Analysis shows that recruitment, funding and commissioning are key obstacles to delivering the Future in Mind vision
Eighty five per cent of local children’s mental health plans require some or substantial improvement, according to an analysis of the first year of the Future in Mind programme by the Education Policy Institute's Mental Health Commission.
The commission rated local transformation plans published by clinical commissioning groups on five areas – transparency, involvement of children and young people, level of ambition, early intervention, including links with schools and GPs, and governance.
There were 121 published plans, yet only 18 areas or 15 per cent have ‘good’ plans, the analysis found. In addition, 58 plans (48 per cent) ‘require improvement’ and 45 plans (37 per cent) ‘require substantial improvement’.
Not fit for purpose
The plans were particularly weak on involving children and young people, level of ambition for service reform, and having strong governance to ensure effective implementation, the commission found.
On average, localities in the Eastern and West Midlands regions performed best. The mean score for the Eastern region was 34.9, while the mean score for the West Midlands was 34.4. Plans from the rest of the South East and the East Midlands received the lowest mean scores: 30 and 29.3 respectively. There was, however, wide variation within regions between different local plans
“When I launched Future in Mind in March 2015, my aim was to modernise the way children and young people's mental health services operate,” said Norman Lamb in the foreword to the report. “The vision of Future in Mind, with the additional funding secured in the Budget last year, is to move towards a system focused on prevention and early-intervention, where specialist services are integrated with wider health and care support.”
“A huge amount of work has been going on across the country to explore new ways of working, reduce waiting times and increase access for young people. I pay tribute to the dedication and commitment of people working within Child and Adolescent Mental Health Services who do not always get the thanks and attention they deserve,” added Norman Lamb. “These clinicians and other workers share our vision of a different approach. Nevertheless, they are often frustrated in their endeavours by working in a system which is not yet fit for purpose.”
The analysis of the published plans demonstrated the variation across the country, he added.
The commission highlighted that the analysis showed:
- Every area of the country has developed a plan,
- Local health and care leaders have been working together to coordinate the design of new services;
- The process has delivered some much needed transparency to the system
- Data is now beginning to be gathered nationally to inform service improvement;
- Some excellent examples of local transformation plans have been produced.
However, The Education Policy Institute identified six key barriers to the effective delivery of Future in Mind: Workforce, Funding, Commissioning, Data, Fragmentation and Intervening too late.
Workforce – It emerged that 83 per cent of trusts which responded stated that they had experienced recruitment difficulties. Mental health nurses were the most difficult profession to recruit, followed by consultant psychiatrists. These recruitment challenges had led to an 82 per cent increase in expenditure on temporary staffing in the last two years. In 2015-16 nearly £50m was spent on agency staff by 32 trusts.
Funding - The £1.25bn over five years announced in March 2015 equates to £250m per year. Only £143m was released in the first year, and of that only £75m was distributed to local health leaders. It is not yet clear how much of this has been spent on frontline services. For 2016-17, £119m has been allocated to local areas, but this has been included in their total baseline allocation. It has not been ring-fenced and so there is a risk that it will be spent on other priorities.
Commissioning - A recurrent theme in our research was the complexity and quality of local commissioning (the system by which local services are planned and paid for). Commissioning is fragmented across national and local bodies, which causes conflict and confusion. Clinical commissioning groups and local authorities do not always have the expertise in mental health to design services effectively and hold them to account.
Data - Child and adolescent mental health services are still operating without the data they need to plan services effectively. There is no up to date information on how many young people need treatment and what the projected increase in prevalence is over the next five years, which makes it difficult for services to know by how much they need to increase capacity. Similarly, there is no nationally agreed measurement of waiting times or access thresholds, which means that it is very difficult to bench - mark performance and hold providers to account.
Fragmentation - A key barrier to delivering services more effectively is the way in which children and young people’s mental health care is delivered across so many different organisations. This causes fragmentation in the system and risks young people falling through the gaps between services.
Intervening too late - A consequence of the fragmented system is that young people frequently find it hard to access the care they need. Our research has found that this is often a result of a system which is set up to focus on specific diagnostic thresholds. While a diagnosis is important for the delivery of evidence-based treatment, there are young people with risk factors or symptoms which have not reached a particular diagnostic threshold who might benefit from early assessment, detection and intervention.
The reports urges Health Education England to work with provider trusts and local health and care commissioners to ensure that the workforce strategy to support CAMHS transformation covers recruitment and retention of key staff, improving the skill-mix between the different professions and covering training needs for specialist and universal staff such as GPs, health visitors and teachers.
In addition, it says there must continue to be a rigorous process of assurance of how local areas are planning to spend the additional investment and the development of local plans as part of the business planning process for the second year of implementation, particularly given the risk that the transition to baseline funding and ‘mainstreaming’ the plans will shift the focus away from children and young people’s mental health.
At a national level, there should a stronger focus on where action is needed across departments such as with schools and children’s social care, the commission concludes.
“Unless improving CAMHS services remain a top priority for the government… there is a risk that levels of access will remain the same, or even deteriorate. Our aim is to ensure the implementation of Future in Mind is as effective as possible in order to tackle the treatment gap outlined in our first report,” the report concludes.