Latest figures published by the Health and Social Care Information Centre (HSCIC) show that, as of 31 March, there were 223,680 "open referrals" for under-18s within the National Health Service. The impact on the lives of young people who experience mental health problems in childhood can be devastating and enduring: those with conduct disorder, such as persistent disruptive and aggressive behaviour, are twice as likely to leave school without any qualifications; four times more likely to become a drug addict; and 20 times more likely to be imprisoned.
Despite these stark statistics, the amount of money invested in child and adolescent mental health services (CAMHS) has stayed at roughly six per cent of the overall NHS mental health budget over the past decade. In fact, figures provided through a parliamentary answer last year by then health minister Norman Lamb showed spending on children's mental health services had fallen £50m in real terms between 2009/10 and 2013/14.
The failure for CAMHS funding to keep pace with demand - combined with more recent austerity measures resulting in cuts to local authority-run mental health support services - has had a significant effect on levels of provision. The average wait for appointments for psychological therapy was 32 weeks in 2015/16, according to NHS England's Five Year Forward View for Mental Health.
A more recent survey of CAMHS provision carried out by the Office of the Children's Commissioner for England found just 34,700 (14 per cent) of the 248,000 young people referred to CAMHS in 2015 received immediate provision (see graphics). Meanwhile, 144,000 were put on a waiting list, with the average wait for those with "life-threatening" conditions being nearly four months; while 69,500 were not allocated a service at all.
Inpatient care concerns
In addition to community services struggling to cope with demand, concerns have also arisen over inpatient care. HSCIC data shows 175 under-18s were detained in hospital wards at the end of March. However, in recent years, children have been detained in police cells and placed in hospitals hundreds of miles from their home area due to a shortage of age-appropriate beds. In 2014, the government provided an extra £7m to commission an additional 50 inpatient beds in an effort to tackle the problem.
It is not the only new investment in the children's mental health system. On the back of the Conservative/Liberal Democrat coalition's pledge for more funding for children's mental health services, the government last year unveiled a £1.4bn package to fund improvements to services from 2015 to 2020. It will deliver some of the key recommendations in the Children and Young People's Mental Health and Wellbeing Taskforce's Future in Mind report, including reduced waiting times targets, improved access to perinatal care and more eating disorder services for adolescents.
The extra funding has been accompanied by a legislative drive across government. Department for Education minister Sam Gyimah has responsibility for child and mental health services, and for strengthening links with the Department of Health (DH). This in turn has led to a host of large and small-scale initiatives, including a national programme to redesign how CAMHS is delivered across the country (see Frank McGhee comment, below), a DfE-backed England-wide trial of peer mentoring in schools, and roll out of the Children and Young People's Improving Access to Psychological Therapies (IAPT) scheme. Here is a summary of some of the key pieces of legislation and policies:
No Health Without Mental Health - Implementation Framework
Published in July 2012, the implementation framework for the 2011 Mental Health Strategy No Health Without Mental Health set out how schools and local authorities should work together to promote children and young people's wellbeing and deliver parity of esteem between physical and mental health services. This was followed by Closing the Gap, a strategy that set out two major commitments for young people:
- The expansion of Children and Young People's IAPT countrywide by 2018
- Introduction of the special educational needs (SEN) code of practice and more support for schools to help them identify problems sooner.
Waiting time standards
In late 2014, the first waiting time standards for mental health services were introduced. By April 2016, it wanted to see:
- 75 per cent of people referred for talking therapies to start treatment within six weeks and 95 per cent within 18 weeks
- Half of people experiencing a first episode of psychosis to get help within two weeks of referral
- Commit to implementing waiting time standards for mental health services by 2020.
Eating disorder services
A five-year £150m investment was announced in 2014 by the then coalition government, linked to the introduction from 2017/18 of new waiting time standards for accessing treatment for eating disorders. This will require young people to be seen by a specialist within one month of being referred, or within a week for urgent cases.
Future in Mind
In the March 2015 Budget, the chancellor announced an additional £1.25bn for children's mental health to deliver the recommendations of the Future in Mind strategy. Of this:
- £1bn was earmarked for improving services so that 110,000 additional young people can be seen by CAMHS by 2020 within the timescales set out in access standards
- £118m was allocated to fund children and young people's IAPT across the half of the country not yet covered by 2018/19
- £75m to boost perinatal and antenatal mental health support for women. This was later increased to £290m so that 30,000 additional mothers will be able to access specialist care.
- £75m given to clinical commissioning groups (CCGs) and local health partners to develop and implement local transformation plans for children's mental health services
- £1.5m to pilot joint training for designated leads between CAMHS and schools
As part of Future in Mind, the DH commissioned the first national survey of children and young people's mental health since 2004. When it reports in 2018, the intention is for the survey to be used to shape future service developments. It also emphasises the important link between parent and infant mental health, and calls for an expansion of programmes to strengthen parent/infant attachment, such as Parent Infant Partnerships (see NorPIP practice example).
Mental Health Taskforce
This independently chaired review for NHS England made a series of recommendations for improving mental health outcomes over the next five years, including that 70,000 more children should have access to high-quality care when they need it.
Policing and Crime Bill
This bill going through Parliament now includes measures to stop instances where people, including some under-18s, are held in a police cell as a "place of safety" for up to 72 hours while waiting assessment by a mental health crisis team. Cells and some adult hospital wards have been used as "places of safety" because of the shortage of age-appropriate inpatient facilities in some regions, notably the South West.
The Crisis Care Concordat, published in 2014, asked NHS areas to sign up to banning the use of police cells as places of safety - latest figures showed their use fell by about half between 2014 and 2015. But by amending the Mental Health Act 1983, the new bill will ban the use of police cells as places of safety for all under-18s.
Mental health in schools
The important role schools and other education settings play in supporting the mental health and wellbeing of children has been recognised for more than a decade, with children's mental health charities such as Place2Be, YoungMinds and 42nd Street (see practice example) running school-based support programmes. In recent years, the DfE has made schools the focus of much of its work to boost support, despite axing its mental health in schools champion Natasha Devon in May. Initiatives include:
- Creation of the MindEd education resource to help teaching staff identify problems in pupils
- Non-statutory guidance for teachers on supporting pupils and where to turn for help
- Publication of a blueprint for school counselling services that offers schools advice on how to deliver high quality counselling
- Guidance from the PSHE Association on providing age-appropriate teaching about mental health problems across the key stages
- School Link Pilots to test a named single point of contact in 255 schools across 22 areas to improve joint working across services
- DfE ministers have expressed a desire to expand school peer mentoring, with national guidance on good practice to be produced for schools
- Focus on subjects that build pupils' resilience, character and wellbeing in the curriculum.
Children's services and health commissioners are starting to think more creatively about how they best meet pupils' mental health needs. Through work undertaken as part of its CAMHS transformation plan, Oxfordshire CCG has developed a service where health and care practitioners are placed in every secondary school in the county to provide support for pupils and give advice to teaching staff, who can also access a helpline staffed by specialists.
In Lincolnshire, an advice service has been set up, while teaching staff are also being trained by CAMHS in how to identify problems and where to refer pupils. Meanwhile, redesigned care pathways better integrate education and health services (see practice example, p28).
Children with mental health conditions have a higher probability of experiencing health and social problems in adulthood. Disadvantaged children are also at greater risk of developing problems - research has shown that two-thirds of young people in custody have one or more mental health conditions, while 60 per cent of looked-after children have some form of mental health problem (see research evidence).
Such levels of impairment can have a significant effect on school attainment - HSCIC data shows 44 per cent of children with emotional disorders were behind in their intellectual development, while a third of children with a conduct disorder were two or more years behind - with vulnerable groups below the national averages for GCSE grades.
The trauma of abuse on children's mental health is also increasingly being recognised, with services such as Achieving Change Together to help victims of child sexual exploitation in the North West being developed by agencies (see practice example).
Future in Mind: Delivering local transformation plans
By Frank McGhee, national transformation adviser, children's mental health, NHS England; and director of integrated commissioning, Derby City Council and Southern Derbyshire CCG
When I first read the Future in Mind report, I said to myself ‘what an opportunity'. Future in Mind set out a vision that acknowledged the experience of children and young people in their families, in their schools and in their communities. It asked us what we could do together to deliver a better response to the overwhelming need in our communities. It has made us think how those of us in children's services - from schools, general practice, public health nursing, child health services, early help, social care, youth provision, the voluntary sector and, of course, our mental health provision - can really work better together every day.
It was good to see NHS England's five-year strategy for mental health, published in February, reiterate the message that simply increasing capacity in services is not enough. We all recognise the need for a whole-system response that includes improving the skills of staff, trying new ways of working, engaging with children and young people throughout and getting better at recording the impact and difference we make.
There was an added bonus when Future in Mind was published: extra investment to support this transformation to build capacity and capability. For the first time in my career, sustained, significant additional resources are being made available to improve how we respond to children and young people with psychological or mental health distress.
We need to harness this alignment of policy, funds and public interest. There has been progress over the past 15 months. There are now 123 Local Transformation Plans in place and being delivered (see Lincolnshire practice example, p28), while plans to improve children and young people's mental health are feeding into whole-system Sustainability and Transformation Plans. There is investment in evidence-based provision, as well as the testing of new ways of working such as with schools. Cross-agency partnerships are firmly in place in many parts of the country and there is a real spirit of joint effort to make the best of this opportunity. But we need to do more.
My own area has the same challenges many local authority and clinical commissioning group (CCG) staff are experiencing as we move from planning to delivery. We are all facing increasing demand for services, the need for additional workforce and capacity pressures. What I hadn't anticipated then was that I would be joining NHS England working to support continued integration and joint working across England.
These challenges help our focus. We must develop new ways of working across professional groups, and co-produce the future. As children's services continue to change, this is our opportunity to embed interventions and tools that make a real difference to how an individual responds to psychological or mental health distress. We need to keep our foot on the accelerator as we are already a year into a five-year programme. The extra funds allocated to CCG baselines for the next five years allows us to plan with confidence, refresh our plans and build upon our progress year on year.
‘Funding must filter down to the frontline to deliver Future in Mind reforms'
By Sue Bailey, chair of the Children and Young People's Mental Health Coalition
There is unprecedented interest in children and young people's mental health. Future in Mind sets out the blueprint for improving children's mental health, and was reinforced by the Mental Health Taskforce report. While the sector is largely behind Future in Mind, we need to ensure that it is fully implemented, so that every child and young person has easy access to high quality mental health support, where, when and how they need it. Previous policy often failed because it was never fully implemented.
An extra £1.4bn over five years was announced for children and young people's mental health, but there are real concerns that it is not reaching the frontline. The funding was put into clinical commissioning groups' (CCG) baseline allocations, so it can be spent on competing priorities. The Department of Health has said that it has "no legal power to ringfence funding allocated to CCGs".
Local authorities, who commission early intervention services, have faced huge cuts to their budgets in recent years. Possibly as a result, there have been increased referrals to specialist NHS child and adolescent mental health services, resulting in a bottleneck in the system with longer waiting times and tighter criteria for referrals.
Local Transformation Plans - recommended in Future in Mind - require local areas to outline how they will transform services. While all plans have been quality assured by NHS England, there are concerns about how well they consulted children and young people, and engaged with stakeholders such as schools. These plans are supposed to be living documents, so hopefully they will be improved when refreshed. However, there are concerns regarding the implications the new Sustainability and Transformation Plans will have on local plans to improve services.
Schools have an important role to play. Like the NHS, they have budgetary pressures and problems with staff retention, but schools need to be part of the local transformation work and get a share of available funding. The concern is that there is not always a joined-up approach, with all local stakeholders working together.
To implement Future in Mind, we need a workforce that has the range of skills needed to promote mental health as well as treat problems. Health Education England is looking at new ways of delivering training for child psychiatrists, building the workforce to deliver psychological therapies and to further enhance the skills of the current workforce, for example in early intervention psychosis teams. But we need to consider the rest of the children's workforce, such as teachers.
A challenge still to be met is how we persuade policymakers across government departments to invest in early intervention to achieve sustainable healthcare for all. This is the ultimate values-based and value for money solution to healthy, emotionally flourishing children. Given the way the world is changing around children and young people, it's more important than ever to provide the social scaffolding needed to support them.