Health Committee
Oral evidence: Children’s and Adolescent Mental Health and CAMHS, HC 1129
Tuesday 1 April 2014
Ordered by the House of Commons to be published on 1 April 2014.
Written evidence from witnesses:
– Dr Jane Roberts, Royal College of General Practitioners National Clinical Champion for Youth Mental Health
– Professor Peter Fonagy, National Clinical Lead, Children and Young People’s Improving Access to Psychological Therapies programme
– Dr Peter Hindley, Chair of the Faculty of Child and Adolescent Psychiatry, Royal College of Psychiatrists
– Sarah Brennan, Chief Executive, YoungMinds
– Barbara Rayment, Chair, Children and Young People’s Mental Health Coalition
Members present: Mr Stephen Dorrell (Chair); Andrew George; Grahame M. Morris; Andrew Percy; David Tredinnick
Questions 63-146
Witnesses: Dr Jane Roberts, Royal College of General Practitioners National Clinical Champion for Youth Mental Health, Professor Peter Fonagy, National Clinical Lead, Children and Young People’s Improving Access to Psychological Therapies programme, Dr Peter Hindley, Chair of the Faculty of Child and Adolescent Psychiatry, Royal College of Psychiatrists, Sarah Brennan, Chief Executive, YoungMinds, and Barbara Rayment, Chair, Children and Young People’s Mental Health Coalition, gave evidence.
Q1 Chair: Thank you very much for joining us this afternoon. I am sorry that we are slightly thin on the ground; there is a competing interest in the form of a Second Reading of the Finance Bill on the Floor of the House this afternoon so we do not have quite as full an attendance from the Committee as normal. This is, none the less, an important inquiry and we look forward to this evidence session. I open it by declaring a personal interest as an unpaid trustee of Place2Be, which I am sure the panel are aware is a charity committed to the delivery of psychological therapies in schools. It is an interest that I have, wearing another hat. Having got that off my chest, could I ask our witnesses to introduce themselves, please?
Dr Roberts: Good afternoon. I am Dr Jane Roberts. I am an academic GP. I am the nominated youth mental health clinical champion of the Royal College of General Practitioners. We have this year announced youth mental health as a clinical priority. I am a practising GP in the north‑east of England and an academic GP who has done on GPs’ responses to young people with psychological difficulties.
Professor Fonagy: Good afternoon. My name is Peter Fonagy. I am professor of clinical psychology at University College London. Currently I am also national clinical adviser to the Children and Young People’s Improving Access to Psychological Therapies programme. I am also chief executive of the Anna Freud Centre and hold a number of positions as visiting professor at various US universities, including Harvard and Yale.
Dr Hindley: I am Dr Peter Hindley. I am a consultant child and adolescent psychiatrist at St Thomas’s and I am representing the faculty of child and adolescent psychiatry of the Royal College of Psychiatrists.
Sarah Brennan: Hello. I am Sarah Brennan. I am the chief executive of YoungMinds, which is a national charity championing children and young people’s mental health and emotional wellbeing.
Barbara Rayment: Hello. My name is Barbara Rayment. I am chair of the Children and Young People’s Mental Health Coalition, but in my day job I am director of an organisation called Youth Access, which is the national membership body for information, advice and counselling services for young people.
Q2 Chair: Thank you very much for that. Looking through the evidence that the Committee has received since we issued a call for evidence in connection with this inquiry, one or two quite choice phrases come out of it. Child and adolescent mental health services have been described as “a system under siege,” and have reported “significant reductions in resources,” and all of that is against a background of rising demand. To set the scene, could each of our witnesses describe how you perceive these services? Most importantly, are they services that face rising demands and, if so, why is that the case and how are the services responding to the patterns of demand that they are experiencing?
Dr Roberts: It is a complex subject to discuss pithily. In terms of children’s and young people’s presentations within general practice, it is a difficult one in the sense that very often the children and young people whom we see are there through parental direction: parents have booked the appointment, navigated the system—because they are all changing—and they have managed to get them there. They are not accessing services in the same way as some of the organisations that Barbara and Sarah will have close familiarity with, which are directed for young people to access themselves, so already we are involved in pictures where you have parental mental health impacting on children.
Then we have our own difficulties with the assessment of children and young people with psychological difficulties, which I am sure we will refer back to in this meeting today, specifically around the fact that between 30% and 40% of GPs at the point of being independent practitioners will have had no prior experience in their postgraduate years of seeing children and young people, because there is no mandatory requirement to do that. You have the situation of parents very often, or young people themselves—but, as I said, it is typically family driven—who are accessing help, often at the point of need and of crisis, with the GP feeling relatively unskilled about dealing with it and then being aware of demand on services into which they can refer. We have all faced the situation of realising that CAMH services are under pressure and therefore thresholds are very often raised. Many GPs talk to me about getting referrals bounced back because they are not quite meeting the criteria, and then wondering how they respond to that.
Q3 Chair: Thank you. Let us go through the panel.
Professor Fonagy: The first part of your question was about rising demand. The answer to this is quite complicated. There is evidence of increase in particular categories of mental disorder from epidemiological studies. For example, for a very serious problem like deliberate self‑harm, the prevalence of that in the average school may be as high as 15% or 16%, which is very different from when we were young. It is obviously a very worrying thing because it is very highly associated with suicide, which is one of the leading causes of death for youngsters—adolescents certainly.
For other disorders, such as eating disorders, depression and conduct problems, there is also a suggestion that the trend is towards an increase. This sounds like terrible news, but another way of looking at it is that all of us in society have worked incredibly hard to make mental disorder more acceptable, and for people to declare that they have a mental health problem. More young people presenting with mental health problems is also probably an indication of them feeling that it is acceptable to do so. We know that only a small fraction of those who actually suffer mental illness are known to services in this country, particularly among young people; it is probably less than a quarter. That is part of the increase in demand, but I have to say that the tiered nature of child and adolescent mental health services means that tier 2 to tier 3 CAMHS depend on adequate tier 1 services. If we are putting more pressure on young people and we are not making available resources that would guide and help them to cope with that pressure within schools, at the ordinary level of their societal experience—whether it is schools, youth clubs or whatever—or if there are insufficient resources at that point, obviously it is going to create an upward pressure, which will be then very difficult for CAMH services to deal with. But that is just part of it.
Q4 Chair: In tier 2, as you define it, are they all subject to referral from GPs or are they typically direct access?
Professor Fonagy: No; under the service transformation that we are trying to bring about, even at tier 3 we are trying to encourage self‑referral. In fact, a recent study has shown that GP referrals are most likely to be turned back. A study from Cambridge has shown that in GP referrals the GPs are—I think that was something that Dr Roberts indicated as well—in some ways the least knowledgeable about what are appropriate referrals. Referrals from social services and from education are much more likely to be taken up by CAMHS at the moment. This is not a desirable state of affairs, but it is indicative of the level of distress that social services and education are willing to tolerate before making a referral. I think that may also be the level at which resources are being heavily drawn upon.
Chair: Thank you.
Dr Hindley: The information I have is from returns from the members of my faculty, so it is presentations to services, and it does not necessarily reflect underlying epidemiological findings, but I would very much support what Professor Fonagy said: presentations of self‑harm seem to have increased very significantly over the last three to four years. Various of my members reported increased referrals of autistic spectrum disorders, eating disorders and a wide range of emotional problems. Again, I would very much concur with what Professor Fonagy said in the sense that I think, in part, this reflects difficulties lower down in the tiers, particularly tiers 1 and 2, where there would have been a buffering in days gone by. Services such as youth services and parenting services would have absorbed a lot of the distress that young people and families are experiencing. The absence of some of those services in some parts of the country may partly explain some of the increased presentation. The other thing we need to bear in mind is that often these services are delivered by local authorities who are facing major dilemmas as to which services they should be funding. It is not an easy task that they face.
Another thing we probably all need to bear in mind is that we know that times of economic hardship often coincide with increasing prevalence rates. The figures for adult suicide have gone up since the period of economic hardship. That may partly explain some of the increase in self‑harm, for example, because young people are particularly exposed to some of these difficulties if they come from more deprived backgrounds. Young people are much more subject to unemployment than older people. That would be worth bearing in mind.
Q5 Chair: Would it be unfair to describe the picture you are painting—all the witnesses so far—as based on experience and impression, rather than analysis of why the services are experiencing rising levels of demand?
Dr Hindley: Certainly in terms of the funding, the CAMHS benchmarking report in 2013 confirms the picture that particularly tier 1 and tier 2 services have been badly affected by the loss of the district grant. It is called the area grant, isn’t it?
Professor Fonagy: That is right.
Dr Hindley: That has confirmed it at an official level. Certainly the figures that have been collected show an increasing presentation to CAMH services. It is not just an impression; it is also supported by statistics.
Sarah Brennan: I would absolutely agree with what has just been said. In summary, with reducing stigma and increasing awareness over the last 10 years, you would expect there to be, therefore, an increase in demand, and we have seen that. The freedom of information questions that YoungMinds has carried out over three years—we are just starting again—around spend on CAMH services have shown that it is very uneven across the country, but what has actually been hit have been the tier 2 services, as both Dr Hindley and Professor Peter Fonagy said. We have to look at the commissioning landscape around that. It is largely funded by local authorities and that is one of the reasons why that part of those services has been hit so badly. Also, the third sector is an important partner in delivery, as is Place2Be. It is always the third sector that seems to be the easy target when local authorities are under pressure financially, so again those services have been badly hit. We know factually that the resources going into that area have reduced.
I would like to turn briefly to the experience of growing up and young people’s lives. A survey that YoungMinds carried out this year really indicates some of the pressures that young people experience growing up, where they are turning to, and why, for instance, things like self‑harm are happening. “Do we know it is increasing?” brings us on to the prevalence surveys and also, locally, how people are assessing need in their area for JSNAs. We know from a survey carried out by the Children and Young People’s Mental Health Coalition that old data from 2004 are being used as the basis on which JSNAs are being drawn up. This is old information that is being used—from before Facebook was invented, indeed.
Coming back to the experience of young people, our poll was of 2,000 young people. Over half of children and young people—11 to 14‑year‑olds—believe they are a failure if they do not get good grades at school. Over half 11 to 14‑year‑olds have viewed online pornography, with four out of 10 saying that it had affected their relationships with others of their age. Half of the children and young people have been bullied. Four in 10 11 to 14‑year‑olds skip meals to stay thin, and a third of children and young people do not know where to turn to get help when they feel depressed. I know we see a lot of it in newspapers and the media, but I think this paints a different experience of growing up today from before social media were available. I think that has increased the pressures that young people are feeling and experiencing, and sharing and participating in. That is probably enough.
Dr Hindley: At the same time, it is important that we do not demonise young people. There are also a lot of very healthy and well‑functioning young people. We do not want to give the impression that all—
Sarah Brennan: No, it says their experience. Finally, one part is also, in terms of schools—you will know from your experience of Place2Be—that the experience that we have had working across the country has been largely that schools are desperate for help. Actually, although they sometimes are painted as not being interested in mental health, they are very aware, in our experience, of the needs of their young people but are finding it difficult to know the best way of resourcing those needs. That is enough to be getting on with.
Barbara Rayment: Perhaps I can add something from the perspective of voluntary sector providers who are offering information, advice and counselling services, largely across the age range 13 to 25 in fact. In many cases, the experience of those services echoes some of what has already been mentioned. We have been running a survey—Youth Access, not me with my coalition hat on—since 2010, looking at the impact of cuts on services, many of which are funded through local authorities but also some through NHS funding, CAMHS and so on, and also at what the demand has been from the impact of the economic climate. Over that period, although a number of them experienced considerable cuts right at the start when local authorities moved in to cut services, the picture has stabilised somewhat since then. However, what has not stopped is a rising tide of need in terms of demand. Certainly self‑harm is something that most of those agencies say is increasing. Many of them are also talking about more young people presenting with suicidal feelings; they have always presented with these issues, but these are services that have been existent for a number of decades, so they have tracked these problems. They are also seeing depression and anxiety, and they are witnessing an increase as a result of abuse within the home—pressures from domestic violence, and neglect and physical abuse. Some of the cause of that, I think, from their perspective, is that they see cuts that have happened in terms of statutory CAMHS having an impact on them; statutory CAMHS have raised the threshold of entry into their services, and that has not been something that services who are open‑door or self‑referral will do. It has meant that there has been a rising tide of demand. In some areas, it has been reported that CAMHS will not see any young person unless they have attempted at least one suicide. So these services are holding some very desperate and at‑risk young people, and they are doing so on a very vulnerable funding base, frankly, in many instances.
Q6 David Tredinnick: It is hard to know where to begin. Professor Fonagy, you were saying that it is different now and it is sort of a generational thing. I would identify with that; my recollection of my school and post‑school era is being told to “Sort it out yourself.” You were expected to have a degree of toughness about you; you would address things yourself and not immediately reach for help. There is that change in attitude, I suspect—I am not an expert and we are here to hear you as experts, but just from one’s own experience—that society has become less robust and less capable of addressing issues itself. Secondly, the issue of self‑harm was unheard of. I know not one single person of my era growing up many years ago who practised self‑harm. Thirdly, despite the poverty issue, these issues seem to affect everybody, from those who are the most privileged to the least possessed.
Lastly, my own experience of dealing with cases in surgeries is that very often antidepressants, for instance—some of the treatments—just stall the problem; they prevent the problem from being addressed and people get on a cycle of treatments. Sometimes when people come to see me—I have been in the House as long as the Chair, for 27 years, and I have probably done 140,000 cases, so I have some experience of seeing people—I say to them, “Look, I can send you off somewhere, but how about really trying to work this out for yourself, because once you are on the merry‑go‑round of health care I don’t know when you are going to come off?” It may be the wrong advice, and you may say it is the wrong advice, but I think I have stopped some people getting more and more into that treatment cycle, and made them sit up, look at themselves and possibly address things. I do not know if you want to comment on what I am saying. Maybe I am completely out of touch.
Chair: Who would like to come back on that? Everybody. I will go to Dr Hindley first, and then move to the left.
Dr Hindley: In relation to your view that people need to sort themselves out, there certainly is really important work we can do in terms of building people’s resilience, and building the resilience of schools to manage young people’s problems, and help them and their families to manage their difficulties. But I think in your era—I am probably roughly the same age as you—there were also people who did have significant mental health problems, who did not seek any help and whose lives were very seriously affected by them. I think we need to get the balance right. Yes, we need to build resilience, but we also need to make sure that people who have very significant mental health problems access the right help.
On the other issues about treatment, all of us would, I think, advocate psychological and social interventions first where we can; there are some mental health problems where it is very appropriate to start treatment very early. I saw a young boy with first presentation of psychosis a couple of weeks ago; we started him on antipsychotics very quickly and he has started to recover very quickly. But in most circumstances in child and adolescent mental health, we are talking about psychological and social interventions, and actually those are quite expensive and staff intensive, so when resources become strained people start to shift to the less expensive interventions and they then resort to medication more readily.
Professor Fonagy: I find your challenge really very refreshing and intriguing; it speaks to something that I suppose we are all responsible for in one way. We have created a culture for young people which is different from cultures certainly that I was part of when I was young, where responsibility and authority travelled together. We make them at the moment very responsible for their lives, but we give them very little control over them. The combination of an absence of authority with a great deal of responsibility is not good; it creates stress at any age, in adults as well as children. It has been known as a combination that makes for great difficulties for all of us.
The major problem that I would like to highlight for you, though, is what we now know people tend to do, when you send them away, to cope with mental health problems. For example, 43% of young people who smoke have mental health problems, and we know that that will travel down the line to create massive problems for health care. This country is actually the most overweight country in the western world. We have an obesity crisis on our hands, certainly in Europe; we are not able to compete with the United States on this. We certainly know that obesity is very substantially associated with mental health problems. We also know that for amenable deaths in the western world—preventable deaths—we unfortunately are at the bottom of the statistics that I am sure you are very familiar with. We are at the bottom of the league in the western world. Certain diseases—cardiovascular mortality, for example, and diseases linked to diabetes—which all actually have their origin in childhood, are made worse by psychological distress. These, I think, will come back to haunt us later on. There was a phrase that Margaret Mead used: “The solution to adult problems tomorrow depends in large measure upon how our children grow up today.” How children grow up will determine how adult health care problems affect us. Our united front in front of you of concern for childhood mental health—I wish to support more than just ask people to sort themselves out—is rooted in, I think, a fairly well scientifically grounded understanding of how health care and the development of physical as well as mental health evolves in the long run.
Q7 Chair: We do not want to have five speakers to every answer, otherwise we are going to be here till supper time, but we will go to Dr Roberts, and then Andrew Percy.
Dr Roberts: I will keep it brief and respond to two points. I agree with you that the rise, as we understand it, is happening. Although we do not have the epidemiological data to capture it, we do understand that mental health illness in young people affects those in the most affluent families—as you raised—as well as those in the most deprived. However, we know that one in three children and young people in Britain today lives in poverty, and those who live in low‑income households will have at least a three times increased risk of mental illness.
On the second point, you talked about the practice of self‑harm. I would respond to that by saying that, admittedly, we have not expanded the definition of self‑harm, which in a sense is more than cutting and taking overdoses. It is the spectrum of deleterious behaviour to oneself. Anybody here who knows the north‑east of the country—obviously it is not just particular to there—knows that the practice of dangerous drinking, where young men will drink to oblivion and use substances and then drive cars and commit very violent acts, really is in itself an indicator of self‑harm. I would say that it is a response to distress. Rather than it being a practice, it is the discharging of a turmoil of emotion which reflects all sorts of things, not least youth unemployment, which is three times the national average. In certain parts of the country—again, I refer to the north‑east—the picture is devastating for young people; the opportunities that they have to go into training and education are so limited. In that situation many of them will come and say, “Doctor, I feel s‑h‑i‑t and I don’t have a job. What am I doing with myself?” In response to the point about the use of antidepressants, I would say they are pointless, because what that person wants is meaningful occupation in their life. Thank you.
Chair: Now the Member of Parliament for Goole, which is not quite in the north‑east but on the way.
Q8 Andrew Percy: It is the north, and supper time up north is a custard cream and a cocoa at 10 o’clock at night; it is not the same thing as it is down here. I am happy to stay here till 10 o’clock.
Before I go on to my questions, my understanding is that the demand for CAMH services has increased year on year for the last decade or more. Has there been a year in which demand has fallen off?
Professor Fonagy: No.
Q9 Andrew Percy: This is why I am interested in the links that have been made between funding and some of these other things. On the issue of unemployment, during that period, unemployment levels for young people have gone up, down, up and down again. Yet the demand for services has always increased. So I am just unsure as to some of the more simplistic links that seem to be made about what is actually going on in the background, given that across all of this time there has been record money in some years in certain services and then less in other years, yet every year the demand has continued to go up. Certainly something I saw when I was a school teacher was that the issues behind all of this were so complex that they were often beyond being touched by money. It was something much deeper in society, which is why I am just a little bit unsure when we have the link made. In my own area we have had more money going into youth services than ever before, but we have still seen a demand for services.
Dr Hindley: The point I was making in relation to self‑harm was that, for instance, there was a fall in the suicide rate and then, as economic austerity bit, it started to rise again. That was the link I was making in relation to that.
Q10 Andrew Percy: Okay. But in general there has been a growing demand year on year regardless of what has been happening in the economy and regardless of how much money has been ploughed into whatever service. That is why I think we have to be very careful. There seems to me to be something much deeper in society which cannot just be explained away through Facebook.
We did not have anybody mention anything about drug use and drug abuse. I could point to the kids in my class who were probably going to end up with some sort of mental health issue, and there would be a history of drug use in the family. I am trying to be careful with my words, but you could pick the families, basically, from which these young people would come very often—not always. That is why it seems to me there is something much deeper.
Professor Fonagy: I would totally agree with you on that analysis because, when you look at international figures, the UK figures are not out of line with figures in Europe. Where we are out of line is that, whereas in Switzerland there are approximately, I think, 4,000 children per medically qualified mental health practitioner specialising in kids, in Finland the figure is similar and in France I think it goes up to 6,000 or 7,000, in this country there are 30,000 children for one medically qualified practitioner. The figures are going up, but we have very limited resources on the ground to deal with it. I would want to maintain a concern that it is not shared—
Andrew Percy: Yes. I just do not want to get into a position where we have a report where it is all about money, which brings me to a question which is all about money.
Chair: Sarah Brennan wanted to come in.
Sarah Brennan: The period of time you are talking about also relates directly to a period of time when there has been a very definite shift in awareness both of the connections between physical and mental health, in terms of development of the brain and emotional development, and also in terms of growing awareness and growing investment. If you put services in place, you are responding to a demand but also creating a demand. That is one part.
The other part is in connection with the complex families that you are describing. We know that, in terms of children and young people, mental health is influenced by nature, nurture and events, and what you are indicating there is what is happening in terms of nurture and nature, and probably events as well. We are also very aware of the generational aspects. You are pointing to the much broader societal changes and experiences and how those are passed on generationally, which absolutely is borne out in all the research. I do not think there is any magic. What we were describing earlier about funding was responding to a particular crisis that is happening at the moment, but I think none of us would disagree that demand has been increasing, over the last 10 years in particular, I think. There are reasons for that, but there are the more underlying social causes that are beyond the capacity of a service to respond to.
Q11 Andrew Percy: Sure, point taken. In‑patient beds has been a big issue over the last year—it is partly what led to the NHS England review, given the concerns—and it has been an issue in my own area in terms of access to tier 4 beds and all the rest of it, and people having to travel a very long distance. Can you give us your assessment of the current provision of beds? Is there a shortage and is that putting patients at risk? I do not know who wants to start.
Dr Hindley: There is probably an imbalance in the kind of beds that are available. I think, in terms of the relative amounts of generic adolescent beds, particularly against forensic or other more specialist beds, the proportion probably is not quite right. There are certainly certain parts of the country where there are more difficulties in terms of provision, Humberside and Yorkshire being one area and the south‑west probably being another area, but in other parts of the country there is probably adequate provision. The difficulty over the last year has probably been as a result of a complex range of factors. One of the factors has been the rise in demand, which we probably do not fully understand. But certainly members of our faculty have reported a very significant increase in demand over the last year for admission. Another factor has probably been disruptions to some of the local networks that helped people avoid admission. Certainly, as a child and adolescent psychiatrist, I try to avoid admitting the young people I look after as far as possible. In various parts of the country people have set up systems to provide greater support in community settings, in order to avoid admission or to enable young people to be discharged more quickly, and some of those systems have been disrupted. I think the other factor is that some of the wider facilities that have been around to support young people in distress, particularly through social care, have been quite significantly reduced, so it has been more difficult to sustain young people who are in distress in a community setting. Those are probably the range of factors that have been important.
Q12 Andrew Percy: Where does the solution come from? What should I be arguing as a local Member of Parliament? Should I be saying, “We need more of these beds locally provided?” Or does the solution come further down the system in terms of better community services? Unfortunately, the focus is always around beds. One thing on the adult mental health service is that we lost our unit in Goole in 2008. I was part of the campaign then to try and prevent that, but we were always told: “Beds are the last place we want people to be. It is all about crisis management in the home, community services,” and all the rest of it, and now we seem to be having this national debate about “Do we need more beds for young people in mental health services?” Where does the solution come?
Dr Hindley: My personal view is that you need well‑resourced, what we would call, tier 3‑tier 3.5 services to support young people. You need beds which are reasonably geographically accessible but you also need the right staff skill mix. That is going to mean that there will be some areas of the country where it is going to be quite difficult to get the balance exactly right, because you need a unit of sufficient size in order to have the right skill mix, with the right therapeutic modalities available and so on. The balance is going to be tricky, but my personal view would be that the emphasis should be on developing services that enable management of young people in communities, and making sure there are good crisis services available, so that you can minimise the number of admissions to in‑patient units.
Sarah Brennan: It is about the commissioning arrangements as well. The commissioning arrangements have been changed, which seemed to make sense because the numbers of young people needing in‑patient care are nowhere near as large as for adults. But centralising that, or regionalising it, has cut the links with local services. As to what you are describing about having community services, those arrangements have been cut. Yes, we want to keep young people out of in‑patient care as much as possible, but to do that you need to have the services connect, with the step‑down, step‑up arrangements very clearly laid out, and very close working between those teams. Those arrangements have been lost, so they cannot commission, according to local need, what the in‑patient service requirements are.
Q13 Andrew Percy: Can you explain how they have been lost?
Sarah Brennan: Previously the in‑patient units were commissioned locally—
Andrew Percy: By the PCTs.
Sarah Brennan: By the PCTs, whereas now it is centrally done in—
Andrew Percy: NHS England.
Sarah Brennan: In four regions, yes. It is taken as a much more global view rather than as a response to local needs.
Dr Hindley: Can I add a little detail? The services are still there, but it is often much more difficult to manage. If you have a unit, say, in Oxford that was previously managing Oxford and Buckinghamshire, local counties, and is now receiving referrals from Yorkshire and the north‑east—actually the flow is mainly from the south up to the north, in fact—for those teams, which previously had very good relationships with the local specialist CAMHS teams and the local social services teams, it is much more difficult if you are managing children who have come from very long distances away. Equally, the further away you are from your referring team, the more difficult it is for the referring team to work collaboratively with the in‑patient unit. Those sorts of things are undermining previously well‑established systems.
Q14 Andrew Percy: The solution to that is more units locally then.
Dr Hindley: No. The solution to that is you need to look carefully at the commissioning arrangements and think about how you can create more effective risk sharing between in‑patient units and their local areas, so that you can have investment in shorter stays, enabling young people to be supported in the community. They may well need an admission, but you can shorten the admission and enable them to come back into the community and go back into their lives more readily.
Barbara Rayment: A number of our members certainly were providing that step‑down kind of facility to young people in the community, but that, again, has been lost in the new way of commissioning provision. I would like to mention something about the age profile as well. For lots of young people trying to access help, it can be very difficult depending on what age they happen to be at the point at which they seek help. We know that many of them tend not to access help beyond 16, from the statutory provision that is available, either because that provision cannot see them, and has cut the service off at a particular age range—services have done that—or young people themselves are choosing not to go to those services if they feel they have that need. There is a real mismatch, I think, quite often between the trajectory of mental health need, if you like, the rising crisis in terms of the age profile at which young people are experiencing problems, and the way in which the system itself responds to those needs at particular points, particularly as young people go into later adolescence and into early adulthood. I think there are some critical problems at that age point.
Chair: Could we move on?
Andrew Percy: My final question was on out of hours.
Chair: Go on, and then David wants to come in.
Q15 Andrew Percy: I think Peter’s submission stated that the “provision of out of hours care varies across the country,” and that 20% of respondents to the survey said they did not have an out‑of‑hours service. What is the panel’s view on the current provision of out‑of‑hours service and its adequacy?
Dr Hindley: It is very variable. There are some areas where you have excellent out‑of‑hours provision, and other areas where you have minimal out‑of‑hours provision. My view is that you should have at least access to a child and adolescent mental health professional who can provide an out‑of‑hours assessment, with cover from a consultant child and adolescent psychiatrist in case that young person has very severe mental health problems that need psychiatric treatment or admission to an adolescent unit. The returns I have had from our membership suggest that there are lots of places that are able to sustain that, but again, particularly in rural areas, it is quite difficult to get the right sort of mix of professionals and staff. In some areas you are going to have a mixture of adult services supported by child and adolescent mental health services providing that sort of input, but there should be out‑of‑hours service coverage in all parts of the country. That would be a very important part of ensuring that young people received the right sort of service; they will not necessarily need to be admitted if they are assessed quickly and can be linked into appropriate community service. You can often avert a crisis with a good out‑of‑hours assessment.
Q16 David Tredinnick: I want to move on—we have covered some of it—to talking about the Children and Young People’s Improving Access to Psychological Therapies programme and related issues. We have heard reports of resources for children and adult mental health services being reduced, at the same time as referrals and complexity are increasing, leading to referral criteria being tightened. Is this a picture that you recognise? It is a very soft ball, really, isn’t it? I am trying to open this up. It is a simple opening question. Is it simple? We have services being reduced at a time when referrals and complexity are going up.
Professor Fonagy: Yes.
David Tredinnick: Leading to referral criteria being tightened. That is what our understanding is from the briefing I have. Is that correct?
Professor Fonagy: There is a substantial evidence base for that from a number of sources, including probably the best evidence base that we have at the moment, which is coming from CORC, a CAMHS collaboration focused on outcomes, a kind of voluntary collaborative that covers about 60% of CAMH services and collects data directly from those services. There is precisely evidence of the kind of trend that you describe.
If I could just say something about Improving Access to Psychological Therapies, it is really important that we should be open and frank about the problem with CAMHS. CAMHS has not been traditionally a particularly uncontroversial area of health service provision. In this country, but also in the United States and in many countries in Europe, the outcomes that were observed from CAMH services were not markedly better than the outcomes that we might have observed through natural progression of the disorder—that is, the outcomes were poor. I think even more important, from my point of view, young people often felt in many ways that they had joined a disjointed service that was fragmented; schools communicated poorly with CAMHS, and CAMHS communicated poorly even within the NHS with paediatrics, but certainly with social care. Improving Access to Psychological Therapies tried to address three key issues, which I think remain important to address, and have been, to some degree, compromised by the funding crisis. The first is to improve levels of engagement. Services have to do better than engaging 40% to 60% of people who turn up at the door. That used to be the statistic. They also have to do better in terms of the delivery of evidence‑based care, and there has been difficulty in ensuring that that was the case. But I think most important, and what I think probably we would all agree in wanting to draw to your attention, is that outcomes accountability mechanisms within children’s and adolescent services have been really non‑existent until the last three years and—
Q17 David Tredinnick: Because there was no information.
Professor Fonagy: There was no information. One of the major initiatives that Children and Young People’s Improving Access to Psychological Therapies brought in was to ensure that outcomes information was collected routinely from each child or young person seen. I would want to assert—with a certain degree of evidence behind what I am saying—that this is a battle that has been won, both in the voluntary sector but also in statutory CAMH services. The recognition of the importance of collecting outcomes information, not just from the point of view of collecting information that will help commissioners and policy makers but, even more important, from the point of view of engaging young people in monitoring their own treatment, has been a major step forward that has been taken in this country. So I personally feel quite optimistic. It is true that—
Q18 David Tredinnick: We are also conducting an inquiry into data in the NHS—how they are held, how they are put together and all the issues about whether they are on the market or not. Are you saying that in big data, for example, there are no data to collate on mental health services and actually there is just a gaping hole?
Professor Fonagy: Adult IAPT services currently provide the best data in mental health services. Adult Improving Access to Psychological Therapies, I believe, last time I looked at the figures, had 97% completion rates on their outcomes information. This is exactly what we are aiming for. If you are going to properly develop child and adolescent services, it needs to be evidence based from the point of view of being guided by best available research evidence but also guided by practice evidence, although this is something that we are struggling with, as is everyone else in the NHS. If you have done a review of this, you will not need me to tell you that the level of IT provision is not perfect yet in many trusts.
Chair: That is an uncontroversial statement.
Professor Fonagy: Having said that, the level of clinicians’ willingness to participate in active data collection to guide treatment and improve outcomes has been a major achievement of the last three or four years.
Q19 Chair: The real challenge there is not merely to collect data but to get clinicians to change practice in response to the information that the data offer, as it were.
Professor Fonagy: I do not want to take too much time, but one of the achievements of the Children and Young People’s Improving Access to Psychological Therapies has been to take clinicians, their supervisors and their managers and train them in how to use data to improve both engagement and clinical practice with the individual young person and child, rather than simply how to use data to pass up the chain of command, which we know has been tried again and again and has had limited effectiveness, although Place2Be, I want to acknowledge at this point, Chair, has been quite effective in this context.
Q20 Chair: I am sorry. My intervention reflected an internal debate.
Dr Hindley: Can I say something about raising thresholds, because that will give the impression of people just pulling up the drawbridge? I am aware that my colleagues are also trying to think of creative ways of providing services by consultation, consulting with professionals about young people they are looking at without providing necessarily a direct face‑to‑face service, but by supporting other clinicians, other professionals, who are working with them. People are trying to work out ways of continuing to provide a service even though they are aware that thresholds are rising. There are different ways of providing services other than just seeing people face to face. The problem is that that is very difficult activity to collect, and for commissioners to recognise, I would say.
Q21 David Tredinnick: Shall I ask a couple of other questions just for the purpose of keeping things moving? I am sure the Chair will agree with that.
I think the Mental Health Foundation has argued that “it is essential that waiting time limits are established for children’s and young people’s mental health services.” Do you think that would help? How long, on average, are waiting times for children and adolescent mental health services at the moment?
Barbara Rayment: I will kick off. Yes, I do think it could help to have a target on that, absolutely, but that would also suppose that there were then resources that followed the need to address that target. Again, speaking for voluntary sector organisations, they manage waiting lists in a slightly different way, I think; because many services have a kind of under‑one‑roof, drop‑in type of facility, they can fast-track young people into help if that is what is required, but also they can offer other sorts of help through drop‑in, more informal‑type support arrangements while they might wait for a more formal therapeutic—
Q22 David Tredinnick: Are you saying that voluntary services make better use of resources, generally speaking?
Barbara Rayment: I think they have learned to, because, if you are given £20,000 a year to offer your counselling service, you are going to find very creative ways to run that service, so they will.
Q23 David Tredinnick: This comes back to what my colleague was saying about resources—that actually it is not just a resources issue.
Barbara Rayment: No.
Q24 David Tredinnick: What you are highlighting is a very important management issue—
Barbara Rayment: Yes, absolutely.
David Tredinnick: —if you have limited resources. What you are actually saying is, “We are very flexible. We have better access because people can drop in.” One of the problems that we get in our surgeries is that we cannot get through these doors—we have too many gatekeepers and too many people out there deciding who goes where—whereas your model is slightly more relaxed, isn’t it, and may be more suited to the problems of people who really cannot get it together to organise going to see anybody?
Barbara Rayment: I think there is a truth in that, and young people who are in often quite complex need—particularly if, for example, they are homeless and if they have ongoing drug or alcohol problems—may well find it more helpful to access a drop‑in facility than an appointments‑based service, which they would find quite difficult to manage. Yes, I do think that model works well and there is lots of evidence to suggest that it is a model that young people themselves like. But I have to say that is what CYP IAPT itself is now trying to move towards. Some of the kinds of principles that I think have been around for a long time within voluntary sector organisations, such as self‑referral, encouraging young people’s participation and so on, are now being exemplified in exactly the kind of CYP IAPT provision that I think we are all trying to see really increased across the whole sector. But it is, I think, also being slightly compromised by cuts. I know people do not want to hear “cuts” as well, but actually I know that—
Q25 David Tredinnick: There is evidence of cuts having an impact on the programme, is there? I think you said that in your briefing.
Barbara Rayment: It is a service transformation programme that is trying to influence the way current services operate, but they can only do that if those staff are in place. If they get made redundant, effectively, you have wasted the whole training resource on a person who is no longer going to be within that setting. There is a tension, I think, in that kind of approach, yes.
Q26 David Tredinnick: I was in the Army years ago—not for very long—and when you are on a battlefield it is always said that you can never have enough ammunition. It is true. There is never enough ammunition because you can go on firing it for ever if you have an enemy out there. The same applies to the health service in a funny sort of way. There is never enough money. When you have enough money to solve one problem, you create a new one out there; there is a new disease, a new issue or a new something. It is exponential demand. You will never satisfy demand.
Chair: Discuss.
Dr Hindley: I worry about setting the statutory sector against the voluntary sector.
Barbara Rayment: We are not against each other.
Dr Hindley: I think it is very important to think about the complementary nature of the relationship between the voluntary sector and the statutory sector, because the statutory sector delivers a range of treatments that the voluntary sector cannot deliver, and with a set of governance arrangements that are very necessary if you are going to be managing medicines, for example. You have to recognise some of the constraints that the statutory sector works under. We are very conscious of the need to deliver services efficiently and effectively as well. I would have a slight disagreement with Barbara, in that I would be wary about waiting‑time targets, because they can create perverse incentives. For instance, if you have a three‑week wait and somebody needs to be seen today, there is an incentive to say, “We will put that off,” and equally it can create situations where you have a public‑facing target that is achieved, but an interior set of waiting times that actually mean it creates other problems. We were debating whether or not another alternative might be to say that the CCG should be achieving a certain level of prevalence penetration in terms of the number of children it sees—“Should it be 20%?”—and that should be the target you should be aiming for, which, in a way, encourages people to think about how to use resources effectively.
David Tredinnick: Thank you very much.
Grahame M. Morris: I have a couple of questions. I want to say to Barbara that I do not think you should be telling the Committee what they want to hear. If the evidence from your organisation suggests that cuts are damaging to the service and the evidence backs that up, you should say it whether we like it or not.
I have a particular question that I wonder if I might have your opinion on in relation to the evidence that you submitted from the Children and Young People’s Mental Health Coalition suggesting that the joint strategic needs assessments are not sufficiently prioritising children and young people’s mental health. There are concerns that you have highlighted, and that other members of the panel have, about the huge variations between urban and rural. It is not a north‑south thing, but is it a rich‑poor thing? I do not know. Dr Hindley mentioned variations in out‑of‑hours assessments provision. If we come back to the health and wellbeing boards and the joint strategic needs assessment, do we not have a champion for children and adolescent mental health? What is the problem?
Barbara Rayment: What is the problem? We did a very big piece of work last summer looking at over 140 JSNAs and health and wellbeing strategies. Unfortunately, most of those JSNAs were very poor in identifying children and young people’s mental health needs. One third did not assess any need at all. There was, as can be expected anyway, an over-reliance on out‑of‑date data, because the prevalence data is so old and out of date. However, it also has to be said that many of those JSNAs made no links between some of the known-to-be high‑risk young people. For example, if they had large numbers of young people in the care population, they did not make the leap to suggest that, actually, that might be an indicator of high risk in terms of mental health, or, for example, young refugee populations or whatever else. That was one problem. Then when you looked at the health and wellbeing strategies, only a third of them identified children and young people’s mental health as a priority. That is quite shocking, frankly, as it is one of the biggest health risks facing children and young people. It is not their physical health but their mental health that is the greatest risk factor, which is what is going to drive the commissioning as well in the end. It is a real problem.
Q27 Grahame M. Morris: I want to come on to that. I want to ask Dr Roberts about the commissioning, if you do not mind, because time is short and I know there is a lot to get through. The evidence highlights the complexity of the commissioning arrangements and the joint strategic needs assessments that we have been talking about. What should we do, as a Committee, in terms of making recommendations to support commissioners? Do we need a national strategy with some local delivery mechanism? Do we need a national plan? What are your thoughts, Jane, about how we can best do that?
Dr Roberts: With reference to your first question about what is the problem, you said, “Do we need commissioning champions?” To go to the heart of the problem, the clinical leadership within commissioning comes from GPs and, to reiterate my earlier comment, a third of those will have had absolutely no postgraduate training in children and paediatrics, and certainly not in adolescents. My own experience of adolescents was one lecture from a particularly animated CAMHS psychiatrist about the transition to senior school. In the albeit changing picture of the QOF framework, which determines priorities within primary care, children and young people were less than 3% of QOF indicators, so it is on nobody’s agenda to do anything about it. The GPs who then elect to become involved in commissioning generally will be representative of the whole cohort, and will have had no experience of it, and certainly will not actually see the growing perspective that those of us who are interested in it recognise around the life‑course approach. That is a novel term, if I speak to my peers, so most of the commissioners who are making these decisions, as Barbara highlights in that report, pay very short attention to those JSNAs, because it is a random age group that they perceive as not being core business. There are moves: I have a role within the strategic clinical networks of recent onset and I am aware that Geraldine Strathdee is launching a leadership programme for mental health leads, so that is good. It is just in place. Obviously commissioning has been around for a year and people who have been doing it will not have been privy to that.
Q28 Grahame M. Morris: Do you have a date for that?
Dr Roberts: I think there are dates actually, but it also reflects the very adult‑centric nature of the NHS: it was set up, as we know, to keep the workers in good health and, as children’s commissioners have constantly drawn to mind, including Maggie Atkinson, it has for ever very much been around an adult‑centric focus. Your second question was, how do we improve?
Q29 Grahame M. Morris: How do we support commissioners? Are you identifying better training for GPs in particular?
Dr Roberts: Yes, that is critical.
Q30 Grahame M. Morris: What about a national strategy?
Chair: Do you want a national plan?
Grahame M. Morris: A national plan. I am not trying to put words in your mouth; I am just seeking your opinion.
Dr Roberts: My college would say that, with a national plan, we need to look at the numbers of GPs. The fairly harrowing data currently suggest—this is new data from the college—that there are now three hospital consultant posts created for every one GP. While we continue to run with an under‑number of GPs, we will continue to run with shorter consultations, and what we know is that young people need longer consultations because they do not just want to talk about their pill or their acne; they also want to talk about parents splitting up, online bullying or any number of things that may well be part of their very complex lives. They need longer consults, and what we are faced with is a year‑on‑year demand of patients wanting to be seen on the day, so we have to make more appointments available. But we are not increasing the work force, and commissioners have to operate within that.
Sarah Brennan: The other element is that the commissioners need good data on which to actually base any decisions or recommendations. There really should be a year‑on‑year, or at least a biennial, requirement for a national prevalence survey so that we have good information upon which we are basing all other planning decisions. That is exactly what the commissioners need. It is their job and they do not have the raw data on which to make reasonable decisions.
Dr Roberts: Absolutely. It is also the CMO’s recommendation that we relaunch the data that have not been collected since 2005.
Dr Hindley: There is a good commissioning guide published by the Royal College of GPs and the Royal College of Psychiatrists for child and adolescent mental health services, which is an excellent guide for commissioners. The other thing is that the outcome forum is working harder on developing child and adolescent mental health outcomes to include within the dataset.
Sarah Brennan: The other part around commissioning is that this is not just about the CCG’s commissioning of services. Actually, what we are all talking about here is developing good emotional resilience in our child population because of the impact on all outcomes across their life span. There should be shared commissioning, not just with the CCGs but with the local authority and children’s services, and schools should also be part of that mix. There needs to be consideration of a systems approach rather than just piecemeal commissioning of particular bits and bobs to service very local need.
Dr Hindley: That is where the health and wellbeing boards play a really crucial role.
Sarah Brennan: They should, but they do not connect with schools.
Professor Fonagy: Could I just add one thing? I think that is absolutely right. I have a slight concern that I wish to express. There are, as Dr Hindley indicated, very good examples of excellent collaboration between education, social services and CAMHS in, say, Liverpool, Torbay and a number of areas. All that I know from implementation science tells me that a Government initiative to combine those pots will not achieve the intended consequence of bringing those services together. I would like you to consider quite seriously a recommendation for these organisations to work much more closely, exactly as Sarah Brennan was saying. The platform they need to work on should be outcome focused, so that if they have a particular target to achieve—maybe that is not quite the right word—or if they are held to account for, rather than the number of cases coming through, the number of cases who have “recovered,” they will then be forced to work together to achieve that and it will create a common platform. I will give you one instance that will illustrate for you exactly the problems we have been discussing. I have recently been told about a social worker who worked up a case of severe child abuse, really—the mother—very beautifully presented and held together, who then referred the case to CAMHS for therapy. Actually that social worker was in the best position to offer therapy but she was told by her manager, “You need to close that case,” because, from the manager’s point of view, they needed turnover within the system and she needed to take another case. But that kind of unintended consequence is going to happen unless you really get the services to have a common focus centred on the child, the family and their outcome.
Q31 Chair: Isn’t it completely barmy, as Sarah Brennan just suggested, that there should be a health and wellbeing board discussing the strategic needs assessment of young people in an area and the education people not be present?
Professor Fonagy: Yes.
Dr Hindley: Yes.
Sarah Brennan: Yes.
Chair: Thank you.
Professor Fonagy: I chaired the NICE guidance on childhood and adolescent depression; it was some years ago. We again and again asked for education to be present to help us draw up the guidance. They did not turn up. That is a very high level of absence of collaboration.
Dr Hindley: But there are very good examples of situations where schools and local services do collaborate very effectively—
Professor Fonagy: Absolutely.
Dr Hindley: —both to promote wellbeing and to intervene early. So I do not think we should—
Q32 Chair: There is a more serious point, isn’t there? In the health and wellbeing board process, education people do not need to be there if you are talking about care of the elderly, but they need to be there sometimes. In other words, it should be a revolving population of people who have an interest rather than a group of people with a name tab in front of them.
Professor Fonagy: Yes, and I hardly need to underscore for you how much evidence there is that schools are in many instances the most appropriate vehicle for delivering mental health care for children and young people.
Chair: You do not need to tell me.
Q33 David Tredinnick: On schools intervening, in Leicestershire the police commissioner has set aside some of the budget to target some very troubled families before they break the law. This is a police budget being applied to dealing with a tiny number of people at the end of law distribution who are the really difficult cases. Maybe we need to develop something on that theme for early intervention, or more early intervention. It is something that Graham Allen, who is a Member, has worked on for years—a Labour Member actually.
Sarah Brennan: There is a real connection, as we know, between education, antisocial behaviour, youth offending and mental health problems. That is a really excellent initiative by the police, but community safety partnerships often recognise that linkage as well. When we are talking about young people and mental health problems and services, it is absolutely right to be thinking across the piece around the range of young people and those who are at risk, and where the intervention can happen. School, as Peter says, is often the place—if not where children are, where they should be—where there is a really good route in terms of accessing young people most at risk, and we can actually be not just reactive once problems have emerged but proactive too, which again has positive outcomes across the piece.
Q34 Andrew George: Dr Roberts, in both your written evidence and the comments you made today, you referred to the inadequacy of the 10‑minute consultation time and the fact that the vast majority of GPs have no requirement to have experience or training in this arena, and very few of them have. You paint a pretty depressing and worrying picture of the adequacy of primary care services, which may well be the first interface of a young person with the kind of assistance that the GP provides gatekeeper access to. In reflecting on that, the days of single‑handed practices are over—if they are not over, they are almost over—and, as far as I am aware, in most GP practices there is recognition of some specialties which perhaps one in the group of GPs needs to concentrate on, on behalf of the others, or more so than others. Is that not a pattern that is now developing well in GP practices, and is that not the way to address the kind of problems you have described, rather than expecting every GP in the land to bring themselves up to a level of training or resource which clearly is not going to happen?
Dr Roberts: Sure, most certainly, and I have ill‑served the Committee, in a sense, if that was the conclusion of my evidence. I guess I would expand it. Again it is complicated. I would begin by reiterating where we are in terms of looking at “Is GP training fit for purpose?” I draw the Committee’s attention to “Shape of Training,” the latest report from Professor Greenaway, which again endorses the RCGP’s view of the situation; that our current period of three years’ training ill‑prepares the GPs of the future for the complexity and breadth of presentations that we see. Our frail elderly population will carry on increasing, but mums still get pregnant and we are still going to have the 0 to 5s who need to be looked after and have particular needs. Then we have our 5 to 10‑year‑olds and our increasing understanding, as has already been alluded to, around the rapid process of development that goes on between 10 and 24, which really has only come about in the last 15 years. The majority of GPs who were involved in commissioning leadership posts will certainly not have had that experience. We are still catching up, so in a nutshell—this was led by Clare Gerada and has been taken up as a theme by the college—our training is not equipping us for the demands that we are facing today.
I totally take on board your point that it would not be the intention to up‑skill everybody. I will never develop specialist interest in orthopaedics or diabetes, and my own research talked about how we have to have different sorts of GPs, who deal with different problems. I talked about the fixers and the future planners, where most GPs work, who have an understanding of the biological, biographical nature of presentations. Then we have those who want to work more closely and develop something called the therapeutic alliance, which needs time. But in relation to pressure on services currently, particularly the immediate need to be seen by a GP, I have been working in a practice recently where you cannot electively book an appointment; you have to ring up, speak to the receptionist, the GP rings you back and you are seen that day. That promotes what I call a fixer approach, so people come in with a short problem, which for young people will be something that they feel okay talking about, but it will not go to something that is much more multi‑layered and demands some kind of relationship, a belief that they can trust this person, that their confidentiality will be respected and the person’s GP has respect for them and knowledge about young people. In essence, the increasing demand on general practice is leading to this kind of quick‑fix approach in our consultations.
As to the aged single‑handed GP, there are still plenty of them in the north‑east. We are moving towards, theoretically, more federated models—hugely complex, I think—and it will be impossible, in a sense, to get to the point where, within each practice, or even in federated models, you can say, “We will only appoint, in this instance, a GP who is good on musculoskeletal problems because we already have our paediatrics and young people covered,” because of the nature of turnover, and recruitment issues. There are certain areas which will struggle to recruit GPs, and other areas where there will be a surplus of people wanting to work.
The issue about creating specialist GPs is again a thorny one. I was recently at a college discussion about this because it now comes down to—again in this changing landscape of commissioning—who would be responsible for that training, and who would be responsible for monitoring it and making sure that a GP who presents themselves as a specialist in whatever remains up to date. There is a discussion now about whether that should fall within commissioning, and then which aspect of commissioning it would fall within. None of these can be easily addressed.
In summary, there is definitely concern at the moment that our training is not equipping GPs, particularly around paediatrics and young people’s health because there is no mandatory recommendation within that. If that were to be the case, the whole period of training would need to be extended.
Q35 Andrew George: Is it worth perhaps reflecting on something that Professor Fonagy mentioned a moment ago, that, rather than looking at the service as a set of inputs, you measure the outputs? That might provide a better incentive for GP practices to look at the issue. Rather than making sure that you have enough time or that you see certain numbers of patients or tick certain boxes, you are able to look at the community that it serves and at the outcome in terms of the mental health of the population as a whole, and how much early intervention you have managed to achieve over a period of time.
Dr Roberts: Absolutely. I fully endorse an outcome‑based approach. In terms of looking at your service, it would be much more helpful to the practitioners and the users of the service than an entirely target‑focused one. I would echo what Peter said about how there are perverse incentives and that people chasing targets are always taking their eye off the ball. But again we already know—there is stacks of evidence—about what young people would like from youth‑friendly primary care services. I did a sabbatical in Australia and had a look at what was happening there. I am part of international groups where we get representation from Europe and the States. We know what they want, and, by and large, it will come down to the fact that they want more time. They want consultations where they can talk about the different elements of their life without a doctor needing to get them in and out, or taking a kind of simplistic approach, which goes back to my fixers. I would fully support the notion of looking at that. If a practice looked at “How well do we address the needs of our young people?” and did a needs‑based survey, I still think it would come down to the fact that “We would like to have a youth drop‑in service,” for instance, in the locality. So the practices would say, “How do we free up a GP from here to man that clinic when we haven’t got enough appointments for all our patients?”
Q36 Andrew George: I am going to come on to the issue of electronic media, and I talk as someone with neolithic—extremely challenged—IT skills, or rather lack of them, so I am already out of my depth even just using those terms. As far as young people are concerned, we know that the vast majority of them can communicate very well in those media. Is there not at least an opportunity for GP practices, in the case of young people in particular—perhaps either after consultation or helping them to kind of screen their way into making sure they get the most appropriate initial consultation—to use electronic media, or at least e‑mails, straightforward communication, as a means of facilitating that? It can be done very efficiently and would not need even 10 minutes to deal with.
Dr Roberts: Most certainly. There is growing awareness both nationally within the college and internationally about how we use digital media more effectively. There are concerns around confidentiality, and there are whole pieces of work going on within the college about how we might be more flexible about how we use e‑mail in correspondence with patients. You will be aware that the media picked up on the use of Skype.
There are issues that need to be bottomed out, and the college is looking at that. I am aware of the use of electronic media in terms of what might be called screening interviews before young people see the GP. Some of those again have resource implications. I have certainly been at conferences where centres—not in the UK, I have to say, but in the States—have available digital devices that young people could complete, and then the answers would be fed back so that when the clinician sees them there has already been some preparation. But they are not going to come free. Yes, there is definitely awareness and there is a mixed response. You talked about your own kind of hesitancy about engaging with those media and, equally, that is also represented among my peers. Others are very quick to want to embrace those media, but they would talk to the fact that, if you have contact with a young person through Skype, it still needs to be counted as an encounter. In the same way that Peter was talking about a more creative way of responding to need, unless we then measure it and recognise that it is a piece of work to which there is a time element, GPs will be slower to embrace it because it is not necessarily recognising the flow of labour.
Q37 Andrew George: Are there any other comments on this specific issue?
Dr Hindley: With electronic media, there are certainly a number of CAMH services around the country that have been using electronic methods to do pre‑assessments—sending parents questionnaires that they can complete would form a significant part of the assessment prior to them attending. Also, they are using social media as a way of engaging young people. I was just exchanging a note with Sarah Brennan about the Big White Wall, which is an issue for adults, but it is a model that could be used for children and adolescents quite easily as well. As clinicians, we often face slightly perverse problems within our organisations—you are not meant to e‑mail outside the organisation. I know several places where it is a disciplinary offence if you communicate any kind of clinical material outside the internal network.
Chair: The NHS was described at a meeting I was at this morning as being the only remaining customer on earth for fax machines, which omitted HMRC.
Dr Hindley: I think there is a lot of willingness among clinicians to work with electronic media.
Professor Fonagy: Part of the achievements of Children and Young People’s IAPT was to introduce iPads as part of the evaluation of outcomes with the kids, and they relate fairly well to that.
Andrew George: I want to move on.
Barbara Rayment: Very quickly, I am aware of a number of services now offering online counselling as well, alongside the face‑to‑face offer. Also Jane and I are involved in a national project at the moment called the GP Champs project, and we are working in 10 local sites. At the site in Cornwall they are trialling a very small‑scale piece of work at the moment with a Facebook page called “Dr Grace,” which enables young people in a rural community to access the help of a GP via a dedicated Facebook page. That seems to be working well too. There are things.
Q38 Andrew George: That is a very good link to my next question, which is more generally on the issue of digital or cyber-bullying. Often you see in the newspapers, the media and elsewhere extremely upsetting stories when young people, it is alleged, have been bullied online and have taken their lives as a result. There are apparently sites that actually encourage self‑harming, and enable and perhaps seduce some impressionable people into accepting the route of suicide and other practices. Obviously, this is extremely upsetting. To what extent do you believe that this is a genuine trend, or is it just others in the media simply wanting to find an excuse or a scapegoat for something that is going on anyway?
Sarah Brennan: Our experience with young people is that it is genuine. This is absolutely a different experience of growing up, and for young people it is endemic and almost expected. If Tanya Byron was here now she would be talking about how they are digital natives, but we do not have any kind of road map in terms of young people being equipped to manage the risk for themselves. The genie is out of the bottle and we cannot stop this, but we do not enable young people to learn how to manage the internet and look after themselves at all. Certainly, it is genuine in terms of the impact on their mental health, and I think this is something that we, as the adult population, are slowly recognising, and we are finding ways of providing help. There are helpful sites online; we should not always see it as being the demon. Young people say to us that they access help online which they would not be able to get anywhere else, and they feel able to share things. There is risk and opportunity in that obviously. Therefore, we need to be promoting—and some of the work we have done around the use of the internet is actually having more good things available online—more positive help and more access to good, well‑managed healthy young people online so that that can be as easily found as the dangerous and negative sites, which seem to be very easily found by young people.
Professor Fonagy: The rates of cyber-bullying at the moment run at between 20% and 40%.
Q39 Andrew George: Sorry, can you explain that?
Professor Fonagy: If you randomly sample young people at the moment, 20% to 40% of them will say they have experienced cyber-bullying.
Q40 Andrew George: Or have bullied. The evidence we have is that young people bully as well as receiving it.
Professor Fonagy: Yes. That has been a pattern for ever. However, there is a recent finding that shows, when comparing kids who are bullied face to face versus kids who are bullied on the internet, that being bullied on the internet has a much greater effect. The reason for that is several-fold.
Q41 Andrew George: Can you give a percentage? You say that 20% to 40% have experienced bullying online. What percentage have experienced bullying face to face?
Professor Fonagy: I would have to come back to you on that.
Q42 Andrew George: It is presumably lower, is it?
Professor Fonagy: It is somewhat lower.
Q43 Andrew George: I think we had a figure of 10%.
Professor Fonagy: It is difficult. You always have to give a range. I think 10% would be at the very bottom end. This has been an area of research of mine, so I am a bit hesitant about giving figures that are not current. There is something very specific about internet bullying that is really worth thinking about. There is no getting away from it; kids cannot get away from it. Also, the audience is massive. The most important difference, and what protects kids from the perpetrator in bullying normally, is bystanders—other kids hanging around. There are no bystanders in internet bullying, which makes you exposed to them without any help. You feel helpless. The other side of that, from the point of the bullies, is that when you see someone—this is true for violence of any kind—when you do harm to a person, their reaction usually blocks you from carrying that further. You see the impact that you have on them and there is a biological system that blocks you. When you are bullying someone face to face you might stop short when you see the upset you have caused. When you do cyber-bullying, you do not see the impact that it has and that makes it a much graver problem than playground bullying. What we do know is that school‑wide interventions on this work quite well. The kind of initiatives that have been done—there are outcomes studies on this—are multi‑disciplinary, whole‑school, interventions. You move into the school and educate all the staff in the school. In fact, we know that bullying interventions do not work unless you involve everyone, from the school administrator to the teachers, teaching assistants and domestic staff. Everyone has to understand about bullying in order to properly deal with either face‑to‑face or cyber-bullying.
Q44 Andrew George: Can anyone inform me about the impact, say over the last 20 to 25 years? Obviously the activity has clearly increased and the social networks clearly were not in place a generation ago, or at least I do not think they were, not to my knowledge. Someone will no doubt correct me. Can you put your finger on statistics that show a relationship between mental health outcomes, suicides and internet cyber-bullying, and so on? Is there a pattern?
Professor Fonagy: There is a study. I can name three studies.
Q45 Andrew George: Young people tragically commit suicide anyway. In other words, can you say that you can see a spike or a relationship which says that this has increased the preponderance of suicide in young people?
Professor Fonagy: I do not know a study of suicide, but I know a study of depression, which is strongly associated with suicide. Victims who are cyber-bullied have very severe and long‑term depression, anxiety and emotional disorders that are associated with self‑harm and suicide. The most important fact is that a victim of playground bullying is likely to tell a teacher or an adult. A victim of cyber-bullying is not likely to share. They keep it to themselves. That is part of the reason why I think a school‑wide intervention where you are involving everybody is so important.
Dr Hindley: The other thing is recognising that social media are a core part of young people’s lives. You cannot just say, “Stop doing it.” It is about young people learning how to use the internet in a wise and self‑protective way, and talking about it.
Sarah Brennan: The other point is that the impact of bullying is not just temporary. It has now been shown that the impact carries on over a long time in life, in terms of both depression but also the replaying. The impact on the person’s functioning has a continued effect into their adult life.
Q46 Andrew George: You mentioned earlier that there are now some very good sites; in other words, the antidote is there in the electronic world as well.
Sarah Brennan: Some, yes. There need to be more.
Q47 Andrew George: Given the fact, as I understand it, that more than 85% of young people have now got Facebook, or are engaged in social media in one form or another—is that the right terminology?
Sarah Brennan: Yes.
Andrew George: Given that that is the case, you cannot turn the clock back. This is a fact that cannot be erased. Therefore, having the antidote more effectively in place and in the right places—presumably when the bullying happens there is help and assistance available to support young people—what more can be done to help young people, and, if more can be done but it is not happening, who is stopping it?
Sarah Brennan: First, just to start us off on that, there isn’t any one thing. Secondly, there certainly was some work previously around what needs to be done in terms of educating young people about using the internet safely. I do not know what progress has been made on that. There was a Government strategy, and I think Tanya Byron chaired that committee. I do not know where that has got to in terms of being delivered.
Many of the sites are informal. They do not have the clinicians and the background there to support young people as well. They are informal sites that may have been set up by other young people. We have a lot of work to do to catch up in terms of matching what is good alongside other more negative information. There is a lot of improvement to be done.
Q48 Andrew George: There is no kind of CAMHS or NHS England strategy for this.
Sarah Brennan: You will know more, Peter.
Dr Hindley: Within the faculty, we have just started a group looking at how you could try to promote resources on the web that would be more adaptive for young people. But you have to involve technologies, because, if you look at how you maximise whether or not you are at the top of the list in a Google search, there are all sorts of technical difficulties. It is something that needs to be addressed, definitely.
Sarah Brennan: YoungMinds has just put out—
Q49 Chair: This was exactly what Tanya Byron was looking at on behalf of the Government.
Sarah Brennan: Exactly, yes.
Professor Fonagy: You may not be familiar with it, but last week MindEd was released, which is a partial answer, a partial challenge, to that. Among other things, it is supporting professionals in the field, teachers and policemen, increasing the mental health literacy that has been shown to improve resilience. It is something that parents can have access to as well.
Sarah Brennan: One last thing about this is that we actually have to engage with young people, because this is their territory. What is it that they find helpful and what is it that is actually dangerous? Again, with CYP IAPT, the engagement with and involvement of young people in service design, as well as their own particular therapeutic pathway, is core. That is absolutely essential if we are going to have internet services that actually work. If we are looking at it, we will not do it right. YoungMinds has produced—it has gone live now—a new website called HeadMeds, which explains medications in young people‑accessible ways and language. That had alongside it young people advising at every step of the way. In all of these services we need to really refer to what young people are telling us very actively.
Chair: The mention of parents is your cue, Grahame.
Q50 Grahame M. Morris: I do not want to go over the ground again; you have already touched on it, and Professor Fonagy mentioned MindEd. In terms of the range of tools in the tool box—if I’ve got the terminology right—it is important that we use the new social networking media and so on, but what can we learn from things like the phone lines that are used in the context of adults? I was thinking about what works in east Durham in relation to drug and alcohol misuse, where having a dedicated phone line for young people seeking advice and so on proved to be quite successful. You have given your views in relation to the need for education for a range of professionals, policemen, social workers and others, but what are your thoughts generally in terms of how we can best engage with young people beyond social media?
Sarah Brennan: I am sure other people have thoughts. At the moment, in terms of national availability, we have a phone line for parents who are worried about the emotional wellbeing or mental health of their child. The only nationally available similar resource for children and young people is ChildLine, and we actively work with them. Social media have come into that space around online help, and there definitely has been a move away from funding phone lines. There has been a plethora of different kinds of phone lines available and it is an area of great difficulty in terms of their ongoing survival. In terms of phone line counselling or further advice, I am not aware of anything else on a national level beyond ChildLine. Barbara might be aware of local services.
Q51 Grahame M. Morris: If I might interrupt you for a moment, earlier on in the session Dr Roberts referred to parents making the referral, bringing their children along with them. In terms of a step change, is this something that we should be recommending, in terms of children making the referral themselves and how they might do that?
Dr Roberts: I think you pick up on a really important area, which is how do you address mental health problems with parents, how do you support them and, certainly within the general practice framework, how do you support them to let go of their child and young person so that they can be equipped to book their own appointment and turn up and see the doctor on their own? Certainly at the coal face you see such a spectrum of young people, particularly those who have had to grow up early or quickly because of multiple pressures at home, or for a whole host of reasons, who will have to be quite emotionally mature and see the GP on their own. Then there is the other end, people who are still coming in with a parent—whether they are 16, 21, 25 and plus. Certainly at regional and national meetings where I have been present we talk about this, looking at transition, which is obviously a huge area: how do we support parents to embolden their children and to pull back? That again, to go back to GP education and training, really would not feature in core training.
Q52 Grahame M. Morris: In relation to the importance of working with schools, I represent a constituency in County Durham, east Durham, and the numbers are frightening in terms of the children who require services for support and counselling and so on. Is that something that we should be highlighting and working on more with schools as an interface?
Dr Roberts: Just to pick up on all the discussions around commissioning, unless—
Grahame M. Morris: I am sorry, I have not given Barbara a chance to come in.
Dr Roberts: Okay. Unless we have joint commissioning that really is across local authorities, schools, education and health—
Barbara Rayment: We are talking about a wide age range, so schools are one answer, but we should not get fixated on one‑size‑fits‑all approaches. The internet has a place and we need to develop more sophisticated ways; Sarah’s point about involving young people in how those kinds of developments are happening is really important. But the place for face‑to‑face advice, counselling and help is also important—statutory or voluntary; it is the mix. Some young people want their parents involved and some do not. We really need to allow young people to have a much greater say and choice about how they want to access help. They are in charge of their mental health, and I think they can be helped to know what suits them best.
Dr Hindley: I have two points on that. One, it is very important to think a bit about parental mental health, particularly how we approach the management of things like depression in parents. We know there is strong continuity between parental depression and childhood depression, and, if we could approach that in a more joined‑up way between general practice, CAMHS and adult psychiatry, it would be very helpful. The other thing is that, from a clinician’s perspective, parents are very important resources to children and young people. From a clinical perspective, I would want to work not just with the young person but also with their parents, if they want to, because they can be very important sources of support.
Chair: Andrew, do you want to develop the questions about schools?
Q53 Andrew Percy: Yes. We kind of got into the schools debate already. I wonder if you could give me collectively, as easily as possible, what your current perception is on the adequacy of the teaching profession and schools—be careful now—generally to deliver—
Chair: In this narrow respect.
Andrew Percy: In this very narrow respect, to deliver support to young people who are suffering mental health problems.
Barbara Rayment: Can I kick off? I am a school governor and I would say that the school where I am a governor is very effective and strong. However, that is not true across the piece. I think the answer is that it depends where you look in terms of the investment that schools make in their whole pastoral care system and the importance they place on PSHE. Some schools do that very badly, some do it very well and some have very good anti‑bullying strategies and really help young people to use the internet well and safely. It is very, very different depending on where you look. It should be better, and maybe some of the things that we are asking for are not well surfaced in the Ofsted inspection as well. If we were actually asking Ofsted to look at some of these things rather better than perhaps it does at the moment, we might get better performing across the whole school system.
Sarah Brennan: I absolutely agree with what Barbara said. It depends on the head teacher, absolutely. We have seen a big change in schools, often described as the atomisation of schools. The local support structures that were there sometimes are still there but have, in the main, broken down or are breaking down. They are certainly weaker.
Q54 Andrew Percy: In what respect? What exactly?
Sarah Brennan: There used to be programmes that local authorities provided. There was the Healthy Schools Programme, which provided support in schools and also facilitated schools to work in cluster groups. Some of those cluster groups have remained, some have not, so the support that used to be available to head teachers—that they could call on—is not there as much. They have the cash in a way that they did not have before, which often they are very pleased about, but it means that it is their pot of money that they are working with, rather than necessarily thinking about working across the piece. Again, this varies. However, our experience is that many schools are very aware that, if they support the emotional wellbeing of their pupils, it will help them academically, which is their driver. They are very concerned about some of the issues that are happening in their schools, as was mentioned earlier, and are at a loss about what they should do about that or how they do it. Certainly the relationships between CAMHS and schools can often be very disjointed, at the least. There are examples of some very good close working where schools pay for a CAMH service in their school, or they might pay for another independent service like Place2Be, and they broker that relationship with CAMHS on the school’s behalf. But I think there is a gap, which does not help CAMHS and does not help schools, where both feel that the other should be doing more, where schools feel that CAMHS have pulled up the drawbridge and CAMHS feel that schools are not doing their bit to help those pupils. If those relationships were improved across the country, I think we would see an improvement in terms of how schools feel they can function, and also in awareness and knowledge.
One of the bonuses in the areas where there are CAMHS coming into schools is that they are there as advisers for the teachers too. The teachers then pick up information and knowledge and their own knowledge base grows, so they are able to access something about the emotional wellbeing of the teachers too. There is work that we have done with some head teachers and schools on enabling them to think about who are the young people most at risk and what is going on in their lives. There are some very simple things that schools can do which can help the whole school, and in particular young people’s achievement.
Q55 Andrew Percy: Would your perception be that teacher training is inadequate in this respect? From my teacher training days, it was very much around physical disabilities, the autism spectrum and behavioural problems. But on other mental health issues I do not think that was something—beyond the basic counselling role of sitting down and talking with pupils who are having a bit of a difficult time—
Sarah Brennan: I would say that it is more about understanding children and young people’s development, what can go wrong and what signs you might see; what behaviour means rather than its being labelled “mental health,” because that brings into it the whole connotation of illness and problems, when actually some of the issues are about what happens to a teenager, about the developmental stage and the behaviour that is being seen. Is that a problem? Is it just about how you manage teenagers or has something happened at home recently that is causing that behaviour in school? It is much more about understanding how children and teenagers work, rather than seeing it as being mental health, because, generally, what we mean by “mental health” is mental health problems and illness.
Dr Hindley: Children with mental health problems are children first and foremost, and being treated as children in their own right by teachers is a very good thing for them. Teachers often provide very important and positive role models for children. Some teacher training is about skilling teachers to manage behaviour problems in school much more effectively, which is important, but equally it is important that teachers do not think, “That is a child with a mental health problem. They need to be treated in a different way.”
The other thing that is worth thinking about is some of the interventions that are available before school to promote healthy development in infancy and early childhood, and using services like health visiting to enable healthy early development so that, as children come into school, they are prepared for school and prepared for—
Q56 Chair: Just to reinforce this, is it not basic to any form of professional education, whether it is in teaching or a clinical profession, to know the limits of your professional expertise and to know when to call for help?
Dr Hindley: Yes.
Chair: Is that part of your question?
Q57 Andrew Percy: Yes, absolutely. From my perception of teaching, I would not necessarily know when a child has really complex needs. I do not know where the tipping point would come in terms of when I need to refer that child on. You try and work your way through. In some cases, if it is violent behaviour or there are drug dependency issues, it is much more obvious, but otherwise it may not be.
Dr Hindley: That is where services coming into schools can be very effective in terms of providing live supervision and live training, if you like, to help develop that set of skills.
Q58 Andrew Percy: Sure. I wonder how you get that into teachers. I did teacher training through PGCE, the proper—sorry, the other—route for doing it. Strike that from the record. That is one route in, but of course, a decade or so ago we had the GTP created, so we have lost that kind of classroom‑based teacher training where you actually study cognitive development and all the rest of it. I wonder whether or not there has been any evidence that that has had an impact at all. I sound like the NUT now, which is a position I do not want.
Chair: It is counter-intuitive.
Professor Fonagy: I am not sure that there is any evidence yet in relation to that point, but there is a great deal of evidence that decoupling wellbeing from educational goals has not served us terribly well within the current system. There are, at the moment, literally hundreds of programmes in this country on social emotional learning that have been shown to improve mental health outcomes by about 10 percentile points at the same time as improving educational outcomes by 10 percentile points. Having removed wellbeing from the Ofsted check‑list—their list of concerns—one of the intriguing things is that in Finland, a country that is held up as having very high educational values, their view is that their priority should be the child’s wellbeing, and then the education will take care of itself. They prioritise ensuring that the children are reasonably comfortable.
Q59 Andrew Percy: Is there any evidence around that, though? A lot of it is perception, just as my question a moment ago was purely around personal perception; there is clearly no evidence to support what I think. Is there any actual evidence around that, or is it just a perception that, if you take it out of the Ofsted framework, obviously schools will stop doing it?
Professor Fonagy: There are three buckets of evidence, if I may say that. One bucket of evidence shows that focusing purely on educational goals increases difficulties for children in terms of stress, as you would predict: the more pressure you put on a kid educationally, that is—
Q60 Andrew Percy: But the framework is not just that, is it? Safeguarding is still in there, and one of the key parts of the framework now is how safe a child feels at school, which is surely all part of it when it comes to cyber-bullying and all the other stressful areas.
Professor Fonagy: What has been removed, though—
Andrew Percy: We have not just gone to purely academic—
Professor Fonagy: No, and I am not trying to imply that. What we do not have any more is systematic structured teaching of life skills. There is a lot of evidence that, in‑built, schools have a very important and significant potential role in enhancing the resilience of a child, the child’s capacity to problem-solve—real‑life problems, not mathematical problems.
Q61 Andrew Percy: But where is this?
Professor Fonagy: This is Martin Seligman’s Penn resiliency project that has been rolled out in the United States in many places. It has been tried in this country as well, and it has been shown to have an effect. At the moment it is one of those situations where you demonstrate that, and as soon the programme is withdrawn the effect disappears. What we now know is that you have to keep the programme going in order to keep the outcomes. That is the third point that I was going to relate to your question. We need to change the priorities of teacher training slightly in the direction of being more focused at achieving resilience goals for the kids rather than outcomes in educational terms. We know that high educational attainment does protect kids to some degree, but it only protects kids in advantaged homes. It does not protect kids in disadvantaged homes. By focusing on educational attainment—by epidemiology, this needs to be shown—it seems likely that you are going to increase the inequality rather than reduce the inequality in wellbeing.
Chair: I think we are stretching the joint strategic needs assessment quite widely.
Q62 Andrew Percy: I have one more question. You mentioned health visitors, Peter. I had forgotten about this because of course we had the big commitment before the last election to almost bring back to life that role, which seemed to have been slowly dying. What has actually been the impact of that, given that there has been a big increase in the number of health visitors? Has that had a major impact at that early age?
Dr Hindley: I know about the impact of the Family Nurse Partnership project in terms of the more vulnerable mothers and its effectiveness. I am not aware of evidence of the impact—
Q63 Andrew Percy: I just wondered, because, if there was any evidence surrounding that, it would seem a perfect—
Dr Hindley: It seems sensible and logical that providing early support and promoting good relationships between parents and children, carers and infants, will lead to good outcomes, but I do not know whether or not expansion of the health visitor work force has led to that.
Dr Roberts: My own experience locally and clinically is that, with health visitors moving into local authority jurisdiction, there is huge uncertainty, fear of the unknown and anxiety about moving out of health and into a different area that, I guess, they might worry does not understand them as well, which I think reflects back to the new landscape leading to so much more fragmentation.
Q64 Andrew Percy: But if it is all about integration, is that not the way to integrate, if you have health visitors to rely on in the process, which seems to be where one of the divides is at the moment?
Dr Roberts: Indeed, but then you need very facilitated and good communication between the local authorities, the CCGs, NHS England and Public Health England, all of whom dance to different tunes and masters. They need to be brought together. There is always history, of course, behind that. In the area where I am involved in commissioning, there are two local authorities, and the relationship with the CCG is very different because it reflects the history of the PCT and very often the same individuals, of course, who moved out of one post and into another. That then evokes personal relationships as well. Again, it is a complex answer.
Sarah Brennan: If we want to recognise the different cultures of the different departments—I am sure you know this—it comes down to language as well, and acronyms. One of the things about working around mental health is that the language used to describe the same young people is different—the language that education and teachers would use, that a social services social worker would use and a mental health CAMH clinician would use—but it would all be describing the same child with the same behaviours. I think the language trips us up a lot of the time and also creates divisions between those departments; the culture and the way of thinking is different. As much as we want integration, it is chasing the pot of gold at the end of the rainbow, and maybe we need to think about joint working but recognising the differences and trying to make some common language between us around children’s mental health.
Q65 Andrew George: On perinatal mental health, I wonder whether, Barbara Rayment, I could come to you first on this issue, as you have described the current situation as patchy. Certainly from my experience campaigning for a mother and baby unit in Cornwall—the nearest one, I think, is about 300 miles away—it seems to me worse than patchy. It seems to be a desert with only very few oases—the kind of adequate facilities that can cater for both mother and baby in the postnatal period. Is there any kind of strategy that you can see to make sure this is covered, or is patchy the right word? In other words, it responds to local demand rather than there being a national overview as to what is going on.
Barbara Rayment: That is my understanding. It is not my area of expertise at all, but, certainly within the coalition itself, the NSPCC and Mental Health Foundation have both done quite a lot of work in this area. What I understand is that there has been an absence of thinking about what happens in that 0 to 5 age range in terms of even describing children of that age as having mental health. In that very important relationship, there is increased recognition; it goes back to the health visitor question about how to pick up postnatal depression and so on. But I do not think we have done very much work at all in thinking in terms of that baby’s own individual growing mental health. I would need to come back to you, and ask some of the people in the coalition, to respond better.
Q66 Andrew George: I imagine others might want to add a clinical perspective, but there are two separate issues. There is the post‑partum psychosis and so on, the issues relating to the mother and whether she should be treated separately from her newly born baby and all of the difficulties that that might create. Then there is, as I understand it, the first thousand days being really very important in developmental psychology. One can only be wise in hindsight. How can you pick up a mental health issue in a 3‑day-old child?
Dr Hindley: There are two separate and related issues. In relation to perinatal maternal mental health, I think NHS England, within the mental health specialist clinical network, are looking at the number of beds. You may want to ask them to come and give evidence because I think there is a development strategy and an awareness that the provision of mother and baby units be more than just patchy; it has really developed according to personal interest, and enthusiasm will be the key driver, I think.
The other issue is about infant mental health and early childhood mental health, which in some areas was always an area of interest for child and adolescent mental health services but has become more and more difficult to prioritise as services had to become more generic and had to focus on a wider age range; on the whole, younger people tend to attract attention more than very young infants. But there is good evidence for interventions early in infancy, mainly focusing on the relationship. I do not think you would say that an infant has a mental health problem, but you can say that there are significant difficulties in the relationship, and there are good interventions to affect and improve the relationship in such a way that you can improve outcomes for infants.
Q67 Andrew George: Is this health visitor territory or is this in‑patient support?
Dr Hindley: No. Again, there are several layers. There are universal interventions that you can deliver through health visitors, but there are also more targeted interventions that you can deliver through specially trained health visitors who can identify couples, if you like, dyads who are in difficulty. Then there are more highly specialist interventions, maybe for mothers with severe mental illnesses or mothers with personality disorders where you need a much more sophisticated intervention.
Q68 Andrew George: Most of these cases are a bit like Andrew Percy’s earlier question in that you know who these people are before the baby is born and therefore there is some intervention—
Dr Hindley: Some you will know, yes.
Andrew George: And you are going to wrap it around them, whether they like it or not, or it is going to be offered to them.
Dr Hindley: One of the problems is that in most areas of the country there is a bit of disjunction between the maternal perinatal mental health services and the infant mental health services. North‑east London is one of the few areas where you have a joined maternal mental health service and an infant mental health service. You need a service which follows the infant’s development and does not suddenly stop at nine months when the maternal mental health service stops. But there are not many examples of that quality of joined service, if you like, in the country.
Q69 Andrew George: I do not know whether Professor Fonagy wants to add anything. You look like you are chomping at the bit.
Professor Fonagy: It is an area that I worked in for some years. I do not want to talk too much about it, but I want to highlight that 10% of women are affected. When you are looking at the very extreme end of psychotic illness, that is a very small proportion, but about 10% of children—1 in 10—will have a mother who is suffering from perinatal mental illness.
Q70 Andrew George: That is very high. You said it was very low—
Professor Fonagy: It is very high. I am trying to alert you to the size of the problem. We also know that if you identify these cases early you can prevent them from being in‑patients, so it is a problem that exacerbates for reasons that are very easy to understand: if you are a mum alone with a baby and unsupported, it is difficult.
One very important thing that I think this Committee could help to highlight is the myth that a lot of mums come with that their babies are going to be taken away if they manifest indications of mental illness. That will add to a late referral, exacerbate the problem and make it more likely that the things they fear will happen. In terms of what health visitors can do, there are three things: one is to be properly trained in identifying mental health problems; the second is to have training in evidence‑based practice rather than using their intuition as to what to do about it, trying to incorporate into their training some degree of evidence‑based interventions that are known to help, which are usually aimed at supporting the mother‑baby relationship, as Dr Hindley was identifying for you. The third thing is that there should be, as I think you were hinting earlier, within maternity services specialist midwives who have the particular skills that need to be drawn upon. At the moment, as Dr Hindley indicated, the services are such that, if you have a good person in one place, you would be very lucky.
Q71 Andrew George: Dr Hindley, you quite rightly made a separation between maternal health and the developmental psychiatry of the infant. If there is a lack, for example, of a mother and baby unit and the kind of facilities and services associated with it, is that an alarm bell which actually indicates that, as far as infant psychiatric support is concerned, the facility will be poor as well, or is that a rather lazy association?
Dr Hindley: I am not sure that you can make that link. The important thing about mother and baby units is that they are mother and baby units, so you can keep the mother and baby together and can manage any concerns about risk that the mother might present. The core thing is that you want to keep a baby with a mother as far as you possibly can, but there may be some instances where you cannot. I said that they are separate, but obviously they are conjoined, aren’t they, because you need a service which follows both the mother and the baby through? It may be that the mother recovers very quickly and does not need further support, but they may be then more vulnerable to later difficulties. If you could have a properly integrated service, both the mother and the baby would receive a much better quality of service.
Professor Fonagy: What you need is a perinatal mental health care pathway, which at the moment we do not have, where mother and baby units are a very appropriate end point. In South Africa and other countries there is a stepped‑care approach.
Q72 Andrew George: Who designs that pathway? Is that a commissioned service or is that something which the—
Professor Fonagy: It would have to be a commissioned service.
Q73 Andrew George: So the commissioner just makes a decision.
Professor Fonagy: Yes.
Dr Hindley: Just to clarify, of the 10% of mothers with mental health problems, only a tiny proportion need in‑patient care.
Professor Fonagy: Yes.
Andrew George: Of course, yes.
Chair: Part of your assessment and follow‑up plan, hopefully.
Q74 Grahame M. Morris: Just moving on, there are a couple more issues that we need to address. As was touched on a little earlier, the transition from adolescent—I presume—mental health services to adult mental health services has frequently been raised as a problem. I think Sarah or Barbara said that we should not have a one‑size‑fits‑all kind of approach, and that we should not be too prescriptive when we are drawing up a framework. Could you tell us what the current arrangements are, what the particular problems are and what needs to be done to address them?
Barbara Rayment: The transition problem is a long‑standing one. Certainly from where I sit, a lot of the focus has been particularly on trying to bridge what seems an unbridgeable gap between statutory sector services—which are often prescribed up to 18, although quite often it is earlier—and the move into an adult sector, which is often not well suited or well designed to meet the young person’s needs. Quite clearly, just because you are 18-and-one-day-old it does not mean that necessarily you operate in any different way than you did two days beforehand. There is a real mismatch in terms of service design. That is where a number of the services—within the voluntary sector, on the whole; they tend to be the information, advice and counselling providers—have always worked across this 13‑25 age range and therefore have always bridged that gap. The big problem that most of them face is that they cannot engage adult commissioners in helping to support that age range. There are good instances where particularly adult mental health stepped in and jointly commissioned with CAMHS a piece of provision that works very successfully, so that young people do not face any kind of gap whether they are 18, 19 or 20. But in many areas across the country you cannot get adult commissioners to recognise the distinctive needs of that young adult population and then work with CAMHS or youth commissioners. I do not think this problem is necessarily confined to the mental health system either. It is across the piece. In drugs and alcohol, the same sorts of problems persist. In the prison system, there has been evidence of the particular problem for young offenders and so on. This is something about our perceptions of when adulthood begins. Because young people suddenly acquire a legal status on their 18th birthday, it does not necessarily mean that, developmentally, psychologically, they make that great or significant a change.
Sarah Brennan: The issues are around how mental health is perceived and what kind of service the person needs. Assessment thresholds are very different in adult and in children’s services, and also there is variation across the country around what happens at 16, 17 or 18. In some services it is 16, and they say, “Well, you’ll be going to adult services soon so we won’t take you on.” A teenager can be left without a service at all for a period of time, or they are seen and then the age changes. It varies as to whether it is 16, 17 or 18 when the cut‑off happens, but certainly it is very traumatic for families and for those young people. There are experiments around the country about ways of doing the service differently. Peter and I visited a service in Norfolk which goes up to 24, but then the danger is that you have two transitions, one at a younger age when you are going from a children’s service to more of a youth service type, around 14 or 12, and then another one at 24 when you need to move to adult‑style services. It is fraught with difficulties and there does not seem to be an easy solution; it seems to be intractable. It is about how that can shift. It is at a point of great vulnerability for young people developmentally, and we are actually compounding problems rather than helping them.
Dr Hindley: It clearly is a very important issue. I think this is something where we can learn from physical health in terms of how they manage transition, which is seen in a much longer framework, with planning for transition starting at 14. That, in turn, depends on the particular groups of children you are talking about. In many ways, we have had to think about transition services according to the different care pathways, because the kind of transition planning you want for a young person with a psychotic disorder, which you know may well have a life‑long course, or with an autistic spectrum disorder, which again is likely to have a life‑long course, might be very different for a young person who has depression, say, where they may recover. We have to think about a number of flexible solutions, but emphasise co‑working between adult and child and adolescent mental services, and have young people right in the middle of them.
Q75 Grahame M. Morris: I wonder if I might raise one more issue. I presume you are familiar with the Department of Health’s document “Mental Health Crisis Care Concordat.” My question is in relation to section 136—the place of safety provisions. Do you think the Department’s response adequately addresses the concerns that have been raised in relation to the use of section 136?
Dr Hindley: I do not think they really thought through the specific needs of young people. I think young people presenting in crisis often have quite complicated interrelated needs; sometimes they are physical needs, sometimes they are social care needs and sometimes they are mental health needs. Locating it purely within a mental health framework I think will do a disservice to quite a number of children. It would be really helpful to be able to revisit the concordat at its next revision and think much more specifically about the needs of children and young people in crisis.
Q76 Grahame M. Morris: When will it be revised?
Dr Hindley: I do not know, but I know that all of these concordats are due for revision, and I think it definitely needs a fresh look with respect to children and young people.
Q77 Grahame M. Morris: Do you agree with that, Professor Fonagy?
Professor Fonagy: I would certainly very strongly agree with my learned colleague. Children are all too often forgotten.
Q78 Grahame M. Morris: Is it appropriate to use the section 136 provisions?
Dr Hindley: In some circumstances, yes. If you have a 16‑year‑old who is acutely disturbed and is physically aggressive, the 136 route is the right place to be, but if you have a 12‑year‑old with autism who is also acutely disturbed, the 136 route may be the very last thing the person needs. It needs a much more thought‑through and integrated approach.
Professor Fonagy: It needs mental health expertise on the ground—that is what you often do not have—to be able to tell the difference between the two.
Q79 Chair: Andrew, do you want to ask about suicide? No. I have one concluding question, which is that underlying quite a lot of this discussion has been uncertainty about where the rising trend of demand is coming from. I am conscious there is some work planned in the next financial year, or in the new financial year about to begin, on the prevalence of mental health issues in children and adolescents. I would like to be clear as to where the cash for that prevalence survey is going to come from. Can you give the Committee confidence that this work will be completed and the evidence presented on time?
Dr Hindley: The methodology is very well established. We have the right people with the right skills to do it. We lack the wherewithal. That is the problem.
Q80 Chair: In other words, it has not been a funded survey yet.
Sarah Brennan: It has not been publicly stated.
Professor Fonagy: It has not been announced.
Sarah Brennan: It has not been announced, but we are confident—or it has been reported that it is possible to be confident—that it will be happening this year. But that is a one‑off. That is the crucial thing. What happens next year and the year after? If it comes to pass, it will be fantastic and a real achievement, but it should not have to be this big achievement. We need this as baseline information. It should just be standard—
Chair: It should be routine information.
Sarah Brennan: It should be routine, absolutely.
Q81 Chair: Who is it that is giving you confidence that this work will be undertaken?
Sarah Brennan: The Department of Health.
Q82 Chair: Okay. It would follow from what you have said, would it not, that you see it as part of the core function of the Department of Health going forward that that prevalence survey should be part of the work that—
Sarah Brennan: Would it sit there? Would it sit in NHS England Informatics?
Dr Hindley: It should be the DOH, because it is such core information. How can you take a strategic view nationally if you do not have that information?
Professor Fonagy: Also, you create perverse incentives for certain things being found or not found.
Q83 Chair: I suppose the query in my mind is: is it them or is it Public Health England?
Professor Fonagy: Public Health England doesn’t do—
Dr Hindley: It is broader than just Public Health England because it is to do with delivery of services—child and adolescent mental health services. My view would be that it has to be DOH, however much help that is.
Sarah Brennan: It is core business of the DOH.
Chair: Fine. That is the evidence. Thank you very much.
Oral evidence: Children’s and Adolescent Mental Health and CAMHS, HC 1129 2