Future in mind: the story so far


The Future in Mind strategy promises wide-ranging improvements to mental health provision for children and young people. Joe Lepper looks at the key proposals and assesses progress made to date.

Backed by £1.25bn in government funding, the Future in Mind strategy aims to overhaul children and young people’s mental health services by 2020.

Launched by the coalition government in March and taken forward now by the Conservative government, the strategy came in response to worrying findings from the Children and Young People’s Mental Health and Wellbeing Taskforce.

This found that three-quarters of children and young people with a mental health disorder are not receiving the appropriate support from Child and Adolescent Mental Health Services (CAMHS).

Meanwhile, as many as seven out of 10 children and young people with severe mental health problems are unable to access support early enough.

One in 10 children and young people aged between five and 16 have a mental health disorder, according to latest estimates.

The taskforce, which was set up by the coalition government in 2014, is calling for a range of improvements including better access to support, a greater focus on prevention and early intervention, more joint commissioning and a greater involvement of all children’s professionals to target and support this vulnerable group. So what is the progress so far in these key areas?

Transformation plans

In the summer, GP-led clinical commissioning groups (CCGs) were asked by NHS England to work with councils, local schools, youth justice groups and health and wellbeing boards to develop transformation plans, detailing how they intend to spend Future in Mind money to improve services during 2016/17, as well as looking ahead to future spending plans up to 2020.

These plans were submitted over September and October to NHS England, which will let them know this month whether they have been approved or need further work.

Strategic clinical networks, set up in each NHS England region to offer advice on commissioning issues, will offer further support if any parts of the plans need improvement, according to an NHS England spokeswoman.

NHS England hopes all plans will be published by the end of this year.

“The key thing we want to see is that they offer a truly joined-up strategy with clear involvement from schools, the voluntary sector and local authorities,” says Sarah Brennan, chief executive of the charity YoungMinds.

“We also want to see that young people are being listened to and that early intervention is key as this is the area where the cuts have been.”

YoungMinds is concerned adult mental health representatives are not being involved in drafting transformation plans in many areas, making it difficult to address problems around the transition between children’s and adult services.

“We have to be realistic about what these plans will achieve and we are not getting a sense from local areas that adult mental health services are being involved,” adds Brennan.

Commissioning

CCGs are taking the role of lead Future in Mind commissioner. It is anticipated that local arrangements will reflect “continued partnership working” with councils and other local partners, according to an NHS England spokeswoman.

Peter Fuggle, head of clinical services at child mental health charity the Anna Freud Centre, is sceptical about whether all CCGs are up to the task.

He says they are “variably equipped to take such leadership” and “there are substantial differences between CCGs in terms of how far they have been able to adopt the ambition of Future in Mind”. This is especially true when it comes to “their readiness to create joint integrated proposals”, he adds.

Royal College of General Practitioners’ clinical lead for mental health Dr Liz England – who is also mental health lead for Sandwell and West Birmingham CCG – believes Birmingham is a good example of an area where CCGs, councils, health trusts and local charities are working well together to commission improvements to children and young people’s mental health services.

Earlier this year, a group of CCGs in the city, led by Birmingham South Central CCG, put out a tender to providers to run a revamped CAMHS. This will see CAMHS support young people up to 25 in a system that has a stronger focus on prevention, early intervention and joint training.

The contract was won by a consortium of providers including The Children’s Society, Birmingham Children’s Hospital NHS Foundation Trust and Worcestershire Health and Care, with the new service set to launch in April 2016.

Ahead of this launch, councils, CCGs, school and health representatives are meeting every two weeks to further cement links, says Dr England.

Although this commissioning pre-dates Future in Mind, the CCGs have drafted transformation plans to ensure they can still tap into Future in Mind money.

“We were ahead of the game on this, but Future in Mind, our transformation plan and the extra money has enabled us to upscale the plans a little bit more,” she says.

Funding

While the extra funding for Future in Mind is welcomed by children’s mental health campaigners, the charity YoungMinds points out it comes amid years of savage funding cuts to CAMHS.

YoungMinds found out via a Freedom of Information Act request in July that £35m was axed from CAMHS budgets in 2015 alone.

Since 2010, an estimated £85m has been cut from CAMHS budgets and a fifth of councils have either frozen or cut spending in this area every year since 2010, the charity discovered.

CAMHS also still lags far behind adult mental health spending even with the extra Future in Mind money, explains Brennan.

“CAMHS was getting six per cent of the total mental health budget before Future in Mind,” she says. “All this does is increase it to eight per cent, so it will still be grossly underfunded.”

As a result, she believes Future in Mind should not be seen just in terms of extra funding, but “should also be an opportunity to do things more efficiently”. Key to this is slashing the number of mental health assessments young people have to undergo and making better use of mental health professionals.

“Within CAMHS, after your first assessment you may get referred to an eating disorder specialist for another assessment, then perhaps another with a self-harm specialist,” says Brennan. “This is very inefficient. There needs to be just one assessment that can pick up on these issues there and then.”

Fuggle of the Anna Freud Centre says Future in Mind’s focus on early intervention work is another way of using funding more sensibly, as it saves money in the long term by reducing the risk of a young person reaching crisis point.

But he is concerned the mental health sector has been blighted by a “short-sightedness of policy, commissioning and service leads” that makes it difficult for such a long-term focus.

Future in Mind is unlikely to rectify this short-term approach, warns Dr England, as it only commits funding up to 2020. She wants to see a funding system that allows commissioners to look at least a decade ahead. “The funding system doesn’t really work for mental health,” she says. “When you look at early intervention investment, you may not see the results of that work for years. That is why you have to have long-term contracts in commissioning.”

Despite concerns Future in Mind is still too short term, Warwickshire council leader Izzi Seccombe firmly believes the strategy and extra funding will significantly improve support for children and young people in her area.

This is particularly the case for the council’s mental health consultation, advice and training service to schools and other children’s professionals that “at the moment cannot meet the demand”, she says.

Seccombe, who is also the Local Government Association’s community wellbeing spokesperson, adds: “Future in Mind allows us to maintain the existing services we offer as well as deliver the change that is needed.”

In Warwickshire this includes “investing time and resources” to ensure that young people have a greater say in the design of local mental health support.

School involvement

All those who work with children, not just health specialists, are important to supporting children’s mental health, according to the Future in Mind strategy, which specifically wants to see stronger links between schools and CAMHS.

In addition, guidance published by the Department for Education in March also called for more counselling services to be made available in schools.

Fuggle agrees involving schools and other professionals in mental health support should be a “must have” within transformation plans. “The attitude that ‘children’s mental health is someone else’s problem’ has to end”.

But involving schools in CCG-led Future in Mind plans will not be plain sailing, says Kevin Gallagher, who until August spent four years placing independent psychologists into schools.

He says CCGs are used to a system where they can “engage with collective bodies” such as CAMHS and councils. But to engage with schools, they will need to cope with a far more disparate system, which includes academies as well as free schools “with no collective mechanism for them to work together”.

Schools are also more financially autonomous and, due to funding cuts to CAMHS, have already started to look to the independent sector to offer counselling on site, which adds even more layers to local mental health support.

Gallagher, who is now managing director of Amberleigh Care – a specialist therapeutic care provider for boys with inappropriate sexual behaviour – says pupil premium money for disadvantaged children has been the main source of funding used to draft in independent psychologists and therapists.

But this has left links between CAMHS and schools “almost non-existent at the moment”, he adds.

An Association of Teachers and Lecturers (ATL) survey of 850 school staff in March highlighted the erosion of this relationship, when almost half – 43 per cent – said their pupils were struggling to access CAMHS.

As Dr Wanda Wyporska, lead equalities officer at ATL puts it: “It is one thing to know when to make a mental health referral, it is another actually being able to make that referral if CAMHS are not available.”


Future in mind: key proposals

Promoting resilience, prevention and early intervention through offering counselling services in schools, a focus on mental health in personal, social and health education classes, and investing in parenting programmes to promote attachment between parents and children.

Improving access through involving the voluntary sector in developing single points of access in the community. There should also be more peer support and schools should consider appointing a named lead on mental health issues. The use of police cells to accommodate young people having a mental health breakdown should be banned, with access to in-patient care in health settings improved.

Care for the most vulnerable by being more flexible, ensuring vulnerable children are not discharged if they fail to attend appointments. Mental health assessments should also include a greater focus on possible causes of problems, such as neglect, violence or abuse. The victims of sexual abuse should be prioritised for support. Access and waiting time standards should also be developed for support for young people with an eating disorder, another priority group.

Improving accountability and transparency including making local spending by commissioners “fully transparent” and developing local measures for access, waiting times and outcomes, so local areas can be compared against a national average.

Developing the workforce through building child development knowledge into initial teacher training and joint training involving school staff and child and adolescent mental health specialists.

Improving partnerships across health, social care, education and the voluntary sector, particularly in commissioning.


Key dates

November 2015
NHS England checks Future in Mind transformation plans. Pending approval, funding is released from this month

The government’s Mental Health Taskforce, set up in March 2015, is due to publish its five-year strategy for mental health support across all age groups

December 2015
Transformation plans due to be published

November 2015 to April 2016
Clinical commissioning groups start commissioning Future in Mind funded services

2016 to 2020
Transformation plans reviewed and adopted across all local agencies, including councils


Passport helps avoid repetition of key facts

Too often, children and young people with a mental health problem have to repeat their story to a number of different professionals.

This causes unnecessary distress and slows down support, according to responses from young people, parents, carers and mental health professionals to an NHS England Future in Mind consultation.

The solution has been to create a “passport-style” brief of key facts that can be handed to professionals by young people.

Guidance was published in October by NHS England to encourage the development of this new resource across England. This includes the publication of a template passport, setting out information to be included such as history of diagnosis and any specific needs.

Professor Dame Sue Bailey, chair of the Children and Young People’s Mental Health Coalition, backs the idea, but warns it may be hindered in some areas by a reluctance across health and social care to share the information needed. “The words ‘data’ and ‘confidentiality’ frighten people as they think they will get sued if they share information,” she says.

Among those to have reservations about how secure information on the passports will be is Dr Liz England, the Royal College of General Practitioners’ clinical lead for mental health.

“What worries me is who holds it and how do we access it? If you receive multiple sources of care, how do we each make sure we all have a copy?” she says. “Yes, it should be held by young people, but I have two young kids and I wouldn’t trust them to look after anything, let alone a care plan.”

Local Government Association community wellbeing spokesperson Izzi Seccombe says passports are in the early stages of development in Warwickshire, where she is leader, but concedes work needs to be done for the NHS “to release some of their anxieties about sharing information”.

Another obstacle is prioritising its development at a time of wider funding cuts across the NHS. “Sometimes people are so dragged down by finance worries, they lose the thinking part of their brain,” says Professor Bailey. “All they can do is think about the moment rather than developing long-term ideas such as this passport.”

However, she is optimistic such barriers can be overcome due to the simplicity of the idea and the fact a passport-style card, or picture book, with health information is already used across the UK. “It is already used in some areas for those with learning difficulties, so it is hardly reinventing the wheel,” she concludes.

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