Health and Social Care Committee Education Committee 

Oral evidence: Children and Young People’s Mental Health, HC 239

Wednesday 2 September 2026

Ordered by the House of Commons to be published on 2 September 2026.

Watch the meeting 

Health and Social Care Committee members present: Layla Moran (Chair); Ben Coleman; Jen Craft; Josh Fenton-Glynn; Andrew George; Gregory Stafford.

Education Committee members present: Helen Hayes (Chair); Sureena Brackenridge; Jodie Gosling; Manuela Perteghella; Mark Sewards; Peter Swallow; Caroline Voaden.

Layla Moran took the Chair.

Questions 155 - 220

Witnesses

I: Professor Subodh Dave, President, Royal College of Psychiatrists; Rebecca Gray, Director, Mental Health Network at NHS Alliance; and Dr Sachin Sankar, Clinical Lead, East Midlands CAMHS Collaborative.

II: Dr Samantha Jones, Officer for Mental Health, Royal College of Paediatrics and Child Health; Vanessa Longley, CEO, Beat Eating Disorders; and Victoria Hornby, CEO, Mental Health Innovations (Shout and the Mix).

Examination of witnesses

Witnesses: Professor Subodh Dave, Rebecca Gray and Dr Sachin Sankar.

Chair: Welcome to today’s joint session of the Health and Social Care Committee and the Education Committee. This is our third session in our joint inquiry into children’s and young people’s mental health. I start by asking the panel to introduce themselves very briefly.

Professor Dave: Hello. I am Professor Subodh Dave. I am a liaison psychiatrist and the president of the Royal College of Psychiatrists.

Chair: Welcome, and welcome to your appointment.

Rebecca Gray: I am Rebecca Gray. I am the director of the Mental Health Network, part of the NHS Alliance, which represents NHS organisations and organisations commissioned to provide NHS care.

Dr Sankar: Hi, I am Dr Sachin Sankar. I am a jobbing child psychiatrist and part of the East Midlands provider collaborative, which last year won the best provider collaborative in the country in the HSJ awards, and then won the NHS clinical excellence award for making a difference to patients.

Q155       Chair: Thank you, all three of you, for being with us. I am sure, like many of my colleagues, my postbag is full from families in huge distress because they cannot access CAMHS. CAMHS services in Oxfordshire have some of the longest waiting lists in the country. The obvious question, which I know everyone at home is asking, and which I will ask first of Professor Dave, is, in a nutshell, why is CAMHS so broken?

Professor Dave:  I would not quite agree that it is entirely broken. There are examples of good practice. We just heard from Dr Sankar, and Rebecca will also probably outline some examples of good practice.

Demand has been rising; we know that. Complexity of presentations is rising. It is a real challenge for parents and young people not to have their whole care owned by someone. The risk of falling between two stools is very high. Our systems of commissioning and the outcomes framework incentivise that kind of fragmented working. Rather than having a whole-pathway approach that encourages joined-up working, there is a real incentive to work in silos. That is why people have to wait until they are in a crisis to be seen.

Not everyone on the waiting list is equal. We know that some people on the waiting list need to be seen earlier. They have more severe presentations and more dysfunction that need urgent assessment, but that does not always happen. I feel that there are already solutions and potential solutions happening in parts of the country, and we need to try to disseminate them across the board.

Q156       Chair: Thank you very much. Rebecca, maybe I could ask you: the mental health investment standard definition was changed last year. It used to be that the share of spend for mental health would rise in proportion with the NHS budget at ICB level. It is now with inflation. Has that been having any effect on the ability to improve and access mental health services for children and young people, from your perspective?

Rebecca Gray: It is quite hard to understand the link within this financial year. Overall, it has been challenging in some places to see adherence to the mental health investment standard and to make sure there is proper playing by the rules as to what is included in it. We were glad that the standard was maintained in some form. It is in some ways a quite crude tool for trying to protect investment in mental health, but share of spend is now moving down slightly as a proportion of whole NHS expenditure.

It is important that for the next few years we are able to maintain at least a floor for that expenditure within each area. We have great ambitions. The Government have stated great ambitions in children’s mental health. There is going to be a new mental health strategy in order to deliver the transformation, which is primarily about making sure we invest in preventive and early intervention services, and do not focus all our spend on acute and crisis care. That will require some investment, not only in the NHS but in partnerships with local authorities and the VCSE. There is a real risk, if the MHIS is undermined in any way, to that happening in the short term.

Q157       Chair: Undermined further—or can we just not tell?

Rebecca Gray: Undermined further. It depends, obviously. Where inflation sits will impact on it. The overall increase in the expenditure of an ICB may shift whether it is a better or worse outcome for the NHS in any given year. There is an ongoing risk to the MHIS as a concept. There are challenges to why mental health needs specific protection within budgets, compared with other areas of care; but we know, if we are even thinking big-picture economic growth and societal health, that there is a real risk of under-investment and its consequences in the long term.

Q158       Chair: Professor Dave, you wrote in your evidence to the Committee that “reforms to CAMHS services are not the answer”. That is quite striking in the context of the inquiry and what we hear from our constituents. Could you flesh that out a bit more for the Committee? What exactly do you mean by that? How would it help, say, one of my constituents, who regularly has to wait years just to be put on the waiting list for a pathway, let alone actually to get to the end of a pathway full stop? Could you expand on that?

Professor Dave: We tend to see—I will give an example from my world, the adult world, to illustrate the point—that when there are long waiting lists and a rise in people walking into ED, the temptation is to create another solution somewhere else to manage that and reduce footfall in ED. That will work well if you are thinking of the whole pathway, but if you are not, and if you create another service that just manages that little bit, you just shift it. You press the balloon and it pops up somewhere else.

That is the real risk for your constituents. You create a service that says, “We will assess you.” We have seen that with some of the neurodevelopmental conditions. You get an assessment but you then wait for treatment to start. The ball is just lobbed in the air, and there is no one to pick it up. Who is going to pick up the solution for managing the condition?

I do not feel that we need new services or a new structure of services. We need better integration between the services that already exist. Parents want support in schools. If the issue is raised in school, they want someone to pick it up. If that someone is, say, in primary care and identifies the problem as a severe one that requires the involvement of CAMHS services, they want CAMHS to pick it up, and so on. That integration is missing right now. We tend to see that that is why people fall between two stools. That is probably one of the biggest issues that parents and young people complain of. Their care is not owned by anyone and they keep falling between stools.

Clearly, that is also compounded by the fact that sometimes we create a workforce in one area. We say, “At the front end, we need to triage and support people, so we will have an increased number of support workers,” but clearly people have complex severe presentations, and we need our CAMHS psychiatrists. In pretty much each of your constituencies, I think, if you looked at the data, the real-term vacancy for CAMHS psychiatrists is almost one in three. You can imagine what kind of pressure that produces. If you have a complex severe presentation and get referred to a CAMHS psychiatrist, it is likely that you will not be seen very early.

I feel that that can lead to a situation where there are duplicate assessments, without any resolution of the problem. You present a crisis, or you text one of those online services, and each time you get a little plaster to hold you at that point of time; but there is no proper assessment or diagnosis, or proper formulation or personalised care plan, so that you as a parent, child or young person—and your team—are fully aware that this is what is happening. That is why my answer to the Committee was that what we need is—

Q159       Chair: I am not trying to put words in your mouth, but trying to understand: you are advocating a reimagining of the whole system. We are not looking to fix various bits of CAMHS. We need a root and branch reform of CAMHS itself.

Professor Dave: Aligning the frameworks, I think: as a college we create standards or good practice—evidence-based practice. Evidence-based practice should be aligned with the regulatory framework, and that should be aligned with the commissioning frameworks. There should be a straight line—a golden thread that runs through all of them.

Q160       Chair: We are going to come to the standard frameworks in a moment, but is this what you are looking for from them?

Professor Dave: Absolutely, yes, and to make sure that the regulatory and commissioning frameworks, and the investment, are all aligned—and that there is accountability. Whose job is it to ensure there is that investment? We know the population need. Each of you must know what the need is in your areas. We also know that it takes at least 14 years to train a CAMHS psychiatrist, so we are not going to be able to produce one overnight. If you know that we need x number of eating disorder psychiatrists, and the CEOs and CMOs in your areas will know that, what is the plan to produce that number?

Chair: It is almost like we need a workforce plan.

Q161       Josh Fenton-Glynn: On that bombshell, that we might need an NHS workforce plan, there is huge regional variation. I just wonder, Dr Sankar, as someone in one of the best-performing trusts, what distinguishes the better-performing trusts from the worst-performing ones?

Dr Sankar: I 100% agree with what Dr Subodh said. We have taken a whole-pathway approach. Looking at the statement that CAMHS is broken, in east midlands we have reduced our admissions by 61%. There used to be 330 admissions to CAMHS in a year, and we are now at 129.

Q162       Josh Fenton-Glynn: Can I just pause you, to clarify the terms? When you talk about an admission—

Dr Sankar: To an in-patient unit. We have reduced the length of stay by 80%. It used to be about 200 days per patient. We are now on 40 days.

Q163       Josh Fenton-Glynn: Is that treatment in the community or is it people who do not need treatment?

Dr Sankar: Yes, we have put that in. I will come to this whole-pathway approach. We have reduced referral waiting times by 85%. It is only five days, on average. That five days is also procedural. Usually we have a bed. In east midlands we have a 60% vacancy rate in our CAMHS beds, so we face a problem of what to do with empty beds.

Q164       Josh Fenton-Glynn: It says on my notes you have five or six days; Hampshire and the Isle of Wight have a 103-day waiting period. Is the clear pathway through this what you are getting right?

Dr Sankar: I think it is like what Dr Dave said. It is not a sticking-plaster. When we started out, we said “We’re going to start with a blank sheet of paper, and go from beginning to end.” The input of social services coming on board on day one is, I think, one of the most significant changes we have made. We have the first what we call care programme approach meetings within three days—72 hours. We drum it through and we insist that the social worker is there for that meeting.

Q165       Josh Fenton-Glynn: Is that a kind of multidisciplinary team around the child?

Dr Sankar: Yes, multidisciplinary: the social worker and schools representative are there, and of course our mental health representatives are there. I have been doing child psychiatry for a long time. When we started out we used to do paired outcomes: we had a questionnaire, and we said, “Your anxiety came down by 20%. I am a fantastic psychiatrist.” That has no real-world meaning. Our children don’t care. What does it mean to them? We need targets that are focused on the real world. We need to say, “What percentage of our children has over 85% attendance?” This is possible only with a combined approach to things. How many are able to get more than a level 3 in their GCSEs? We keep focusing on A-level percentages going up and down. In my world, it does not matter. I am really focused at the other end.

Q166       Josh Fenton-Glynn: Just a side point on that: obviously there is a huge association between mental health issues and school attendance.

Dr Sankar: Yes, and because we get them early on, we can move people out quickly and then we are done. We are invested in—

Q167       Josh Fenton-Glynn: And then do we see better outcomes?

Dr Sankar: Yes, and we have what we call an ECRT, which we have set up with the money we have saved.

Q168       Josh Fenton-Glynn: I am going to ask you to explain every acronym.

Dr Sankar: Yes, sorry, I will. We were lucky because we had a bid where we were able to develop tier 3.5—you know, in the old tiering system. This is about keeping kids from coming to in-patients. With that, we got some seed money and over time we have cast our bread back on to the NHS waters.

Q169       Josh Fenton-Glynn: Sorry, can you just go back and explain the acronym?

Dr Sankar: Oh, sorry, yes: it is the enhanced care referral team. They will come and assess every kid. All of my children are assessed by this team, who will suggest alternatives to care. With that, and our tier 3.5, we have a surplus of money. We returned £28 million and we have £6.5 million recurring funding that we are putting in apart from this.

We also put in another innovation that I think is really great: our family ambassadors, who are family members of our care users, who have come back to work for us and talk to people who come. As a result, the communication, from day one, is really good. They are talking to our family before they come in.

Q170       Josh Fenton-Glynn: Thank you, Dr Sankar. I am going to pause with you; there is a rich seam there, but I do not want to impinge on my colleagues’ questions. I want to ask Rebecca something. The NHS Alliance called for a better national focus on the reduction of waiting times and the aim of a four-week maximum. Whenever I think about waiting times, I cannot get over the parents I meet who are so stressed about the pathways that they want to get their children on, and the impact that that has on them and their health, as well as their kids’ health. What difference would proper standards in waiting times make in practice?

Rebecca Gray: We know, in the health system, that targets make a difference. They focus energy, investment, commissioning and planning. They are not the whole answer, but I think that if we have an expectation that people should get treatment in hospital within a reasonable period, it seems even more urgent to make sure that children who have emerging mental health needs do so, too. As Dr Sankar said, we have great examples of where children are waiting less than four weeks. It is more the midlands, but North Staffordshire is another example, with 98% of children being seen within four weeks, and 96% in treatment well within 18 weeks.

Some of the answers are simple: it is really good collaboration with the voluntary sector, a single point of access and really good triage. That national focus is really important. We have been calling for it for quite a long time. We think there should be equivalent targets in mental health to those we have in physical healthcare.

Q171       Josh Fenton-Glynn: It is interesting, because you have both spoken about services working together. You will notice that there are a lot of us around the table, because we are bringing the Health and Education Committees together. It feels to me that the real win, here, would be both sides, and social services as well, sticking their hands up and saying, “We are responsible for this child’s wellbeing.”

Rebecca Gray: Absolutely—and not neglecting the role of the VCSE in this. Some of the most effective examples we have are trusts with very long-standing, really robust partnerships with the voluntary and community sector, schools and local authorities, built on really good contracts, as well. I was talking to a trust—Surrey and Borders—last week, that has developed a programme that is mainly schools-based. The contracts it has with its VCSE partners are seven plus three. A 10-year contract is very unusual within the NHS and the voluntary sector, but we are trying to create sustainable, long-term programmes. Not all children need clinical care; part of what we are thinking about in the system at the moment is how you divert children as quickly as possible, where the support that they need is not down a clinical pathway. That needs these really robust partnerships.

Josh Fenton-Glynn: In the health service we talk about the shift from hospital to the community, and that feels exactly like that.

Q172       Caroline Voaden: The Health and Social Care Committee’s 2021 report raised concerns about high rates of rejected referrals and overly restrictive CAMHS thresholds. I hear regularly from young people and parents in my constituency about not being able to access CAMHS because they are either not ill enough or too ill. There is a sort of missing middle, isn’t there? Five years on from that report, how significant is that issue, and what action do you think should be taken to bring down the number of rejected referrals?

Dr Sankar: I feel that when we look at referrals and rejected referrals we are talking about what is at the end of the system. If we think about ourselves, when do we get angry and frustrated? It is very much the same with our children. They get angry and frustrated, and mostly it is because they are trying their best, but, for various reasons, which are sometimes not purely mental health, they are not able to get help. If, as Freud said, they turn it outwards and externalise it, it comes out as violence. When they turn it inwards, it becomes depression and violence towards themselves—self-harm and all that. The incidence of both has gone up significantly, as you are all aware.

The question is then: why are these children like this? I totally accept your question about rejected referrals. We should not reject any referrals. These are children in distress; but it is the right door for the right child. If we have a child with a neurodisability, who is having a burnout and very great difficulty, putting him in an in-patient unit—locking him up for any period of time—is doing him a massive disservice. Often that is seen as rejection from CAMHS—rightly, because we are not saying what the answer is.

I would say, as Professor Subodh already said, that they should have a proper, universal assessment to look at where the issue is. Then they should get support for that. It is not always with medication, therapy or in-patients. We need that kind of universal examination that looks at the child. They need help initially, because sometimes patterns of behaviour are stuck, so saying, “Go away and get better help in schools,” is, again, a terrible thing to do, frankly; but we need proper assessment. We should not be keeping children locked up or putting them in an in-patient unit, or giving them pointless therapy for things that are not going to change.

If you have a neurodisability—the word is that: it is a disability. You have ability and disability. That is not going to change. Their IQ is not going to change. Their social skills can be improved and worked on, but that internal mechanism—the brain mechanism—is not going to change; so we have to scaffold this child and make them effective.

Sometimes, the factor is not even child-centred. It may be just lack of care. What percentage of looked-after children keep knocking on our door repeatedly, and people are saying, “Treat this child”? But this child has no locus of control. It is totally external. The child has externalised it, because they have lost the internal locus of control. So we have to scaffold the child properly and have that kind of universal care system which supports that child to move forward.

Q173       Caroline Voaden: From your experience, if you see children so quickly, get them through the door and give them treatment early on, logic suggests that there will just be fewer children who reach crisis point and need more intervention at the other end.

Dr Sankar: Can I just say that “treatment” is in inverted commas. I frankly feel that, whenever we talk, we should always say, “children and families”. Sometimes it is just that. Can you imagine something as simple as a child who has not had breakfast when he comes in? Their behaviour is going to be terrible. They are going to feel more wretched about themselves. If a child who is not potty trained comes to school which does not have proper facilities, and they are sitting in dirty diapers the whole day, how do you expect that child to behave?

Q174       Caroline Voaden: In the interests of time I will move on and ask Rebecca about rejected referrals. What is your view?

Rebecca Gray: It is interesting. We have been looking quite hard at where the best practice is and where the lowest rates are. What we see is completely open-access systems—self-referral, direct referral from GPs, platforms that allow people and families to self-refer—and assessment that is well informed by good, senior professional expertise. So children are getting on to evidence-based pathways, if they need them, very fast. I recognise that that is not the experience of many of the families in the constituencies of people in this room, but there is something about a shift. It is not a complete reworking of CAMHS, but a reworking of the pathway in. I think that can be helpfully facilitated by digital. There are ways we can use different types of workforce better, to make sure that it works smoothly.

There are other workforce issues in this as well. While Dr Sankar is absolutely right that treatment is not appropriate for every child—there is a whole range of social and other needs—there are specific areas where there are waits because children would benefit from very specific evidence-based interventions. That is particularly children who have experienced PTSD or who have a complex emotional need where specific types of therapy may be the right solution for them, but we have not been able to train enough of our workforce to deliver some of those interventions. For a workforce strategy, we need that focus on the psychiatric and psychological workforce. We have grown the mental health workforce in this area quite extensively—mental health support teams in schools, and health and wellbeing practitioners—but there are still gaps, sometimes in crucial areas, within those evidence-based pathways.

Q175       Caroline Voaden: Thank you. Briefly, Professor Dave.

Professor Dave: I think we are all breaking out into wild agreement here. The main thing, which comes back to Mr Fenton-Glynn’s point, as well, is having those key performance indicators or incentives over the whole pathway. Right now, I think there are silos. Obviously, the reason why people reject referrals is that you try to protect your own territory. Your KPIs—your key performance indicators—are not aligned. There is no stake in the whole pathway; there is no stake in you having an investment in the child going back to school. Your stake is managing the workload of your team. That is why it promotes that kind of referral rejection. It promotes containment rather than solving. That was the plaster thing I was talking about.

If each child or young person had a comprehensive assessment with a personalised care or treatment plan, I think that would solve things, rather than shifting the burden somewhere else. I hope that this Committee can offer solutions that will be applicable across the board, because we are seeing the same in the adult world. You create a four-hour target, or whatever target, in the emergency department, and it encourages people to say, “We’ll create corridor care so now you are not technically needy, so that we do not breach.”

Chair: Our report on adult mental health services recommended exactly that.

Q176       Sureena Brackenridge: I would like specifically to consider the missing middle that was referenced earlier. Due to the high thresholds, it is becoming increasingly difficult for children and young people to access NHS mental health services when their needs are too complex for universal services but they do not meet the thresholds. Therefore, their needs are escalating. Specifically, how could the Government meaningfully close the gap in accessing support for the missing middle?

Rebecca Gray: I referenced a couple of points before, but I think a meaningful workforce strategy is crucial to this, and sending signals to commissioning organisations that this is a priority. As you say, it is not about a system that is entirely broken, but it needs a bit of reimagination. It needs some imaginative thinking about commissioning things in a different way, and that transition often costs money. If you are moving from one system to another, you need to invest in different ways of working and sometimes a slightly different workforce.

I think there is something about the Government making it absolutely clear that young people’s mental health is a priority, and sending the message to commissioners that they need to commission for a set of outcomes for young people that are not just about how quickly they access services, but what happens as a consequence of them; participation in school is a really good indicator as one example of that. In our understandable focus on making sure that acute hospital care is accessible and people get to see their GPs, we must not lose sight of this particular area of care. If we are thinking about our society, economy and communities in five, 10 or 15 years, and we recognise the particular challenge that NEETs present at the moment—I am not always that fond of that terminology—this is a fundamental part of dealing with that. It needs a focus for commissioning, appropriate investment and a strategy around workforce, and supporting organisations like ours and others to make sure that the good practice we are talking about today is well seen, understood and shared as far as possible.

Q177       Sureena Brackenridge: Dr Sankar, from your experience, what would you hope that the Government push further with?

Dr Sankar: I would hope that we focus on outcomes in the workforce plan. It should be about who can deliver that kind of therapy, rather than the position. One of the biggest hurdles or one of the biggest time-wasting meetings we have in the NHS is where we say, “Oh, the population is 100,000, so we need to have four doctors, three psychologists, five nurses and three dogs.” What does that mean at all? As Rebecca said, we need an evidence base. We need people who can deliver CBT-informed therapy or DBT-informed therapy. Who can deliver that? If we can get somebody who can deliver that in a proper manner, that is all we need. They should be judged by their outcomes: how many people come to you and how many you can get back into school.

Q178       Sureena Brackenridge: That leads me on to mental health and the modern service framework for children and young people and severe mental illness. Professor Dave, will that lead to meaningful improvements in widening access to support?

Professor Dave: There is sometimes a philosophical challenge to diagnosis. We know that evidence-based practice has been referred to all the time. Right now, there is almost a 15-year gap between the evidence being available and patients accessing it. If we can narrow that gap, we could already solve a lot of the problems. It is relevant to adult mental health, too. If we do not pick up severe mental illness at a young age, diagnose it appropriately and then manage the transition well, we know that they add significant workload to the adult services. It is actually in the nation’s interest to invest in early intervention, and I say that as an adult psychiatrist.

It is absolutely critical that we invest in young people’s care. That requires that comprehensive diagnosis and evidence-based pathways. None of it is rocket science, but it is about ensuring that there is not one single pathway. For sure, we need a single point of access. The pathway must be evidence-based, depending on your needs, diagnosis and the formulation. Then you access social care or medical care or a combination of all those, depending on what your particular needs are.

Q179       Sureena Brackenridge: Yes. Rebecca, do you want to add anything?

Rebecca Gray: The MSFs are promising. We look back to the national service frameworks and some of the funding that went with them. I have some concerns that, without funding attached, it may be challenging to make radical transformation quickly. We have much of the evidence about what works in mental health, and it is too often not the case that it is applied or applied appropriately, and we can see that in children’s and adults’ care.

There is a real logic to the MSF for children—whole child physical and mental health care. It could be so broad that it may potentially lack specificity in terms of some of the standards that might be applied, but I am optimistic. On severe mental illness, there is potential for it to provide a clear direction of travel in terms of where the evidence base is. I know it is incredibly frustrating for senior clinicians to know that, within their own services, sometimes the right evidence is not being applied within care, and that has a consequence for the people they are treating. I am optimistic about that and the development of a mental health strategy that, hopefully, will bring some coherence to all these pieces of work.

Sureena Brackenridge: Okay, thank you.

Q180       Helen Hayes: My Committee, the Education Committee, has taken a great interest in the parallel but overlapping crisis in special educational needs and disabilities. One thing that we heard in a previous inquiry is that there is a significant overlap between the children who are in the SEND system in one way or another and children who are known to mental health services in one way or another, but actually very little exchange of information between those two systems.

One thing that we saw in our inquiry is the compounding impact on children and families of waiting lists upon waiting lists. Children end up waiting within the SEND system, sometimes for diagnosis and very often for any type of meaningful support to be provided. While they are doing that, their mental health deteriorates. They then end up on a waiting list for CAMHS. They then end up in an absolutely terrible state, and lose years of their childhood that they won’t ever get back.

I want to ask you about the relationship between the SEND system; the waiting lists that we have for diagnosis around autism, ADHD and other SEND diagnoses; the lack of support that is available as a matter of course for children who have those needs, and the increase that we have in the population; and CAMHS services. What is the relationship as you experience it as people who are responsible for delivering services? What do we need to do to stop that compounding of the impact of waiting lists upon waiting lists on children and young people?

Professor Dave: I will make a broad point first, and then maybe Dr Sankar can come in and talk about the specifics. First, not everyone on the waiting list is equal. We need to recognise that. There will be some children—I see this as an adult psychiatrist—who are sometimes assigned a certain label of a neurodevelopmental condition, and because they have not had that comprehensive, high-quality assessment, maybe because of the lack of joined-up working between the education and health system, you then find that they have actually had a severe mental illness that has been undiagnosed and undetected for a long time. That then adds up, and you end up delaying evidence-based treatment that could have helped them earlier.

What is needed is an approach of a whole pathway where expertise is available—that includes CAMHS expertise—at earlier touchpoints. The multidisciplinary team needs to be involved, which is what all three of us have been saying. You cannot have this divide between what mental health support teams and schools do, what families are doing and what the voluntary sector is doing. It needs to be joined up. There needs to be access to escalation points wherever that is needed, and building the supervision capacity. That is where the joined-up thinking is needed.

I have been involved in looking at job planning for psychiatrists and other medical workforce. Sometimes that work around supervision is not really counted as proper work, when you advise a social worker or when you speak to a teacher. Because that is not counted, they then say, “What are you doing? You have only seen two children in the whole week.” You have been talking to a whole range of multidisciplinary team professionals. That is the kind of joined-up working that is needed across the pathway. We need to build in time to provide that supervision to teams at multiple touchpoints. I appreciate that we have to start solving the waiting lists. The way to solve that is also to make sure that, while people are waiting, they get access to those multiple touchpoints from specialists as and when required.

Q181       Helen Hayes: What needs to happen to unlock that joined-up working across the system? We are very far from it. We have parallel systems that treat the same children in entirely inadequate and not at all joined-up ways in large areas of the country.

Professor Dave: We started with this vision, at least in England, of integrated commissioning and integrated care working, and that vision has just not been realised. That is what we need. It cannot be left to chance or some leaders making it happen through their will and drive. This needs to be designed, and the design is that you commission for that to happen. You have to make it work because your key performance indicators are aligned in that way. They are not aligned in that way at all at the moment.

Rebecca Gray: We are waiting for the report from the independent review of prevalence, and I am sure that this will be a feature there. Our reliance on always pushing people down a diagnostic path is not necessarily a helpful one. The logic that you try to think about how needs can be met without the requirement, even if a diagnosis may be required at some point, is a really central one.

We talked to South West London and St George’s mental health trust recently. It set up a completely open-access service for families and children with emotional behavioural challenges. They may or may not end up down a route where they are assessed for autism or ADHD, but there is enough expertise within that service to be able to build some support around the family and the parent without having to sit on a waiting list. More of that within schools and outside schools is probably needed.

We also need to have some differentiation on waiting lists, as Professor Dave said. We are starting to see examples of commissioners looking at how needs can be differentiated so that the children with the most significant needs, or the most significant impact of those needs not being met, can be prioritised within systems.

As for the join-up, mental health support teams have part of the solution here, as Dr Sankar said, with integrated local teams built around thinking about the needs of the child at this point. What does a multidisciplinary approach that includes education, social care and health brought in fast and dealt with quickly look like? Then there is the right information exchange. We know that some of our primary care members are concerned that they are not always getting the information back from mental health support teams in schools and some of that flow is not quite working. We have to be very careful around protection of data and privacy, but there must be better ways of using the systems that are being developed to have easier information flows.

Dr Sankar: This particular question obviously takes up a lot of my time in thinking and so on. I oscillate between despair and ecstasy. I think neighbourhoods are part of the answer. To me, the question that we are asking ourselves in Northampton is, what is the difference between five different services in an area and a neighbourhood team? How is the neighbourhood team going to differ from five agencies delivering in a neighbourhood? The answer is integrated work. One of the good terms that we have invented in this country is “a child in need”. When this child is being referred, it is a child in need. They have needs, and they have needs across the spectrum. There are specific deficiencies. When you come, you must have a really good universal assessment. We have that with our health visiting and we do that up to four, but that does not feed up into the higher thing, and that is such a tragedy. Why is that not happening when they come in there? You will have specific things.

The other thing that is absolutely still poor and is a crusade of mine is that the family should be included as co-therapists. You cannot have a plan that does not do that. As with all people, there is a whole spectrum of understanding. You may have people who are extremely well read and know it on paper but cannot deliver it on the ground, and vice versa. How are we getting the—I use the generic term—mother or the single most important carer, if one wants to be politically correct, to be able to get involved in the care of this child and support? A lot of the time, you will find that, as much as the child is frustrated, the parents are even more frustrated, because they are really doing their utmost. They are going from pillar to post, and nobody is there who is taking them in hand and saying to them, “Okay, fine. We’ve got you. This is the thing of the child.”

One should also make the difference between state illnesses and trait illnesses. What do I mean by that? When you ask for a diagnosis, people often think of state illnesses such as depression or tuberculosis. You have tuberculosis. You have depression. You treat it. You are no longer depressed. You no longer have tuberculosis. But when it comes to neurodisability and things like that, it is going to be for the rest of your life. Your autism is not going to end. Your ADHD is not going to end. Your intellectual disability is not going to end. So what does it mean at every stage? If you are four going into school, what does that mean? Then what does that mean in terms of mental health at eight?

The bit that always makes me so sad is that we have our health visitors, who have that information and who have put that information in there, but we are not taking it or moving it forward. It is that, along with a proper neighbourhood team that knows that these are the kids who will be knocking on our door. If we solve the problem at school entry, that will not be the problem at middle school when they hit their teenage years and start thinking of dating and so on. Again they will have hurdles to cross, and that will not be the hurdle when they come to their GCSE level. I am talking about that sort of lifelong planning, universal planning, and a proper, good assessment that will then be able to predict that this child has a trait, this is going to last and this is going to be their support, which should be carried on.

Q182       Peter Swallow: You all mentioned joined-up commissioning. Do you feel that ICBs currently have enough responsibility to deliver on EHCPs? Are you satisfied with the current system, where it feels often as if all the responsibility falls on the local authority to deliver an EHCP and none of it falls on the ICB?

Professor Dave: That is why we need to strengthen the accountability framework. We need to make sure that ICBs are supported, because they do not know what they do not know. That is my real worry. You can see that there is a lot of information available here, and I am not convinced that all the commissioners know all of this, or at least they are not able to utilise this information. A lot of commissioning still happens with pages and pages and reams of spreadsheets, and then you are tempted to solve this waiting list or this particular red line.

It is the individual stories and cases that actually inform what is going wrong. I do not think that kind of knowledge will come into the system unless we have clinicians involved in that. For me, the biggest worry is that clinicians are not properly involved in those commissioning decisions and the accountability frameworks are not robust enough. One change I would like to see is greater clinician involvement in those commissioning decisions at the neighbourhood levels and the ICB levels, which will then drive that integration that we are all talking about. We know that that integration is possible, because we have those examples of good practice.

If I may add quickly, digital has a role to play, and we have not touched on that. We have talked about assessment. A good assessment is absolutely mandatory and absolutely important. Access to that good assessment is absolutely critical, too. As a clinician, I sometimes find that I have to spend three hours to find that good-quality assessment, even if it is already on the system. We have seen this again. Rebecca, you talked about it. The marginalisation of psychiatry and mental health is real. None of us is here with a chip on our shoulders. We have seen that with digital investments. That digital investment should be directed at the right sorts of things, making those assessments accessible to clinicians at the right time to have two-click access rather than 30 or 40-click access to those assessments, as well as investing in prevention. I would like to talk about that, but maybe a bit later.

Q183       Peter Swallow: We will definitely come back to that. I was going to ask all of you what you wanted to see in the mental health strategy to address this. I feel as if that has pretty much been covered.

If I may very briefly, Rebecca, I would love to delve further into your remarks about the fact that too often—this is something that all of us as local MPs know really well from speaking to constituents—parent carers are waiting for that diagnosis. They finally get that diagnosis and think, “Oh, fantastic. Finally, my child will get the therapeutic support that they need,” and then realise that, on the other side of that diagnosis, because we built a system that too often uses its resources to focus only on diagnosing and not on addressing the actual health needs of the young people in the system, there is no support, or not sufficient support. How can we change a system where the resources that we have—of course we need to grow them as well—are targeted at addressing needs and not just providing a diagnosis without the support?

Rebecca Gray: I have lots of examples of what that would look like, but I go back to North Staffordshire because it is a good example. You can talk about the east midlands very effectively. It is the combination of getting away from a point that everybody is getting on to a list and then you wait and you get there. If you look at the model in North Staffordshire, it is a mix of the offer. It is good assessment up front. It is a single point of access that GPs and families can trust. Then it is a combination of providing resources for self-help and a mixture of interventions, whether it is group interventions or individual interventions, which will vary from child to child. Family interventions are bringing family and carers into the mix. There is schools-based support, using the VCSE. Then there is making sure that, when children’s needs are quite intense and more complex, there is quick access to specialist intensive support via CAMHS.

In some ways, we are asking the wrong question, aren’t we, in terms of what happens when you wait and you do not get what you want? It is how you start the process in the way we have tried to describe today, in a way where the children may actually not need clinical intervention. They may need some support in building confidence, and that might be through a completely different type of approach and mean that they are not sitting on a waiting list. I talked to the person leading CAMHS in Lancashire and South Cumbria NHS foundation trust, who said that the absolute priority is to make sure children are on the right pathway first. They are assessed really well. There is nothing worse than talking to a parent who has waited 52 weeks to be told their child has been waiting for the wrong service and they should have been assessed differently.

Things that are not rocket science can be built into some of this, but it is very tough. Mental health trusts are operating and often being asked to make cost savings in the next year of 4%, 5% or 6% of their current expenditure. They are making really difficult choices. In making these kinds of transformations in that environment, it sounds as if we are painting a story of, “This is how you do it.” It can be very difficult to shift a model of care within very limited rules.

We have talked a lot, as we should do, about prevention, early intervention, getting in fast and dealing with need quickly. We should not ignore the opposite end, where children have very severe and complex needs, the kinds of young people who show up in A&E very regularly, with very high levels of self-harm and attempts at their own life. Again, there, it is about connected services. We have good examples of really effective co-operation with local authorities to create residential settings for young people to be able to get intensive programmes of things like DBT.

Peter Swallow: I do not want to interrupt, except I think our next set of questions is on that very point.

Q184       Manuela Perteghella: I will start with Rebecca. What progress has been made in shifting care from in-patient CAMHS settings into community-based alternatives? Where barriers remain, what should Government do to tackle them?

Rebecca Gray: One of the best examples is sitting next to me. Sometimes these things happen by necessity, not design. Lincolnshire Partnership NHS foundation trust essentially could not staff its 13-bed in-patient unit, so it took a really different approach. It focused its resources on intensive home treatment and crisis support in the community, and pretty much removed the need for those beds entirely. For a long time, the direction of travel in psychiatry has been to reduce to a minimum the number of young people who are in an in-patient bed. Many trusts are moving in a relatively positive direction towards that place.

When I talk to chief execs about the patients who keep them up at night, they often talk about young people with what might have been diagnosed in the past as borderline personality disorder or emotionally unstable personality disorder, or complex emotional needs—a complex mix often co-existing with autism or ADHD, often a complex history of trauma, and often disordered eating of some form. They will often be the young people who are in hospital the longest, with challenges to finding an alternative which is not an in-patient bed.

The example I was trying to use earlier is Hertfordshire Partnership university NHS foundation trust, which has a really fantastic unit called Cherry Tree Cottage, entirely joined with the local authority. It is a local authority-registered children’s home for relatively short-stay, very intensive care. It is not an in-patient unit. It is not a ward but a space where children can get a variety of support for a short period. They have had no admissions back into in-patient care for that cohort of patients, who are very regular admissions into in-patient services.

On the question about what the Government should do, in setting out their mental health strategy we need a focus on early intervention and prevention, but we cannot ignore what is required for those children who have often been in the care system—not all of them have. I know that the 10-year plan said we will have a specific focus on the mental health needs of young people who are care-experienced. We have to see that really play out in the mental health strategy.

Manuela Perteghella: Professor Dave, would you like to add anything?

Professor Dave: It is broadly similar to what has been said. I will not waste time. I don’t know if Dr Sankar has anything to add.

Q185       Manuela Perteghella: Well, I have a special question for him. We heard about the East Midlands CAMHS collaborative and how significantly you have managed to reduce admissions while improving access to community support. We heard about some of the very best practice, such as effective collaboration between all partners and getting parents as co-therapists. What else would you like to see in the forthcoming mental health strategy to support similar approaches across the country?

Dr Sankar: Thank you very much for that question. One thing that we talk about in our CAMHS meeting is the so-called golden thread. That is from the door of the patient back to the door. There is a challenge that I am working towards, the moonshot, which is not to have to admit any of those patients Rebecca talked about as in-patients at all, but to manage them in the community. What do we have? We have the crisis team that can support them. We have what we call crisis cafés. They can come, have a cup of tea and get some support. They have a biscuit. It takes care of that small thing. The next level is day hospital, which we are developing, and then we have the intensive outreach team, which can go and see patients more than once a day. On top of that, we also want to develop what we are calling the virtual ward or hospital at home, so that they will get all the support.

This is a very vexatious issue that we have. We often get criticised for these kids, and they are the ones who really keep us awake at night. The problem is that you take them out of their home environment and put them in a fully scaffolded, supported environment of an in-patient unit where there is very little stress, where my wonderful nurses ask them questions like, “How would you like your toast? Would you like it lighter or darker?” This is the kind of stuff that passes for care, which is fantastic. Then they come back into that home environment, and within a week they are again looking for admissions. Therefore, the care and support must be developed in the community. We need to go to this virtual psychiatric bed model of supporting these children in the community to develop their skills.

What are we developing? We are trying to develop resilience. We are trying to develop a locus of control within themselves. They have exported this locus of control to people outside. That is why they go and stand on the other side of the bridge and they hope to get rescued. If they do not get rescued, they jump and they die. This is the terrible state that we are in because they are not able to contain this. We need to support and develop this structure where we can care for them and make people understand.

This thing of diagnosis is fantastic, but, if we look at the GIRFT data that we have, even at in-patient admission only about 40% to 60% of the cases have a diagnosis, because that is the nature of children. The fact that they do not have a diagnosis does not mean they do not have a problem. They have a problem, so they need to have a formulation that will then support them. It is about these life skills. It is about giving them a locus of control that is within them. It is about developing the resilience. This must be done as close to their home as possible, so as not to export it out and not to send them to hospital. This is what CAPSS’s work about distance from home shows: the further away from home children are placed, the longer will be the stay, the more will be the impairment, and the more difficult will be their recovery. I totally, 100% have day-to-day evidence of that. I do not need a paper, because I know it.

Q186       Andrew George: Dr Sankar, earlier you referred to time-wasting meetings that you go to. It must be very frustrating. You described the pointless utopia planning of conceptual, big-picture issues. Does that mean to say that the modern service frameworks are rather pointless and a distraction from you getting on with your job and actually delivering the services?

Dr Sankar: It is the best that we have. As Dr Subodh said, it is great. I have been in the NHS since 1996. We have made enormous strides since then. Now we have come to where we need real-world solutions. We need to be focused on the real-world outcomes that he talked about. We need to say, “Why haven’t you got this child back into school? Why is this child not predicted to sit in class for a whole class? He is just sitting one hour a week.” We need to focus on those things and get the answers. We end up spending a lot of time thinking about other things like, “Does this child have this or that?”, but not tying it to the end product, such as, “What is useful to this child?” If it is not useful to the child, why are we talking about it?

Q187       Andrew George: What about prevention? You talked earlier about pre-school potty training. All of you referred to integration of services. If there was an effort going in the direction of prevention at the earliest possible stage, is that not where the modern service framework needs to concentrate its efforts?

Dr Sankar: The thing about it is that it is the classic example of the house on fire, is it not? Your house is on fire. Talking about building regulations, how to build better houses is good, but you have to put the fire out. I think there is a place for both.

Rebecca Gray: It is interesting we talk about prevention. Probably some of the best evidence around prevention is in parenting support, yet we do not necessarily invest vast amounts of money. There are really good examples all over the country that parenting support has a very well-evidenced impact on child mental health and adult mental health consequences.

Q188       Andrew George: From your point of view, with your perspective, is that going to be cost-effective? Are the bangs for bucks from a legislator’s point of view so much better? If you do not put the investment in then, it is more expensive later.

Rebecca Gray: I do not have the data to hand, but I am more than happy to send that to members of the inquiry. The Centre for Mental Health and others have pulled together the evidence around the cost impact of parenting interventions.

Andrew George: That would be helpful.

Professor Dave: It is almost a £4.5 return on £1 of investment. The problem with these is that first £1 issue. Where does that come from? How do we carve out the returns? The returns will be returned in different places in the system. Some will go to social care, some to healthcare, and some to education. This is not beyond the ken of our current thinking. There are bonds and things that are beyond my expertise but that people can design.

We have a really strong point in our favour, which is that we have a national health service. We really need to tap into the strengths of that. Prevention is really important. There are examples in Australia where they have been getting parents to upload neurodevelopmental data of their children alongside the things that would be uploaded in the red book, such as growth charts and vaccination schedules. You can imagine how powerful that would be if the NHS app or a similar digital platform was able to track the zero-to-five neurodevelopmental milestones. We know, as Dr Sankar said, that neurodevelopmental disabilities are lifelong. We would know sooner who has severe autism and who has severe neurodevelopmental delays that need earlier intervention. Right now, sometimes these children are waiting till they are in their teens or presenting later in school. These are relatively modest investments.

Q189       Andrew George: As far as the modern service frameworks are concerned, are they useful tools to you as professionals, or do they just sit on the shelf?

Professor Dave: It is how they are done. We know that the national service frameworks when they were outlined, when they came in with the Labour Government of yore, were supplemented with policy implementation guidance and money. If you have that alignment, you can make things happen. We went from no crisis intervention teams and no early intervention teams to almost having those teams across the country. If you have a framework, the policy implementation guidance and the investment, and align them all, you can make magic happen.

Q190       Chair: Thank you very much. That brings us to the end of our first panel. I am going to allow you one thing. If you were to recommend to Government one thing only, what would that be?

Professor Dave: Good strategic commissioning, involve clinicians in it, and design the commissioning framework to make that integration happen.

Rebecca Gray: That is a good one. I will go with workforce strategy.

Dr Sankar: A proper universal assessment that one can rely on.

Chair: Thank you very much, all three of you. It is much appreciated.

Examination of witnesses

Witnesses: Dr Samantha Jones, Vanessa Longley and Victoria Hornby.

Chair: Could we please begin as we did with the first panel? Whoever fills their water glass first is who I will go to first. It looks like it is Dr Samantha Jones. Would you mind very briefly introducing yourselves and what you do?

Dr Jones: Good morning. My name is Dr Sam Jones. I am a paediatric emergency medicine consultant. Just for clarity, that means I am a paediatrician who has spent 20 years in emergency departments for children. I am also here as the RCPCH—the Royal College of Paediatrics and Child Health—officer for mental health. That is two roles.

Victoria Hornby: I am Victoria Hornby. I am the chief executive of Mental Health Innovations. We run two services: Shout, which is the UK’s only 24/7 crisis text service, and a service called the Mix, which is an early intervention digital support platform for young people.

Vanessa Longley: Hello, I am Vanessa Longley. I am the chief exec of Beat Eating Disorders. We are the only national four nations charity for supporting people with an eating disorder, and we provide national helpline programmes and support.

Chair: Fantastic. Thank you very much.

Q191       Helen Hayes: I want to consider the terrible situation that we have at the moment around young people with a mental health crisis accessing emergency support. We had a discussion with the previous panel about whether CAMHS and children’s mental health services are broken. When we look at what is happening in our accident and emergency departments, we see a service that is broken. I know that the royal college had something to say today about the increasing numbers of young people, children as young as six, going to emergency departments because they are in a mental health crisis, waiting, the press release said, for as long as 12 hours—all of us know examples of much longer waits than that—in an environment that is further traumatising for them and not at all suitable. First, I want to ask your views on that crisis support provided in A&Es as an appropriate route to support for children who are in a mental health crisis and how we can do it better.

Dr Jones: You are talking about my lived and breathed experience on a daily basis. There are really good examples of good crisis support at a time when a family and young person are already in crisis. It is devastating that they are in crisis, in that much need, that they feel the only option available to them is where the door is open, which is the emergency department. Families and young people come to us because they tell us there is nowhere else to go. That does not mean there isn’t anywhere else to go. Certainly 24/7, it is a place where they can walk through the door and get the help that they have been crying out for, for a long time.

These children who are in crisis are younger and more complicated. Often, we know who they are in terms of the more complex-need children. They are SEND children. They are children who are care-experienced. They are children who live in abject poverty. From my perspective, whether they remain in an emergency department for an extremely long length of time, or they get admitted to the children’s ward, they also wait for extremely long lengths of time. When you start looking at the data, it is not just days and weeks; it is months in children’s hospitals. Across the board, I totally agree with Dr Sankar and Professor Dave that these children do not need tier 4 psychiatric units, but there is a mismatch between what they need and what is available, and what is available to them at the time that they need to be there.

For children who remain in emergency departments, trusts individually have to take a really difficult decision about the least worst and the safest space for a young person who does not need any form of hospitalisation. That is not to say they do not need help, but they do not need to be there. The agencies are almost at stalemate/loggerheads to unpick that, and those children are kept in the middle. The FOI shows the visibility of the ones in the emergency department, but we still have some invisibility around young people stuck in paediatric wards as well.

When we say we are reducing admissions—I am very fortunate; I work in Dr Sankar’s area—that is true. The question, though, should also be: if those children are not in the tier 4 units—which they do not need to be, and I would fully support that—where are they? When families are in crisis, when care homes are in crisis, and when care homes have served notice, whether with the right timeframes, or whether they just turn up with a child with two black bin bags and their belongings at an ED and say, “We’re out,” who is looking at them? That is what the FOI aimed to demonstrate. There are children stuck within our processes who are almost slightly invisible. We talk about the missing middle. They are missing. They are missing from the data, they are missing from the evidence, and clinicians can tell you where they are.

Victoria Hornby: We see it from a slightly different perspective, which is the self-referral to our crisis service. We typically get requests for between 1,500 and 2,000 conversations a day for support. About 40% of those conversations relate to suicide and suicidal thought and intent, and a further 15% to self-harm. What we can see, which matches your experience, is that the numbers are getting younger. We have seen a very significant increase in under-13s using our service. There are now about 250 conversations a day with that age group. Just under 40% of those relate to suicide. We have seen that creep younger. We have also seen over the eight or nine years that the service has been running that the percentage of conversations relating to suicide has increased quite substantially.

What we see from young people particularly is that there is an element where they feel they have to be saying that they are in that level of crisis to be able to get help and support. In about 2% of our conversations, roughly speaking, we work with the Met to get emergency support to that person straightaway by locating them through their phone number. That percentage has not changed. The 2% of conversations where we believe that there is imminent risk to life has remained stable, but the percentage of conversations that relate to suicide and self-harm has significantly increased, which we think supports the view that young people and parents of young people now feel they have to say that their child is suicidal or they have to say they feel that they are going to end their life in order to get any help and support. That is a problem that is driving additional issues. Kids are getting the message that they are not sick enough to get help.

Dr Jones: Would you mind if I came back on their suicidality? I have been a paediatrician for too long. When I was training, the 10 to 17-year-old group were vulnerable from sepsis, malignancy and risk-taking behaviour, as it was known back then—road traffic accidents and the like. In that timeframe, we have had public investment into road safety and education and support for young people. The highest rate of mortality in this day and age for our 10 to 17-year-olds is death by suicide. They are the ones who are calling and getting help, but there is also the other group, which is where it is too late. That is a reality and a figure that is out there from the National Child Mortality Database. It is either the leading cause or the second leading cause for malignancy, depending when you look in the last five years. It is right up there. Our children are dying on our watch from their mental health distress.

Vanessa Longley: What you are hearing from us is this very aligned view. If we do not consciously design to avoid a crisis, that is always where we are going to end up, because these mental health issues do not disappear if you ignore them. We are seeing through our helpline that over half our contacts are children and young people. Of those, 5% are active safeguarding issues. The analysis by Nuffield is showing that, compared with pre-pandemic, we are seeing double the number of emergency admissions for eating disorders among children and young people. There were 200 in January.

It means that children and young people are ending up in general wards. It is not their fault, but staff have very little specialist training, in this case in eating disorders. I visited a ward last week to see a young woman, and a healthcare assistant came in through the door of an open ward and yelled across the ward, “I’m updating your notes. Did you eat lunch or dinner?” I do not think she could have realised the impact that had, but I can tell you the impact. That young person said to me that she will never ask for help again. It will be a while, but when she collapses and is taken back to hospital via A&E we will have crafted the system that has led to that crisis.

We know what the answers are. We have these extraordinary community-based services. There is the hospital-at-home service in Thames Valley. You know this well. Oxford Health NHS foundation trust is the lead provider. What it is doing there is extraordinary work keeping children out of hospital. These are the children we most worry about, who previously would have sat in an in-patient unit not just for days but for months, if not years. Of the patients they have treated, only 13% have ended up requiring hospital admission, and it costs 60% less than in-patient care. The opportunity that we have here, especially with eating disorders, is to provide a better service, to provide a service that works far better for the children, and to save money. It is very rare that I walk into a room and say you can save money and give better care, but we have some of these answers. We just need this delivered nationally.

Q192       Helen Hayes: I want to ask you a bit more about good community-based care, what that delivers and what that looks like. I cannot help but mention the children who are missing from the system. I had constituents come to see me about their son just before summer recess. Their son, who is a teenager, had an acute mental health crisis in January this year that left him unable to attend school. The only support that the system was able to offer was a two-year wait for CAMHS. Children are attending A&E because it is the only front door that is open to them, but they are also sitting at home entirely invisible to the system, with their families absolutely beside themselves, because we do not have a system that can deliver the support they need, when they need it, in a way that we would expect for any other type of health condition.

Dr Jones: If you look at RCPCH, we are very concerned about attendance in some form of educational setting and what that sets up. Then there is the wider economic impact not just for that young person and the educational attainment for them, but the parents who will need to take time out of work and may even stop working. There are the siblings. The ripple effect for a family when we are looking at the economics of this is far-reaching. It is obvious, but our children are not children for that long. They will flip over into being adults. They are 25% of the population, yet they have 8% of mental health funding spent on them. It is disproportionate.

The college’s ask is that there is equitability on both focus and funding around children. If you are talking about preventive strategies—I am not an adult clinician, but if you are looking at the adult mental health world—it has to start before 18, because often the door is bolted. We are seeing it in younger children. We need to address it now. By the time we have a 10-year strategy, that is great, but for a lot of hospitals our 16-year-olds will have flipped over into adult services by then. There is the here and now and the mountain of the here and now, and then there is absolutely the preventive stuff. If we do not do them in parallel, we will fail probably one to two generations of families and young people. We have two problems that are competing a little. At the moment, it is all around crisis care, and that is great, but what do we do in the prevention area as well?

Q193       Helen Hayes: You have all talked a little bit about crisis care support in communities, what that can look like and what earlier access to help as a crisis approaches or to avoid a crisis looks like. Could you say a bit more about your experience of what those services look like? What should we be aiming for in terms of crisis services in communities right across the country so that we can put a stop to attendance at A&Es, where there is an unsuitable environment and waits that are far too long?

Dr Jones: You have examples of community-based care that work up and down the country. You just heard some that work really very well, but it is very piecemeal. It is patchy. We speak for the four nations. Dr Sankar has worked very closely to decide a model that works. Why are we not following that? Why are we not doing the home intervention? Where are we using the digital support? What are we doing? The accountability to be able to take good models of care and replicate them up and down is really important. It is too piecemeal.

This is a slightly more unorthodox point. What I am about to say does not mean I am saying that mental health in children is equivalent to safeguarding children, though obviously for some there is an overlap. You have a structure within children’s safeguarding that has an expectation on the three agencies to work together: health, education and social care. I do not understand why we cannot utilise that at a really high level to say, “Actually this is what you need,” in exactly the same vein. You need the same sort of expectation, accountability and set-up, not for the legislative statutory requirements of safeguarding, but the structure that works and is there and protects children could be something that we could mirror, with a greater expectation that that would reduce the variability across the UK.

Victoria Hornby: It is being able to provide some support to children and young people without them having to go through the diagnostic process. At the moment, the thresholds get higher and higher. In our case, we see children and young people usually in the middle of the night. That is when our service is busiest. We are busiest on a Sunday night because Monday is stressful. We can predict all these things. We know when things are going to be worrying and stressful for people. Particularly younger children will use our service multiple times. We can see that they are moving into crisis. We need to be able to get them away from the crisis service and into some very easy open-access counselling, peer support or whatever it might be that does not require them to go through a long diagnostic process, does not require them to be sicker, and does not require them to prove that they need help and support in that way.

We are asking them to climb a higher and higher bar all the time, whereas we should be able to say to them, “It looks to us as though you are going through a very difficult period at school.” For most of the children and young people who use our service, it is life that is difficult. School is difficult. Bullying is difficult. Relationships are difficult. Home life is difficult. Money is a real worry for them. They are worried about their future. If we could say, “We can see that that is a problem. We will provide you with four, six or eight sessions of counselling, and you can start that tomorrow,” that would make a huge difference. Digitally, we are much more able to do that than we are in physical spaces. That is not to say that we do not need the physical spaces. We 100% need them, but for a lot of the young people we see, young people who identify themselves as being neurodiverse, having autism or ADHD, digital services work very well, because they do not have to do the face to face. It all needs to be, as you say, part of a not patchy national offer.

Vanessa Longley: Crisis does not come out of nowhere in most cases, especially when we are talking about eating disorders. One thing that I am still shocked by is that, nationally, we have never met the access and waiting time for children and young people with eating disorders—never. It therefore seems quite obvious that we are going to have children and young people ending up in crisis. We should not be asking why the system is broken at that end. Dr Sankar was talking about needing to put out the fire. Yes, Dr Jones is absolutely correct: you have to build the firebreak at the same time as putting out the fire. We are seeing massive variations in access and waiting times across different ICBs. I speak to children and young people who are waiting so long that they are ageing out of children’s services. There are families who believe that sometimes that is being done as a convenience, because it is a way of passing on people who are becoming critical.

We also have this real blocker around NICE guidelines. NICE guidelines are really clear. The latest guidelines that came out in January for children and young people with an eating disorder are early access to special assessment, which you have already heard about a lot this morning; no single measure, not just using BMI as a single measure to either admit or not admit; and co-ordinating care. None of these things is new or shocking, but what is happening is that we have young people turning up at their GP who are told they are not sick enough, or they are turning up at another service which says they are too high risk to be seen. You have to have this Goldilocks illness where you are just right for the service that happens to be offered to you rather than the service you need.

I speak regularly on this, and I am sorry if you have heard this before. Last year, I met a young woman who had five A&E visits for self-harm. They would not refer her to the crisis mental health team because she was under the eating disorders team. The eating disorders team won’t start seeing her because she has complex PTSD as a result of trauma from treatment in the past. The clinician who could offer her the specialist PTSD treatment will not start it because that young woman is not stable enough, and keeps self-harming and going into A&E. I spoke to her again this year. We are now up to 11 A&E admissions, and there is no route out for her. We are designing crisis into our system. This is not us saying the clinicians are not doing a good job. It is saying that there are answers out there, but we need to make sure those are offered early and quickly enough. We know from Australia, certainly with eating disorders, which are seen as one of the most complex things, that open access, digital support and self-guided psychoeducation can stop people ending up in A&E. That is something that we need to embrace.

Q194       Sureena Brackenridge: I would like to follow on from the extremely tragic point that Dr Jones made, that the highest rate of mortality in young people is death through suicide. We are all aware that the rate of self-harm and suicide with young people has been increasing for a long time, and it predates the pandemic. There is nothing recent about this. For every child or young person who self-harms, it will not lead to suicide, but it is a major risk factor. What are the key opportunities for earlier intervention in children and young people who are self-harming?

Dr Jones: The thing for me—I feel we are repeating ourselves a lot—is the joined-up approach, because we are too much in silos in terms of sharing the information. That is where I draw the analogy with how you run a safeguarding strategy meeting. The information held by a school is not going to be available to me on a Monday evening, and I am not going to be sure what is going on. The only person who can give me that information is usually the young person themselves, who is in crisis, the parent, if they are even aware of what is going on, or the carer, if they have been made aware of it. For me, it is still crisis management by the time you get to the emergency department, but the requirement is to look at young people who are visiting regularly, who are now called high-intensity users, sharing those records among our local authorities and our education colleagues, and wrapping that round and having thresholds. Within our organisation, one attendance for self-harm is there because that is given, and we offer and signpost to support. Two attendances will get you a formal referral. It is devastating to hear about your young person, Vanessa—their journey is very classic and they get tied between all those people.

I am sorry, I am emphasising the preventive of the now, but we did have mental health champions. As a paediatrician in an acute trust, there was NHS England funding for people like me to take on this role. We are not necessarily mental health experts. Our children do not need mental health experts. They need to be listened to, heard, and for us all to be talking and joining up information. It ran for a couple of years. Where you have had good examples of that working, we have been able to liaise with physical and mental health people. I can ring up—I have really good links with my CAMHS colleagues—and say, “This young person has attended three, four or five times. Could we have a wraparound meeting? What about the home intensity support team? What about the preventive stuff?” When we talk and share our information, as in safeguarding, it works, but that funding has been withdrawn. People cannot get that time within their organisation. They are doing it on top of things, if it exists at all, and the problems seem insurmountable. We need some investment in mental health champions for the here and now, and bringing us together so that the local authority, education and health are all talking at a way earlier stage. The information is there; it is just not connected.

Q195       Sureena Brackenridge: Victoria, is there anything that you would like to add?

Victoria Hornby: Only that with a lot of these things, certainly on our service, we see them coming much earlier. Most of the young people who contact us do not require hospital care, but they tell us that they are self-harming and they tell us why. Self-harm is very normalised in young people. It is a coping mechanism for a lot of young people, and we see that early.

There are two things that I would like to say. One is that there is very little support for digital organisations like ours in terms of safeguarding and safeguarding legislation. All safeguarding legislation assumes that you are sitting in front of the child and you know where they are. There has been no update to safeguarding legislation that recognises that there are a lot of digital services where we do not know where the child is. We have a very complex and expensive safeguarding system internally, but we are not helped by the fact that there is nothing for us to rely on or to work alongside except to contact the police. We can contact the police with a phone number and the name. Sometimes we have as much as a first name, and then police have maybe an idea of age. That is not enough for the police to use the Investigatory Powers Act. It is not sufficient. It has to be imminent risk, risk to life or crime in progress. We are kind of stuck because we could be really supporting that process and particularly the process in schools where we know that a child is talking to us about self-harm and where we could be supporting the school.

Q196       Sureena Brackenridge: I would like to hear your views regarding the role of social media and the Government’s response in terms of bringing in the banning of social media for under-16s. Is that sufficient to meet the challenges around online harms?

Vanessa Longley: I wish there was a simple answer. If there was a simple answer around social media, we would have all found it and be pushing for it. I ask for a bit of patience around the nuance. What I can tell you is that, when we speak to children and young people with an eating disorder, 90% of them have seen toxic content that has caused harm, and caused harm around their eating disorder. It is particularly difficult when you are in recovery. However, the more marginalised and the more vulnerable some of these young people are, the more likely they are to also have found their support groups online. It is, therefore, a very difficult balance. We are definitely of a mind that children should not have access to social media. It is impossible to manage for very young people. However, vulnerability does not stop at 16. In fact, with eating disorders, they emerge most commonly between the ages of 15 and 25. If you just do a straightforward ban up to the age of 16 and then unleash this world on to vulnerable people, you will still see this huge influx of issues. We need to put the pressure on to these providers and these platforms to provide a safe environment.

One thing that is a real insight is that I spoke to a young woman who is absolutely aware of the damage that social media can do. One thing she said is that she does not dare report toxic posts because, if she pauses in order to report a post, the algorithm will see that as interest and serve her up more. She has learned to move past as quickly as possible. She feels personally responsible that every time she flicks past one of those posts she leaves it for someone else to see. How have we got to the stage where we expect this very capable but vulnerable young woman to be the guardian for every other young person on the internet? We have to put the pressure on the platforms to make it safe for all of us.

Q197       Jodie Gosling: I very clearly hear what you say about children being left in a state in hospitals. A good friend of mine who was discharged from hospital was told that she had not been suicidal enough. What a ridiculous and heartbreaking term that is. As a teacher at the time, I clearly hear what you say about safeguarding and all the investment that goes into keeping children safe in education. There are times that that support is not there. My questions are around what role schools can play in that. As a previous teacher, I understand that I was severely lacking in qualifications and experience in this area to support the children I was teaching. What is it that schools can do to respond to self-harming and suicidal ideation?

Dr Jones: Your story is not unique, very sadly. It would be fair to say that in the entire children’s health workforce, whether that be in health or education, or a care home manager, none of us feels particularly trained in the responses that are required, in the language that we use and the behaviours that we take. We desperately want to be. The passion is there, but we do not know about it. There is a definite gap in education, training, crisis management and early things we can do that do not make the situation worse. We in the college say that children’s mental health is everybody’s business. We have married up our physical health and our mental health for our young people because that is what they are asking us. Why would we separate them? It is a bit crazy that we would separate them.

You have a really challenging job in education. There are also the youngsters who are not in education. I would hate to propose solutions to education, because you are experts in your field. You guys know what you are dealing with and how you are dealing with it. Training is available out there. National programmes can teach all of us how to make the dysregulation better, how to be able to try to distract young people, and what things we might need to know. Certainly within the health setting, we have realised that you do not need the consultant necessarily to be the person who knows this training, although there are parts of that training you definitely need. You can have healthcare assistants. You can have the equivalent of what would historically have been known as youth workers, whose role is to address the needs of the young person who is escalating at that time, in a way that would help them come down before they reach crisis.

I do not know enough about schools, but I do know there are people who work within units within schools who can help with that. It is much more universal, and it is there from the early years and then right the way through. For me, it is about that unified children’s health workforce strategy that looks at all of us who work with young people, and knowing what we need and the requirements of what we need to be trained and educated in. Upskill us, because we are all running a little blind, if we are really honest.

Q198       Jodie Gosling: This is to Victoria as well: how can schools be more effective partners? What resources do teachers need to be able to have that holistic view of the child and that interconnected system?

Victoria Hornby: The interesting thing that we would say in terms of our interactions with teachers and with schools more generally is that, because, often, the CAMHS door is shut, schools feel as if they are very much left holding the baby, and they do not really have access to the kind of support that they would like to be able to put in place for children. Certainly from our digital perspective, it is about some access to schools to help and support that is not CAMHS level, because again it comes back to this whole piece about how sick you have to be. We do not want to be putting teachers in a position where they cannot get any help or support for children and young people in their schools until they reach a certain threshold. That leaves teachers in an impossible position because they are then trying to make that judgment themselves without, as you say, the skills.

I completely agree on the training and on schools having access to support that they can call on for young people they are worried about. We are talking about earlier intervention. In schools, particularly the transition from primary to secondary is so challenging now, and continuity and support for children and teachers is really difficult. It is thinking about how we are preparing our children for that transition from primary to secondary, which now happens at around the same time as your transition from childhood to adolescence, which is a nightmare combination. I think about my own kids going through that transition, and it was hard enough, but that was 10 years ago. It is getting worse. It is thinking about how we are supporting children, how we are providing them with the skills, the knowledge and the capacity to make that transition so that they are not arriving in secondary school already in a really difficult position, or just not going to secondary school because it is too terrifying, or not going enough. We would very much like to see some support.

From our perspective, we think that could be done digitally very easily. It is in schools, it is for parents, it is for teachers, and it is for children. They are all on the same platform. They are all learning about their mental health and understanding how to make those transitions and how to build resilience, which I know we do not often like talking about with young people, but that is what they need.

Jodie Gosling: Fantastic, thank you.

Q199       Ben Coleman: You are all very interesting. I would like to talk a bit more about eating disorders. I want to come to something else at the end about gambling, if I may. Back in 2023 I visited the launch of the Ark day centre in my constituency of Fulham. I was fascinated. It was my first real exposure to the challenge of eating disorders among children at a community-based service. It depends on first having a diagnosis. Vanessa, I am going to ask the other two witnesses to come in first because you have been extremely clear and interesting already about the challenges in the current state of eating disorder services. Would either of you like to say what the main challenge is and how it should be overcome?

Dr Jones: I take my RCPCH hat off and my emergency medicine hat off, and I help support our service in eating disorders. We in the east midlands were probably a little bit later to the party, in that we did not have a set-up eating disorder service established, but we had young people coming in who were medically unstable and needed admitting. I am not going to start with the challenges, if that is okay. What I am absolutely wedded to is that, when you put the mental health team and the physical health team together with the wraparound care for children and young people, we have reduced their length of stay and their re-attendance rates. They are aligned. The mental health teams have assurances that, waiting that little bit longer, there is no physical consequence that means they need to come in. Similarly, the physical health guys can be a bit more assured because the mental health support they are getting—because we are not trained in that way—is married up together and we learn from each other. That is not just two consultants, although—

Q200       Ben Coleman: That sounds great. I am going to stop you because we are short of time. When that happens, it works or it can work. Why does it not happen more?

Dr Jones: Historically, CAMHS and physical health have been worlds apart. I do not just mean physically; they are geographically not placed. We do not know each other. We are not linked. There is no liaison.

Q201       Ben Coleman: Is that because the integrated care board does not see it as a priority to bring it together?

Dr Jones: No, we work in different hospitals. Saying send somebody to the Royal does not really mean anything, but if you had your mental health champions and that is what came out of it, it does. I know I am pushing for those, because if we are looking at the here and now, those people would be challenged to bring that liaison and bring it much closer together. Then you extrapolate, and you extrapolate to community care.

Q202       Ben Coleman: What you are saying makes sense. You are in a very important position, and you will be making this case in different fora. How much do you think local health authorities, local councils and the people who work together, whether it is through ICBs or health and wellbeing boards, get that?

Dr Jones: There is a reason we only have 8% of mental health funding for children. ICBs do not get it, is what I am trying to say. The problems in adults become quite overwhelming. Children and young people, despite being a quarter of the population and 100% of the adult population of the future, are always fighting for their voice. That parity is not there. The child health investment strategy is critical.

Q203       Ben Coleman: Thank you. That is very helpful. Victoria, I will come to you.

Victoria Hornby: The BMI bit that Vanessa talked about is probably the biggest problem, because by the time you hit that BMI, by the time you reach that threshold, the psychological interventions no longer work, because you are too unwell.

Q204       Ben Coleman: What should happen?

Victoria Hornby: It needs to be earlier. It needs to not be BMI-based. It needs to be a psychological assessment, particularly for the young people we see with eating disorders on our service where, again, they are being given the message that they need to be thinner to get help.

Q205       Ben Coleman: They are given that message?

Victoria Hornby: They get the message that they need to be thinner to get help.

Dr Jones: You are not sick enough.

Victoria Hornby: You are not sick enough.

Q206       Ben Coleman: Oh, I see. Is that because that is the way that the people they are talking to, the medical professionals, are trained?

Vanessa Longley: Can I pick that up? This is definitely a hobby horse. Let us be really clear: the vast majority of people with eating disorders will fit within an ordinary criteria for BMI. There is not a direct association between very, very, very seriously ill and BMI. We need to look across the full range of eating disorders. This is one of the barriers. People are coming in front of a GP or within their schools. The questions are around education. What should we fix? Where can we start? How do we tackle crisis?

Q207       Chair: We covered a lot of this earlier. What we are trying to get at is what needs to be different.

Vanessa Longley: We have some of these answers. We have evidence-based care, which is what the first panel referred to.

Q208       Ben Coleman: I apologise for the way we have to push you, but we have so little time. We have already covered the problem. Why are we not tackling the problem?

Vanessa Longley: We are at the moment.

Q209       Ben Coleman: We are. How well?

Vanessa Longley: In some areas. If you look at the FREED model, which originally came from South London and Maudsley, and is that first-episode, rapid, early intervention, we know it reduces crisis and admission to hospital. There was some really good funding during the pandemic which allowed it to go across—now it is within about 50% of services.

Q210       Ben Coleman: Across the country, you mean.

Vanessa Longley: Yes. It has a huge impact, but it is only in 50% of services. The frustration that you will hear from this side of the desk is that there is evidence-based care out there. We are asking the same question as you. When we, either the voluntary sector or researchers, can demonstrate that these things work, how do we roll them out nationally?

Q211       Ben Coleman: Okay, so 50% of the country is doing this. Why is the other 50% not? Victoria, I can see you bursting to come in.

Victoria Hornby: There is a real challenge with commissioning; there just is. We made the case very successfully for 24/7 crisis text services in the UK. It is in the 2023 national suicide prevention strategy that it should be rolled out across the country. There is a very clear NHS England specification for how that needs to be delivered. It was meant to be delivered originally by 1 April 2025. It was then extended to 2026. We still do not have cover.

Q212       Ben Coleman: Why do you think that is?

Victoria Hornby: Because they spent the money on something else.

Q213       Ben Coleman: They spent the money on something else. Why?

Victoria Hornby: Or they have commissioned something that does not meet the specification because it is cheaper.

Q214       Ben Coleman: Why do you think that is, though? Is it cheap? They have gone for the wrong thing because it is cheaper, or they are not taking notice because these are kids? Sam, you are gagging to come in.

Dr Jones: For me, it is the parity. We have it on a local level right the way through to a national level, through to the four nations. It is a parity in terms of children are only 25%, and if your fire is burning in the 75%, it is hard for the 25% to be heard.

Q215       Ben Coleman: That reflects my own experience. I used to be on an ICB, and our director of children’s services in the council was always saying, “Why don’t you talk about children?”

I am going to ask you a completely different thing, if I may. We talked about gambling recently in the Committee, and about it being a possible cause of suicide. I was visited by parents from my constituency who lost their son, a young man, to gambling. Is that something that is a concern for you when it comes to suicidal thoughts among young people? Has the impact of online gambling crossed your desk, so to speak? It may not, but I am just asking.

Victoria Hornby: It does, but it is quite small. For the young people we see, it tends to be a multiplicity of things, not one thing. That said, we have had multiple conversations over the years with gambling companies. There is not really a willingness, I do not think, to accept that problematic gambling is a contributor to suicide.

Q216       Ben Coleman: Is that because they think the evidence does not exist?

Dr Jones: It is a really good question to ask. There is a child death overview panel for those who die by suicide and every other child death. I believe that the investigative powers—it is not my area of expertise—are changing. What can be seized, what the young person may not have told anyone about and what can be looked at so that lessons can be learned is quite challenging. I do not think we know, is the honest answer. That is lack of evidence. By the time a young person has taken the steps where they have died by suicide, the information gathering of what might lead up to that can be really challenging, but the legislative changes that are coming to enable us to examine what is on computers, mobiles and things like that will hopefully lead us to be able to answer that a bit better in future.

Ben Coleman: I am sorry I have to stop there, but thank you very much.

Q217       Jen Craft: We do not have a lot of time left, so I will be very succinct and hopefully cover a question around the modern service framework. It was touched on a little bit by the previous panellists. Would you share their view that perhaps this needs to happen in partnership with a more strategic overview as well as investment, or is a modern service framework in and of itself something of a panacea?

Dr Jones: I would echo Dr Sankar. It is what we have. One of your colleagues asked, “Do they just sit on the shelves?” They do not, actually. They do not in our institution, because I shroud-wave them everywhere. If you have standards, you can take them to the right people to advocate to uphold the standards and what is expected. If you do not have a standard, you do not have something to work towards. For me, it is really important.

The content of it is difficult to know. The one ask for me would be that joined-up working, bringing us together across children’s support. That has to be key. This is where it gets split. You have a modern service framework for mental health and you have the modern service framework for children and young people. They also have to be aligned. Running them separately means that they are a bit quiet. We are a small portion of the population being looked at for the mental health section. If you look at the children’s and young people’s modern service framework, you have physical health and mental health. There is this Venn diagram of where the focus can be challenged. My request would be to make sure that they overlap, work together, are seamless and have the parity on both, because children say, “See me as a whole.”

Q218       Jen Craft: Thank you. I will move along the panel.

Vanessa Longley: I talk about this as a three-bus moment, in the sense that we have the prevalence review, the modern service frameworks and the mental health strategy. That presents this massive possibility. It is pretty exciting right now in the voluntary sector that you can see there are some of these golden threads that were referred to earlier that could come together.

The “could” is that scepticism and cynicism, because you can see already the potential gaps where things could fall through. One of those would be that we know one of the crucial points is these transitions, as Victoria referred to, between children and adult services. The children and young people modern service framework is great, but we need that to align with adult standards of care around eating disorders. We need to recognise the importance of being focused on neighbourhood place and local place. That is incredibly important knowledge that ICBs can bring to the table locally, but we also need good standard national frameworks so that people know what evidence-based care really looks like and can apply that in the region.

Then we need to monitor it. We have such variability around ICBs meeting any of these standards. The parents are making legitimate points to us. We have parents selling houses to move into the right postcode for mental health care. What is happening then is that this is turning good NHS care almost into private care, because only those who can afford to live near it get it. You used to move near a really good school, and now you move near a really good ICB. We really need to ask ourselves as a society if that is what we want.

Q219       Jen Craft: It is quite striking. I imagine there are probably questions about equity and about who can afford and have the wherewithal to research. There is a good advertisement for east midlands here today, but who actually has the ability to do that, and who also has the ability to sell up, move house and change jobs?

Vanessa Longley: It is where the opportunities are within the MSF and also within education. I will be incredibly brief because I know this was not my question. Within the education sector, we have that opportunity. Teachers and teaching staff already are frontline workers. If you look at the NEU survey, 80% of our teaching staff at secondary schools are seeing pupils with an eating disorder. It is being able to put resources into those, whether that is initiatives like the Body Project or adaptations of that, such as the Brown is Beautiful Project, which are these culturally competent interventions that are evidence-based. It is as simple as you find out what works and you do more of it. We have a whole battery across the country of extraordinary best practice. We are asking, as a voluntary sector, whether we can find a way through the MSFs and through the mental health strategy to make those applied nationally.

Victoria Hornby: There needs to be greater recognition of the role that the voluntary sector is playing in picking up the pieces, where they are not being met by ICB commissioning. That is particularly the case in mental health. There is a real challenge for ICBs particularly, or commissioners generally, in terms of commissioning digital services. In our view, they do not really have the capability to do that. That is not a comment on individual commissioners. For mental health commissioners to understand how to commission digital services it is very difficult.

Jen Craft: We touched on this in a previous session, when we discussed issues around Palantir and bringing that in. It is a really good point. It is not a small issue; it is quite major. Thank you for highlighting it.

Q220       Chair: That brings us to the end of this session. There are many recommendations that you guys have made very clear, but you get one more, so long as you can be very succinct. I will start with Vanessa. Go ahead.

Vanessa Longley: Introduce a really evidence-based, stepped care model across all mental health, including eating disorders, so that everyone knows what works and then can choose what is going to work specifically in their ICB or in their area.

Victoria Hornby: A national digital mental health service. By digital, I mean using technology to connect people to other humans so that we can get that rapid access to support as quickly as possible, and scaled.

Dr Jones: I am going to push my luck. I am going to go for two. In the here and now, standardise, have expectations and formalise at a very high level what should happen when children are stranded in hospitals, whether emergency departments or in the wards. And the future is around using the mental health strategy to ensure parity of spending, focus and expertise on the children of our future.

Chair: Thank you so much. That is all very clear.