How this translates to demand for services is seen in data collated by NHS Digital. This shows there were 344,000 children and young people referred to either CAMHS or adult mental health services in May 2017, of which 42,500 - 12.3 per cent - were accepted for treatment. During May, 106,000 children were receiving treatment, while 148,000 were registered as "in contact" with services.
Evidence shows that half of all lifetime mental health illness begins by the age of 14, yet analysis by the Children's Commissioner for England reveals that just 6.3 per cent of clinical commissioning groups' (CCG) mental health spending is on CAMHS, only 0.74 per cent of their total spending.
To try and address the historic underspend, the former Coalition government pledged an additional £1.4bn in 2015 to deliver the Future in Mind Strategy. The funding was to help CCGs implement local transformation plans to overhaul CAMHS. Under the strategy, health chiefs expect significant improvements in local child mental health services by 2020. However, CCG self-assessments of progress show that 60 per cent are failing to meet the expected rate of improvement, according to the Children's Commissioner for England Mental Health Briefing published last October.
Ensuring that Future in Mind reforms do not lose momentum in light of new measures in the children's mental health green paper will be key to improving local services.
Through measures in the green paper, the government has pledged £300m to train teaching staff in mental health awareness, appoint mental health leads in all schools and boost links between schools and CAMHS. The drive comes amid education unions warning about the rise in mental health conditions among pupils - a survey in November 2017 of 600 school leaders and governors by hub4leaders and Leeds Beckett University found more than four out of five reported there had been an increase in pupil mental health concerns since 2012.
In addition, 58 per cent said there was insufficient mental health provision in school, just 61 per cent indicated that staff were sufficiently trained to meet these needs and three quarters reported difficulties in obtaining local mental health care for pupils. The green paper plans aims to build on the school link pilots run in 2016/17, and the government hopes that the improvements in teacher knowledge, contact with CAMHS and referral handling reported by the pilots are replicated nationally.
Despite the Future in Mind funding and government pledges to improve access to services, CAMHS waiting times remain worryingly high, particularly in some parts of the country. The green paper includes plans for a four-week waiting time for accessing treatment.
A 2016 parliamentary inquiry raised concerns about the standard of mental health support for looked-after children, who experience higher levels of need (see research evidence). In response, the government pledged last year to appoint virtual leads to oversee looked-after children's mental health and introduce mental health checks for children when they enter care. However, some experts believe the government should go further by giving children in care priority status for accessing CAMHS. Some residential child care providers, such as Cove Care, have already developed specialist services to aid recovery for looked-after children (see practice example).
Here, five experts write about the key emerging policy issues on children's mental health, while the Association of Directors of Children's Services outlines the need to redesign the system so interventions are available when and where needed (see ADCS View, below).
SUPPORT IN SCHOOLS
By Jaime Smith, programme director for mental health and wellbeing in schools, Anna Freud Centre
The green paper includes a series of proposals to boost mental health support in schools. New "mental health support teams" will aim to improve joint working between schools and CAMHS. The teams will provide a wide range of support and treatments in or near schools and colleges, tackling problems earlier and speeding up referrals to CAMHS. A further £95m will be used to train senior school staff to become designated mental health leads.
The Anna Freud Centre has particular cause for celebrating the green paper because some of the key policies emerged from our research findings.
The research was based on a Department for Education funded programme, The Mental Health and Schools Link pilot, which aimed to strengthen joint working between schools and specialist children and young people's mental health services by delivering joint planning workshops.
The pilot looked at statutory mental health services for children and young people as well as the wider network of organisations working with children with differing levels of need. In all, 22 areas with 27 CCGs and 255 schools took part.
In spring 2017, an independent evaluation of the pilot was published. It found that by bringing together CCGs, schools and other organisations, teachers became more confident in promoting children's mental health and signposting them to the correct services (see graphics). Professionals from schools, NHS providers and other children's mental health services worked better together and shared knowledge and good practices. Many areas used the opportunity to develop new referral protocols and guidance for schools and "maps" of services. Some areas extended the programme to additional schools. Of particular value was having a single point of contact in schools. All of these principles are embedded in the green paper.
One of the interesting findings was that by learning more about mental health, schools were able to signpost to more appropriate services and offer more timely support.
We are now carrying out a larger programme working with 1,200 schools and colleges which will refine our understanding. We are already seeing great changes on the ground with schools and colleges working more closely with CAMHS.
LOOKED-AFTER CHILDREN
By Alison O'Sullivan, former co-chair of the expert working group on the mental health of looked-after children
There are great opportunities from the consultations on the green paper and new statutory corporate parenting guidance, but they also create the hazard that the particular needs of children in care could get lost.
In the desire to do "something" there is always the temptation to propose the easily achievable - real ambition is easily eroded particularly when money is tight. We know that the system is under pressure and that almost half of all children in care have a diagnosable mental health disorder. Their needs are often not fully understood and even when the right help is agreed there can be delays and inconsistency in support.
As they hold lead responsibility for corporate parenting, local authorities play a vital part in securing mental health support for children in care. However, we need to see strong leadership from all parts of the local system to create what have been dubbed "corporate parenting partnerships".
There is a long running debate about whether special treatment for children in care is justified. Overall children in care have higher needs and therefore should attract a commensurate higher level of support. Yes, specialist roles and specialist teams have a part to play and have been seen to be successful where these have been implemented, but actually doing the basic things right would represent a huge step forward. Until children in care get their share of help, we need to advocate for those children, to highlight the need for good services and to check whether the particular needs of these children are being properly met.
At a national level it's vital that the emerging proposals designed to improve support for children in care are linked together. We may have many of the right ingredients for change, but it will require real determination to see the connections across what is a complex system make real improvements.
For example, the proposal in the green paper that a person in every school oversees the mental health needs of children must include that children in care are always considered; the anticipated corporate parenting guidance must specify that the mental health needs of individual children in care should be addressed and local agencies must cooperate to fulfil their collective corporate parenting responsibility; and NHS England and public health leaders must ensure that local transformation plans meet the needs of children in care.
None of this is special treatment. It's doing the basics. It's corporate parenting in action - local authorities fighting for their children.
WAITING TIME STANDARDS
By Barbara Rayment, interim policy lead, Children and Young People's Mental Health Coalition
If implemented properly, waiting time standards for children and young people's mental health services (CYPMHS) could drive improvement nationally and put meeting the demand for CYPMHS on an equal footing with other areas of health.
The greater clarity and transparency targets should bring could also help reverse the postcode lottery for accessing services.
The green paper proposals will see these new waiting time standards piloted in a couple of areas at first. A careful introduction and testing process is important, but it must lead to wider change. We are yet to see a strong commitment and plan for national implementation.
There is also a lack of clarity around whether the waiting time standard is only to be applied in NHS-provided CYPMHS, or if it will also include other services such as those operated by the voluntary and community sector that are funded by the NHS. The help young people receive is both a matter of choice, and local service availability. That's why, as a minimum, we need to see commitment to testing this new standard in all relevant NHS-funded settings. Ideally the pilots will also include relevant services funded through both schools and local authorities - reflecting the complexity of funding arrangements of current provision. An effective waiting time standard will demand the whole system plays its part.
The pilot will also need to dive into the depth and complexity of what a young person's interaction with mental health support involves. We need to look beyond measuring only the point at which they have "access to treatment" by also measuring things such as the time it takes for first contact with a service through to general advice, an assessment, as well as any specialist intervention.
Good data collection is critical to transforming access to services. This means making sure services have the resources and capacity to properly measure and account for their work. This cannot be an afterthought and must be factored into the implementation costs from the outset.
DELIVERING FUTURE IN MIND
By James Kenrick, chief executive, Youth Access
Those looking for concrete proposals in the green paper on prevention, community-based services, the role of the voluntary sector, services for young adults or online provision will be disappointed. However, the proposals are explicitly intended to build on, rather than supersede Future in Mind's blueprint, which has been driving the transformation of children and young people's mental health services since 2015. This ongoing work has not been without its problems, some of them well-publicised, but evidence from our surveys of frontline youth advice and counselling providers offers promising signs of progress in many parts of England.
Two thirds of our members report at least some progress in their local areas towards the implementation of an early intervention approach. More than half report being in receipt of increased funding as a direct result of Future in Mind. We have also seen collaboration between statutory and voluntary sector providers improve considerably.
These gains are not insignificant, but haven't yet been realised in some parts of the country. The NHS funding crisis has led to resources intended for young people's mental health services being diverted to cover CCGs' deficits in some areas.
There are also major aspects of Future in Mind's vision where far too little progress has been made. Concrete action to address the social determinants of young people's mental health has been absent. We've seen little effective join-up with social care, youth services, housing and justice. High-quality co-production of plans and services with young people remains rare. Of greatest concern is mental health services for young adults, the age group that experiences the greatest gap between need and provision, seem to be deteriorating. Despite a consensus for Future in Mind's 0-25 approach, transformation funding is targeted at under-18s and we are yet to see adult commissioners making an appropriate contribution.
There is a need to move much faster on these issues. It is unacceptable that young people's rights to access age-appropriate mental health services are still being breached every day.
We cannot afford for commissioners and providers to become overly distracted by the green paper. Now is the time to increase the pace of service transformation across the system and redouble our focus on implementing Future in Mind's vision.
ADCS View: Inpatient care needs attention too
By Alison Michalska, ADCS president and DCS at Nottingham City Council
The systemic issues in child and adolescent mental health services (CAMHS) are well rehearsed: growing waiting lists, a shortage of clinical specialists and variability in the quality of care. CAMHS arrangements are dysfunctional, albeit unintentionally, which is resulting in gaps and duplication. Against a backdrop of rising demand, every penny counts, particularly as early help services are dependent on unstable and falling funding.
Dealing with issues sooner is the central focus of the green paper as is the role of schools in identifying children with mild to moderate needs and their role in signposting and support. Earlier access to support will help secure better outcomes. Schools are at the centre of their local communities and well placed to spot early signs of distress. The introduction of statutory personal, social, health and economic education in all schools will have a positive impact if children understand the importance of looking after their mental, as well as their physical, health and know how to access help if required.
It is surprising that the green paper does not actively address the challenges in accessing specialist in-patient beds for those with the highest level of need.
Last summer, the acute difficulties in securing a Tier 4 placement hit the headlines following an unprecedented intervention by Sir James Munby, president of the Family Court, on behalf of a 17-year-old girl. NHS England is looking at this provision, but greater engagement with children's services is required. The level and complexity of mental health needs being seen in children in secure children's homes, for whom Tier 4 beds are not available, would seem to indicate that demand is high and rising. This cannot be ignored.
I hope that greater synergy in health and children's social care will be a priority for the government in 2018. Commissioners and providers of CAMHS must work with children and their parents and carers, to design a system that delivers services when and where they are needed, at weekends and utilising digital solutions. We need to find a way to break down professional barriers and join up the key commissioners - NHS England, clinical commissioning groups and local authorities. This will be no small task, but it must be done.
Provider View: We need a population approach to children's wellbeing
By Paul Burstow, chair, Social Care Institute for Excellence, and chair, Tavistock and Portman NHS Trust
Most life long mental ill-health has its first signs in the teenage and early adult years, its roots running back still further. Despite this, nowhere is yet investing at the scale necessary to avoid the consequences of acting too late.
The green paper said little on the transition from child and adolescent mental health services to adult services (CAMHS), yet the evidence points to this being in urgent need of attention. At the moment when teenagers and young adults are most likely to have need of mental health support the systems is at its most fragile. Arbitrary age cut offs have no place in transitions and decisions should be person centred, based on the individuals' readiness and circumstances.
At the heart of what is needed is a population approach to the mental health and wellbeing of children and young people. By scaling the support and the services for children and families we can bolster their resilience and respond earlier to their needs, as well as getting help quickly to those who need it.
Similarly, understanding the critical role of context, environment and relationships in shaping who we are and how well we function and feel is crucial.
This informed development of attachment theory at the Tavistock centre in the late 1950s, and recently it has helped us to shape the Thrive model for CAMHS. We deliver the Thrive model in Camden and with our partners are spreading it across England including in Greater Manchester.
It is now widely accepted that accident and emergency departments function best when senior clinical expertise is deployed at the front door holding risk and ensuring people get the right care in the right place. The quality of decision-making improves patient outcomes and ensures the best use of resources. Our experience of implementing Thrive has put this principle at the heart of improving the mental health of children and young people.
If the green paper is to realise its potential government must acknowledge the scale of the task and commit to sustained investment.
FURTHER READING
- Transforming Children and Young People's Mental Health Provision, DfE and Department of Health, December 2017
- Mental Health Briefing, Children's Commissioner for England, October 2017
- Mental Health Services and Social Link Pilots: Evaluation, Ecorys for DfE, February 2017
- Progress and Challenges in the Transformation of Children and Young People's Mental Healthcare, EPI, August 2016
This article is part of CYP Now's special report on Children's Mental Health. Click here for more
