systematically the criminal justice services and the Youth Justice Board and the Hillside Unit.

Very Challenging Behaviour 14.47 Problems with behaviour span a huge spectrum. At one end are children who are behaving ‘normally’, but for whom adults have inappropriate or unclear expectations. At the other, are young people who show the gravest of disordered conduct. Some are criminal, others are mentally ill or mentally disordered offenders and others may have suffered abuse or severe aberrations in their

164 Mental Health Act Commission. Seventh (1997), Eighth (1999) and Ninth (2001) Biennial Reports. London: The Stationery Office. 165 The National Assembly for Wales, 2000, Child and Adolescent Mental Health Services Residential Units Wales: A Review of Safeguards and Standards of Care Follow up Inspection, Cardiff : The National Assembly for Wales 166 Paragraphs 8.19-8.24. 167 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, 120 Cardiff: The National Assembly for Wales. Paragraphs 93-97. development. Between these two spectral ends are a huge variety of problems and circumstances and it is evident that problem behaviour is now presenting a severe challenge to all services for children. The single most common feature is that, usually, these young people are the subject of complaint from adults rather than raising concerns for themselves. 14.48 The causes of challenging behaviour are often multiple and may lie at a distance in time from the declaration of the problem. For example, recent research has shown the long-term impact on behaviour of hearing problems earlier in childhood168,169. 14.49 It may be extremely difficult for education, social services and healthcare organisations to find resources for persistently troubled and troublesome young people, and the problem is compounded when their behaviour presents a risk to others. In these circumstances, it is tempting to view the problem as the primary responsibility of another agency. The same young person might be viewed by differing agencies as someone needing an education support service (e.g. education in a particular type of special unit), as a requiring a child protection or social welfare intervention (e.g. case-work, parenting advice or counselling offered by a trained social worker) or as mentally disordered and requiring psychiatric care (e.g. specialist psychiatric day-care or admission). 14.50 While some children and adolescents with problematic behaviour may have a primary or a co-morbid mental disorder, many others do not and many are not best helped by a medically-led approach. The boundaries are difficult to define and lack of an agreed language shared by the agencies is particularly evident in this arena. Also, the impact of burden as the main reason for referral (sometimes undeclared) between the agencies may be greatest for young people whose behaviour is a problem to others around them170. Often, the most troubled children require a package composed of interventions provided by a variety of agencies working together in a planned way. 14.51 We have come to the view that a rational approach to families in which their children’s behaviour is challenging is best approached from a multi- disciplinary perspective in which the needs of individuals and methods of most effectively approaching them are at the core.

Integrating Specialist CAMHS with Other Healthcare Services 14.52 Within healthcare, all CAMHS, including specialist CAMHS provided by the NHS at Tiers 2, 3 and 4, should be integrated as fully functional components of broadly defined, child-centred health services within the concept of managed clinical networks. 14.53 Better integration of CAMHS at all tiers is also required with other mental health services. Examples include situations in which: • Children have a learning disability; • Parents or carers of children in need are in receipt of mental health services for adults; and when • Older adolescents require to transfer to mental health services for adults.

168 Bennett KE, Haggard MP, Silva PA, Stewart IA, (2001). Behaviour and developmental effects of otitis media with effusion into the teens. Arch. Dis. Child. 2001;85 91-95. 169 Butler CC, MacMillan H, (2001). Does early detection of otitis media with effusion prevent delayed language development? Arch. Dis. Child. 2001;85 96-103. 170 Rawlinson S, Williams R, (2000). The primary/secondary care interface in child and adolescent mental health services: the relevance of burden. Current Opinion in Psychiatry 2000; 13 389-395. 121 14.54 We are pleased to see that ‘Everybody’s Business,’ deals with these issues. A key theme running through our Report is that there should be good reciprocal relationships between the range of services that impact directly and indirectly on children and young people. The intention is that children in need are not faced with fault lines between different services that reflect the ways in which they are organised rather than the patterns of care that children require. 14.55 The mental health services for adults of working age should be better integrated with CAMHS. There are several aspects to this issue. 14.56 We agree with ‘Everybody’s Business,’ that much greater clarity is required for older young people about the age coverage of the various mental health services. The boundary between services for adults and CAMHS cannot be allowed to continue to be an arena for dispute in which the needs of children fail to guide the way in which services flow and are made available. Ideally, we believe that CAMHS should move to cover all young people up to their 18th birthdays. However, we acknowledge the considerable resource, estate and workforce issues that have to be tackled in achieving the plan in ‘Everybody’s Business.’ Nonetheless, the goal should be services that cover all minors, but, while the necessary developments are brought on stream, the arrangements between the adult services and CAMHS must be explicit. 14.57 There is now ample evidence that occurrence of mental health problems or disorders in adults is a factor that raises the risk of a number of health problems for the children in their care. Yet we were told that few mental health services for adults have the capacity or capability to provide services that are able to recognise and respond to the needs of families. 14.58 In some other cases, GPs make inappropriate referrals of children who have no mental disorder to the specialist CAMHS when their adult relatives have serious relationship problems of their own or where an adult patient has problems in discharging their role as a parent due to their own mental health problems. Often, GPs refer in the hope of engaging a service that deals with intra-familial relationships and because of lack of such an orientation and capacity elsewhere in the system. Yet, these referrals are inappropriate, in our opinion, as they risk longer-term labelling and stigmatisation of children and families. 14.59 For these reasons, we are keen to see adult mental health services develop approaches that include the capacity to recognise and intervene with family problems. Similarly, much greater availability is required of services that are able to deal with family relationship problems and offer active interventions with positive promotion of good-enough or better parenting. These services may be provided by the statutory mental health services working in partnership with the local authorities but also importantly by the voluntary sector. In this regard, we believe that statutory and non-statutory cross agency services need to be expanded considerably and in a manner that creates an integrated range of services better able to respond to families in which there are significant relationship problems. 14.60 As we have said earlier in this Report, all services, including mental health services for adults, must be aware of the risks of abuse and misuse of relatives and especially dependant people of all ages. In our opinion, they must be capable of recognising risk to relatives, and particularly children, even when the

122 index patient is an adult. For this reason, we are keen to see training in child protection increased within services primarily focused on adults. Government has issued guidance on children visiting adult inpatients in mental illness units with the intention of drawing attention to the necessary balance between three matters: ensuring that children continue to have contact with adults who are important to them; protecting children; and responding to the reasonable wishes of the adults involved for sustained contact with the children in their families. Similar guidance may be required on the wider child protection issues.

Risks of Abuse in CAMHS 14.61 In terms of risks of abuse by staff, CAMHS presents especial difficulties. Troubled and dislocated patients are most likely to be vulnerable to inappropriate attention, and least likely to be believed. The experience of our Gwynfa case study (see Chapters 4 and 5) has confirmed that there is potential for abuse by staff in psychiatric inpatient units to remain undetected for long periods unless robust disciplinary, investigative and management procedures are in place and understood profoundly by all staff. Conversely, it is in such units that there is the greatest potential for false accusations: as with true accusations, falsity can arise very long after the event, and can be especially difficult to disprove because of the disappearance of documents and the lapses of memory. Vigilance and rigorous procedures are in the interests of everybody. 14.62 Staff at all levels inevitably develop close relationships with patients: this is right, as in all treatments and not just the psychological ones such as cognitive and behaviour therapy a level of personal confidence held by the patient in the clinician (sometimes called the ‘therapeutic alliance’) is often the key to recovery. 14.63 Experience of the many institutional abuse cases now known to have occurred demonstrates that abuse is more likely to occur in close pastoral or therapeutic relationships than in more casual situations, and the consequent breaches of trust can be all the more worrying because of the closeness. Experience has shown too that such relationships may involve staff who have performed well for many years, who fail unaccountably with perhaps just one patient, and destroy their own lives in the wake of the relationship. Contrary to the sometimes simplistic views of parts of the media, not all abusers are definitively bad people: some are good people who lapse badly from their usually high standards. We see our task as legitimately including the protection of staff from the indefinable factors occasionally giving rise to unexpected abusive relationships.

Appraisal and Mentoring 14.64 With this in mind, we regard it as especially important in CAMHS that there should be developed professional appraisal schemes for all staff and not only consultants. Appraisals should include a review of child protection procedures and their use, so that lessons may be learned by individuals, and those requiring corporate review are addressed by the organisation and transmitted to the responsible unit in the National Assembly structure. 14.65 In Chapter 5, appraisal, mentoring and continuing professional development are identified as important protections against professional isolation and service dislocation. On a wider canvas now, we make similar recommendations. Clinical

123 supervision should be introduced for all professionals. All staff, including ancillary colleagues, should have mentoring available to them, somewhere to go for advice and review of their attitudes, activities and behaviour.

Workforce Development Recruitment, Retention and Training 14.66 In Chapter 5, we recognise the considerable workforce planning problems that lie at the core of making progress with developing CAMHS. The challenge is not only that of recruiting sufficient staff from all disciplines at a time when the training schemes are producing insufficient graduates to fill current establishments but also providing the quality and content of training that is required by all. The answer to recruiting sufficient staff to work in CAMHS does not lie in considering any dilution of training: rather, we consider the converse to be important. We regard it as vital that all staff who work with children should have a basic level of training in child development including children’s emotional development. Staff who have more specialised responsibilities for work with children should be trained to do that work. 14.67 Our review of the past papers relating to Gwynfa provides some insight into the endeavours that were required to ensure that in-service training took place. It appears that until relatively recently, there has been no assumption at more senior management levels that continuing education for all grades and disciplines of staff should be a core requirement. 14.68 The answers to these challenges lie in long-term approaches and a coherent workforce development plan. We cannot emphasise enough the requirement for prospective investment in staff against better predictions of need as the longer we postpone action to tackle the problems, the longer will be the solutions in arriving. The National Assembly for Wales should take responsibility for ensuring that a workforce plan is developed in conjunction with the appropriate academic institutions and the standard setting bodies and for identifying investment to support the plan. 14.69 Critically, delivering some of the key recommendations in this Report, particularly those relating to the staff of the NHS, depends on establishing and benefiting from a coherent plan to develop the workforce. Increasing the numbers of staff and inspiring their training are vital elements.

Nurses in CAMHS 14.70 Training for nurses in this field has always been poor and non-systematic and in our opinion it is likely to remain so until there are UK-wide standards. Presently, there are no standards for the training required by nurses who work in CAMHS agreed by professional standard setting bodies. However, we are pleased to note that, in Wales, the Nurse Executive Group has agreed a set of standards proposed by the All Wales CAMHS Nursing Forum. We believe that such a set of standards should be developed on a UK-wide basis. 14.71 In the 1970s, most nurses who worked in CAMHS staffed in and day patient units and any training available had that task as its focus. The last decade in particular has seen a rapid expansion in the demand for nurses with the tasks

124 expanding to include community, outpatient and therapist roles. But neither the volume and availability nor the breadth of training available has kept pace. In our opinion, training for nurses, recently recognised as a key part of the workforce plan for child and adolescent mental health services in Wales, requires a thorough overhaul and promotion.

Child Clinical Psychologists 14.72 In similar ways, the roles and requirements for child clinical psychologists have expanded. Although there are now in place rigorous doctoral training programmes for them, the volume of places available is too low to meet the rising demands from services to make appointments despite there being many able applicants who are turned away.

Child and Adolescents Psychiatrists 14.73 Recruiting sufficient trained psychiatrists to achieve high quality services is another major problem. There are vacancies in posts already established in Wales, but even, if all current posts were filled, we recognise that the numbers of psychiatrists would still be too few to provide the kind of service we envisage as needed in this Report. Training of psychiatrists has developed as the academic departments and rotational training schemes in the NHS have expanded. There are now many well-developed training schemes available and the numbers of trainees continues to rise but at a rate that continues to fail to fulfil the requirement for new consultants.

Transfer of Staff 14.74 A potentially excellent staff resource lies in transfers of people working in adult mental health services to CAMHS. However, staff who do this must realise that different attitudes, perceptions and skills may well be needed in dealing with children who have a mental disorder. Additional training is essential for all staff transferring from adult services to children’s services, and for staff who work primarily in services for adults that provide too for children and adolescents.

Therapy Mix 14.75 The Review was concerned too about the inconsistent mix of nurse and therapy skills in CAMHS provision. The evidence indicates that in just about all areas, and not only but including particularly the rural parts of Wales where service skills and disciplines are thinly spread, it is not always possible to provide the therapies most relevant to patients’ needs. The improved understanding of common psychiatric conditions including, for example eating disorders, anxiety and phobic disorders and pervasive developmental disorders mean that particularity in therapy techniques can improve outcomes significantly. In developing specialist CAMHS from the present patchy baseline and when appointing staff, providers should focus strongly on having the appropriate skills mix, and should remain prepared to make secondary referrals where the patient’s needs can best be met thus.

125 14.76 We are conscious of the difficulty caused by limited budgets and skills shortages in recruiting a service of all the skills competently delivered; and of the reluctance of some to apply for jobs in areas distant from centres of excellence or geographically remote. Nevertheless, all should reflect upon the truism that in healthcare outcome is everything. Providing the wrong form, or failing to provide the right form of treatment diminishes outcomes, and raises even higher the real risks of distracting litigation in a society in which clinical negligence claims are a growing hazard in both quantity and cost to precious resources.

Positioning CAMHS in the NHS The Issues 14.77 This Review has debated at some length where responsibility should lie for child and adolescent mental health. In which service should the NHS components of CAMHS be? It seems sensible that Tier 1 remains a central part of primary care but the challenge is much greater for the specialist NHS services. Some panel members suggested that they should be separated entirely from adult mental health, as part of a discrete and complete children’s health service covering all aspects of child and adolescent health. Others were of the view that as part of a children’s service it would always be a neglected poor relation compared with more publicly appealing subjects. This is an important debate. 14.78 We have encountered the fervent argument that far too much attention can be given to structures, and that this can operate as a severe distraction from good care procedures. Much more important is the principle, described thus in ‘Everybody’s Business’ 171: "Good joint working is the Holy Grail of all attempts to improve delivery of health, education and social services. It is easy to see its vital importance but it is very difficult to achieve." 14.79 We agree with the proposition that the health of children is enhanced by a holistic approach, in which clinicians do not separate the psyche and the soma, the mind and the body. We are encouraged that this conclusion is consistent with the NHS Health Advisory Service view of CAMHS. Many children who come into the CAMHS arena are physically ill, and require clinicians from non-CAMHS areas. Abused children often suffer physical as well as psychological symptoms. There can be no excuse for the failure to give them the treatment they need across the health spectrum. 14.80 If there is to be no separate and total child and adolescent service including CAMHS, effective joint working across therapeutic disciplines must become the norm. Considerable effort is required to develop and maintain good networks that are centred on the needs of young people and work across boundaries. 14.81 This requires expert management. This situation was recognised in ‘Together We Stand’.172 Recently, work has been undertaken in the NHS to develop and test concepts of managed networks of care that are functionally determined around the needs of groups of patients. 14.82 We have concluded that the efficient provision of safe CAMHS services is best achieved without major institutional and structural reorganisation; though some Review Panel members remain of the opinion that CAMHS should be

171 The National Assembly for Wales, 2001, Child and Adolescent Mental Health Services, Everybody’s Business – Strategy Document, Cardiff: The National Assembly for Wales, Page 23, Paragraph 4.3 172 The NHS Health Advisory Service, 1995. Together We Stand - the commissioning, role and management of child and adolescent mental 126 health services. London: HMSO. separated entirely from adult psychiatry into an overall paediatric service. The majority were especially conscious that the pressure of working on structures can impede caring for patients. However, where it has not already occurred (and there are examples of excellent practice in Wales) we are clear in our view that managed clinical networks, in which clinicians and managers from the highest level downwards are committed to a child-centred approach, should achieve functional unity without major reorganisation. All providers should be able to identify the effectiveness of managed clinical networks for young patients, with a particular focus being necessary on those children with CAMHS involvement.

Managed Clinical Networks 14.83 The provision for children with mental illness or mental disorder does not end with CAMHS. Experience in Scotland, where managed clinical networks first emerged as a formal concept, is that they work when they bring together a web of functional relationships required in services for children, including education and social services. The core of the effectiveness of such networks depends upon: • a professional or manager with overall responsibility for the network; • ‘contractual’ agreement by all involved to full participation; • direct involvement of patients, their carers and advocates; • good documentation of the evidence base for combined action; • a demonstrable basis for good quality assurance; and • annual reporting, appraisal and scrutiny. 14.84 The establishment of networks and their management should occur in tandem with current legislation and the connected structural changes. We believe that they could be incorporated into the re-structured NHS after the upcoming structural changes. 14.85 The Review is concerned too that there should be a useful level of investment in clinical management and leadership development. The NHS obtains a proportionate return on its investment in this sphere: it represents value for money, and deserves greater attention. In Chapter 5, we present this conclusion as an important lesson from our review of Gwynfa.

The Mental Health Act 1983 14.86 During our evidence gathering, the Review visited a large independent psychiatric hospital in England accepting Welsh children where we were told that their practice was only to treat children subject to their detention pursuant to the ‘Mental Health Act 1983’. We were told that children could be made subject to this restriction of their liberty for the purpose of securing their admission in accordance with hospital or ward policy. We are concerned by the effect of this apparently blanket policy in the hospital, which could have the effect of further stigmatising some patients by a ‘section’ after they have already suffered the stigmatising effect of abuse leading to psychiatric intervention.

127 14.87 We do not accept that it is a proper use of procedures under the Act to make the kind of requirement described. The provisions of ‘S131(1) of the Mental Health Act 1983’ remind us that nothing in the Act is to be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or mental nursing home in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or mental nursing home in pursuance of such arrangements after he has ceased to be so liable to be detained.173 If hitherto voluntary patients need to be sectioned for any of the purposes envisaged by the 1983 Act, that step is always available. It should not be a pre-requisite and any such practice in any hospital should stop.

Customer Research 14.88 The beneficial development of CAMHS services safe from abuse must be founded upon children’s fundamental and statutory rights, including the legally paramount welfare principle174. To achieve this, the views of children and their families should be sought actively by NHS planners, commissioners and practitioners and incorporated whenever possible into plans and service delivery. This means that there should be a great deal more customer research than previously in CAMHS, and a methodical way of measuring responses. At the very least, all the safeguards that apply to children who are physically sick should apply to those with mental health problems and disorders or learning disabilities. 14.89 ‘Voices in Partnership,’175 a report of a thematic review on involving users and carers in commissioning and delivering mental health services from the NHS Health Advisory Service, provides two typologies of user and carer involvement in service planning and a summary of advice. This statement is well worth re-visiting by current service managers.

Recommendations 14.90 We recommend that detailed appraisals, clinical review and corporate supervision should be developed for all grades of clinical staff working in child and adolescent mental health services. (Paras 14.64, 14.65) 14.91 We recommend that all CAMHS staff should have mentoring services available on demand. (Para 14.65) 14.92 We recommend that the services provided currently by psychological therapists in primary care should be the subject of detailed evaluation, with a view to their being consolidated into CAMHS strategy at Tier 1 while remaining a part of primary care. (Paras 14.36, 14.37, 14.38) 14.93 We recommend the development of managed clinical networks for all young patients, with a particular emphasis on those children with a CAMHS involvement. (Paras 14.82-14.85) 14.94 We recommend that the statutory and non-statutory agencies should plan together with the intention of avoiding unilateral decisions on the remit of particular agencies, avoiding making unwarranted assumptions about the capabilities and spans of responsibility of other relevant organisations and to

173 S131(1) of the Mental Health Act 1983 174 See the Children Act 1989. 175 NHS Health Advisory Service, 1997. Voices in Partnership, ISBN 011 321872 9. London: HMSO. 128 share responsibility for identifying and filling gaps in services between them. (Paras 14.17-14.20) 14.95 We recommend that a multi-disciplinary body accessible to and by the National Assembly should be established to ensure that ‘Everybody’s Business’ is implemented and that the patient-centred, multi-disciplinary approach that it requires is implemented in full. (Para 14.23) 14.96 We recommend that NHS bodies should provide a skills mix for CAMHS patients to meet all expected requirements, and should always be prepared to buy in services from elsewhere to ensure appropriate care. (Paras 14.75, 14.76) 14.97 We recommend that in CAMHS there should be investment in clinical management and leadership development. (Para 14.85) 14.98 We recommend that staff who are not trained in CAMHS should have no involvement with CAMHS patients even when they are in adult wards. (Para 14.41) 14.99 We recommend that staff transferring from adult mental health to CAMHS, and staff working with both adults and CAMHS patients, should undergo additional training including that on child protection issues. (Para 14.74) 14.100We recommend that progress should be made towards providing sufficient secure CAMHS accommodation within Wales for all Welsh patients. (Para 14.45) 14.101 We recommend that CAMHS patients should only be made subject to Mental Health Act 1983 restriction orders when it is strictly necessary for genuine clinical reasons. (Paras 14.86, 14.87) 14.102 We recommend that there should be ongoing and volume consumer research into satisfaction levels with CAMHS services. (Para 14.88)

129 15. AN ABUSE PROOF SERVICE?

15.1 When we started our process members of the Review Panel felt the ambition of attempting to provide the National Assembly with so safe a NHS as to make it proof against abuse was desirable. Having gathered and analysed a large body of evidence, we realise that abuse-proofing can never be achieved: the extremely devious child abuser will inevitably find their way into the health service from time to time. However, we feel confident that there will be a considerably safer service if the bulk of our proposals are adopted. The children of Wales deserve a safer health service than current evidence indicates. 15.2 In making our recommendations we have attempted to attend closely to the recommendations of the Waterhouse Report ‘Lost in Care’,126 which provided the background to our appointment. We have tried too to retain consistency of approach with the many other reports and reviews on connected subjects, some of which are referred to in the body of our Report. Certainly we worked from the foundation of an extensive bibliography. 15.3 We have concluded that, though structures current in 2000/2001 do need to be changed, in future structural change to the NHS should be kept to the necessary minimum to sustain and improve services. The NHS is a complex organisation, apparently the largest organisation in Europe. It is like a great and ancient tree: reorganisation drains sap from the tree, and de-energises healthy growth. The process and consequences of devolution give the government of Wales, through the National Assembly, the opportunity in the present round of legislative and organisational reform to create a structure that can change organically rather than dramatically. If this is a consequence, it will benefit staff and patients alike. The tree will flourish. 15.4 As can be seen in many parts of this Report, we have concluded that devolution to a community of about 3 million people provides an excellent opportunity for improved senior management and direction, greater authority for policy, and increased unanimity of purpose. We venture the possibility that Wales, which demographically is a microcosm of the United Kingdom as a whole, might be seen as pioneering a workable and variable model for a devolved NHS throughout the United Kingdom. 15.5 In the context of children’s safety from abuse, most crucial activity and quality is co-operation. If agencies and practitioners co-operate, whether in separate or united organisations, in the sharing of information and devising of solutions, children will be safer. Every official and practitioner who allows concern for the preservation of their own ‘turf’ to intervene in empirical problem solving of issues around abuse will be failing children personally and inexcusably.

Whistleblowing 15.6 The success of child protection policy within the NHS depends to the greatest extent upon the courage and sense of responsibility of people working within the service. It is glib (but of course true) to say that every person who perceives sexual, physical or emotional child abuse within their own part of the service has a duty to report it. Indeed, in some of the professions it is, and in all should be serious misconduct not to report it. The fear of reporting is

176 Waterhouse R, Clough M, le Fleming M, 2000, Return to an Address of the Honourable the House of Commons dated 15 February 2000 for the Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 130 1974, Lost in Care, HC 201, London: Stationery Office understandable. The example of the experiences of Dr Stephen Bolsin and other whistleblowers in Bristol177 cannot fill the observer with confidence, though we hope that the Bristol report’s recommendations178 on what it describes as sentinel events will provide the impetus to remove the climate of apprehension surrounding whistleblowing. We support the establishment of a national reporting system suggested in that report, the protection from disciplinary action of those making reports promptly, and the incorporation into every NHS trust’s written procedures of clear processes concerning the reporting of sentinel events.

Assembly Responsibilities 15.7 Without repeating all we have said about the National Assembly as the guardian of children’s health, and of the functions it should undertake, in this final chapter we think it worth emphasising its place as the umbrella under which all Welsh public functions shelter. As a representative and executive body, it should ensure that it acts as the diligent and continuing scrutiniser of co-operation between different agencies, including agency to agency reporting of child protection issues and incidents. 15.8 The National Assembly holds too the key responsibility for ensuring and warranting appropriate interaction between sections of the Assembly’s own large civil service. Another important Assembly duty is to provide for clear, preferably concise and fully distributed circulars and other written material to ensure that all relevant NHS staff are fully up to date with child protection knowledge and practice affecting their areas of work. 15.9 Continuous monitoring and audit of all children’s services is essential in updating and improving standards. This could be done using existing audit processes such as the Commission for Health Improvement (CHI) and the Care Standards Inspectorate. Developing links between these inspectorates would help to cover services with multi-agency staff.

Public Understanding 15.10 Another responsibility of the National Assembly is to create an informed public. Those who might be minded to abuse children within the NHS should know of the culture of vigilance against abuse of all kinds. Those who fear abuse or are abused should know that they have somewhere to go, and that their complaints will be attended to efficiently and effectively. The wider public should know of the activity of the National Assembly and all its subsidiary bodies in addressing child abuse, which has become appreciated in the last 20 years as one of the most insidious threats to the development of balanced and healthy adults.

Priorities – "Nothing less than" 15.11 It may well be that those of our recommendations as are accepted and adopted will have to be prioritised. In our view a very high priority should be to the improvement of CAMHS services, which have for too long been a Cinderella in the palace of the NHS. The overall highest priority is a general one - in the context of child protection nothing less than best practice will ever suffice. In our

177 See ‘Learning from Bristol’ generally Kennedy I, Howard R, Jarman B, Maclean M, 2001, Learning from Bristol – the report of the public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 – 1995 CM 5207 (1) . London : The Stationery Office. 178 Ibid, See Page 451, Recommendations 113-118 131 approach to the panoply covered by our Review, all of us involved in child protection issues could do worse than improve practice so that we could justifiably repeat frequently the mantra of the French psychotherapist Coué: "Every day, and in every way, I am getting better and better". 179

Recommendations 15.12 We recommend that whistleblowers in the NHS be protected by the incorporation onto the NHS in Wales of the recommendations on sentinel events made in the report ‘Learning from Bristol’. (Para 15.6) 15.13 We recommend that the National Assembly for Wales should take the necessary organisational measures to ensure that it remains fully accountable on all issues of child protection, including co-operation between and within agencies, and the dissemination of information. (Para 15.7)

179 De la suggestion et de ses applications: Emile Coué (1857-1926). "Tous les jours, à tous points de vue, je vais de mieux en mieux" 132 Carlile Review Recommendations

Putting Children at the Centre 1. We recommend that all staff having access to children should be trained to a full understanding of children’s rights and an appropriate level of awareness of the needs of children, and that they should be required by their employers, as a matter of specific contractual obligation to respect and apply those rights rigorously. (Paras 1.13, 1.14, 1.15, and 1.20) 2. We recommend that there should be competent, independent, trained, accessible, informed and funded children’s advocates available to all children in the NHS. (Para 12.3) 3. We recommend that every NHS establishment should display prominently in foyers, waiting areas and resource areas notices containing information about how to contact a representative selection of crisis and advice organisations and advocacy services. (Paras 4.46 and 12.4) 4. We recommend that all children’s advocates and those running advocacy organisations should be police checked. (Para 12.11) 5. We recommend that advocates should generally be allowed to see children in private, and also to introduce themselves in wards and explain their roles direct to patients and families. (Para 12.15) 6. We recommend that advocacy services should always be made available for children with communication, language or sensory difficulties and disabilities. (Para 12.17) 7. We recommend that sick children should be placed in children’s wards whenever possible. If in adult wards, they should be nursed in a side room and access should be refused to other patients who are not their close relatives. Children should be removed from adult to children’s wards as soon as possible. While on an adult ward children should have the same access to parents, qualified staff and facilities that they should have on a children’s ward. Total management should be overseen by the paediatric team. (Para 13.8) 8. We recommend that the goal of separate adolescent provision from children and adults should be explored by policy makers and considered actively by management in all hospitals. (Para 13.9) 9. We recommend that each hospital in England providing acute facilities for Welsh children should be required to agree a policy for the placement of adolescents. (Para 13.10) 10. We recommend that the National Assembly for Wales should develop a complaint procedure specifically for children and young people and their families, that is accessible and child friendly. (Para 12.20) 11. We recommend that NHS complaints procedures should be strengthened, with each NHS body to identify a senior person with specific responsibility for handling cases of professional abuse. (Para 8.16)

133 12. We recommend that all NHS Trusts and Local Health Boards should appoint a children’s complaints officer to act in the best interests of the child. (Para 12.20) 13. We recommend that commissioners of tertiary services from English providers ensure compliance by those providers with the recommendations of this report. (Para 13.6) 14. We recommend that all the safeguards and standards that apply to children who are physically sick apply to those with mental health problems and disorders or disabilities. (Paras 4.48 and 5.59) 15. We recommend that the Director of the NHS in Wales should take action to secure the same high standards of childcare in all statutory provision regardless of agency and agrees with the Chief Inspector of the Social Services Inspectorate for Wales that the NHS will reduce voluntarily the qualifying period for S 85 to one month irrespective of whether or not young people have weekend leave. (Paras 5.12 and 12.14) 16. We recommend that the National Assembly should produce and disseminate effectively two new NHS ‘children’s charters’, one aimed at parents and the other at the older range of children themselves. (Para 12.16) 17. We recommend that a National Director of Children’s Healthcare Services be appointed for Wales, to promote improvements in clinical healthcare services provided for children. (Para 13.19) Leading From the Front - Strategic Leadership and Management

18. We recommend that a small number of accurate and comprehensive policies and protocols on child protection should be agreed on an All Wales basis as the recognised guide to good practice. These should be reviewed regularly and systematically. They should be disseminated in a routine and efficient way. (Paras 1.09 and 1.22) 19. We recommend that the effect of the devolution of power to Wales, and the increase in democratic accountability consequent upon the creation of the National Assembly, should be taken fully into account in the formation of child protection policy. In the light of this, we recommend that ‘ownership’ of child protection policy should be seen as a national responsibility, though functionally devolved to the different parts of Wales. The reasoning behind policy and the force for its implementation should come from the National Assembly, which should be the foundation upon which robust child protection policies are laid. There should be an audit-capable consistency of approach and delivery at functional level. (Paras 2.20, 2.21 and 2.22) 20. We recommend that the strategic management of child protection in the NHS in Wales should come from the National Assembly. (Para 2.24) 21. We recommend that civil servants implementing the recommendations of this report and any policy connected with child protection should be trained in child protection issues; that the National Assembly’s Child Protection Committee (NACPC) should develop transparent and formal links with the Cabinet Children’s Committee; and that links with Welsh education, social and police services should be a routine part of the consultative processes of all concerned in policy development and implementation in respect of child protection in the NHS. (Paras 2.17 and 2.21) 134 22. We recommend that, following the current round of reform, government policy towards the NHS in Wales should be founded on a presumption against further major change unless it is clearly necessary to improve clinical effectiveness and the safety of patients. (Paras 2.25 and 2.26) 23. We recommend that Local Health Groups and their successor bodies should be required to ensure that all single handed GPs keep up to date on child protection issues through networking with similar practices and joint training initiatives: each practice should be required to provide evidence of child protection procedures. (Para 3.73) 24. We recommend that guidance is issued to the NHS that makes it clear how best to harmonise the procedures on child protection, untoward incidents, clinical governance and discipline in cases of alleged abuse. (Paras 4.38, 4.39 and 4.40) 25. We recommend that the National Assembly for Wales and the NHS should agree a structure and process for managing serious untoward incidents and events and the role that the National Assembly will play. (Paras 4.70, 4.78, 4.79, 4.89, 4.90, 5.30 and 5.62) 26. We recommend that the guidance in ‘Working Together’ should be issued to the NHS under similar statutory provisions to those which apply to the social services departments of local authorities. This may require primary legislation. (Para 4.40) 27. We recommend that systems are set in place for more effective communications across the responsible divisions, branches and sections within the National Assembly for Wales and we commend a client group approach. (Paras 4.67, 4.89 and 5.61) 28. We recommend that procedures for investigating and responding to allegations made by children and their families against NHS staff should be balanced and fair and recognise the differing positions of children and families. Guidance be reviewed on procedures for dealing with complaints against NHS staff relating to children. (Paras 4.90 and 5.60) 29. We recommend that the new lines of accountability between the Director of the NHS in Wales and the NHS should include responsibilities for implementing ‘Everybody’s Business’. (Para 5.30) 30. We recommend that the National Assembly for Wales should review urgently the adequacy in Wales of therapeutic services for sufferers of abuse in the light of the current knowledge, skills and thinking on this topic and encourage the Minister for Health and Social Services to set this as a high priority within the agenda created by the All Wales CAMHS Strategy. (Paras 5.32-5.34) 31. We recommend that, within a year of the publication of this Report, a Welsh national child protection set of documents be produced, containing policies, protocols, standards and publications appropriate to every NHS setting. (Paras 6.4, 6.5 and 6.7) 32. We recommend that every NHS organisation and each local authority should consider urgently ways of improving services to children, taking into account the opportunities offered via the new flexibilities envisaged under the ‘Health Act 1999, section 31’. (Paras 6.20 and 6.21)

135 33. We recommend that, within 6 months of publication of this Report, all designated and named professionals should be allowed protected time to perform their given function. (Para 7.3)

34. We recommend that all designated and named professionals should, for the child protection part of their work, be managed by an All Wales NHS Child Protection Service. This Service should be ultimately accountable to the National Assembly, with a dedicated management group having few competing priorities. There should be a Director of the Service, a consultant in public health medicine. The Director should be required to prepare an annual report on child protection for the National Assembly. (Para 7.7)

35. We recommend that the Director of the All Wales NHS Child Protection Service should chair a group consisting of all the designated professionals in the country, together with co-opted members from outside interests connected with child protection. This group should act as the centre for training initiatives and for information distribution throughout the Welsh NHS. Area groups chaired by designated professionals should follow the same pattern. (Para 7.9)

36. We recommend that named professionals should continue to lead child protection procedures at trust and local health boards level. (Para 7.10)

37. We recommend that in every NHS organisation there should be designated a suitable person to act as liaison with the Children’s Commissioner for Wales. A small amount of protected time should be provided to facilitate this role. (Para 7.13)

38. We recommend that designated professionals should be appointed in each area to take a strategic lead in the provision of health services for looked after children. (Para 8.15)

39. We recommend that the National Assembly should give full support to the development by the new Criminal Records Bureau of a call centre providing in a speedy and efficient way certificates required by NHS employers in Wales. (Paras 11.9 - 11.10)

40. We recommend that all trust and local health boards undertake an annual review of safeguards for children based on an audit of compliance with child protection procedures. This information should be made available to the Director of the All Wales NHS Child Protection Service to identify training needs and assist with monitoring the implementation of the child protection policy in the NHS in Wales. (Para 13.12)

41. We recommend that the National Assembly for Wales should take the necessary organisational measures to ensure that it remains fully accountable on all issues of child protection, including co-operation between and within agencies, and the dissemination of information. (Para 15.7)

42. We recommend that a multi-disciplinary body accessible to and by the National Assembly should be established to ensure that ‘Everybody’s Business’ is implemented and that the patient-centred, multi-disciplinary approach is implemented in full. (Para 14.23)

136 Effective Structures in the NHS – Operational Leadership and Management

43. We recommend that all NHS service providers should develop improved human resources policies that include: systemic methods of investigating allegations of abuse; acceptance by staff and managers of timely and efficient disciplinary procedures (sometimes necessarily including suspension) as the means of investigating abuse and determining whether it has occurred; and the provision of proportionate advice and assistance to accused staff to deal with allegations and hearings. (Para 1.19) 44. We recommend that the NHS should recognise fully the value of the expertise that has been developed by community paediatricians in ensuring the safety of children, and that the target should be for every community in Wales to enjoy a paediatric service in which this expertise is appropriately represented and available. At present, this means that there should be an appropriate balance between hospital and community paediatric and child health services. In the future, if these two branches of paediatrics were brought closer together, the functions required of an integrated paediatric and child health service should be kept under review. Either way, a proper balance of community and hospital based expertise and functions must be maintained and the posts required must be funded. (Para 3.16) 45. We recommend, as already required by DGM(94)26, that there should be a registered children’s nurse on duty at all times in every children’s ward and staff trained and experienced in the care and treatment of children available at all times in accident and emergency departments and minor injuries unit, and in outpatient departments where children are seen. (Para 3.17) 46. We recommend that every NHS Trust should review the provision and development of children’s community nursing services, to reduce hospital admissions and manage continuing care in the home setting. (Paras 3.17-3.21) 47. We recommend community children’s nurse teams be developed as part of the integrated child health services to meet the needs of children who could be managed in the community setting. (Paras 3.17-3.21) 48. We recommend an All Wales strategy to develop managed networks for children’s community nursing to best use resources. (Para 3.21) 49. We recommend that the formal partnership between the Prison Service and the NHS is used to promulgate the improvements in child protection identified in this review. (Paras 3.22-3.23) 50. We recommend that, as refurbishment and new development occur, it should be a design criterion that accident and emergency departments and minor injury units and outpatient departments should have separate entrances, waiting areas and treatment areas for children. At the very least, there should be separate waiting areas. (Para 3.40) 51. We recommend that staff working in accident and emergency and minor injury units are trained to recognise that teenagers presenting with substance misuse or deliberate self harm may be demonstrating underlying illnesses for which they need attention. (Paras 3.43-3.48)

137 52. We recommend that all allied health professionals should be given clear information as to their lines of management and professional direction. (Para 3.52) 53. We recommend that all allied health professionals working in the paediatric field wherever possible have permanently designated paediatric posts and be trained in child protection issues. (Para 3.52) 54. We recommend that all school nurses should be employed within the NHS, and seen clearly as a valued part of the primary care system and the recommendations contained in ‘Recognising the Potential: A Review of Health Visiting and School Health Services in Wales’ should be implemented. (Paras 3.56-3.59) 55. We recommend that every NHS trust should review the provision and management of the school nurse service, with the aim of providing an attractive career structure and a more effective service. (Paras 3.56-3.59) 56. We recommend that NHS organisations should review the public health function of health visitors, to enable them to make a greater contribution to child protection among vulnerable groups in the community. (Para 3.62) 57. We recommend that nurse, midwife and health visitor consultant posts should be created in primary care settings. (Para 3.64) 58. We recommend that, within 6 months of the publication of this Report, every GP practice in Wales should have written basic procedures for dealing with child protection issues; and that there should be a nominated lead practitioner in each practice on child protection issues. (Para 3.74) 59. We recommend that all optometry practices should develop written child protection procedures and relevant training, and that connected aspects of clinical governance should be provided or led by local health boards and as with all other primary care staff they should be police checked before they can work with children. (Para 3.82) 60. We recommend that NHS Direct Wales should always have on duty at least one appropriately qualified person to deal with children’s issues. (Para 3.85) 61. We recommend that an independent procedure should be established to enable just determination of situations in which a teaching institution wishes to exclude a student whom it considers to be of a personality or character unsuited to clinical practice. (Paras 3.89-3.91) 62. We recommend that the Welsh Risk Management Standards are amended to take account of the recommendations of this report. (Para 3.99) 63. We recommend that all clinical directors, managers and operational level leaders should have sufficient protected time away from their continuing professional responsibilities in order that they can be expected to perform their management and leadership duties well. (Para 5.57) 64. We recommend that hospitals have clear policies and procedures setting out the duties placed on employers and staff for ensuring the safety of children in their care when outside NHS premises that balance children’s freedom to leave hospital premises on their own. (Paras 4.38, 4.39, 4.45, 4.48 and 5.10)

138 65. We recommend that the National Assembly for Wales should ensure that the NHS, all agencies responsible for children, educational establishments, and any other bodies responsible for training staff, professional or otherwise, who come into contact with children, issue competent personnel guidance on disciplinary and performance processes and proper recording of them. The advice should include guidance on disclosure of confidential information and of all relevant health records, the timing, thresholds and mechanism of referral to statutory regulatory bodies, and the impact of POCA and the ‘Care Standards Act 2000’. (Paras 4.42, 4.43, 4.58-4.60, 4.76-4.79 and 4.90)

66. We recommend that all NHS bodies (especially Trusts) should appoint professional and legal advisors who are members of the children’s panel and who are familiar with the children’s services that the NHS body provides. They should advise and train the board and subordinate managers and practitioners on lawful and appropriate delivery of care and treatment of children. (Paras 5.51 - 5.52)

67. We recommend that measures be taken to avoid isolation of the child and adolescent mental health services and particularly of day care and inpatient units. (Paras 5.65-5.75). They should include ensuring that :

a. Each unit is linked to a network of outpatient services in the area it serves (notwithstanding the requirement of the All Wales CAMHS Strategy that these services should be commissioned on an All Wales basis with which we wholly concur);

b. All senior staff of all disciplines in day and inpatient units should have duties elsewhere that take them away from the unit for a part of each week;

c. Some staff whose duties are primarily elsewhere should have part-time duties in inpatient units;

d. No consultant works as the sole consultant to a specialised unit;

e. There is a consultant in clinical charge for each unit who has clear contractual requirements for explicit leadership and managerial responsibilities that pertain to his or her post;

f. The appointment of consultant in clinical charge should be rotated between two or more consultants over a period of years in a way that balances stability with openness to new ideas and new emphases;

g. Professional mentoring and supervision are available;

h. Every member of staff has a personal development plan, funded CPD and is appraised annually; and

i. Non-executive directors and directors of the professions as well as responsible directorate and trust board level managers make regular and purposeful thematic visits.

68. We recommend that the standards for nursing should include appropriate levels of nurse provision on paediatric and children’s psychiatric units and clear recommendations on how nursing staff should be led and managed. (Para 5.68)

139 69. We recommend that all agencies must be enabled to discharge their statutory responsibilities through receiving inputs from other agencies. This is likely to require enhanced support to SSDs and LEAs from primary and secondary health care services and vice versa. (Para 6.11)

70. We recommend that all units in the NHS should have management arrangements in which who is in charge and the lines of communication between the person in charge and their superior managers and subordinates are clear. (Para 5.79)

71. We recommend that re-appointment into designated professionals’ posts should be an exception to the embargo on new Health Authority appointments between now and April 2003. (Para 7.3)

72. We recommend that all existing NHS staff in Wales whose work brings them into contact with children should be police checked as soon as is compatible with the establishment and development of the Criminal Records Bureau. (Para 11.12)

73. We recommend that, in the interval before the new CRB system is in place, attention be directed by employers in the NHS and the universities to resolving the most evident irregularities and inconsistencies in the present system. (Para 11.12)

74. We recommend that the standards advocated by the Association for the Welfare of Children in Hospital are audited in every hospital on a regular basis. (Para 13.12)

75. We recommend that consideration should be given to a pilot project in Cardiff whereby the children’s services of the University Hospital would take over the running of children’s acute and community services throughout the Cardiff city and county area, building on the example of the Philadelphia Children’s Hospital in the USA. (Para 13.17)

76. We recommend that clinician managers should be able to prove their competence to manage, and should be given protected time for allocated sessions to carry out their managerial role. (Para 13.19)

77. We recommend that NHS bodies should attempt to provide a skills mix for CAMHS patients to meet all expected requirements, and should always be prepared to buy in services from elsewhere to ensure appropriate care. (Paras 14.75 - 14.76) People Principles - Recruitment and Selection

78. We recommend that where agency nursing staff are employed, they should be suited to purpose and fully insured to carry out all role appropriate functions. (Para 3.24)

79. We recommend that all NHS employers should place especially stringent contractual terms on employment agencies for the quality assurance of locum doctors. (Para 3.32)

80. We recommend that no locum doctor should start work without a full and proper check having been carried out on his/her references, in accordance with good human resources practice. (Para 3.31)

140 81. We recommend that before staff recruited directly from abroad are placed in jobs with unsupervised access to children they should have completed at least a 6 months’ continuous probationary period with the same UK employer, and should have been fully trained and counselled on the importance of child protection and child protection measures. (Para 3.37) 82. We recommend that the reasons for taking any disciplinary proceedings; the nature of the proceedings and the outcome of the proceedings should always be clearly noted on the personnel file of the individual. (Para 4.60) 83. We recommend that in every part of the NHS, whether for clinical staff or others, rigorous recruitment procedures based on sound human resources practice should be followed. (Para 10.3) 84. We recommend that employment practices consistent with ‘Choosing with Care’ should be applied universally in the NHS. (Paras 10.11 - 10.12) 85. We recommend that for the employment of staff from abroad wherever possible attempts should always be made to follow the same recruitment procedures as for UK staff. (Para 10.20) 86. We recommend that appointments in the NHS or contractor professions offering NHS services should only be offered after the completion of police, professional and personal checks, and that no staff should be allowed unsupervised access to children before completion of all checks. (Para 11.4) 87. We recommend that every NHS employer should designate an officer at senior management level who will make decisions about whether an appointment should be made in cases where a previous conviction or other relevant information is disclosed following a Criminal Records check. The reasons for any such decision should be clearly recorded. (Para 11.4) 88. We recommend that measures be taken to secure a sufficient number of paediatricians to meet the needs of Welsh children, so that paediatric medicine can function without a ‘ration’ mentality. (Paras 3.14 - 3.15) 89. We recommend that the employment of play specialists should be developed widely, and that they be supported in their training and their qualifications be duly acknowledged. (Para 3.55) 90. We recommend that it should be the invariable practice for written references to be followed up by telephone conversations with referees. (Para 10.9) 91. We recommend that giving a misleading reference should be regarded as a serious breach of discipline. (Para 10.10) 92. We recommend that every NHS employer should have designated appointment officers above the level of appointees, to ensure that correct recruitment policies have been followed in each case. (Para 11.4) People Principles - Education and Training

93. We recommend that urgent measures be pursued to increase college places for registered children’s nurses including the encouragement of mature nurses to develop their skills and opportunities through such training. (Para 3.10)

141 94. We recommend that the ability to recognise the signs of sexual, physical and emotional child abuse should form part of the mandatory and continuing training of all staff having contact with children. (Para 3.12) 95. We recommend that career pathways for registered children’s nurses should be appropriate to care for children in the community and school settings. (Paras 3.17-3.21, 3.56-3.59) 96. We recommend that radiologists and radiographers who deal with children should be trained in child protection issues. (Para 3.53) 97. We recommend that there should be a child protection component in GP training, and that continuing professional development co-ordinators should bring greater focus to bear on child protection. (Para 3.75) 98. We recommend that all GPs out of hour’s services have written child protection protocols and provide training for their staff on this issue. (Para 3.88) 99. We recommend that prospective training programmes be established for any staff in the NHS Directorate in the Assembly who are likely to deal with abuse. (Paras 4.68, 4.81 and 5.34) 100. We recommend that induction training for all NHS staff should include a suitably tailored child protection component. (Para 10.21) 101. We recommend that local health boards should lead self-financing training sessions for taxi and minibus drivers from the private sector used to transport children for NHS purposes. (Paras 3.92-3.93) 102. We recommend that all relevant organisations should review the training, supervision and support of all staff who deal with sensitive and potentially traumatic material. (Paras 4.68, 4.81 and 5.34) 103. We recommend that the standards for training and managing nurses developed by the All Wales CAMHS Nursing Forum be used as the basis for seeking agreed UK-wide training standards for nurses working in CAMHS. (Paras 5.46 - 5.47) 104. We recommend that all clinical directors, managers and operational level leaders should have leadership and management training and a requirement to undertake CPD in these areas. (Paras 5.53, 5.55-5.58) 105. We recommend that all board members of NHS organisations should receive child protection training; and that both executive and non-executive members of the boards of NHS bodies should hold responsibility for child protection issues, with regular reporting to the full board as part of their function. (Paras 10.22 - 10.24) 106. We recommend that staff should be encouraged to obtain further qualifications, and to receive continuing leadership and management development. (Para 10.26) 107. We recommend that staff should be trained in the ‘one up two down’ principle, to ensure deeper knowledge of the areas in which they are employed, and better and more flexible skills. (Para 10.26)

142 108. We recommend that staff transferring from adult mental health to CAMHS, and staff working with both adults and CAMHS patients, should undergo additional training including that on child protection issues. (Para 14.74)

Achieving and Maintaining Standards – Clinical Practice and Delivery

109. We recommend that postmortem examinations of children should be conducted by paediatric pathologists and should take place as near as possible to the place where death has occurred or been certified. We recommend that where possible the Paediatric Pathologist should obtain a full clinical history from a Consultant Paediatrician before confirming the cause of death. All parents should be fully informed at all stages and in detail of the postmortem procedures that are being followed including the removal and examination of organs. (Para 3.49)

110. We recommend that it should be the practice in radiology areas for parents to remain with their children to the greatest extent possible. (Para 3.49)

111. We recommend that a consistent set of policies should be developed on the funding of trained interpreters independent of the clients for ethnic minority communities. (Para 3.66)

112. We recommend the provision of increased payments to enable GPs to attend case conferences, and the timing and location of case conferences should be more sensitive to the particular circumstances of GPs; and that at the very least it should be mandatory to send a report. (Para 3.71)

113. We recommend that NHS Direct Wales should be enabled to gain access to local authority child protection registers. (Para 3.86)

114. We recommend that all working in the field of child protection recognise that the degree of confidentiality in each case should be governed by the need to protect the child, so that all professionals dealing with the educational, social and health needs of a suspected victim of abuse should have reasonable access to relevant information. (Paras 6.29 - 6.30)

115. We recommend that, subject to secure password safeguards, accident and emergency outpatient and minor injury units staff should be able to gain access to local authority child protection registers; and that social services should on reasonable request be given access to the relevant parts of a child’s health records provided that disclosure is for the protection of the child’s physical or mental health. (Para 6.30)

116. We recommend that it is essential that looked after children can be identified by the NHS, wherever they are. (Para 8.8)

117. We recommend that there should be specific training in the needs of looked after children for all interested professional groups such as teachers and health professionals, and school governors. (Para 8.8)

118. We recommend that priority should be given to improving access to good quality healthcare for the most socially excluded groups of children, including asylum seekers and children from black and ethnic minority communities. (Para 8.10)

143 119. We recommend that inspection arrangements between different types of establishment should be rationalised, to produce more consistent standards. (Para 8.14) 120. We recommend that standard clinical indicators should be further developed for looked after children, together with a co-ordinated approach to the collation of information. (Para 8.18) 121. We recommend that the arrangements for healthcare at the Hillside Unit and any other non-NHS secure unit opened in Wales should include direct access to secondary psychiatric, psychological and paediatric services. (Paras 8.22 - 8.23) 122. We recommend that the potential use of a single system or compatible data systems capable of acquiring, exchanging and sharing information between the NHS and local authority social services departments should be explored. The development of an all Wales health and child protection database would be in the interests of children. (Paras 9.15 - 9.16) 123. We recommend that the statutory and non-statutory agencies should plan together with the intention of avoiding unilateral decision on the remit of particular agencies, avoiding making unwarranted assumptions about the capabilities and spans of responsibility of other relevant organisations and to share responsibility for identifying and filling gaps in services between them. (Paras 14.17-14.20) 124. We recommend that progress should be made towards providing sufficient secure CAMHS accommodation within Wales for all Welsh patients. (Para 14.45) 125. We recommend that detailed appraisals, clinical review and corporate supervision should be developed for all grades of clinical staff working in child and adolescent mental health services. (Paras 14.64 - 14.65) 126. We recommend that staff who are not trained in CAMHS should have no involvement with CAMHS patients even when they are in adult wards. (Para 14.41) 127. We recommend that all CAMHS staff should have mentoring services available on demand. (Para 14.65) 128. We recommend that the services provided currently by psychological therapists in primary care should be the subject of detailed evaluation, with a view to their being consolidated into CAMHS strategy at Tier 1 while remaining a part of primary care. (Paras 14.36, 14.37 - 14.38) 129. We recommend the development of managed clinical networks for all young patients, with a particular emphasis on those children with a CAMHS involvement. (Paras 14.82-14.85) 130. We recommend that CAMHS patients should only be made subject to Mental Health Act 1983 restriction orders when it is strictly necessary for genuine clinical reasons. (Paras 14.86 - 14.87)

144 Making the Difference – Quality counts for the Safety of the Child - Continuous Quality Improvement

131. We recommend that local health boards should monitor the performance of GPs in relation to child protection as an element of clinical governance. (Para 3.74) 132. We recommend that the General Medical Council should consider amending ‘Good Medical Practice’ by adding a separate section reminding doctors of the need to inform themselves of child protection issues as a prerequisite of competent practice. We recommend the General Dental Council to consider taking corresponding steps. (Para 3.77) 133. We recommend that GPs and general dental practitioners who fail to introduce sufficient arrangements to deal with child protection issues should be regarded by their registration bodies as failing appropriate tests of good performance. (Para 3.80) 134. We recommend the UKCC and its successor review the current information for employers and managers and to give consideration to how it receives evidence from children in their processes for conducting investigations and hearings relating to professional conduct in cases of alleged child abuse. (Paras 4.73-4.75) 135. We recommend that the Care Standards Inspectorate for Wales should be given responsibility for regulating and inspecting all NHS inpatient child and adolescent mental health units following the same principles as those for the regulation of residential child care facilities. (Para 5.81) 136. We recommend that registration bodies should include with registration information details of all adverse disciplinary findings recorded by them. (Para 10.14) 137. We recommend that critical incident recording should be enhanced; and that tape-recording facilities should be made available to enable those with parental responsibility, advocates and Gillick competent children to make a recording of a discussion with a healthcare professional when a serious complaint is being discussed. (Para 12.18) 138. We recommend that provision should be made for staff to obtain separate legal advice independent of management where issues surrounding abuse are made, in the absence of such advice being available via trade unions and professional bodies. (Para 12.19) 139. We recommend that legal advisers to management should only be engaged once the organisation has satisfied itself that they have the knowledge and expertise to deal with child protection issues as they arise. (Para 12.19) 140. We recommend that in CAMHS there should be investment in clinical management and leadership development. (Para 14.85) 141. We recommend that whistleblowers in the NHS be protected by the incorporation onto the NHS in Wales of the recommendations on sentinel events made in the report ‘Learning from Bristol’. (Para 15.6)

145 142. We recommend that there should be ongoing and volume consumer research into satisfaction levels with CAMHS services (Para 14.88) Sharing Information to Achieve Outcome

143. We recommend that information concerning child protection issues should become readily available to GPs via the Internet. (Para 3.74) 144. We recommend that all NHS Trusts and other healthcare providers should have robust but realistic mechanisms for recording and learning from untoward events that are sensitive to the needs and circumstances of children and young people and open to audit. (Paras 5.59-5.64) 145. We recommend that the National Assembly for Wales should review its methods of transmission of important guidance and agrees with the NHS a timescale, the resources and training required for implementation and feedback pathways in each instance. (Para 4.41) 146. We recommend that the quality and information for children in need contained in medical records be improved, with a view to the emergence of a ‘virtual clinic’ to develop a personal health record unifying all health information. This would be especially valuable for looked after children. (Para 8.17) 147. We recommend that the National Assembly’s proposed National Plan for Information Management and Technology takes further account of the recommendations of this report. (Para 9.8) 148. We recommend that the previously recommended development of a NHS data set forming an electronic health record at primary care level be expedited; and the development of a Welsh data set, in which primary health care records could be linked with local authority held child protection information. (Paras 9.3 - 9.4) 149. We recommend that all potential contributors of child protection data should receive training in the creation and analysis of such data. (Para 9.9) 150. We recommend that a study is conducted with all interested agencies into the feasibility of establishing a residential therapeutic facility for mothers and babies in Wales. (Para 13.15)

146 Annex 1 Panel Membership

Lord Carlile of Berriew Alex Carlile QC, Review Chair Mr Timothy Brown Director of Social Services, Powys County Council Miss Marion Bull Retired Chief Nursing Officer, Welsh Office Professor Roger Clough Professor of Social Care, Lancaster University Mrs Caroline Crimp Chair, The Association for the Welfare of Children in Hospital Professor D P Davies Professor of Paediatrics and Child Health, University Hospital of Wales, College of Medicine Mrs Jayne Dulson Director of Care Services, Ty Hafan Children’s Hospice Ms Carol Floris Support and Advice Manager, Voices from Care Mrs Julie Harvey Superintendent Paediatric Physiotherapist, Bro Morgannwg NHS Trust Dr Kamila Hawthorne General Practitioner, Cardiff Ms Ruth Henke Barrister, specialising in family and child care law (Counsel to the Review) Mrs Joyce Hughes Designated Nurse, Child Protection, North Wales Health Authority Mrs Anne Mills Senior Nurse Child Health, Cardiff & Vale NHS Trust Dr Heather Payne Senior Lecturer in Child Health, University of Wales, College of Medicine & Consultant Paediatrician in Child Health for Caerphilly Dr Quentin Sandifer Director of Public Health, Iechyd Morgannwg Health Authority Ms Alison Sparrow Children’s Services Manager, Gwent Healthcare NHS Trust Mrs Greta Thomas Head of Children’s Services, National Society for the Prevention of Cruelty to Children, Cymru Wales Mr Ray White Retired Chief Constable of Dyfed Powys Police Mrs Ann Williams Head of Children’s Social Care and Housing, Carmarthenshire County Council Mrs Catriona Williams Chief Executive of Children in Wales Dr Hywel Williams Consultant Paediatrician, Designated Doctor, Child Protection, Bro Taf Health Authority Mrs Jan Williams Chief Executive, Bro Taf Health Authority

147 Annex 1 Professor Richard Williams Professor of Mental Health Strategy, University of Glamorgan and Consultant Child and Adolescent Psychiatrist in the Gwent Healthcare NHS Trust Dr John Wynn-Jones General Practitioner, Montgomery, Director of the Institute of Rural Health

National Assembly for Wales Professional Advisors Dr Jane Ludlow Senior Medical Officer Mrs Heather Wood Nursing Officer

Secretariat Mr Peter Lawler Family Health Branch, NHS Directorate, The National Assembly for Wales Mrs Megan Hutchings Family Health Branch, NHS Directorate, The National Assembly for Wales Mrs Claire Bond Family Health Branch, NHS Directorate, The National Assembly for Wales Administrative Support Mr Neil James Family Health Branch, NHS Directorate, The National Assembly for Wales

148 Annex 2 Terms of Reference

1. To undertake a review of the arrangements for the care and safety of children and young people under the age of 18 who are treated by and cared for by the NHS where this care and treatment is either provided by or contracted by the NHS in Wales; the review to consider the whole spectrum of NHS care from primary health care and community NHS services through to specialist children’s units. 2. Taking account of the HAS 2000 review of standards and safeguards for inpatient CAMHS units in Wales (July 2000), findings of the Report of the Tribunal of Inquiry into the abuse of children in care in the former counties of Gwynedd and Clwyd ‘Lost in Care’, relevant guidance and best practice and other developments, to consider and make recommendations on: 2.1 Regulation and monitoring of safeguards and standards of care for children and young people treated by and cared for by the NHS (whether on children’s wards, in CAMHS units, in adult wards or as out patients or treated by primary health care or community NHS services). 2.2 Responsibility and accountability of managers of Health Authorities and NHS Trusts in Wales, up to and including Board level for the care and safety of children and young people (including responsibility for children in need, children looked after by the local authority and child protection). 2.3 Application of the conclusions and recommendations of the Report of the Tribunal of Inquiry ‘Lost in Care’ for the care and safety of children and young people cared for or treated by the NHS. 2.4 Handling of allegations of abuse of children or young people. 2.5 The role of the National Assembly for Wales including data-collection, monitoring, and resourcing of and guidance on children’s health services. 2.6 The need for improved NHS staff training and qualifications in childcare and child protection. 2.7 Interagency and inter-professional issues for the NHS in dealing with children. 2.8 Changes to secondary legislation and representations to Central Government regarding changes to primary legislation. 2.9 The review will report to the Assembly Secretary for Health and Social Services by end 2001.

149 Annex 3 Guidance Issued to the NHS in Wales in Respect of Child Protection

1971 WOC 71/100 Hospital Facilities for Children 1971 1976 WHC (76)11 Health Service Development 1976 WOC 63/76 Non-Accidental Injury to Children 1976 WOC 82/76 Non-Accidental Injury to Children 1976 WOC 80/76 Non-Accidental Injury to Children: 1976 Area Review Committees WOC 95/76 Health Services Development, 1976 Social Services Development, Educational Services Development WHC(76)32 Health Services Management: 1976 the Management of Violent, or potentially violent, hospital patients WOC 173/76 Non-Accidental Injury to Children: 1976 The Police and Case Conferences 1977 WHC(77)20 All Wales Policies and Priorities for the planning, 1977 and Social Services from 1976/77 to 1980/81 1978 WOC 120/78 Children in hospital: Maintenance 1978 of family links WHC (78)29 WHC (78)41 Health Service Development: Major Aspects 1978 of guidance on children in hospital’ 1988 WHC (88)10 Protection of Children: Disclosure of criminal 1988 background of those who have access to children WOC 26/88 Working Together for the Protection of 1988 Children from Abuse CMO (88)18 Guidance for the medical profession on the 1988 diagnosis of child sexual abuse WOC 25/88 Child Abuse 1988 1989 Mental Illness Services: A Strategy for Wales 1989 (Welsh Office)

150 Annex 3

1990 WOC 37/90 Child Protection 1990 1991 WOC 59/91 Working Together: Revised Edition 1991 WHC (91)97 The Welfare of Children and Young People 1991 in Hospital 1992 WHC (92)5 NHS Trusts and Integrated Care 1992 1993 WOC 54/93 Protection of Children: Disclosure of Criminal 1993 Background of those with Access to Children Choosing with Care - The Report of the 1993 Committee of Inquiry into the selection, Development and Management of Staff in Children’s Homes The Welsh Language Act (HMSO) 1993 A Guide to Consent for Examination or 1993 Treatment (Welsh Office) Protocol for investment in Health Gain: 1993 Mental Health (Welsh Office) 1994 ‘Seen but not heard’ Co-ordinating Community 1994 Child Health and Social Services for Children in need. CNO (94)3 The Allitt Inquiry: The Independent inquiry 1994 relating to the deaths and injuries on the children’s ward at Grantham and Kesteven Hospital during the period February to April 1991’ DGM (94)26 Report of the Independent inquiry relating to 1994 deaths and injuries on the children’s ward at Grantham and Kesteven General Hospital during the period February to April 1991 (The Allitt Inquiry) WOC 11/94 Plans for Children’s services: Second Phase 1994 of Warner Report Implementation WHC (94) 61 Protection of Children: Disclosure to NHS 1994 Employers of Criminal Background of those with access to children Caring for the future (NHS Cymru Wales: N/A Welsh Office Central Office of Information) WOC (94) 57 The Education of sick children 1994

151 Annex 3

1995 WHC (95)17 WOC 16/95 NHS Responsibilities for meeting the 1995 continuing Health Care needs WHC (95)38 NHS Responsibilities for meeting continuing 1995 health care needs WOC 47/95 Arrangements for reviewing decisions on 1995 eligibility for NHS continuing inpatient Care WOC 51/95 Joint Working in Health and Social Service 1995 Checklist for Health and Local Authorities WOC 52/95 Protecting Children from Abuse: The role of 1995 the Education Service WOC 54/95 Drug Misuse: Prevention and Schools 1995

WOC 60/95 Clarification of Arrangements between the 1995 WHC (95)59 NHS and other Agencies 1996 WOC 19/96 Guidance on the care of people in the 1996 community with a mental illness WHC (96)26 WOC 20/96 Plans for Children’s Services: Further Guidance 1996 WOC 35/96 Child Care Procedures and Practice in 1996 North Wales: Implementation of the Report of Ms Adrienne Jones Forward Together: A Strategy to combat 1996 Drug & Alcohol Misuse (Welsh Office Central Office of Information May 1996) Patient’s Charter: Services for Children and 1996 Young People(Welsh Office) 1997 WOC 46/97 Guidance to Hospital Managers and Local 1997 Authority Social Services Departments on the Sex Offenders Act 1997 WOC 56/97 Police Checks on Staff Working in Registered 1997 Private Children’s Homes and Small Unregisterable Children’s Homes DGM (97)70 Policies and Priorities for NHS Wales 1997 for 1998-1991 The Health of Children in Wales 1997 1998 DGM (98)30 Reporting Untoward Incidents 1998

152 Annex 3

WOC 37/98 Education Act 1996 – The Use of Reasonable 1998 Force to control or restrain Pupils Child and Adolescent Mental Health Services 1998 Residential Units in Wales: A Review of Safeguards and Standards of Care Five Welsh Health Authorities’ Six 1998 Monthly Progress Reports: The Health of Children in Wales (Welsh Office) Working Together – The report of the Joint 1998 Working party on Medical Services for Children (Welsh Office) 1999 WHC (99)48 Guidance on Joint NHS and Social Services 1999 Priorities for 1999-2000 WHC (99)38 Children’s Safeguards Review 1999 ‘Choosing with Care’ WHC (99)70 The Children First Programme in Wales: 1999 Transforming Children’s Services NAWC 10/99 Leaving Care: The Government’s Response 1999 to the Children’s Safeguard Review NAWC 11/99 Guidance to Local Authority Social Services 1999 Departments on visits by Children to Special Hospitals Child and Adolescent Mental Health Services 1999 Residential Units in Wales: A Report of Compliance visits 2000 Child and Adolescent Mental Health Services 2000 Residential Units Wales: A Review of Safeguards and Standards of Care Follow up Inspection Flexibilities for joint working between 2000 Health and Local Government Working Together to Safeguard Children under 2000 the 1989 Children Act – 1989: a guide to arrangements for inter-agency co-operation for the protection of children from abuse Working Together to Safeguard Children 2000 2000 Waterhouse ‘Lost in Care’ February 2000 2000 2001 All Wales Strategy for CAMHS 2001 ‘Everybody’s Business’ 153 Annex 4 Children’s Commissioner for Wales Initial Functions under the Care Standards Act 2000 1. The Commissioner’s statutory office, appointment and initial functions were established under Part V of the Care Standards Act 2000. They extend to all of the social care services regulated or to be regulated by the Act ie. children’s homes, residential family centres, local authority fostering and adoption services, fostering agencies, voluntary adoption agencies, domiciliary care, private and voluntary hospitals/clinics, the welfare aspects of day-care and childminding services for all children under the age of eight, and the welfare of children living away from home in boarding schools. 2. The functions include: • the review and monitoring of arrangements for dealing with complaints, whistleblowing and advocacy; • the examination of the cases of particular children; • the provision of assistance, including financial assistance, and representation, in respect of proceedings or disputes or in relation to the operation of procedures and arrangements monitored by the Commissioner; • the provision of advice and information; • making reports, including an annual report on the exercise of his functions to the National Assembly; and • the power to require the provision of information and the disclosure of documents.

New and extended functions under the Children’s Commissioner for Wales Act 2001 3. The 2001 Act amends Part V of the Care Standards Act 2000 by introducing new functions and extending his existing functions. 4. The 2001 Act: • provides that the principal aim of the Commissioner in exercising his functions is to safeguard and promote the rights and welfare of children; • confers on the Commissioner a power to consider, and make representations to the Assembly about, any matter affecting the rights or welfare of children in Wales. (This means the Commissioner will have a statutory role in matters that do not lie within the functional fields devolved to the Assembly); • confers on the Commissioner a new power to review the effect on children in Wales of any existing or proposed legislation of the Assembly, or of any other function of the Assembly or a public person exercising statutory functions or providing statutory services in Wales in a functional area devolved to the Assembly. It is this power to review the effect of policies and delivery of services across the board that is expected to support the bulk of the Commissioner’s activity; • extends the Commissioner’s functions under the Care Standards Act to a wide range of public bodies operating in Wales, including the Assembly, who have statutory functions or provide statutory services relating to functional fields devolved to the Assembly. 154 Annex 5 National Assembly Child Protection Committee (NACPC) Terms of Reference

1. The NACPC should have general oversight of the National Assembly’s child protection policies and of its relations with child protection agencies. 2. The NACPC should include representatives from the Child Protection and Placements team (Chair and secretariat), Social Services Inspectorate for Wales, Health Professional Group, Nursing Division, Pupil Support Division, Office of Her Majesty’s Chief Inspector and Primary and Community Health Division. 3. The NACPC should meet approximately 8 times per year (every 6 weeks or so). 4. The NACPC should draw up a statement of Assembly policy. 5. To assist officials in their consideration of Area Child Protection Committee (ACPC) case reviews and business plans, the NACPC should develop internal guidelines that would permit members to handle them in a rational and coherent way. 6. The NACPC should host development events for all ACPC members. Events should focus on cross-agency issues and areas where the ACPC has to take the lead. There should be at least one such Assembly-led event each year.

155 Annex 6 Gwynfa Sub Group – Terms of Reference Sub Group’s Working Methods

Terms of Reference 1.1. The group will: a. identify ways in which child protection procedures then in force may have failed to protect children who were patients at Gwynfa; b. identify the child protection issues and associated matters that arise from any failures at Gwynfa; c. use the issues so identified to make recommendations to the full Carlile Review panel. 1.2. In particular, in order to fulfil that task the group will consider the following issues with a view to deriving benefit for the future protection of children and young people in the NHS in Wales: a. allegations made by former patients at Gwynfa (whether those allegations were made in writing or orally); b. the practice of professional and other staff who worked at Gwynfa; c. management of the service provided at and for Gwynfa; d. the interaction of the NHS and other relevant organisations, in relation to the management of Gwynfa and in connection with child protection issues; e. the actions, inaction and omissions of the Welsh Office, Health Authority and NHS Trust in relation to the management of Gwynfa and in connection with child protection issues. 1.3. In the course of considering the matters listed above, the group will identify any other relevant matter of fact or procedure that remains unresolved and in the views of the sub-group ought to be answered. 1.4. The group will not decide the credibility or otherwise of any specific allegations, nor will it seek to attribute blame or criticism to individuals. Judgements of that nature would be inappropriate to this type of procedure, which is a policy review.

Oral Evidence 1.5. The group took oral evidence during June and July 2001. Table 1 lists the people interviewed by the group.

156 Annex 6 Table 1

Name Appointment Mr Peter Gregory Director of the Welsh Office and the National Assembly for Wales Health Department from 1994 to 2000. Mrs Clare Lines Former secondee from the NHS to a post as a branch head within the Welsh Office and now a manager within the Specialist Commission for Health Services in Wales. Mr Gren Kershaw Chief Executive of Conwy and Denbighshire NHS Trust. Has had management responsibility for Gwynfa since 1999. Mr Ian Stead Director of Human Resources for Conwy and Denbighshire NHS Trust.

(seen together with Mr Kershaw) Mr Laurie Wood Previously general manager of the unit responsible for Gwynfa when a directly managed unit of the Clwyd Health Authority in a variety of formats from 1986 to 1993 and the former Chief Executive of the former Clwydian Community Care NHS Trust which managed Gwynfa from 1993 to 1999. Dr Peter Higson A variety of managerial appointments in the DMUs that were responsible for Gwynfa, was Director of Operations in the Clwydian Community Care NHS Trust and is now a Director of the North Wales Health Authority. Mrs Irene Train Appointed Director of Nursing Services, Community North in 1983 until 1990 when became Divisional Manager of the Combined Mental Health Unit of the Clwyd Health Authority.

Author of report following an internal inquiry into allegations made in respect of Gwynfa dated 1996.

157 Annex 7 Managerial Responsibility for Gwynfa 1974 – 2001

Dates Name of Health Authorities Name of Responsible NHS Responsible or Major Providing Body Commissioners of Services 1961-1974 Denbigh and Conwy Hospital Management Committee 1974-1982 Clwyd Area Health Authority Clwyd North District 1982-1985 Clwyd Health Authority Community North Unit (a directly managed unit [DMU] of the Clwyd Health Authority) 1985-1990 Clwyd Health Authority Mental Health Unit (a DMU of the Clwyd Health Authority) 1990-1993 Clwyd Health Authority Community and Mental Health Unit (a DMU of the Clwyd Health Authority) 1993-1996 Clwyd Health Authority Clwydian Community Care NHS Trust Gwynedd Health Authority 1996-1999 North Wales Health Authority Clwydian Community Care (formed by fusion of the 2 health NHS Trust authorities and 2 family health services authorities in North Wales) 1999-present North Wales Health Authority Conwy and Denbighshire NHS Trust

158 Annex 8 Caldicott in Context

Preamble & Summary 1. The basic tenet of this annex is that there is nothing within the Caldicott report, the Data Protection Act 1998 or the Human Rights Act 1998 which should prevent the justifiable and lawful exchange of information for the protection of children or the detection or prevention of serious crime. 2. The issue of interagency disclosure of information in the best interest of children who are in need but not at risk is not so clear-cut. However provided the disclosure is in accordance with the guidance given by the Department of Health (DoH) in ‘The Protection and Use of Patient Information’ and is disclosed in the controlled manner recommended in the Caldicott Report, there is no reason why it should not occur. 3. The Caldicott report must be read within the context of its own remit, previous guidance from the DoH and subsequent statutes. Its purpose was to provide a mechanism for the controlled dissemination of information. It should not be used as a barrier to the controlled sharing of information. 4. It is of note that the recommendations in Caldicott are to apply not only to the NHS but that they are to be implemented by all councils with social services responsibilities. It was anticipated that at least in England all councils with social services responsibilities should have appointed a Caldicott Guardian by 1st September 2001. The ultimate aim is to have an ‘Information Governance Framework’ in both the health service and in social service departments. If the frameworks are compatible access to information will be regulated but simple.

The Relevant Guidance, Reports and Statutes DoH Guidance "The Protection and Use of Patient Information"- 7th March 1996 5. On 7th March 1996 the Department of Health issued guidance entitled ‘The Protection and Use of Patient Information’. The guidance was based on: i. the patients’ expectation that information about them will be treated as confidential; and ii. the importance of making patients fully aware that NHS staff and sometimes staff of other agencies need to have strictly controlled access to such information, anonymised wherever possible180. 6. The guidance took into account the prospective implementation of the EC Directive on Data Protection (actually adopted into UK legislation by Data Protection Act 1998)181. The guidance considered that the Directive reflected many of the practices already established in the NHS and confirmed in the guidance182. 7. The basic principle of the guidance was that: "In general – and in all walks of life – any personal information given or received in confidence for one purpose may not be used for a different purpose or passed to anyone else without the consent of the provider of the information. This duty

180 Para 1.1 181 Data Protection Act 1984 already in force 182 Para 1.6 159 Annex 8 of confidence is long established at common law, but with proper safeguards, need not be construed so rigidly that, when applied to the NHS or related services, there is a risk of its operating to a patient’s disadvantage or that of the public generally. Indeed as a number of inquiry reports have shown, the prompt flow of accurate information in sensitive areas such as mental health and child care can often be for the benefit and safety of all concerned."183 8. The guidance summarised the circumstances in which information could be passed on. They are : a. with the patient’s consent for a particular purpose; b. on a ‘need to know’ basis for NHS purposes either where the information is needed for the patient’s care and treatment or where it is needed for specific general health purposes within the NHS eg clinical audit; managing and planning services; teaching; health service research etc.; c. the information is required by statute184 or court order; d. when it can be justified for other reasons such as the protection of the public. 9. In Chapter 4 of the guidance headed ‘Safeguarding Information Required for the NHS and Related Purposes’, the issue of child protection was specifically considered. At paragraph 4.11 the guidance given states that: " In child protection cases the overriding principle is to secure the best interests of the child. Therefore, if a health professional (or other member of staff) has knowledge of abuse or neglect it may be necessary to share this with others on a strictly controlled basis so that decisions relating to a child’s welfare can be taken in the light of all relevant information". 10. The issue of child protection is not explicitly discussed in Chapter 5 which is headed ‘ Passing on Information for other Purposes or as a Legal Requirement’; however, paragraphs 5.6-5.9 of that chapter are relevant. Paragraphs 5.6 and 5.7 are concerned with the occasions when without consent or statutory authority it may be justifiable to release information to protect the public. Such occasions occur, for instance, when it is necessary to discover an ‘iniquity’; to prevent a serious crime; to protect the public from a risk to health or a risk of violence. In such cases will be necessary to share information with other agencies. 11. Paragraph 5.7 gives guidance to be considered when deciding whether or not to share that information with others. It states: "Each case must be considered on its merits, the main criterion being whether the release of information to protect the public should prevail over the duty of confidence to the patient. The possible therapeutic consequences for the patient must be considered whatever the outcome. Decisions will sometimes be finely balanced and may concern matters on which NHS staff find it difficult to make a judgement. Therefore it may be necessary to seek legal or other specialist advice or to await or seek a court order. It is important not to equate "the public interest" with what may be "of interest" to the public."

183 Chapter 2, para 2.1 184 eg S11 Public Health (Control of Disease) Act 1984 160 Annex 8 12. Paragraphs 5.8 and 5.9 of the guidance are concerned with the passing of information to ‘help tackle serious crime’ eg rape; kidnapping; serious sexual offences. In such circumstances information may be passed on if 185:- i. without disclosure, the task of preventing, detecting or prosecuting the crime would be seriously prejudiced or delayed; ii. information is limited to what is strictly relevant to a specific investigation; iii. there are satisfactory undertakings that the information will not be passed on or used for any purpose other than the present investigation. The request for information relating to a number of patients in order to identify one or more is, however, likely to be justified only if there is a very strong public interest. 13. The above paragraphs may be relied upon in cases of child protection to justify releasing information both to protect the child and to aid any relevant child protection investigation. The paragraphs, however, do not provide assistance for disclosure to aid a child who is in need but not at risk. 14. When considering the duty of confidence owed to a child in need but not at risk the guidance gives no specific advice but chapter 4 paragraphs 10, 14,15 and 16 are of assistance. 15. Paragraph 4.10 states that: "Young people aged 16 or 17 are regarded as adults for the purposes of consent to treatment and are therefore entitled to the same duty of confidence as adults. Children under 16 who have the capacity and understanding to take decisions about their own treatment are entitled also to decide whether personal information may be passed on and generally to have their confidence respected186. In other instances, decisions to pass on personal information may be taken by a person with parental responsibility in consultation with the health professionals involved". 16. Paragraphs 4.14-16 are headed ‘Co-ordinating care with social services and other agencies’. The aim is to provide ‘seamless’ care for those in need and to enable information to pass between agencies for that purpose. To enable the passing of information, the patient will need to know that some information sharing is necessary and he will need to give his consent to this. If the patient raises any objections then, the possible consequences of his objection on a co- ordinated care package should be made known to him. If however he continues to object, then his ultimate decision should be respected unless there are overriding considerations such as a history of violence, or a non-accidental injury.

The Caldicott Report – December 1997 (The Caldicott Committee: Report on the Review of Patient Identifiable Information - December 1997). 17. The Caldicott Committee was established in the light of the requirement emanating from the DoH guidance the ‘Protection and Use of Patient Information’ that when the disclosure of patient information was justified, only the minimum necessary information should be used and it should be anonymised wherever possible187.

185 Para 5.8 186 Gillick v West Norfolk and Wisbbech Health Authority (1986) AC 112 187 The Caldicott Report 1.1.1 161 Annex 8 18. The remit of the Committee’s enquiry was to review the transfer of all patient identifiable information from NHS organisations to other NHS or non-NHS bodies for the purposes other than direct care, medical research or where there is a statutory requirement and to ensure that current practice complies with Departmental guidance. 19. The Caldicott report and its recommendations must be viewed against its remit188. The Caldicott report does not purport to be a comprehensive inquiry into the whole area of patient confidentiality189. The legal framework applicable to confidentiality remains unchanged by the report190. Nothing within the report is intended to derogate from the guidance issued by DoH in ‘The Protection and Use of Patient Information’191. Indeed the Caldicott report intended to raise awareness of the principles contained within the guidance . Nothing within the Caldicott report alters the position that confidential information can be disclosed where it is necessary to do so to protect the public, for instance in cases of child abuse. 20. The importance of the Caldicott report is that it provides a framework of good practice in which the legal principles can be applied consistently and conscientiously and the passage of information can be controlled. 21. The Caldicott Committee made 16 recommendations. They are: a. Every dataflow, current or proposed, should be tested against basic principles of good practice. Continuing flows should be re-tested regularly. b. A programme of work should be established to reinforce awareness of confidentiality and information security requirements amongst all staff within the NHS. c. A senior person, preferably a health professional, should be nominated in each health organisation to act as guardian (the ‘Caldicott’ guardian), responsible for safeguarding the confidentiality of patient information. d. Clear guidance should be provided for those individuals/bodies responsible for approving uses of patient identifiable information. e. Protocols should b developed to protect the exchange of patient- identifiable information between NHS and non-NHS bodies. f. The identity of those responsible for monitoring the sharing and transfer of information within agreed local protocols should be clearly communicated. g. An accreditation system which recognises those organisations following good practice with respect to confidentiality should be considered. h. The NHS number should be replace other identifiers wherever practicable, taking account of the consequences of errors and particular requirements for other specific identifiers. i. Strict protocols should define who is authorised to gain access to patient identity where the NHS number or other coded identifier is used. j. Where particularly sensitive information is transferred, privacy enhancing technologies must be explored.

188 The Caldicott Report 1.1.2 189 The Caldicott Report 1.1.2 190 See Appendix A of the Caldicott Report. Same legal principles as annunciated in "The Protection and Use of Patient Information" 191 The Guidance is specifically referred to and summarised in The Caldicott Report at Appendix 5 162 192 The Caldicott Report - Building Awareness at 4.3.1 Annex 8 k. Those involved in developing health information systems should ensure that best practice principles are incorporated during the design stage. l. Where practicable, the internal structure and administration of databases holding patient-identifiable information should reflect the principles developed in this report. m. The NHS number should replace the patient’s name on Items of Service Claims made by General Practitioners as soon as practically possible. n. The design of new systems for the transfer of prescription data should incorporate the principles developed in the report. o. Future negotiations on pay and conditions for General Practitioners should, where possible, avoid systems of payment which require patient identifying details to be transmitted. p. Considerations should be given to procedures for General Practice claims and payments which do not require patient-identifying information to be transferred, which can then be piloted. 22. The basic principles of good practice to be followed and applied within recommendation 1 are as follows: a. Justify the purpose. Every proposed use or transfer of patient-identifiable information within or from an organisation should be clearly defined and scrutinised, with continuing uses regularly reviewed, by an appropriate guardian. b. Don’t use patient-identifiable information unless it is absolutely necessary. Patient-identifiable information items should not be included unless it is essential for the specified purposes of that flow. The need for patients to be identified should be considered at each stage of satisfying the purpose(s). c. Use the minimum necessary patient-identifiable information. Where use of patient-identifiable information is considered to be essential, the inclusion of each individual item of information should be considered and justified so that the minimum amount of identifiable information is transferred or accessible as is necessary. d. Access to patient-identifiable information should be on a strict need to know basis. Only those individuals who need access to patient-identifiable information should have access to it, and they should only have access to the information items that they need to see. This may mean introducing access controls or splitting information flows where one information flow is used for several purposes. e. Everyone with access to patient-identifiable information – both clinical and non-clinical staff – are made fully aware of their responsibilities and obligations to respect patient confidentiality. f. Understand and comply with the law. Every use of patient identifiable information must be lawful. Someone in each organisation handling patient information should be responsible for ensuring that the organisation complies with legal requirements.

163 Annex 8 23. There is nothing within the Caldicott report, its recommendations or conclusions which should create a barrier to the disclosure of information between agencies for the purpose of child protection or indeed for children in need. The protocol attached to the report at Appendix 11 is said to be a good example of a local protocol as envisaged within recommendation 5 above. Paragraphs 3.5 and 3.6 put into practice the DoH guidance in so far as in relates to interagency co-operation for the provision of seamless care (probably most applicable to children in need but not at risk). The deficiency of the protocol is that it does not address the issue of child protection. That however is an issue that is specifically addressed in the guidance ‘The Protection and Use of Patient Information’ at 4.11 and indirectly at paragraphs 5.8 and 5.9 – ‘Help to Tackle serious crime’. There is no logical reason why that at Appendix 11 could not be modified to include the guidance relevant to child protection or a separate protocol drafted to deal with that issue.

After Caldicott The Data Protection Act 1998 24. The Data Protection Act 1998 implemented the EC Directive that had been anticipated both in ‘The Protection and Use of Patient Information’ and the ‘Caldicott Report’. 25. The purpose of the Act is to make new provision for the processing of information relating to individuals, including the obtaining, holding, use or disclosure of such information193. The Act is still in the process of being fully implemented. 26 The Act itself is lengthy. This discussion is therefore confined to those provisions which are in my opinion relevant to the disclosure by healthcare professionals of information which falls within the scope of the Act.

27. The Act applies to ‘personal data’194 which means information which: a. is being processed by means of automatic equipment in response to instructions given for that purpose b. is recorded with the intention that it should be processed by such equipment

c. is recorded as part of a relevant filing system195 or it is intended that it should form part of such a system

d. forms part of an ‘accessible record’196. Medical records are "accessible records" within the meaning of the Act197.

193 Preamble to the Act 194 See S1 of the Act for an exhaustive definition 195 A relevant filing system is defined in S1 of the Act as "any set of information relating to individuals to the extent at, although the information is not processed by means of equipment operating automatically in response to instructions given for that purpose, the set I structured, either by reference to individuals or by reference to criteria relating to individuals, in such way that specific information relating to a particular individual is readily accessible". 196 Defined in S68 of the Act. 197 S68(2) a health record means any record which " (a) consists of information relating to the physical or mental health or condition of an individual, and (b) has been made by or on behalf of a health professional in connection with the care of that individual”

164 Annex 8 28. Records held by health care professionals will undoubtedly include two types of data, namely personal data and sensitive personal data. S1 of the Act defines ‘personal data’ as data relating to a living individual who can be identified: a. from those data, or b. from those data and other information which is in the possession of, or is likely to come into the possession of, the data controller and includes any expression of opinion about the individual and any indication of the intentions of the data controller or any other person in respect of that individual. S2 of the Act defines ‘sensitive data’ as personal data consisting of information as to: a. the racial or ethnic origin of the data subject b. his political opinions c. his religious belief or beliefs of a similar nature d. whether he is a member of a Trade Union e. his physical or mental health or condition f. his sexual life g. any commission or alleged commission by him of any offence, or h. any proceedings for any offence committed or alleged to have been committed by him, the disposal of such proceedings or the sentence of any court in such proceedings. 29. At the core of the ‘Data Protection Act’ are a number of principles which provide the ground rules for obtaining, holding, disclosing, securing, transferring and destroying personal data. The data controller has a duty to comply with the data protection principles in relation to all personal data to which he is the controller unless the data is exempt by reason of S27(1) or Schedule 7 of the Act. 30. The core principles of the Act are set out in Schedule 1. They are: Principle 1 198 – Personal data shall be processed fairly and lawfully and, in particular, shall not be processed unless: a. at least one of the conditions in Schedule 2 is met, and b. in the case of sensitive personal data, at least one of the conditions in Schedule 3 is also met Principle 2 – Personal data shall only be obtained for one or more specified and lawful purposes, and shall not be further processed in any manner incompatible with that purpose or those purposes199. Principle 3 – Personal data shall be adequate, relevant and not excessive in relation to the purpose or purposes for which they are processed.

198 The First Principle is further interpreted in Part II of Schedule 1. In particular note that when considering if the data has been processed fairly regard must be had to the method by which it was obtained, including in particular whether any person from whom it was obtained was deceived or misled as to the purpose(s) for which the information was being processed. 199 Further interpreted in Part II of Schedule 1. Note at paragraph 6 "In determining whether any disclosure of personal data is compatible with the purpose or purposes for which the data were obtained, regard is to be had to the purpose or purposes for which the personal data are intended to be processed by any person to whom they are disclosed." 165 Annex 8 Principle 4 – Personal data shall be accurate and, where necessary, kept up to date. Principle 5 – Personal data processed for any purpose or purposes shall not be kept longer than is necessary for that purpose or those purposes. Principle 6 – Personal data shall be processed in accordance with the rights of data subjects under this Act Principle 7 - Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental lose or destruction of, or damage to, personal data. Principle 8 – Personal data shall not be transferred to a country or territory outside the European Economic Area unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data. 31. By reason of the first principle before personal data can be processed at least one of the conditions in Schedule 2 of the Act has to be satisfied. In relation to ‘sensitive data’ before that can be processed at least one further condition set out in Schedule 3 of the Act must be fulfilled. Not all of the potential conditions in either Schedule have any direct relevance to the disclosure of medical information and the exchange of information between the statutory agencies. 32. The conditions in Schedule 2 which are relevant are as follows: Schedule 2. Para 1 - The data subject has given his consent to the processing Schedule 2. Para 4 - The processing is necessary in order to protect the vital interests of the data subject eg disclosure of a patient’s medical records in an Accident and Emergency Unit when he has been involved in a serious accident . Schedule 2 para 5 - The processing is necessary for:- a. the administration of justice b. for the exercise of any functions conferred on any person by or under any enactment c. for the exercise of any other functions of a public nature exercised in the public interest by any person Schedule 2 para 6 –The processing is necessary for the legitimate interests pursued by the data controller or by the third party or parties to whom the data are disclosed, except where the processing is unwarranted in any particular case by reason of prejudice to the rights and freedoms or legitimate interests of the data subject. 33. The conditions in Schedule 3 which are relevant are: Schedule 3 para 1 - The data subject has given his explicit consent to the processing of personal data Schedule 3 para 3 - The processing is necessary - a. in order to protect the vital interests of the data subject or another person, in a case where -

200 The Guidelines Chapter 3 para 1.2 166 Annex 8 i. consent cannot be given by or on behalf of the data subject, or ii. the data controller cannot reasonably be expected to obtain the consent of the data subject. b. in order to protect the vital interests of another person, in case where the consent by or on behalf of the data subject has been unreasonably withheld. Schedule 3 para 6 - The processing - a. is necessary for the purpose of, or in connection with, any legal proceedings (including prospective legal proceedings) b. is necessary for the obtaining of legal advice, or c. is otherwise necessary for the purposes of establishing, exercising or defending legal rights Schedule 3 para 7(1) - The disclosure is necessary - a. for the administration of justice, b. for the exercise of any functions conferred on any person by or under an enactment, or… Schedule 3 para 8 - The processing is necessary for medical purposes201 and is undertaken by: a. a health professional; or b. a person who in the circumstances owes a duty of confidentiality which is equivalent to that which would arise if that person were a health professional. 34. Unless the conditions required by the first principle are satisfied, ‘personal data’ and ‘sensitive data’ cannot be disclosed. However there are exceptions to that principle. Those exemptions arise by virtue of S27(1) of the Act and can be found in Part IV(S28-36) and Schedule 7 of the Act. For example, by reason of S29 of the Act, personal data processed for, inter alia, the prevention or detection of crime; or the apprehension or prosecution of offenders is exempt from the conditions in Schedule 2 and 3 of the Act in so far as the application of any of those conditions would be likely to prejudice the prevention or detection of crime; or the apprehension or prosecution of offenders. Further under S30 of the Act the Secretary of State can exempt from the subject information provisions or modify those provisions in relation to data consisting of information as to the physical or mental health or condition of the data subject or data relating to social work records202. Under S35(1) of he Act personal data is exempt from the non-disclosure provisions where the disclosure is required by or under any enactment, by any rule of law or by the order of the court. 35. The exemptions should be sufficient to enable the passing of data between agencies when a child is at risk.

201 Medical purposes includes the purposes of preventative medicine, medical diagnosis, medical research, the provision of care and treatment and the management of health care services. 202 Statutory regulations are likely to be drafted in relation to these exemptions. 167 Annex 8 The Crime and Disorder Act 1998 36. It has been asserted that the ‘Crime and Disorder Act 1998’ will drive a coach and horses through the ‘Data Protection Act’ when it comes to the prevention and detection of crime. Thus it will be a useful tool when seeking the disclosure of information relating to a child at risk. However a closer reading of the Act indicates that whilst it will allow for the sharing of information, any information so shared will have to be in accordance with the Data Protection Principles. 37. ‘The Crime and Disorder Act’, amongst other things, creates a duty for agencies particularly Local Authorities and the police to work together to tackle crime and disorder. The first step in the process is to conduct a local crime audit to identify local problems and to draw up local solutions203. The conducting of such an audit may involve the sharing of information between agencies. However the Act does not enable wholesale data sharing or data matching. 38. The legal basis for the sharing of information comes from S115 of the Act. "Any person who apart from this section would not have power to disclose information: a. to a relevant authority; or b. to a person acting on behalf of such an authority shall have the power to do so where disclosure is necessary or expedient for the purposes of any provisions of this Act". 39. The purpose of the Act is at first glance fairly limited – anti social behaviour orders, sex offender orders, child safety orders, drug treatment and testing orders, reparation orders, action plan orders, supervision orders and detention and training orders. However the long title to the Act states that it is an Act ‘for the preventing and detecting crime’ and that wider purpose is underscored by S6 of the Act. It is in accordance with the principle underlying the act and consistent with S6 that it is lawful to share personal information for the prevention and detection of crime. Such a lawful exchange of information would fall within the First Principle of the Data Protection Act and could justify disclosure of information covered by that Act. However the provision of such a lawful basis does not remove the duty upon each agency to consider their personal obligations in relation to the personal data they hold. Hence there will still be a need to consider matters such as confidentiality and to ensure the processes provided by the ‘Data Protection Act’ are in operation.

The Human Rights Act 1998 40. ‘The Human Rights Act 1998’ may be last in this summary but its place in the order of things should not diminish the profound effect it is having on the law of England and Wales, as it incorporates the Convention for the Protection of Human Rights and Fundamental Freedoms (the Convention) into domestic law. It is therefore important to ensure statutory authorities exercise their powers in a manner that is compatible with the Convention. 41. When considering the disclosure of information and the protection of children there are two key Articles to consider under the convention. They are Article 3 and Article 8.

203 See S6 of the Act 168 Annex 8 42. Article 3 provides: "No-one may be subjected to torture or to inhuman or degrading treatment or punishment" In a case204 concerning the corporal punishment of a child at home, the Court in its statement said that States are "required to take measures designed to ensure that individuals within their jurisdiction are not subjected to torture or inhuman or degrading treatment or punishment, including such ill treatment administered by private individuals. Children and other vulnerable individuals, in particular are entitled to state protection in the form of effective deterrence against such serious breaches of personal integrity." 43. Article 8 provides for a right to respect for private and family life. It states that: a. Everyone has the right to respect for his private and family life, his home and his correspondence. b. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others." 44. Access to and the protection of personal information falls within the ambit of private life205. "The protection of personal data, not least medical data, is of fundamental importance to a person’s enjoyment of his or her right to respect for private and family life. Respecting the confidentiality of health data is a vital principle in all legal systems of all contracting parties…. It is crucial not only to respect the sense of privacy of a patient but also to preserve his or her confidence in the medical profession and the health services in general"206. 45. The right to the protection of personal data can be interfered with provided that interference is in accordance with the law and necessary in a democratic society. Where a child is at risk of abuse or indeed is being abused information may be shared in order to protect the child. Such action would be necessary to ensure public safety; to prevent disorder or crime; to protect the health and morals of the child; and to protect that child’s rights and freedoms. Where such disclosure is to be made, it must be lawful. Hence the provisions of the Data Protection Act must be complied with and the common law of confidentiality must be observed.

Conclusion 46. Agencies may share information in order to protect children provided they act lawfully and the dissemination of information can be justified and controlled. 47. Where children are in need the flow of information is likely to be more restricted and ought if possible to be achieved with the consent of the patient.

204 A v UK27EHRR611, See also KL v UK 26EHRR CD 113 205 Gaskin v UK 12 EHRR36 206 Z v Finland 25EHRR 371 169 Annex 9 Child and Adolescent Mental Health Services and the Four Tier Strategic Concepts

Introduction 1. In this Annex, we summarise The CAMHS Concept and The Four Tier Strategic Concept because they have been adopted as policy in Wales. We do not support them for this reason but because, through our work, we have come to see both as not only sensible but also as creating clarity of definitions, a new baseline for cross-sector and cross-disciplinary partnerships and a foundation for improving the quality of services. These concepts begin the task of filling long- term gaps in policy and strategy. Here, we reproduce selected paragraphs from Everybody’s Business for readers’ ease of reference.

The CAMHS Concept 1.1 "Our concept of child and adolescent mental health services (CAMHS) is inclusive. That is, we take the term CAMHS to mean all of the services provided by all sectors that impinge on the mental well-being, mental health, mental health problems and mental disorders of children and young people before their majority. This is what we term here ‘The CAMHS Concept’. Its adoption in Wales will bring into the arena of CAMHS some services, on the basis of their ability to influence young people’s mental health, that, previously, had not considered themselves to be within this field." 1.2 "Commonly, the term CAMHS is taken more narrowly to imply those specialist services provided, mainly but by no means exclusively, by the NHS. These NHS services are of key importance to us in delivering this strategy and we acknowledge that they are under great pressure. They will need to be developed in order to: • better match contemporary demands on them; and • support our intention to develop those other services we now wish to see drawn into CAMHS to become part of an integrated and effective frontline of provision." 1.3 "With this in mind, … we use the term ‘CAMHS’ to refer to the whole enterprise and to include services that do not have mental health or providing for children as their only or key tasks. We use the term ‘Specialist CAMHS’ as shorthand to depict those services that have a particular role and expertise relating to child and adolescent mental health. In short, we see as lying at the centre of our plan the leadership and expertise that the staff in our Specialist CAMHS can and should be enabled to offer."

The Four Tier Strategic Concept 1.4 "In 1995, the NHS Health Advisory Service published a thematic review of CAMHS called ‘Together We Stand’ in which it described this concept. Recent work on CAMHS carried out by the Audit Commission took that four tier strategic approach as its baseline and its report confirms the applicability of this approach to future planning."

170 Annex 9 1.5 "The tiered framework is intended, first and foremost, to be a strategic and planning tool. Its second purpose is as a communication tool. Only third is it a blueprint for how services are practically delivered on the ground. The importance of this framework is that it promotes a better focus on the service functions required of mature, effective and efficient CAMHS through a model that spans the agencies involved and their working practices."

Tier 1- Primary or Direct Contact CAMHS Services 1.6 "Regardless of sector, Tier 1 describes the frontline of service delivery as the public has direct access to its components. Its staff is not necessarily trained as specialists in mental health. But, by virtue of their first contacts with, and their continuing responsibilities for young people and/or their families, staff in front line direct contact services, are well placed to recognise, assess and intervene with children's mental health problems. These staff require basic skills in assessment and intervention practices." 1.7 "It is neither best for the young people nor an effective or efficient use of slender specialist resources if children and adolescents who may or may not have a mental health problem generally go immediately or directly to more specialist services. In order to discharge their responsibilities, staff at Tier 1 require training, consultation and support from Tier 2 and ease of access for cases to it." 1.8 "Tier 1 staff include GPs, many other primary healthcarers, health visitors, school nurses, teachers and other school staff, non-specialist children’s social workers, foster carers and many non-statutory sector workers."

Tier 2 - Services Provided by Individual Specialist CAMHS Professionals 1.9 "Tier 2 is the first line of specialist CAMH services. The staff include members of health-provided specialist CAMHS, the staff of the education support services including educational psychologists and specialist teachers and specialist children's social workers as well as some staff of voluntary organisations." 1.10 "Usually, families are directed to Tier 2 Services by staff working in Tier 1 though this does not have to be the universal case. Together, the functions delivered at Tier 2 are those required in each local authority area. Frequently, staff work as members of teams to which they may refer. Often, families may meet single members of staff from each agency that is involved. While effective liaison between service components is important and potentially time-consuming at Tier 2, this factor in itself does not define such a service as a Tier 3 service."

Tier 3 - Services Provided by Teams of Staff from Specialist CAMHS 1.11 "Services at Tier 3 are more specialised. Some young people and their families may require access to them as a consequence of the complexity of their need, the concentration of skill required or the crucial nature of the inter-service and/or inter-agency planning required to deliver a targeted programme of interventions and care. It may not be efficient or appropriate to provide all

171 Annex 9 modalities of such specialised care in each local authority area but each service at Tier 2 requires access to a definable range of Tier 3 services. Many NHS-based specialist CAMHS are now moving towards working on a ‘hub and spoke’ model with Tier 2 functions delivered locally and Tier 3 provided at central but accessible locations." 1.12 "Services at Tier 3 include a variety of specialised clinics, day-care services, special units in certain schools, specialist fostering and social services-led specialised family intervention centres." 1.13 "An example of the distinction between Tiers 1, 2 and 3 is that of the family work required by many cases. At Tier 1, this might amount to simple family assessment, discussion or counselling. At Tier 2, there should be the ability to routinely conduct systematised family therapy while, at Tier 3, certain young people may require particular forms of focused and intensive family therapy practised by a team that works together regularly. These teams may be composed of staff drawn from a variety of different agencies."

Tier 4 - Very Specialised Interventions and Care 1.14 "Very specialised services that may not need to be available in each district but to which the local specialist CAMHS require predictable access are termed Tier 4 functions. They include very specialised clinics that are only supportable on a regional or national basis, inpatient psychiatric services for children and adolescents, residential schools and very specialised and residential social care."

172 Annex 10 Written Submissions

All Wales Forum for Nurses in CAMHS Andrew Bellamy Director of Corporate Development, Swansea NHS Trust Linda Bevan Senior Nurse Advisor, NHS Director Wales Elaine Blair Secretary, Powys Community Practitioners Health Visitors Association J Bottell Chief Ambulance Officer, Welsh Ambulance Services NHS Trust Keith Bowen Contact a Family Wales Sue Bowyer Welsh Women’s Aid Lynda Bransbury Welsh Local Government Association Susan Bright Royal College of Speech and Language Therapists Robert Brunstrom Deputy Chief Constable, North Wales Police C Burns Head of Health Visiting, Swansea NHS Trust Dilys Calder Senior Nurse, Child Protection, Swansea NHS Trust Alan Coates Detective Chief Inspector, Family Support Unit, Gwent Police Wendy Cogger Chief Executive, Royal College of Anaesthetists Graham Coomber Chief Executive, Gwent Health Authority N Davies Parent Carwen Earles Programme Manager, Child Health, School of Health Science, University of Wales Swansea Nicola Eaton Paediatric Nurse Kenneth Edwards Pembrokeshire Community Health Council Sue Elworthy Director of Nursing, North Glamorgan NHS Trust CH Fardy Lead Clinician in Paediatric Intensive Care, University Hospital of Wales Clare Field Child Protection Co – ordinator, Wrexham County Borough Council Phillipa Ford Chartered Society of Physiotherapists in Wales MS Foster Chief Executive, Pontypridd and Rhondda NHS Trust Dr John Gibbs Lead Clinician, Paediatrics, Countess of Chester Hospital NHS Trust

173 Annex 10 Professor Ian Gilmore Royal College of Physicians Lesley Gleave Planning Officer, Social Services Department, Denbighshire County Council Dr Carys Graham Designated Doctor, Child Protection, North Wales Health Authority Dr Judith Greenacre Consultant in Public Health Medicine, Dyfed Powys Health Authority David Hands Chief Executive, North Wales Health Authority Lesley Harris Radiographer, University Hospital of Wales Jane Harris General Manager, CAMHS, Pembrokeshire and Derwen NHS Trust Dr Kamila Hawthorne General Practitioner, Cardiff G Clwyd Haydon-Jones School Nurse, Ceredigion and Mid Wales NHS Wales Becky Healey Head of Children’s Nursing, Cardiff and Vale NHS Trust Liz Hewett Board Secretary, Royal College of Nursing H W Hodges Parent Nina Hopkins Paediatric Nurse, Student Dr Chris John Royal College of General Practitioners Nicola John Consultant in Pharmaceutical Public Health, Iechyd Morgannwg Health Authority L Kapila Royal College of Surgeons Dr Adele Kelly Consultant Community Paediatrician, North East Wales NHS Trust Peter Langley Principal Officer Child Protection, Torfaen County Borough Council Pauline Langley Member of the public Nick Lawrence Children and Family Services, Blaneau Gwent Social Services Polly Leett Senior Nurse, Child Protection, Ceredigion and Mid Wales NHS Trust Jan Leightley Head of Children and Family Services, Newport County Borough Council Clare Lines Parent Clare Lines Specialised Health Services Commission for Wales C F A Lowe Bereaved Parent Geraint Morgan Caerphilly Local Health Group

174 Annex 10 Dr R J H Morgan Officer for Wales, Royal College of Paediatrics and Child Health, Welsh Committee Dr Gwyneth Owen Director, Child and Family Health Services, Carmarthenshire NHS Trust D Glanville Owen Gwynedd Community Health Council Nicola Peachey Royal College of General Practitioners, Wales Rae Pearsall Designated Nurse, Child Protection, Dyfed Powys Health Authority Sue Pearson Designated Nurse, Bro Taf Health Authority Hilary J Peplar Chief Executive, North East Wales NHS Trust D W Phillips Detective Chief Superintendent, South Wales Police Dr T Rangarajan Consultant Community Paediatrician, North Glamorgan NHS trust Karen Reilly Head of Children’s Services, Flintshire Social Services Jenny Sanders Senior Nurse, Swansea NHS Trust Dr Quentin Sandifer Executive Director of Public Health, Iechyd Morgannwg Health Authority Adrian Savill Centre for Health Informatics Professor Robert Shaw Royal College of Obstetricians and Gynaecologists Professor Jo Sibert Professor of Community Child Health, University of Wales College of Medicine Suzan Smallman Professional Officer, Paediatrics/Community, UKCC Diane Smith Executive Director of Nursing, Velindre NHS Trust Beryl Stevens Deputy College Secretary, Royal College of Obstetricians and Gynaecologists Eddy Street Child Clinical Psychologist in Wales Dr Peter Stutchfield Clinical Director, Directorate of Child and Adolescent Health, Conwy and Denbighshire NHS Trust Rosamund Thomas Chief Officer, Vale of Glamorgan Community Health Council Keith Thompson Head of Children’s Services, Cardiff County Council Keith Thomson Chief Executive, North West Wales NHS Trust Martin Turner Chief Executive, Gwent Healthcare NHS Trust Mair Watkins Nurse Advisor, NHS Director Wales, on behalf of UKCC

175 Annex 10 Dr F G Williams Director, Welsh Blood Service P M Williams Chief Executive, Bro Morgannwg NHS Trust Anne Williams The Association for the Welfare of Children in Hospital Dr Hywel Williams Consultant Paediatrician, Designated Doctor, Child Protection, Bro Taf Health Authority Andrea Woolf Royal College of Psychiatrists Dr John Wynne-Jones Institute of Rural Health

176 Annex 11 Oral Witnesses

All Wales Forum for Nurses in CAMHS All Wales Trust Chief Executives Associate Medical Director, Children’s Hospital, UHW Association of Directors of Social Services Caerphilly Local Health Group Carmarthenshire NHS Trust Centre for Health Informatics Ceredigion & Mid Wales NHS Trust Chartered Society of Physiotherapy Chief Executive, North Wales Health Authority Child Clinical Psychologists in Wales Children in Wales Contact a Family Wales Criminal Records Bureau / Home Office Denbigh Social Services Department Designated Doctor, North Wales Health Authority Dr Elspeth Webb, University of Wales College of Medicine Dr Kamila Hawthorne, General Practitioner, Cardiff Dr RN Roberts, Ophthalmic Advisor to The National Assembly for Wales Dr Saunders, General Practitioner, Butetown Surgery Dyfed Powys Health Authority General Dental Council Head of Health Visiting and School Nursing Services, Swansea NHS Trust Institute for Rural Health Mr & Mrs Lowe, Bereaved Parents North East Wales NHS Trust North Wales Health Authority North Wales Police Authority North West Wales NHS Trust Parc Prison, Bridgend Radiographer, University Hospital of Wales

177 Annex 11 Researcher WORD Fellowship, University of Wales, Swansea Royal College of Anaesthetists Royal College of GPs Wales Royal College of Nursing Royal College of Paediatrics & Child Health Royal College of Psychiatrists Royal College of Speech & Language Therapists Royal College of Surgeons School of Health Science, Swansea University Sure Start Swansea NHS Trust The Specialised Health Services Commission for Wales UKCC UKCC / NHS Direct University of Wales, College of Medicine Vale of Glamorgan Community Health Council

178 Annex 12 Review Site Visits 2001

DATE LOCATION 15 February Children’s Ward UHW, Cardiff Harvey Jones Unit, Whitchurch, Cardiff Brynffynnon Child and Family Centre, Pontypridd 16 February Children’s Optical Clinic, Cardiff University Royal Gwent Hospital, Community Dental Service Royal Gwent Hospital – Young persons ward Looked After Service, Caerphilly Ty Hafan Children’s Hospice, Sully 19 February Llandrindod Wells Community Hospital Llandrindod Wells GP Surgery Newtown Hospital, Powys 21 February Lansdowne Hospital, Cardiff Caerphilly Children’s Centre 22 February St Andrew’s Hospital, Northampton 23 February Guy’s Hospital, London The Maudsley Hospital, London The Children’s Trust, Tadworth 26 February Withybush General Hospital, Haverfordwest Bronglais General Hospital, Aberystwyth 27 February Wrexham Maelor General Hospital 28 February Hergest Unit, Ysbyty Gwynedd, Bangor 1 March Ysbyty Glan Clwyd, Bodelwyddan Cedar Court, Colwyn Bay 6 March Morriston Hospital, Swansea Children’s Centre, Port Talbot Hospital Hillside Unit, Neath 13 July Dyfed Powys Police Headquarters

179 Annex 13 School Visits and Public Meetings 2001

DATE LOCATION 27 February Public meeting, Mold 28 February Mold Alun School, Mold 1 March Public meeting, Bangor 7 March St Cenydd Comprehensive School, Caerphilly Public meeting, Pontypridd 13 July Queen Elizabeth Cambria School, Carmarthen

180 Annex 14 Bibliography

Abbott B, Jordan P, Murtaza N, (1995) Interagency collaboration for children's mental health services: The San Mateo County Model for managed care. Administration and Policy in Mental Health, 22, 301-313.

Audit Commission, (1999) Children in Mind - a report on child and adolescent mental health services. London: Audit Commission.

Audit Commission, (1999) Children in Mind. London: Audit Commission.

Axelrod R, (1990) The Evolution of Co-operation, London. Penguin Books.

Bennett K E, Haggard M P, Silva P A, Stewart I A, (2001) Behaviour and developmental effects of otitis media with effusion into the teens. Arch. Dis. Child. 2001;85 91-95.

British Journal of Psychiatry, (2001) Vol 179.

British Journal of Psychiatry, (2001) Vol 180.

Bullock R, Little M, (1999) The interface between social and health services for children and adolescent persons. Current Opinion in Psychiatry, 12, 421-424.

Bullock R, Little M, Milham S, (1998) Secure treatment outcomes: the care careers of very difficult adolescents. Aldershot: Ashdale Publishing.

Butler C, MacMillan H, (2001) Does early detection of otitis media with effusion prevent delayed language development? Arch. Dis. Child. 2001;85 96-103.

Child Health Informatics Consortium and the Royal College of Paediatrics and Child Health, (2000) Monitoring the Health of our Nation’s Children.

Children Act (1989)

Christian J, Givarry E, (1999) Specialist Services: The need for multi-agency partnership. Drug and Alcohol Dependence, 55, 265-274.

Data Protection Act (1998)

Department of Health, (1994) Health Service Guideline, Protection of Children: disclosure to NHS employers of criminal background of those with access to children. NHS Executive HSG (94) 43. London: Department of Health.

Department of Health, (1997) The Caldicott Committee: Report on the review of patient identifiable information. London: Department of Health.

Department of Health, (1997) NHS Health Advisory Service, Voices in Partnership, ISBN 011 321872 9. London: HMSO.

Department of Health, (2000) NHS Plan London: Stationary Office.

181 Annex 14 Department of Health, (1992) Choosing with Care, The Report of the Committee of Inquiry into the Selection, Development and Management of Staff in Children’s Homes, London: The Stationery Office.

Department of Health, (1992) Choosing with Care, The Report of the committee of Inquiry into the selection, development and management of staff in Children’s Homes. London: Department of Health.

Department of Health, (1994) The Report of the Review Committee on NHS Complaints Procedures, chaired by Professor Alan Wilson: Being Heard : Department of Health.

Department of Health, (1995) The Government’s Proposals in Response to Being Heard: Acting on Complaints : Department of Health.

Department of Health, (2000) Reforming the Health Act. Part I: The new legal framework. Cm 5016-1. London: Stationery Office.

Department of Health, (2000) Report of the Review of Security at the High Security Hospitals. London : Stationery Office.

Department of Health, (2001) Modernisation Regulation in the Health Professions. London : Department of Health.

Department of Health, Scottish Executive, (1999) NHS MEL 10, Introduction of Managed Clinical Networks within the NHS in Scotland, Edinburgh : Scottish Executive.

Department of Health, Welsh Office, (1998) Mental Health Act 1983 explanatory memorandum on parts I, II, III, IV, V, VIII and X of the Act and associated Schedules, and on the Health (Hospital Guardianship and Consent to Treatment) Regulations 1983. London : The Stationery Office.

Department of Heath, (1969) Report of the committee of inquiry into allegations of ill-treatment of patients and other irregularities at the Ely Hospital, Cardiff. London: HMSO.

Elkan R, Kendrick D, Hewitt M, Robinson JJA, Blair M, Dewey M, Williams D, Brummell K, (2001) Evidence-based Healthcare (2001) 5, 67-68, Harcourt Publishers Ltd; ‘Home Visiting has many positive benefits but more evidence about cost effectiveness is needed’. The effectiveness of domicillary health visiting: a systematic review of international studies and a selective review of the British Literature. Health Technol Assess 2000; 4(13) : 1-339.

General Medical Council, (1998) Good Medical Practice, 2nd edition, GMC Publications.

General Medical Council, (1998) Seeking patients’ consent: the ethical considerations, GMC Publications.

182 Annex 14 Gordon D, Parker R, Loughran F, (1998) Disabled children in Britain: reanalysis of OPCS data. Bristol: University of Bristol.

Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, (2000) Child Protection Policy and Procedures. London: Great Ormond Street.

Handy C, (1999) Picture Framing. P73-76 in thoughts for the day. London : Arrow.

HAS 2000, (2000) Child and Adolescent Mental Health Services Residential Units Wales: A Review of Safeguards and Standards of Care Follow up Inspection. Cardiff: National Assembly for Wales.

Hogg C, (1996) Health Services for Children and Young People. Action for Sick Children.

Home Office, (1996) On the Record: The Governments Proposals for access to criminal records for employment and related purposes in England and Wales; Cm 3308; London: HMSO.

Horder J, (2000) Leadership in a multi-professional context, Medical Education, 34:203-205.

Kennedy I, Howard R, Jarman B, Maclean M, (2001) The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary, 1984-1995; CM 5207(1). London: Stationery Office.

Kurtz Z, Thornes R, Bailey S, (1997) A study of the demand and needs for forensic child and adolescent mental health services in England and Wales. Salford: Mental Health Services of Salford.

Local Authority Social Services Act, (1970) Section 7 (1).

McCann J, James A, Wilson S, Dun G, (1996) Prevalence of psychiatric disorders in young people in the care system. British Medical Journal, 313, 1529-1530.

McCartney E. (1999) Barriers to collaboration: An analysis of systemic barriers to collaboration between teachers and speech and language therapists. International Journal of Language and Communication Disorders, 34, 431-440.

Mental Health Act Commission, (1997)

Mental Health Act Commission, (1999)

Mental Health Act Commission, (2001)

Mental Health Commission, (2001) Ninth Biennial Report. London : Stationery Office

Ministry of Health, (1964) H.M. (64)4 In-patient Accommodation for Mentally Ill and Seriously Maladjusted Children and Adolescents

183 Annex 14 Morris, (1998) Still Missing? Volume 2 Disabled Children and the Children Act, The Who Cares Trust.

Morris, (1998) Accessing Human Rights, Barnados.

Muth Z, Williams R, (1995) With Care in Mind : A review for the special Hospital Service Authority of the services provided by Ashworth Hospital. London : NHS Health Advisory Service.

National Assembly for Wales, (2000) Working Together to Safeguard Children, A guide to inter agency working to safeguard and promote the welfare of children. Cardiff: National Assembly for Wales.

National Assembly for Wales, (2000) Health and Social Services Committee, Flexibilities under 31 of the Health Act 1999 [HSS-17-00] Cardiff: National Assembly for Wales.

National Assembly for Wales, (2001) Improving Health in Wales – Structural Change in the NHS in Wales. Cardiff: National Assembly for Wales.

National Assembly for Wales, (2001) Improving Health in Wales – The Future of Primary Care. Cardiff: National Assembly for Wales.

National Assembly for Wales, (2001) Child and Adolescent Mental Health Services - Everybody’s Business, Strategy Document. Cardiff: National Assembly for Wales.

NHS Health Advisory Service, (1995) Together We Stand. London: HMSO.

Nolan, (2001) Review on Child Protection in the Catholic Church in England and Wales, First Report, Catholic Bishops’ Conference of England and Wales.

Office for National Statistics, (2000) Mental Health of Children and Adolescents in Great Britain ISBN 0 11 621373 6. London: Stationery Office.

Office for National Statistics, (1999) Mental health of children and adolescents, ONS(99)409. London : Governmental Statistical Service.

Place M, Wilson J, Martin E, Hulsmeier J, (2000) The frequency of emotional and behavioural disturbance in an EBD school. Child Psychology and Psychiatry Review, 5, 76-80.

Powys Local Health Group, (2000) Figures from Powys Local Health Group for activity in 1999. Professional Counselling and Psychotherapy, Guidelines and Protocols: Defining Psychological Therapy in Primary Care.

Ranade W, (1998) Making sense of multi-agency working. Sustainable Cities Research Institute.

Rawlinson S, Williams R, (2000) The primary/secondary care interface in child and adolescent mental health services: the relevance of burden. Current Opinion in Psychiatry 2000; 13 389-395.

184 Annex 14 Research and Innovation on the Road to Modern Child Psychiatry, (2001) London : Gaskell and ACPP.

Rogers I C, (1996) Loosening the Bond in Mental Health Review.

Salmon G, Williams R, (2001) A Strategic Model for Co-Operation, Partnership And Teamwork - The Inter-agency Challenge of the Mental Health of Our Children. In The Welsh Institute for Health and Social Care - The First Five Years. University of Glamorgan.

Skelton W R, (1992) Mental Health Services for Adolescents.

The Care Standards Act (2000)

United Kingdom Central Council for Nursing, Midwifery and Health Visiting, (1996) Reporting misconduct – information for employers and managers. London : UKCC.

United Nations Convention on the rights of a child, (1989) General Assembly Resolution Document A/RES/44.

University of Wales, (2000) Review of Health Visiting and school nursing services in Wales. Swansea: University of Wales.

Utting W, (1997) People like us, The report of the review of the safeguards for children living away from home. Department of Health, Welsh Office. London: Stationary Office.

Waterhouse R, Clough M, le Fleming M, (2000) Return to an address of the Honourable the House of Commons dated 15 February 2000 for the Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974, Lost in Care, HC 201, London : The Stationery Office.

Welsh Office, (1998) NHS Health Advisory Service, Child and adolescent mental health services in residential units in Wales ‘ A review of safeguards and standards of care. Cardiff: Welsh Office.

Welsh Office, (1989) Mental illness services – a strategy for Wales. Cardiff: Welsh Office.

Welsh Office, (1991) Welfare of Children in Hospital in Wales. Cardiff: Welsh Office.

Welsh Office, (1991) Working Together under the Children Act 1989, A guide to arrangements for inter agency co-operation for the protection of children from abuse : London : HMSO.

Welsh Office, (1996) Patient’s Charter : Services for children and young people in Wales, Produced for the Welsh Office by the Central Office of Information 3/96 WOFF J02-6034. Cardiff: Welsh Office.

185 Annex 14 Welsh Office, (1997) The Health of Children in Wales.

Welsh Office, (1998) North Wales Child Abuse Inquiry, Lessons for the NHS, Expert Workshop Report. Cardiff: Welsh Office.

Welsh Office, (1999) Children’s Safeguards Review and Choosing with Care - WOC (99) 38. Cardiff: Welsh Office.

Wyllie, (1999) The Last Rung of the Ladder, The Children’s Society.

186