The government's implementation of its flagship children's mental health policy, Future in Mind, has recently been criticised by the House of Commons public accounts committee. Developed in 2015 in response to rising demand for services and widespread failings within the children's mental health system, the policy promised £1.4bn of additional funding for services, and to foster a "parity of esteem" between physical and mental health.
In order to receive a share of the funding, clinical commissioning groups were required to develop local transformation plans (LTPs), setting out how they would improve child and adolescent mental health services (CAMHS) in their area; working closely with commissioners and providers from social care, schools and the voluntary and community sector to ensure provision was joined up.
However, four years on, the committee says the government still has "no comprehensive, long-term plan" for how it will accomplish the reforms, and no clear picture "what the practical, meaningful outcomes" will be to establish a parity of esteem.
Accompanying this shift in mental health commissioning towards service improvement and integration with the wider system, is a process of transformation within the system itself. Faced with financial challenges and the necessity for health and social care services to work more closely together to meet the needs of a changing population, NHS organisations and local authorities came together in 2016 to form sustainability and transformation partnerships (STPs) on 44 geographical "footprints". Their approach is one of "placed-based planning", working together to deliver integrated services. Several STPs have now evolved into Integrated Care Systems (ICSs); where NHS organisations, in partnership with local councils and other agencies, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the local population.
Priority areas for transformation in each of the partnerships' plans vary depending on local need, but mental health features prominently in most. However, children's mental health charity YoungMinds has expressed concern that these plans do not adequately prioritise children and young people's mental health, which could "put national and local initiatives to improve services at risk". The charity's research identified that 77 per cent of STP plans gave "poor" or "partial" visibility on their commitment and strategy to increase access to children and young people's mental health services in line with government targets.
There is a risk that with an increase in decision-making and strategy development at STP level, commissioners' ability to develop and improve local CAMHS will be lost. The 44 STP footprints aligned poorly with geographical areas of the 122 LTPs, and further gaps were identified in the plans around meaningful engagement with children, young people and families and working with other agencies, including the third sector, to truly integrate mental health care.
If join-up between STPs/ICSs and LTPs can be achieved, there are opportunities to deliver meaningful and lasting improvement in children's mental health. Using a place-based approach to commission at scale, in a more integrated way, could remove some of the artificial geographical barriers to service access and enable young people's needs to be viewed more holistically. As long as the specific needs of children and young people are recognised within system-wide transformation plans, these may also enable smoother transitions to adults services by planning and commissioning over the life course - preventing the "cliff edge" of provision that vulnerable young people often face at 18. The first steps in this joining up of services have already been taken - the new NHS planning and contracting guidance calls on commissioners and providers to work together through STPs and ICSs to deliver on the reforms promised in the Five Year Forward View for Mental Health.
HOW TO DELIVER PLACE-BASED COMMISSIONING
- In the past, shared responsibility for commissioning and delivering services among different organisations in the system has led to fragmented provision and complex pathways of care. The Care Quality Commission recommends having a "shared understanding of local needs, clear agreements about the roles of different partners and clear priorities and action plans" to make it easier for local leaders to collaborate across the system.
- Collaboration is crucial to success. This means involving not only the different organisations and services within an area in planning and commissioning, but also children, young people and their families. Suffolk and North East Essex STP has recently won praise from its local Healthwatch group for taking a large-scale co-production approach to developing its mental health strategy, but this requires significant investment in time, finance, facilitation and system-wide support to achieve.
- The Education Policy Institute also recommends taking demand out of the system by addressing factors which can impact on children's emotional wellbeing: tackling child poverty, ensuring access to effective early intervention services, and having a schools workforce able to support children with additional needs.
- "Mental health services for children and young people", Commons public accounts committee, January 2019
- Access to Children and Young People's Mental Health Services - 2018, Education Policy Institute, October 2018
- Are We Listening? Review Of Children And Young People's Mental Health Services, Care Quality Commission, March 2018
- "YoungMinds calls for all STPs to prioritise children's mental health", YoungMinds 2018