Written evidence submitted by Mind and Race on the Agenda (ROTA) (MHB0070)
Introduction
We're Mind, the mental health charity for England and Wales. We provide advice and support to empower anyone experiencing a mental health problem. We campaign to improve services, raise awareness and promote understanding.
Race on the Agenda (ROTA) is one of Britain’s leading anti-racist change drivers. Working with communities impacted by systemic racism, ROTA helps create the policies and practices to tackle inequality.
Summary
We welcome the draft bill. It introduces significant improvements that are urgently needed, especially by increasing people’s say over care and treatment and clinical accountability. There are ways to improve it further, to make the reforms more effective, drive change to promote race equity and support children and young people’s rights:
We are aware that the bill has been drafted in most part to apply in Wales as well as England. The provisions on care and treatment plans are excluded because of existing provisions in the Mental Health Measure. However, these are fundamentally different and the new rights for people detained under the Mental Health Act should be incorporated into Welsh legislation.
Question 1. How the changes made by the draft Bill will work in practice, particularly alongside other pieces of legislation including the Mental Capacity Act? Might there be unintended consequences and, if so, how should those risks be mitigated?
1. The draft bill introduces new duties, rights and safeguards aimed at increasing patients’ say over treatment and care. This is an important improvement in rights and could make a significant difference to very many people, and potentially reduce racial disparities. The risk is that there may not be the necessary change in the level and nature of service provision, or in culture and practice, alongside the legislative change to bring about the intended benefits. Advocacy and tribunal review are key parts of the reforms and critical to fulfilling their ambitions.
2. The risk of insufficient change in racial inequality can be addressed through additional measures to address structural and institutional racism in the bill (see Q5) and through a concerted drive that prioritises race equity and encompasses legislative and non-legislative change.
3. The overriding issue people raised with us in engagement for independent review was for easier and earlier access to services before crisis which would then reduce the need for detention. To make the reforms as effective as possible and to see a sustained reduction in detentions, we need more, and more culturally appropriate, services, rights to assessment and treatment, explicit race equity measures, support for clinicians to change practice, and meaningful treatment appeal that will cement the changes made by the bill.
4. There is already rights-based legislation in Wales in the form of the Mental Health Measure, which has made a significant contribution to improving the way mental health support is delivered for many over the past decade[1]. The Mental Health Act reform process is an opportunity to review mental health legislation and practice in Wales, to consolidate and provide greater clarity to existing legislation whilst taking forward much-needed reforms.
5. If the mental health bill is to be legislated in Wales, it is very important to adapt existing arrangements for care and treatment planning to incorporate new rights. The care and treatment planning reforms in the draft bill have not been made applicable in Wales because of existing provisions in the Measure. However, whilst there is some overlap between care and treatment planning provisions in the draft bill and the Measure, both their form and purpose are fundamentally different. The draft bill introduces improved rights for people detained under the Mental Health Act, which go far beyond those included within the Measure. The Welsh Government should therefore ensure that these improved rights are introduced in a way that means the legislation works together seamlessly.
6. Equally, the experience of the Measure, including its holistic approach to care and treatment planning and the right to self-refer back to services within three years of discharge, should inform developments in law and policy for England.
7. We have some concerns arising from the MCA draft code of practice:
Question 2. To what extent is the approach of amending the existing Mental Health Act the right one? What are the advantages and disadvantages of approaches taken elsewhere in the UK?
8. Ideally, we’d re-work the whole law, potentially creating one that was focused on rights to health, giving effect to people’s will and preference, based around people’s capacity to make their own decisions, required support for people to enable them to reach their own decisions, and that created positive rights to care.
9. Some of these features are adopted to a greater or lesser extent in other parts of the UK, with fusion law in Northern Ireland and a criterion of significantly impaired decision-making in Scotland. The current review of the law in Scotland is looking at ways to make their legislation more respecting of human rights and autonomy.
10. We think that the law should be based on people’s wishes and capacity as far as possible and that work should be done to develop new law fit for the 21st Century. However, we are concerned about potential issues for people’s safety in mental health crisis and unintended consequences that may flow from poor quality capacity assessments. Furthermore, there’s a need to avoid conflation of patient’s capacity with disagreement with clinical teams. The UK Government should explore these approaches and test them out with people with lived experience, with a view to more fundamental reform.
11. However, the MHA needs urgent updating now. Most of the proposed changes head in the right direction and, with further improvements, should significantly strengthen people’s rights and voice, and improve experiences and outcomes. So, we support amending the current Act as an immediate, urgently needed step towards a new law fit for the 21st century.
Question 3. Does the draft Bill strike the right balance between increasing patient autonomy and ensuring the safety of patients and others? How is that balance likely to be applied in practice?
12. The draft bill includes harm to self and others as criteria for using the Act; also, clinicians retain extensive powers. We’d like to emphasise the place of patient autonomy in safety. Patient autonomy and the safety of others are often set in opposition to each other but in fact ensuring patients’ rights for the most part supports safety – whether that’s about getting help when you ask for it or being able to exercise some choice and control over daily life on a ward. Getting treatment that is more tailor-made to the individual and ensuring that patients retain and regain their independence and ‘agency’ will allow people to recover more quickly and more fully.
13. The draft bill gives people more say and access to advocacy which should enable them to have their voice heard; it requires clinicians to take greater account of patients’ wishes, and to be more accountable for their decisions. This should make a very positive difference and improve safety by making care more person-centred and informed by the person’s own knowledge of themselves and, where relevant, how they’ve been affected by previous treatment.
14. However, to make it effective in practice, this shift will require a stronger focus on patient autonomy. We recommend:
Question 4. How far does the draft Bill deliver on the principles set out in the 2018 Independent Review? Does it reflect developments since? Is the Government right not to include the principles in the draft Bill?
15. The principles are reflected, and good examples are increased say for patients, choice of nominated person and better access to advocacy. However, the reforms need to go further to deliver on the principles.
16. The principles should be included in the Bill – it would give them more force and better enable people to challenge poor care. We understand that some doubt has been cast on the lawfulness of adding guiding principles to an Act though an amending bill. Mind has had the benefit of advice from former parliamentary counsel Gordon Nardell KC who has advised that this course of action is entirely possible and has given the following examples: The Financial Services and Markets Act 2000, which in its most recent incarnation (flowing largely from changes made in 2013 post-crash) imposes a number of “general duties” on the FCA. See sections 1B onwards
https://www.legislation.gov.uk/ukpga/2000/8/part/1A/chapter/1/crossheading/the-fcas-general-duties. Further, a recent example of a Bill containing a “general objectives” provision see the current Energy Bill https://bills.parliament.uk/publications/47229/documents/2107, Clause 1.
Question 5. To what extent will the draft Bill reduce inequalities in people’s experiences of the Mental Health Act, especially those experienced by ethnic minority communities and in particular of black African and Caribbean heritage? What more could it do?
17. There are welcome policy measures – in particular the Patient and Carer Race Equality Framework and culturally appropriate advocacy pilots – but nothing in the bill directly addresses race equity and it does not necessarily follow that improved rights generally will reduce disparities between groups. Disparities – rooted in structural and institutional racism and one of the main reasons for reform – will only be turned around with explicit and concerted measures in legislation that impact on practice.
18. The starkest race inequity is in use of CTOs, which clinical research shows aren’t even effective, and which we strongly recommend abolishing (see Q11). We’re also concerned about potential racial bias in the new power of supervised discharge (see Q15).
19. One of the reforms in the bill that could advance race equity is recognition of advance decisions and consideration of wishes (including wishes expressed in advance). This could make a big difference to people especially those least heard. Research into joint crisis plans (an approach to making advance decisions and planning future care with the clinicians) found these were most cost effective for Black patients[2]. See Q13 for more on advance decision-making.)
20. Further reforms to advocacy could advance race equity (see Q11).
21. The Mental Health Units (Use of Force) Act 2018, also known as Seni’s Law, includes a role of responsible person to ensure that the requirements of that Act are implemented and to take responsibility for reporting and intervening as appropriate. We recommend that a similar role be introduced in the Mental Health Act, to oversee promotion of race equity. As they would be concerned with similar issues and some common root causes, this could be an extension of the same role.
22. This would help drive action to reduce inequalities and, together with a duty on the Secretary of State to make reports, and a new antidiscrimination principle, give force to the UK Government’s policy intention.
23. Measures we want to see in the bill include:
24. It will be important that any requirements in and beyond the legislation that relate to cultural competence and cultural appropriateness are well defined and explained, and that implementation includes oversight and continuing education.
25. To be effective, these measures would need to be accompanied by the provision of services tailored to needs of racialised communities, as set out in the Key Interventions report from the Ethnicity and Mental Health Improvement Project[3]. Individual feedback we’ve received on what is important includes safe spaces and affordable, culturally appropriate therapies for Black people, personalised care, and early intervention.
Question 6. What more could the draft Bill do to reduce the impact of financial inequalities in people's experiences of the Mental Health Act?
26. Access to legal aid is a key way to do this. There should be non-means tested legal aid across issues relating to the Mental Health Act e.g. legal help for individuals and their nominated persons, judicial reviews, claims for damages and applications for habeas corpus.
27. Being admitted to or discharged from hospital can be a confusing and disorientating experience, even before the demands of navigating a complex benefits system that increasingly requires the claimant to engage. Things can easily go wrong leaving people without any money or unable to pay their rent, which in turn may make their condition worse and stop their recovery in its tracks. Similarly, people’s housing needs and circumstances may change, even risking homelessness. People should never be discharged to homelessness. Therefore, the bill should require a holistic care and treatment plan that addresses these social and welfare support issues during the admission and in planning for discharge, whereby relevant advice and advocacy is provided.
28. People who are experiencing poverty are more exposed to the social determinants of mental health problems, and at the same time face more barriers in accessing and navigating health systems and establishing collaborative relationships with clinicians. Proactive support to make advance decisions and choices, together with oversight of care and treatment plans, will be particularly important for people in these circumstances to ensure that they are able to state their views and have them taken seriously.
Question 7. What are your views on the changes to how the Act applies to autistic people and those with learning disabilities?
29. We don’t have a view on changes to the law that relate to autistic people and those with learning disabilities who do not have mental health problems as this is outside Mind’s remit. Where people with autism or learning disabilities are detained because of their mental health problems, reasonable adjustments must be made so that people are in calm and appropriate environments that aid their recovery.
Question 8. To what extent will the draft Bill achieve its aims of reducing detention, avoiding detention in inappropriate settings and reducing the number of Community Treatment Orders?
30. Reducing detention– better choice, improved access to advocacy, and more transparent care and treatment planning should combine to improve recovery and so reduce the need for ongoing detention. Provision of greater access to tribunal review should ensure discharges at the earliest appropriate time. If tribunals were empowered to direct transfers, leave and community services (as recommended by the independent review and proposed in the white paper) this could further aid people’s recovery and routes to discharge.
31. However, the potential in the proposals will only be realised in practice if:
32. Avoiding detention in inappropriate settings – the draft bill provides greater ability to divert people from prison to hospital, introduces time limits on prison transfers, and ends use of prison and police cells as places of safety, which is very welcome. Levels of service provision will affect the success of these measures.
33. The draft bill doesn’t directly address making settings appropriate to specific needs such as those of autistic people or people who have a learning disability (who have mental health problems), people who are disabled, people who don’t speak English, including deaf people, children and young people, older people, and people with specific cultural or religious requirements. However, the requirements to take account of patients’ wishes should help make professionals more responsive to individual needs and preferences.
34. As the independent review set out, the quality of both physical and social environments in inpatient settings needs to be improved in many cases if people are to receive therapeutic benefit, recover and not be further traumatised by their admission. Ward culture and management need to promote respect, dignity and safety, and end reliance on force. This includes safety for young people, who should not be placed on adult wards, and sexual safety. There needs to be access to outdoor space and a range of therapeutic, creative and physical activities to choose from. These measures require sufficient, appropriately deployed skilled staff.
35. Achieving them will require commitment outside the legislation including through commissioning duties and regulation, but stronger protection in law should be considered. We also recommend giving a role to hospital managers to look at day to day life on the ward and drive quality improvement. This would be a reformed scheme, in which the hospital managers were recruited to be representative of the communities served and were supported in the role.
36. Reducing use of CTOs – We’re calling for CTOs to be removed altogether. Research shows they are ineffective in reducing readmissions[4]; people tell us they are intrusive and coercive (people from racialised communities have described them to us as a form of community surveillance); they represent the starkest racial disparity in the use of the Act with Black people more than ten times more likely to be placed on one than their White counterparts. CTOs were supposed to provide a route out of disproportionate sectioning but have actually perpetuated and exacerbated Black people’s subjection to compulsion under the MHA.
37. While this power remains available, the evidence of their past use indicates that they are likely to be used in a risk averse way, restricting people’s lives when those people would be better served by the provision of care tailored to their needs and wishes.
38. The changes in the draft bill are an improvement on the current situation but we don’t think they are enough to reduce their use significantly or that they do anything to reduce their racist impact.
39. If CTOs are retained, recommendations made by the independent review should go in the bill including:
40. Any reduction in detentions has to be for the right reasons. To achieve its ambitions, we think the bill also needs to include a right to assessment and treatment, to reduce the likelihood of people being turned away from services when they ask for help. This should in turn make it less likely that the Act is used.
Question 9. What do you think the impact of the proposals will be on the workforce within community mental health services and multidisciplinary working practices both in inpatient and community services?
41. Anecdotally, we know that people prefer to work in services that are well run and where they can see people recovering and they know they are making a difference. Working in more collaborative ways should improve therapeutic relationships, reduce tension on wards and thus both improve job satisfaction and staff retention.
Question 10. What changes and additional support do you think will be needed to help professionals and the third sector implement the proposals effectively? Will additional staffing and resources be required?
42. There needs to be:
Question 11. How far will the draft Bill allow patients to have a greater say in their care, with access to appropriate support and avenues for appeal?
43. The draft bill makes significant improvements and we particularly welcome the requirement on clinicians to create care and treatment plans in which they must consider patients’ wishes; the new requirements for clinicians when making treatment decisions; and provision for capacitous patients to make choices and refuse treatment in advance and at the time (see Q13). We also strongly welcome improved access to advocacy, though we have further recommendations on this.
44. However, clinicians can still override people’s wishes and in some circumstances their refusal of treatment, albeit with safeguards. They can provide urgent treatment under s62 (except capacitous refusal of ECT) whilst waiting for SOAD approval. So it is important that decision-making and care and treatment planning are properly scrutinised and that there is a route for appeal.
45. Further changes are needed to give children and young people a greater say in their care, and to make advance decisions and the safeguards that flow from them available to under 18s. (See Q14 below for more on this point and our recommendations)
46. We’re also aware that remote assessments for some MHA purposes are under consideration. Video assessments may be acceptable in some circumstances, with very robust guidance, but we would want to see phone assessments ruled out for SOAD assessments. These are clinical assessments, which may well involve assessing adverse effects of medication, and cannot be done satisfactorily by phone.
47. Advocacy support - We recommend that the bill include:
48. Review and appeal – Several recommendations by the independent review and white paper proposals were not taken forward in the draft bill. We think they are important safeguards and believe they should be introduced:
Question 12. What do you think of the proposed replacement of “nearest relative” with “nominated persons”? Do the proposals provide appropriate support for patients, families and nominated people?
49. We strongly agree with replacing nearest relative with a nominated person. However, because health or social care professionals will need to assess if someone is capacitous or competent to appoint their own nominated person, under 16s are at a disadvantage as there’s no test for competence. Therefore we recommend a test of competence be introduced (see Q14).
Question 13. To what extent is the Government right in the way it has approached people taking advance decisions about their care?
50. We agree with using existing provisions of the MCA, as far as adults are concerned. However, we’re concerned that this excludes under 18s from advance refusal of treatment. It’s essential that this is addressed (see Q14)
51. Many people will need support to make advance decisions and set out their wishes in advance. This is especially important if the new right is to reduce inequalities; without information and support it is only those with privilege who are likely to know about and use the provisions. In the bill as it stands, people aren’t eligible for advocacy support with advance decisions as they are likely to make them some time after an admission rather than while they are detained.
52. Therefore, the bill should include:
53. It is important that advance choice documents are developed as a practical way to facilitate people setting out advance decisions and wishes and clinicians accessing them. These should be accessible to children and young people as well as adults.
54. We are glad that the draft bill does not introduce advance consent to informal admission but are concerned about how this is included in the MCA draft code of practice (see Q1).
Question 14. What impact will the draft Bill have on children, young people and their families? Does it take sufficient account of the existing legal framework covering children and young people?
55. Mind is a member of the Children and Young People’s Mental Health Coalition and sit on their Mental Health Act Reform working group. We endorse the Coalition’s detailed response for further evidence and submissions.
56. However, we also wish to set out a number of key concerns for Mind. The Act is all age but children and young people don’t benefit equally from the reforms even if these are intended for people of all ages.
57. How the bill works relies a lot on the patient’s decision-making capacity. Although there is a general understanding that a ‘Gillick’ competent child can consent to interventions there is a lack of clarity on how to assess whether the child is able to make their own decision, and the Independent Review highlighted a lack of consistency in how Gillick competence was assessed. A statutory test in the Bill and applicable to inpatient admission would provide this clarity and is important for children and young people – and their parents and health professionals – in ensuring effective access to rights and safeguards that depend on capacity (nominated person, consent to admission, consent to treatment, advance decisions – if extended to under 18s).
“Sometimes, this professional says I have competence but this one doesn’t, it could be within the same hour. Competency and capacity should be decided on a case-by-case basis. There should be a set-in-stone process, where you need to tick this box or that box to assess competence.” – young person with experience of going into hospital for their mental health
58. Advance decisions are a key reform aimed at providing greater patient autonomy, but under 18s are excluded from it. This is a serious gap in young people’s rights to be heard. Including under 18s could be achieved by 1) finding a different way to give effect to advance choices rather than through the MCA, or 2) by introducing a complementary mechanism that would apply to capacitous/competent young people. This would require a statutory decision-making test for under 16s for it to work properly for them.
59. Young inpatients who are admitted informally have told us they experience similar levels of control and coercion as detained patients.[6] It’s important that they have the same or equivalent rights and safeguards as their detained counterparts. Young people have also told us that they are treated as less unwell if they are informal and they feel that their treatment is deprioritised. The Government have previously committed to placing care and treatment plans for informal patients on a legislative footing but they do not appear in the Mental Health Bill. Young people we spoke to were consistently positive about making sure the care and treatment plans were extended to informal patients[7]. We think care and treatment plans for informal young people should be on the face of the Bill.
60. Children and young people also continue to be admitted onto adult wards, despite government policy stating that under 16s should not be admitted to adult wards. Placement in adult wards can be traumatising, exclude young people from appropriate treatment, and lead to more restrictive care, for safeguarding rather than clinical reasons. Therefore, we think there should be a presumption in law against placement of under 16s in adult wards and a requirement to notify the responsible local authority when a child is placed in an adult ward and to notify the CQC (within 24 hours of the placement) should be set out in the Bill.
61. Placements out of area can take young people away from support of family, friends and education and there is a growing consensus that in the majority of cases, it is better for a child or young person to receive treatment at home or in their community (Health and Social Care Select Committee, 2021)[8]. A requirement to notify the responsible local authority when a child is placed out of area should be set out in the Bill.
62. Many young people have also told us about problems with discharge from inpatient settings and going from high support inpatient setting to virtually nothing in the community. They’ve told us about the importance of multi-agency working prior, during and after discharge to ensure they have the right support in the community[9]. We believe there needs to be clearer statutory mechanisms for ensuring that children and young people are supported during and after inpatient care.
63. There is no centrally collected data on education provision, but available information suggests that 80% of inpatient education provision are “schools” registered with the Department for Education[10]. Only schools registered with DfE are inspected by Ofsted and we know that education on inpatient settings is often poor[11]. There is also no published data on the number of children and young people with Education Health and Care plans (EHCP) in CAMHS inpatient units. We think the Department of Health and Social Care and the Department for Education should improve education support and publish guidance for secondary schools on how to ensure young people who have been admitted to a mental health ward have the opportunity to access education and learning[12]. We also think that admission to hospital for mental health, should be an automatic trigger for an assessment or review of an EHCP.
64. As set out in the CYPMHC coalition’s detailed response, there are numerous issues with data collection on children and young people in mental health hospitals. Notably, no data is published on the total number of children and young people and the basis on which they are admitted. For example, no data is published on informal patients under 16 and whether they have been admitted on the basis of their own consent or parental consent. 50% of young people we spoke to, who had been admitted informally when they were under 16, told us that it was their parents instead of them who had consented to the admission.[13] The Mental Health Bill should include a duty on the Secretary of State to ensure that national data on the experiences of children and young people as mental health inpatients is regularly collected and published.
“They did not ask me anything when I was first sectioned. They sidestepped me and pressured my parents. This exacerbated the problem. Doctors did not care if I had competence or not. Made me feel bypassed and disempowered” - young person with experience of going into hospital for their mental health
65. Finally, we wish to highlight the lack of provision for a group of young people with complex and varied needs, who have experienced trauma, and who require therapeutic care in a restrictive environment. Whilst they may be admitted as inpatients for brief periods of time, they are various barriers to them receiving long term inpatient care. As a result, these young people fall outside of MHA (although they may have been sectioned and admitted for brief periods of time) and are being placed in social care placement, often unregulated accommodation, due to a lack of suitable alternatives. They often need significant NHS involvement but their care appears to fall primarily to local authorities. There have been numerous judgments from the Family Courts on this group of young people, as well as media reports. It is important to be clear that nothing in the Bill will address the lack of appropriate care and accommodation for this group of young people.
66. We recommend that the bill include:
Question 15. To what extent are the proposals to allow for conditional discharge that amounts to a deprivation of liberty workable and lawful?
67. We disagree with introducing supervised discharge. It is important to address the needs and rights of people that this proposal is intended to benefit. (We understand that there are about 75 people who cannot be discharged for the sole reason that they cannot access the community safely.) They should have the least restrictive care and the opportunity to live as independently as possible.
68. However, we are concerned that:
69. The relatively small specific patient population that would purportedly benefit from this measure could obtain more access to the community via placement, not legislation. Placement in a step-down service that is registered as a hospital would enable the person to gain therapeutically and potentially move towards greater independence, while remaining on section with the ability to facilitate escorted leave. Some such placements have accommodation within the grounds providing patients with their ‘own front doors’ a more homely and independent setting.
70. Given the racial bias in risk assessments that leads to greater use of CTOs on patients from racialised communities, we suggest this new power would similarly be disproportionately applied in practice.
71. Annual tribunal review would need to be clear what the criteria were for the order and hence how the person could be discharged from it; also how they could progress, albeit it on a slower track, towards discharge, and on what basis restrictions would be reduced.
Question 16. What are your views on the proposed changes in the draft Bill concerning those who encounter the Mental Health Act through the criminal justice system? Will they see a change in the number of people being treated in those settings?
72. We welcome the greater ability to divert people from prison to hospital, introduction of time limits on prison transfers, and ending the use of prison (as well as police cells) as a place of safety. We are concerned that people under part 3 of the Act should not be disadvantaged in the extent to which they benefit from the reforms as compared with people on civil sections. However, other organisations are better placed to comment on these issues.
Question 17. Are there any additions you would like to see to the draft Bill?
73. The following summarises the additions we would like to see in the draft Bill; they are all explained elsewhere in our submission:
All age
Children and young people focus
16 September 2022
[1] See ‘The Mental Health Measure: ten years on’, Mind Cymru, 2022 for our research on its impact and recommendations for improvement
[2] Barrett B, Waheed W, Farrelly S et al. Randomised controlled trial of joint crisis plans to reduce compulsory treatment for people with psychosis: economic outcomes. PloS One. 2013, 8(11), e74210.
[3] Ethnicity & Mental Health Improvement Project (2020) ‘Key interventions’. Emhip.co.uk
[4] Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013; 381:1627–33.
[5] Open, online survey, 2021. 725 respondents out of a total of 764 answering the question agreed “Do you think that people should be entitled to have an advocate, or someone else they trust, with them while being assessed for detention (ie before being sectioned)?”
[6] Open, online survey of young people, 2022.
[7] Ibid
[8] Health and Social Care Committee (2021) Children and young people’s mental health (see para 120). Available at: https://committees.parliament.uk/publications/8153/documents/170201/default/
[9] A full analysis of our engagement with young people about the reforms (survey, focus groups and interviews) will be made available to the Committee.
[10] Department for Education (2018) Education in inpatient children and young people’s mental health services Research report. Available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/678683/Education_in_Inpatient_CHYPMH_Services.pdf
[11] Commons Health Committee (2014) Children's and adolescents' mental health and CAMHS. Available at: https://publications.parliament.uk/pa/cm201415/cmselect/cmhealth/342/342.pdf
[12] Mind (2021) Not Making the Grade. Available at: https://www.mind.org.uk/media/8852/not-making-the-grade.pdf
[13] Open, online survey of young people, 2022. A full analysis of our engagement with young people about the reforms (survey, focus groups and interviews) will be made available to the Committee.
[14] Open, online survey of young people, 2022. A full analysis of our engagement with young people about the reforms (survey, focus groups and interviews) will be made available to the Committee.