Psychology Matters: "We are small, but we are mighty when we get an opportunity to sit at the table with our curiosity and compassion."

Can you give an overview of the NEST framework? 

NEST stands for nurturing, empowering, safe, and trusted, and it was co-produced with children, young people, and parents, lots of professionals and community settings. The framework recognises that we all thrive when our environments and relationships are nurturing, empowering, safe, and trusted, but it is the babies, children, and families who need this most, who benefit the most.  

It takes the view that we are all in this together; we're all service users to some extent, and as a psychologist leading the framework's development, I was very keen that was how we went about developing it.  

How is psychology embedded into the NEST framework? 

There are some obvious components such as services needing to be psychologically informed and immersed in equality, diversity, and inclusion. They need to be developmentally informed, which means recognising that development isn't a linear trajectory, and that we develop at different rates. It also needed to be 'strengths-based' by focusing on what a child and family needs to be their best possible selves but also looking at what strengths they all bring.  

The framework also talks about 'no wrong door,' which addresses feedback from families that they were being referred to different services, waiting on lists, only to be told it wasn't the right service for them. It outlines the importance of having easy access to expertise, which addresses the idea that historically the specialist held all the expertise, and you needed a referral, and to wait a long time to get support.  

Of course, there is still a need for specialist intervention, but many problems can be addressed with a lighter touch, with everyone in the child's life contributing to their support. 

The NEST framework promotes the idea that the answers to our problems don't only lie in specialist services, and that we can all make sure that expertise is available through consultation, training, and support at the end of the phone.  

The framework also emphasises that proximal relationships are the most powerful tool in psychology. If you're in a supportive community, who is there for you and welcomes you, and you've got a sense of belonging and purpose, then that's going to support your emotional wellbeing. All of these things come together to create a whole system approach so we're all working towards the best outcome. 

The framework is a big cultural shift. People often talk about 'turning the tanker' as a way of describing how to make culture turn away from deficit models and specialist services towards a much warmer and welcoming society. However, a tanker is big and hard to turn, so instead, we think about system change as a 'flotilla,' where there are lots of smaller boats to turn.  

The more boats that turn towards this way of working, the more chance we stand in making our services more nurturing, empowering, safe, and trusted. 

Psychologically informed approaches are central to the NEST framework. Can you tell us about your involvement in leading its development? 

I've worked for the NHS for over 30 years, with most of that time spent as the Joint Head of Child and Family Psychology at the Aneurin Bevan University Health Board. We'd always felt that, alongside our direct intervention work, there needed to be an equal emphasis placed on early intervention and prevention.  

We also recognised that direct psychological interventions in clinics didn't always fit with the needs of some of the most severely impacted children, young people, and their families. There was a mismatch between the families that could attend clinic and engage in interventions and the families who were really struggling with very significant needs and day-to-day life more generally.  

We were keen to raise the profile of that mismatch, develop services that address it, and place an equal emphasis on training, consultations, upskilling the workforce and creating communities, families, and contexts where children can thrive and that are psychologically informed.  

We wanted to create services that were more formulation-led and psychologists helped with that aspect, but the interventions were often delivered by those who were closest to the young people and who had the best relationship with them, as it is these proximal relationships that are the most powerful in terms of supporting children and young people.  Children with the greatest needs didn't always respond well to time-based interventions and what they needed instead was ongoing relationships, perseverance, and belief in them.  

The framework is a big cultural shift. People often talk about 'turning the tanker' as a way of describing how to make culture turn away from deficit models and specialist services towards a much warmer and welcoming society. However, a tanker is big and hard to turn, so instead, we think about system change as a 'flotilla,' where there are lots of smaller boats to turn.  

In 2018, there was investment from the Welsh Government for service transformation, and we were keen to use this fund for children and young people's mental health and wellbeing. We developed a model that we referred to as the 'iceberg model' which had the familiar triangle of universal, targeted and specialist services, and an equal and equivalent triangle underneath.  

This highlighted the point that traditional service models would only serve a certain function, and more of the same would not address the most concerning issues faced by children and families – those that would not respond to clinic-based interventions. This helped to dispel the myth that traditional services were well placed to meet the need if they were better resourced. 

Children at the 'bottom of the iceberg' were often the ones that services were most worried about. These are children at risk of county lines involvement, absconding, or self-harming but who didn't have a diagnosis, or whose lives were not stable enough to get to regular clinic appointments. They were often left without support, and it was seen as the responsibility of social care to manage them, even though those services don't necessarily have the psychological knowledge to offer that.  

The iceberg model formed the basis of our transformation, and as part of that, we gave evidence to the Committee for Children and Young People at the Senedd who were trying to look at the issues in CAMHS. One of their main areas of concern was what they referred to as 'the missing middle' - children who didn't quite meet criteria for some services but still had significant needs.  

Our work in Gwent attracted the interest of Welsh government and they developed a document called, 'Mind over Matter,' that led to the Together for Children and Young People Programme being extended to develop a framework that aimed to address these issues. 

 
Has the framework had involvement from young people and families? 

Yes, absolutely. Co-production was a huge part of the Together for Children and Young People framework. I was passionate about co-producing our work, and it was developed to align with what people had said needed to be in the framework. 

It needed to be driven by children, young people, their parents, and a range of services including the police, housing, and youth justice. I think historically, mental health has been 'carved off' where mental health problems are dealt with by mental health services and social problems are referred to social services as though there's not an overlap. In reality, the overlap is huge which is why so many children were falling through the gaps. 

Can you describe the impact that the framework has had on children and young people? 

It's early days as the framework took a year to develop and then a year to embed, but we were very pleased when the Welsh government appointed a Nest Framework lead. It's their role to ensure that the framework is rolled out across Wales, and they've developed toolkits to ensure that this happens.  

However, the framework is multi-agency, requiring a partnership approach, where different voices including parents, children, young people, and someone representing babies' voices, as well as social care, healthcare, education and the third sector, are being listened to. 

At a strategic planning level, these groups help identify the gaps in each region and how we can fix them together. At the service delivery level, an example of it working in practice is the SPACE (Single Point of Access for Children's Emotional) Wellbeing Panels.  

In Gwent, which has one health board but five local authorities, there are five SPACE Wellbeing Panels, which have representatives from all services that offer interventions for mental health and wellbeing. Every request that comes in for services gets considered, and the best service or multiple services to meet the needs of that family is identified. 

Families are matched with the services that best meet their need, as opposed to what used to happen, which is referrals would get sent to one service, and they'd say 'yes' or 'no.' This is a forum where everybody works together to think about the best fit. It also helps identify gaps in services, such as if there are several children coming through the forum and there is no service for them, that can get fed back to the commissioners, so they are aware. 

 
What are your hopes for how the framework will be used in the future? 

The hope is that it's got a life of its own, and that it's constantly evolving. I'm not directly involved with it now, but in my new role, I hear and see it all the time. Wales is about to publish its All Age, Mental Health and Wellbeing strategy, and there's a strong emphasis on the NEST framework being the delivery tool framework for children's mental health and wellbeing for babies, children, and young people.   

What I would also say, which is not surprising in some ways, but is really reassuring, is that lots of other policies and developments align really well with it. People are talking about the need for whole system approaches and the need for trauma-informed services. Our nurturing, empowering, safe, and trusted principles absolutely fit with that.  

The 'whole school approach,' is one of the sections within the NEST framework that highlights the importance of co-production, with children and young people having a voice in their education. It also highlights the importance of schools being welcoming and safe spaces where children have a sense of belonging. There's an alignment with a range of other policies that feels really hopeful and positive.  

Wales is about to publish its All Age, Mental Health and Wellbeing strategy, and there's a strong emphasis on the NEST framework being the delivery tool framework for children's mental health and wellbeing for babies, children, and young people.   

Can you tell us about the impact of your work beyond the NEST framework? 

I retired from the NHS in 2023, which coincided with NEST being launched. I'm now the Wales Development Lead for the Parent Infant Foundation. Although it's not a clinical psychology role, my experience, interests, and passions absolutely lend themselves to that role. 

My current role is primarily about trying to influence government. There are obvious gaps around parent-infant relationship services in Wales and across the UK more generally. There needs to be a greater emphasis on the first 1,000 days of a child's life, which is the time when babies are most open to being influenced by the relationships and experiences around them. These set a template for life. 

Their brains are developing at the quickest rate of rapid development and can be impacted in a positive way, or a negative way if they're not getting what they need. There's a big mismatch with services in this area and we're doing a lot of work to address that. 
 
Can you tell us why you think psychology matters? 
I think psychology matters because we are all human and what it is to be human matters hugely. We hear time and time again in services or relationships, that when things go wrong it's because very simple basic human needs have not been prioritised.  

What's really important is that psychology brings fairly common-sense perspectives around connection and kindness together with the research evidence-base to back up why it matters and what difference it makes. 

For me it's about backing up core principles that need to be embedded in all of our lives and in all of society. I'm hoping that the NEST framework does that by focusing on the importance of nurturing, empowering, safe, and trusted relationships. 

What makes you proud about being a psychologist? 

Lots of things make me proud about being a psychologist. We have the potential to make a difference in such a wide and varied way. We can bring our research and rigour but also bring solutions. People are really stumbling at the moment about how to fix big problems, and psychology has got lots of ideas.  

We are small, but we are mighty when we get an opportunity to sit at the table with our curiosity and compassion. 

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