Special report: Childrens Mental Health

Clare Jerrom takes a look at the government’s proposals to improve childrens mental health services and why the plans have been criticised as ‘lacking ambition’.

The government has pledged to improve children and young people’s mental health services and published a green paper late last year.

Transforming Children and Young People’s Mental Health Provision: a Green Paper stated that “a huge programme of work is underway to transform children and young people’s mental health services”.

However, the consultation acknowledged that in some cases, NHS support for children and young people experiencing mental health problems is only available when they reach crisis point and problems get really serious. Furthermore, support is not consistently available across the country, and young people can sometimes wait too long to receive that support.

The consultation then set out proposals to “represent a fundamental shift in how we will support all young people with their mental health”.

Yet the joint select committees of education and health and social care criticised the green paper saying it “lacks ambition and will provide no help to the majority of those children who desperately need it”.

Chair of the education committee, Rob Halfon MP, said: “The government must back up its warm words by taking urgent action to address the mental health issues which children and young people face today. This strategy does not go far enough, which raises the very real prospect of hundreds of thousands of children missing out on the getting the help they so desperately need.”

The green paper outlined a three-prong attack in order to improve children’s mental health:

  • Incentivise and support all schools to identify and train a Designated Senior Lead for Mental Health with a new offer of training to help leads and staff deliver whole school approaches to promoting better mental health.
  • Fund new Mental Health Support Teams to provide specific extra capacity for early intervention and ongoing help, supervised by the NHS children and young people’s mental health staff whose work will be jointly managed by schools and the NHS.
  • Reduce waiting times for NHS services for children and young people who need specialist help.

Designated Senior Lead for Mental Health

Nearly half of schools and colleges have a mental health lead and the role can be successful in promoting a whole school approach to improving mental health.

The role of the leads would likely include:

  • Having oversight of the whole school approach to mental health
  • Supporting the identification of at risk children exhibiting signs of mental health problems
  • Have knowledge of and links to local mental health services
  • Co-ordinating the mental health needs of pupils and have oversight of the delivery of interventions
  • Supporting staff and raising awareness of mental health among staff
  • Overseeing the outcomes of interventions

Training will be rolled out to all areas by 2025, the government said.

Mental Health Support Teams

Schools and colleges need a collective understanding and up-to-date knowledge of children’s mental health services provided locally and access to specialist help. Evidence has suggested that better collaboration between schools and mental health services can improve the mental health support available locally, said the green paper.

The new Mental Health Support Teams will work with Designated Senior Leads for Mental Health in schools and colleges and provide extra capacity locally for addressing the needs of children and young people with mild to moderate mental health problems. They will also provide the link with specialist mental health services to enable young people the access to specialist support when needed.

Specific interventions could include Cognitive Behavioural Therapy, Family-Based behaviour change and group-based intervention.

The green paper highlights that these teams will support existing effective provision in the area by training other professionals including social workers, family workers and early help workers. They will also provide an assessment and referral function and additional support during treatment.

A new waiting time standard

The green paper states that the government wants improved support for mental health linked to schools and colleges to be complemented by swifter action to specialist services. There is currently variation across the country in terms of waiting times from four weeks to 100 weeks for the time from referral to treatment. The average wait is 12 weeks.

Trailblazers will be established to reduce waiting times to enable young people to access NHS-funded services within four weeks. These pilot projects will explore the best ways to reduce waiting times. Evaluation of the projects will examine the impact the Designated Senior Leads for Mental Health and the mental Health Support Teams have on referrals to specialist NHS services. While the government predicts that the lead and teams will reduce the number of children accessing specialist services by increasing early intervention services, the impact will be examined at evaluation.

The government pledged to roll out the new approach to between one fifth and one quarter of the country by the end of 2022-23. A number of trailblazers would be operational from 2019, it added.

Not ambitious enough

However, on the publication of the joint report by the education and health and social care committees last month, chair of the health and social care committee, Dr Sarah Wollaston MP, said: “The green paper is just not ambitious enough and will leave so many children without the care they need. It needs to go much further in considering how to prevent mental health difficulties in the first place. We want to see more evidence that government will join up services in a way which places children and young people at their heart and that improves services to all children rather than a minority.”

The joint report ‘The government’s green paper on mental health: failing a generation’, said: “The narrow scope does not take several vulnerable groups into account, and the proposals put significant pressure on the teaching workforce without guaranteeing sufficient resources. There is also little or no attention to prevention or early intervention. The suggested speed of delivery will leave hundreds of thousands of children with no improvements in provision for several years and with possibly worsened provision if staff leave to join trailblazer areas elsewhere.”

Concerns raised with the committees during their inquiry included:

  • The potential adverse effects of the current exam and testing system on young people’s mental health
  • The lack of action on addressing the transition to adult mental health services
  • The lack of commitment to specific action to address the higher level of need in particular demographic groups, including looked-after children, those in the criminal justice system, those who are in alternative provision and/or off-rolled, and those not in education, employment or training
  • The impact of social media on young people’s mental health
  • The lack of specific action for apprentices and further education
  • Whether the proposed trailblazer approach may inadvertently lead to increased inequality in service provision; and
  • The lack of detail about the training provided for Designated Senior Leads for Mental Health and the voluntary nature of the role.

Long timeframes

The committees also heard about potential risks to implementation of the green paper, such as the capacity and capability of the health and education workforce to meet the additional demands of the green paper proposals.

Further potential risks include the availability of prevalence data to support service development and monitoring as well as data sharing between health, social care and education services. Issues of accountability regarding service provision and funding were also raised as potential risks.

“The long timeframes involved in the strategy will leave hundreds of thousands of children and young people unable to benefit from the proposals. Rolling out the plans to only “a fifth to a quarter of the country by 2022/23” is not ambitious enough. We advocate more widespread implementation and iterative learning methods to inform best practice across the piece,” said the report.

The Association of Directors of Children’s Services welcomed the emphasis on early intervention in the green paper and the acknowledgement that schools play a vital role in the early identification of children with mental health difficulties.

However, their response to the consultation outlined that local authorities have “a unique role” working with schools and health partners to design, commission and deliver a range of early help services and stated that it was “disappointed” that the green paper had not acknowledged that within its main proposals. It added that additional funding should be routed to local authorities in order for them to develop plans in partnership with Clinical Commissioning groups in a bid to prevent funding becoming “lost” within the NHS.

‘It doesn’t go far enough’

It also warned that funding, while welcome, needs to be part of a long-term sustainable funding strategy.

“The proposed scale and pace of the roll out is disappointing and could further compound the postcode lottery in terms of access to services that many young people experience,” the ADCS added.

The Local Government Association added: “If we truly want to get the best for children and young people, we must take practical steps to create a society where good mental health is treated as just as important as good physical health. The consequences of not tackling poor mental health early can be lifelong.

“We therefore welcome the green paper’s focus on earlier intervention with further investment and the emphasis on a whole school approach to providing early support for children and young people. We hope this will help children receive help as early as they need it and avoid escalation that is both costly and not as effective.

“But, we believe the green paper doesn’t go far enough to resolve some of the real capacity challenges that children and young people are experiencing to get the vital care they need. With only an estimated quarter of the country‘s children benefitting from the four week timescale by the end of 2021/22 and promised funding dependent on future spending decisions, many children will still be left without access to treatment and current reforms may be at risk.

In response to the joint committees report, Cllr Richard Watts, Chair of the LGA’s Children and Young People Board, added: “We are pleased the committees share our concerns that the government’s proposed schemes will not be rolled out until 2022/23. This risks leaving many young people without vital support. Children and their families need help and support right now - depression, anxiety, bereavement, and family crises do not wait.

“If we are to tackle the crisis in children’s mental health, we need a root-and-branch overhaul of existing services. We need to develop a system that says yes, rather than no, to children when they ask for help.

Stark warning

Adding her comments to the joint committee’s report last month, children’s commissioner for England Anne Longfield said: “The select committee’s stark warning about the scale of the crisis in children’s mental health services mirrors what I have been saying for some time. Many thousands of children are failing to receive support and care when they need it and too often referrals for treatment are only being made when a child reaches crisis point. In the worst cases, children have even attempted to take their own life just to access services.”

“The committee is right to say the green paper is not ambitious enough. It is time for the government to set itself an ambitious deadline, with staging posts along the way, to deliver a fully joined-up system that closes the gap between spending on adult and children’s mental health services, introduces proper monitoring of need and access, and invests more in early intervention so that problems are dealt with before they become critical,” she added.

Joint action across government

Furthermore, the Care Quality Commission published a report ‘Are we listening? A review of children and young people’s mental health services’ in March which concluded that many children and young people experiencing mental health problems do not get the kind of care they deserve. The system is complicated, with no easy or clear way to get help or support, it added.

“We saw examples of services with caring and dedicated individuals who put children and young people at the centre of what they do. But these people are often working long hours, with limited money and an increasing demand for their services to overcome barriers to providing high-quality care. This cannot be maintained in the long run,” said the report. “Things need to change at the top, so those working with children and young people have the support they need to be able to provide the best care.”

The CQC recommends:

  • The Secretary of State for Health and Social Care should make sure there is joint action across government to make children and young people’s mental health a national priority, working with ministers in health, social care, education, housing and local government
  • Local organisations must work together to deliver a clear ‘local offer’ of the care and support available to children and young people
  • Government, employers and schools should make sure that everyone that works, volunteers or cares for children and young people are trained to encourage good mental health and offer basic mental health support
  • Ofsted should look at what schools are doing to support children and young people’s mental health when they inspect

In 2019/2020, the CQC will report on the progress the different organisations have made to act on the recommendations in the report.

Meanwhile the joint committees are awaiting a response to their report and the government is also analysing feedback to the green paper consultation, which closed in March. The government’s respective responses will confirm whether the sector’s fears have been heeded and acted on and whether their future plans are ambitious enough to make the changes clearly needed to improve children and young people’s mental health services and ensure young people get the help they need, when they need it.

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