Written evidence submitted by the Centre for Mental Health (CYP0037)

Introduction

1. Centre for Mental Health is an independent charity with 35 years of experience delivering life changing research, policy analysis and health economics in mental health. Our work spans themes such as employment, physical health, criminal justice, wellbeing, inequality and multiple disadvantage across the life course. We work closely with NHS mental health providers, mental health and physical health charities and networks of people with lived experience of mental health problems.

Summary

2. Centre for Mental Health welcomed much of the 2017 Green Paper but we are concerned about its progress and clarity around future plans. Given the impact of the pandemic on young people, and predictions of increasing need and demand, it would be timely to revisit plans for improving mental health services.
3. Schools: Schools and colleges can promote better mental health, but they can also put mental health at risk. Recommendations:
• In addition to the Green Paper commitments, Government should enable, with investment and guidance, whole-school and whole-college approaches to mental health across the country and increase the availability of school counselling.
• Department for Education should pause school exclusions during the pandemic and the recovery period. Policies of exclusion and the use of restrictive interventions should be reviewed, and more psychologically-informed approaches to meeting challenging behaviour as the communication of distress should be adopted.
4. Eating disorders: We are concerned of the rising prevalence of eating disorders in young people. Recommendations:
• NHS England and Improvement must ensure the access and waiting time standards are implemented fully in every region.
• Government should review its Obesity Strategy with eating disorder experts (by profession and by experience) as part of a cross-government approach to mental health
5. Workforce: Workforce pressures are a major threat to the implementation of the NHS Long Term Plan and the Green Paper commitments. Recommendations:
• Government should commit to a funded multi-year mental health workforce strategy.
• The voluntary sector workforce should be recognised and funded appropriately as an asset to expanding local capacity.
• Government should commit to developing a workforce which is representative of the communities it services and able to recognise and challenge racism and discrimination in all its forms.
6. Improving access: We lack a plan for how services will meet the needs of all children and young people who need mental health support. We also know that access is poor for young people from racialised communities, autistic children, children with learning disabilities, LGBT+ young people, children from the poorest backgrounds, and children living in remote rural areas, among others. These are the same groups who experience more risk factors for poor mental health. Recommendation:
• Government can address these inequalities in access to support by improving access to wider choice of flexible support; prioritising links between statutory services and community organisations; investing in user-led and peer support groups; commissioning and designing services in partnership with the people who need them; adopting trauma-informed approaches; including equality measures in mental health service access standards; and strengthening the Public Sector Equality Duty.
7. Improving inpatient care: Out of area placements are known to lead to poor experiences and outcomes for children and young people. Our evaluation of Provider Collaboratives evidences the value of investing in community provision to ensure that children can get help closer to home. Recommendation:
• NHS Provider Collaborative models for children and young people’s mental health services should be rolled out nationally without compromising on the approach that made the first wave successful.
8. Early intervention: We agree that a transformational change to a health system which focuses on early intervention and prevention would improve mental health among children and young people. To be successful, this approach would require a cross-Government strategy, investment in public health, more mental health support in communities, protected funding, and better data collection and reporting.
9. Best practice: There are numerous evidence based approaches which have not been implemented widely in the UK. This includes effective positive parenting programmes. Other interventions which address longstanding inequalities in mental health are at an earlier stage in establishing their evidence. These, too, require support. Recommendations:
• Government should make services with well-established evidence, like parenting programmes, available nationally.
• Government should fund and encourage the development of innovative interventions which address the starkest inequalities in mental health.
10. Self-harm and suicide: Evidence and reporting of increased rates of suicide and self-harm among young people are deeply concerning. Recommendations:
• CCGs/ICSs and local authorities should explore community based and peer support approaches and increase capacity in the community so that every young person who is struggling gets support before (and after) they experience a crisis.

Government Progress on children and young people’s mental health

The ambitions laid out in the 2017 Green Paper

11. We welcomed much in the Green Paper and its focus on schools and colleges. We were also pleased to see these commitment incorporated and restated in the NHS Long Term Plan.
12. However, the Government estimates that only 20-25% of children would benefit from the full package of measures by 2022/23. This is a major concern, given trends in rising prevalence of mental health problems for children and young people, and the mental health impacts of the pandemic on mental health, which evidence suggests will create or exacerbate mental health problems amongst 1.5 million young people under 18.[i]
13. There is a lack of clarity on progress being made to implement the Green Paper. This was the case before the pandemic, and we know that the crisis has interrupted progress. The national provider for Designated Senior Lead training has not yet been announced. We are also concerned about progress to recruit, train, and embed Educational Mental Health Practitioners and rollout Mental Health Support Teams (MHSTs) in schools in line with the Green Paper’s commitments. The Green Paper outlined an ambition to double the children and young people’s mental health services workforce by creating 8,000 new roles in MHSTs. Without a comprehensive plan and urgent progress, there is a risk that this ambition is not achieved.
14. We anticipate an announcement from the Department of Health and Social Care, NHS England and NHS Improvement on how the Green Paper programme will be boosted as part of the post-Covid NHS Long Term Plan and service recovery planning. We hope this will clarify whether the £300m originally allocated to the Green Paper commitments in schools will be increased or expanded. Before the pandemic, the Long Term Plan set out a vision of expansion of young people’s mental health services where investment and growth would be the highest among NHS and mental health commitments overall.
15. Recommendation: DHSC should update the plan to deliver the ambitious and necessary workforce growth and should report annually to Parliament to demonstrate what has been achieved against this plan.

Provision of mental health support in schools

16. Government must ensure that schools, colleges and universities have the resources and the policy direction to create healthy, nurturing environments, especially for children and young facing the biggest disadvantages and adversities. The pandemic has presented a vital opportunity to overhaul the education system and the way we conduct assessments and exams. Our education system can place wellbeing – which is critical for attainment – at its heart alongside academic performance, and deliver a fairer, more effective education system than one which ‘teaches to test’. Government must do more to commit to and achieve a balance between these interconnected elements. The disparity between the £350m academic catchup fund and the £8m Wellbeing for Education Return fund (ending in March 2021) suggests that there is a lot to do to achieve this balance.
17. Recommendation: The Department for Education should commission a review of the impact of the exam system and the ‘teach to test’ culture on the mental health of young people.
18. Educational settings have a profound effect on young people’s mental health and wellbeing. The curriculum, timetables, lessons and cultures can make schools stressful places, especially for young people facing the greatest adversity. However, evidence shows that education can also be good for mental health – for example through teaching life skills and creative subjects. That’s why we have welcomed the Green Paper’s focus on improving schools and colleges, the introduction of mental wellbeing into the Relationships and Sex Education (RSE) and health education curriculum, and personal development, including pupils’ mental health, as a criterion for Ofsted inspection.
19. However, as stated, progress on enhancing mental health support in schools and colleges is unclear, and there is no comprehensive plan to improve support in every school in England. The implementation of Mental Health Support Teams and Senior Designated Leads for Mental Health are alone, unlikely to be enough for meaningful results.
20. Recommendation: All schools and colleges should adopt whole-school/whole-college approaches to mental health. The whole-setting approach develops a positive ethos and culture – where everyone feels that they belong. It involves working with families and making sure that the whole school community is welcoming, inclusive and respectful. It means maximising children’s learning through promoting good mental health and wellbeing across the school – through the curriculum, early support for pupils, staff-pupil relationships, leadership and a commitment from everybody.[ii] Inclusive education can also help to address health inequalities faced by young people who have experienced adversity or who are marginalised because of their ethnicity, gender identity, or sexual orientation. It will be fundamental to maximising the impact that MHSTs, SDLs and school counsellors have on young people in education.[iii]
21. Recommendation: School counselling should be made available to every child who needs it. The education system in England should learn from and emulate the national school-based counselling programme in Wales.
22. Finally, we are concerned about the mental health impact of policies which encourage punitive responses to challenging behaviour in schools. Children and young people’s challenging behaviour is often the result of underlying conditions or unmet emotional needs. A punitive response to children communicating distress, such as a greater use of exclusions, has previously been advocated by the government. This can be deeply unhelpful for children’s mental health, especially for children returning to school having experienced trauma, hardship or isolation over the course of the pandemic. The practice of exclusion and restrictive interventions in educational settings can create a vicious circle of trauma, challenging behaviour, restriction and psychological harm.[iv]
23. Recommendation: The Department for Education should introduce a moratorium on school exclusions during the pandemic so that pupils are not being sanctioned when they need support most. Instead, positive behavioural support strategies and trauma-informed approaches in schools can be key to reducing the use of restrictive interventions, as they promote a supportive environment and consider pupil’s individual circumstances.

Provision of support for young people with eating disorders

24. The introduction of an access and waiting time standard for children and young people has set clear expectations around access to evidence-based treatment within maximum waiting times, and funding to support this has been a major step forward. However, NHS England and Improvement must ensure the access and waiting time standards are implemented fully in every region. This is especially important given worrying data on the increasing number of young people who need treatment for eating disorders and growing waiting times for support.
25. At the same time, we are concerned that Government thinking elsewhere has not been sufficiently informed on eating disorders and mental health. The Obesity Strategy, for example, calls for calorie labelling in restaurants and a public health campaign focused on losing weight to reduce the burden on the NHS. These changes could be deeply harmful for people living with and recovering from eating disorders. Amendments to resources, for example excluding people who are ‘underweight’ from using the Better Health app based on self-reported BMI, are insufficiently informed on the complexity of disordered eating.
26. Recommendation: Government should review its Obesity Strategy with eating disorder experts by experience and by profession as part of a cross-government approach to mental health.

Addressing capacity and training issues in the mental health workforce

27. Growing the workforce is a prerequisite for delivering on the ambitions of the NHS Long Term Plan and Children and Young People’s Green Paper. We understand that funding will emerge as part of Covid-19 recovery planning for 2021/22 to invest in workforce training and education. This is a vital step, but workforce is a long term concern which requires multi-year funding commitments. There are workforce shortages in some specialist areas, such as parent-infant specialists. Burnout and stress are major concerns for all those in health and care settings. Improving capacity in services by growing the workforce will also help reduce the pressure and strain on individuals.
28. Recommendation: Government should commit to a multi-year settlement for workforce training and education at the next Spending Review in order to meet the ambition of the NHS Long Term Plan and respond to the mental health impact of the pandemic.
29. Recommendation: The children and young people’s workforce should be encouraged to take up emotional wellbeing support offered by compassionate leaders and managers, and these support offers should be properly funded to ensure capacity can meet demand. This offer should be extended to those working in education and children’s services sectors who have been at the frontline of supporting children but have not been able to access the mental health support packages provided for NHS workers.
30. Recommendation: Government, at national and local level, along with NHS partners, should recognise and invest in voluntary sector services as a professional and effective workforce. Collaboration and integration between community based voluntary sector organisations and statutory services can unlock preventative and early intervention services, reducing the pressure on the specialist mental health workforce and improving outcomes for children and young people who get help early.
31. Recommendation: Efforts to grow an NHS workforce which is representative of diverse communities and equipped to recognise and challenge racism and discrimination in all its forms, are necessary if health inequalities are to be addressed. The Advancing Mental Health Equalities Strategy is an important step and will produce important learning. The wider children and young people’s workforce should also be trained to respond to mental health problems, particularly among young people with autism or a learning disability, whose mental health concerns too often go unrecognised and unsupported.

Improving access to mental health services

32. Children and young people, and their families, often report long waits for help, high thresholds which often only provide support in crisis, and a lack of join up between services. Recent findings from the Children’s Commissioner suggest that only a quarter of children who need help get support from mental health services.[v] There is little available to support infant mental health, and, despite some areas moving to 0-19 and 0-25 service models, the critical transition between child and adult services continues to poor experience for many young people and support is often non-existent.
33. Other population groups also face significant barriers to support. Young Black men, for example, often face multiple risks for poor mental health while being marginalised by public services (including schools, health, police and welfare). Help is less welcoming, less understanding and less accessible than it is for other groups of young people. They are therefore less likely to receive early help and this has been posited as a factor in the overrepresentation of young Black men in restrictive and secure hospitals.
34. Almost one in four LGBT people (23%) have witnessed discriminatory or negative remarks against LGBT people by health care staff, and 14% of LGBT people have avoided health treatment because of worries about discrimination.[vi]
35. People receiving diagnoses of autism have lost the support of mental health services and GPs due to being seen as ‘too complicated’ or ‘complex’ for treatment.[vii] Services are often poorly tailored to the sensory needs of autistic young people.
36. Living in rural and remote areas can create distinct challenges for children’s mental health. Poor transport infrastructure, fewer local choices, alienation and isolation, poor digital connectivity, and a lack of opportunities to socialise with peers outside of school can all have an impact on children and their wellbeing. Years of cuts to public services have made it even harder for local services to offer children the help they need. These difficulties are disproportionately experienced by children living in poverty (which is often more hidden in rural areas), children who have complex needs and children who face other risks of exclusion, alienation and marginalisation (such as young carers, disabled children, children from Gypsy, Roma and Traveller communities, and LGBTQ+ children and young people).[viii]
37. Covid-19 is exacerbating these inequalities. Digital exclusion makes it harder for young people living in poverty to access remote support. Many of those who already experienced inequalities in accessing services live in communities which have been disproportionately affected by the pandemic, including some racialised communities and those living in deprived neighbourhoods. Poor digital coverage and reach also presents a barrier for young people living in rural areas.
38. Recommendation: The Centre’s Commission for Equality in Mental Health found that Government can address these inequalities in access to support by improving access to wider choice of flexible support: prioritising links between statutory services and community organisations; investing in user-led and peer support groups; commissioning and designing services in partnership with the people who need them; adopting trauma-informed approaches; including equality measures in mental health service access standards; and strengthening the Public Sector Equality Duty.[ix]

How inpatient care can be improved so that it is not creating additional stress on children and young people, and how the use of physical and medical restraint can be reduced

39. Sending children out-of-area for mental health support can be highly distressing for them and their families, as well as being costly and extending the amount of time it takes for them to recover. The Centre evaluated six pilot programmes supported by NHS England’s ‘New Care Models’ programme (now called the Provider Collaborative programme). These pilots invested in local mental health services for children and young people, to prevent them needing admission to hospital far from home.
40. The evaluation found that all six areas managed to reduce the number of children being treated in hospitals outside their local area by meeting their needs more effectively close to home. By investing in local services, they reduced the costs of care without compromising on quality. Quantitative changes observed in pilot sites included changes in out-of-area bed use, length of stay and distance from home. The evaluation showed that investing in new, community-based services which offer treatment locally in place of out-of-area beds was cost effective. These models also provided better care for young people – they aspired first for clinical success, not financial gains.
41. Recommendation: We advocate both for wider implementation of the Provider Collaborative models for children and young people’s mental health services, and for services to learn from the principles underpinning these successful pilots: putting patient’s needs first, with clinical decisions the primary factor in treatment; strong governance and good relationships between management and frontline staff; finding solutions tailored to local contexts and environments; team leadership; and a clear, shared aim for services.[x]

The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing

42. Some existing proposals for change have yet to be fully realised. Future in Mind called for services to move away from a tiered approach (the traditional CAMHS model) towards a system that’s young person centred.[xi] Some areas have sought to shift local systems to the new model by adopting the iThrive approach. However, this principle has not been widely adopted or implemented. Any ambition to reform the system requires sufficient funding, access to evidence-based approaches and clear government guidance to support implementation.
43. We support an emphasis on early intervention and the prevention of mental health problems in young people. This could lead to significant improvements in outcomes for children and young people and in performance of services. This approach would recognise and seek to mitigate the risk factors for poor mental health and strengthen the protective factors around children and young people. To be effective, this approach requires a number of wider changes:
44. A cross-government strategy: There are multiple policy initiatives in this area but they are not joining up as part of a comprehensive plan. A cross-government strategy should consider the roles of national and local government, the NHS and other services. It should span all departments and address young people’s mental health in health services, from infancy to adulthood, in education, in welfare, housing, employment, criminal justice, immigration, leisure and culture.
45. Investment in public health: Public health and local authorities can make a significant contribution to improving young people’s mental health and working with partners to provide early help in communities. However, local authorities are hindered by insufficient budgets. While the Public Health Grant grew in 2020/21, it did so in the context of around £1bn worth of cuts over the preceding decade. The neglect of public mental health reduces opportunities to support young people to stay well and puts more pressure on expensive specialist services.
46. Putting mental health support in communities: The delivery of open access, drop-in hubs are an effective way of delivering accessible support in communities. Hubs are designed to provide additional capacity and are not designed to replace the vital support provided by statutory services. They offer easy-to-access, drop-in support on a self-referral basis for young people with low-level mental health needs, up to age 25. A mix of clinical staff, counsellors, youth workers and volunteers provide a range of support on issues related to wellbeing, while a range of services can be co-located under one roof; offering wrap-around support across, for example, psychological therapies, housing advice, youth services and sexual health.[xii] Hubs provide a cost-effective solution to a growing problem, achieving excellent clinical outcomes and achieve higher satisfaction among young people than statutory services.[xiii] There are currently only a handful of these hubs in operation – a reform of the system would benefit from wider rollout, and a focus on process learning from areas which have implemented this model.
47. Protected funding: A meaningful shift towards early intervention and prevention will require significant investment. It is vital that any funding earmarked for children and young people’s mental health is appropriately protected, especially as local systems convert to Integrated Care Systems, where mental health will be considered alongside acute health services. There must also be accountability and assurances around how money is invested.
48. Better data collection and reporting: Data has improved in recent years but it is still poor in reporting on service use and outcomes. This makes it challenging for commissioners to make informed decisions. Local areas also lack robust demographics data around ethnicity, sexuality, gender identity and co-morbidities. This makes it harder to monitor progress in addressing health inequalities. Additionally, as more local areas commission digital support, there is a pressing need to develop robust national guidance on metrics for evaluating digital platforms. Without this, there is widescale potential for ‘gaming’ existing evaluation systems, resource shunting and a lack of comparative information between areas on what has been achieved.[xiv]

How the Government can learn from examples of best practice, including from other countries?

49. Several evidence based interventions have been shown to be effective, in the UK and overseas, but have not been delivered nationally. Government should invest in parenting programmes with an established evidence base so that all families can give children a better start in life. Government should also commit to tackling health inequalities by investing in and expanding the evidence base for emerging interventions to meeting the needs of marginalised young people, enabling more areas to adopt innovative practice.
50. Evidence-based parenting programmes have been shown to bring about significant improvements in family wellbeing and children’s behaviour. Learning has been developed from implementation in the UK, Republic of Ireland, US and Canada. Parenting programmes like Triple P are a low-cost intervention with major benefits to children, families, schools and communities: reduced behavioural problems, reduced mental health problems, reduced child abuse cases, improved parental mental health, reduced parental conflict.[xv] Yet access to effective parenting interventions is patchy, with few areas offering a comprehensive range of options. As a result, most parents who seek help do not get it. The cost of a proportionate universalism model of evidenced-based parenting support would be around £60m over three years for full coverage across every local authority in England. To target the approach in the 20 most deprived local authority areas, the cost would be around £8m over three year.[xvi]
51. Young Black men experience significantly poorer access to services and poorer mental health outcomes by the time they reach early adulthood. The Centre has evaluated models which address these inequalities. The Up My Street project in Birmingham used community activities in to support young black men’s resilience through the use of creative arts. Up My Street’s evaluation found that the projects successfully challenged racist stereotypes that affected the young men’s wellbeing, strengthened self-esteem, self-belief, personal development and skills.[xvii] Another approach, MAC-UK’s INTEGRATE model, supports the most excluded young people in some London areas. It is a community-based approach with prioritises engagement with young people, peer referrals, same spaces for young people, mutual trust between staff and service uses, non-clinical environments, holistic support, co-design and co-delivery of support which young people want, need and will accept. Evaluations have demonstrated that sites using this model increased mental health awareness amongst recipients and reduced stigma; helped bring young people into education, employment and training; led to improvements in mental wellbeing according to clinician-rated measures and young people’s feedback; and helped divert young people away from crime.[xviii]
52. Recommendation: Government should make services with well-established evidence, like parenting programmes, available nationally.
53. Recommendation: Government should fund and encourage the development of innovative interventions which address the starkest inequalities in mental health. These have historically not received investment to develop and evidence outcomes. Capturing new learning and evidence of efficacy must be a priority within this investment.

What measures are needed to tackle increasing rates of self-harming and suicide among children and young people?

54. Evidence and reporting of increased rates of suicide and self-harm among young people are deeply concerning. We echo calls for services to move away from crisis intervention to a more preventative approach to support.
55. Community-based services can provide an effective and acceptable offer for young people. The Centre’s evaluation of The Wish Centre, a voluntary sector organisation in Harrow and Merton, found that the community based, peer-involved, holistic, strengths-based approach successfully improved outcomes for young people at risk of self-harm and suicidal ideation. It achieved high rates of satisfaction for young people, reduced attendance at A&E, and improved outcomes across a range of domains, including emotional resilience, suicidal ideation, anxiety, depression, and self-harm. This approach is likely to be cost effective.[xix]
56. Recommendation: We recommend that CCGs/ICSs and local authorities explore similar approaches nationally and increase capacity in the community so that every young person who is struggling gets support before (and after) they experience a crisis. Our research also suggests that more should be done to develop peer support offers for self-harm prevention; to commission tailored support for young men, for LGBT+ young people, for parents and for carers; to raise awareness, tackle myths and stigma and -encourage help-seeking.

Louis Allwood

Policy and Public Affairs Lead

February 2021

References