Written evidence submitted by Mind (CYP0054)
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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.
- We welcome the UK Government’s commitment to improve mental health provision in schools, but further action is needed to ensure that all children and young people can access the support they need with their mental health. The UK Government must:
- Provide immediate ring-fenced funding for schools to commission mental health support that young people need.
- Accelerate the roll-out of Mental Health Support Teams (MHSTs) and training for Designated Senior Lead for mental health in schools.
- Evaluate who is accessing MHSTs in terms of gender and ethnicity, as well as treatment outcomes.
- Building a skilled and sustainable workforce is critical to delivering improvements to mental health support for children and young people, as set out in the NHS Long Term Plan. To achieve this:
- The NHS needs a multi-year funding settlement in the 2021 Spending Review to pay for an expansion in training places for the full range of roles envisaged in the NHS Long Term Plan to accompany a full People Plan.
- Health Education England should work with the wider mental health sector to develop a mental health careers campaign, encompassing the full range of roles available, including those in CAMHS, setting out a clear narrative on career pathways and opportunities for progression.
- All employers across NHS and social care settings should adopt the Mental Health at Work Commitment.
Access to NHS Mental Health Services
- We welcome the UK’s Government’s commitments to increase young people’s access to mental health services, however thresholds, delivery types and models should not be restricted to meet commitments while young people don’t get the support we need:
- Thresholds for specialist services must not be raised to meet commitments, services must be well-funded and thriving.
- Mental health services should not overly rely on digital access models, at the expense of the many young people who struggle to use services in this way
- More must be done to support new commissioning arrangements for 0-25 models of care in mental health services
- Open access mental health drop in hubs for children and young people should be rolled out across England.
Inpatient wards and reducing restraint
- Further funding for inpatient CAMHS is needed to end the practice of young people being admitted to adult inpatient wards and Inappropriate Out of Area Placements.
- We support the roll out of the Patient and Carer Race Equality Framework (PCREF) to address the mental health inequalities experienced by young Black, Asian and Minority Ethnic people
- Best practice continues to show that restraint can be reduced and these practices need to be adopted across all settings for children and young people.
Introduction: why things need to change
- In 2020, one in six school aged children have a probable mental disorder, up from one in nine in 2017. Half of all mental health problems are established by the age of 14, with three quarters established by 24 years of age. Early access to good quality support is vital to ensuring that young people's mental health doesn't deteriorate to crisis point.
- We don't yet fully know the extent of the pandemic's effect on young people's mental health, but many more will need support for their mental health in school and from mental health services. Current modelling suggests that in England, 1.5 million children and young people under 18 will need either new or additional mental health support as a direct consequence of the crisis. Additional need for mental health services will stem from a range of factors, many of which exist regardless of the coronavirus pandemic but whose prevalence will be exacerbated because of it. Stressors in family life, abuse, neglect, financial and housing insecurity, issues relating to personal identity, such as gender identity and sexuality, bullying, and exam pressure, will all play a part. The current structure of services is unlikely to be able to meet this rising need.
- To meet the scale of the challenge, we must fundamentally re-think our support for children and young people while accelerating the delivery of government and NHS commitments. This requires fast-tracking progress against the NHS Long Term Plan and Transforming Young People's Metal Health Green Paper, alongside greater funding for community services delivered by local authorities, through the NHS and through the voluntary, community and social enterprise (VCSE) sector.
- Longer-term we need to see services that are fully designed around the needs of young people, and are delivered where young people are. We also need to see a full range of trauma-informed care available quickly and to all those who need it.
Provision of mental health support in schools
- The 'Transforming children and young people's mental health provision' Green Paper highlighted the gap in provision within schools and between schools and the NHS. It noted that:
'…support from the NHS is only available when problems get really serious, is not consistently available across the country, and young people can sometimes wait too long to receive that support. Support for good mental health in schools and colleges is also not consistently available'
- To meet the need within schools, the Green Paper outlines several proposals. These included appointing mental health leads in schools to oversee activity and coordinate links with mental health services, and funding Mental Health Support Teams to be managed jointly by NHS Trusts and schools.
Designated Senior Leads for mental health in schools and colleges
- Mind welcomes the UK Government’s commitment to incentivise and support all schools and colleges to identify and train a Designated Senior Lead for mental health.
- We are concerned that the plans to provide this training are not on track and that the responsibility of delivering the training will fall solely to schools and colleges.
- The UK Government must provide the following reassurances in relation to its commitment on having a Designated Senior Lead for mental health in every school and college:
- Reaffirm its commitment to ensure that there will be training for a lead in every school and publish plans on how it will achieve this.
- Shorten the timescale so that training is delivered before 2025, given the impact of the pandemic on children and young people's mental health.
- Identify how it plans to encourage senior teachers to take up the designated senior lead role and confirm whether additional funding will be made available to recruit staff.
Mental Health Support Teams
- Mind welcomes the UK Government’s commitment to fund new Mental Health Support Teams (MHSTs), which will be supervised by NHS children and young people’s mental health staff.
- We are concerned that the long timeframes involved in establishing MHSTs will leave many children and young people unable to access this support, at a time when the impact of the pandemic is having a significant impact on many children and young people’s mental health.
- The UK Government must provide the following reassurances in relation to its commitment to invest in MHSTs:
Support for children and young people returning to school
- In response to the pandemic, greater weight should be placed on mental health and wellbeing within schools and helping children deal with the impact of trauma and bereavement. The link between wellbeing and educational outcomes should be central to decision making – there should be parity between achieving academic attainment and improving wellbeing.
- The £8m Wellbeing for Education Return programme is a training programme to help improve how schools and colleges respond to the emotional impact of the coronavirus pandemic on their students and staff. We welcome initiatives to improve mental health support for students and staff. However, the programme will not be sufficient to address the mental health impacts of the pandemic on children and young people. Mind supports YoungMinds call for the UK Government to provide a ring-fenced fund which would ensure schools could commission the mental health and wellbeing support that young people need. This could include commissioning in-school counselling services, working with local charities, bringing extra staff to provide pastoral support, commissioning digital services or prioritising staff wellbeing.
- Mind is concerned that there is a lack of a joined-up approach to implementing initiatives to improve mental health support in schools. For example, it is unclear how the training for staff as part of the Wellbeing for Education programme is being considered alongside training for designated senior mental health leads in schools, which has been delayed.
- As part of Educating Mental Health: Mind’s inquiry into mental health and secondary schools, we have interviewed mental health and education professionals. It has identified a lack of awareness amongst some schools about the Wellbeing for Education Return programme and there is a need for the Department for Education to better promote this training.
- The Department for Education should consult with school staff to ensure that the format and content of the training meets the needs of teachers. For example, one mental health professional who was delivering the training told Mind that the training would have been more effective if it was delivered in shorter sessions. They also said they had to amend the case studies as these were not relevant to the challenges faced by teachers in their school.
Addressing capacity and training issues in the mental health workforce
- Building a skilled and sustainable workforce is critical to delivering improvements to mental health support for children and young people, as set out in the NHS Long Term Plan. The workforce trajectories included in the Mental Health Implementation Plan indicate that an additional 18,770 staff will be needed by 2023/24. Details of funding to be allocated by Health Education England and NHS England/Improvement for workforce education and training from the 2020 Spending Review settlement are expected shortly and we are expecting significant investment. However, the NHS needs a multi-year funding settlement in the 2021 Spending Review to pay for an expansion in training places for the full range of roles envisaged in the NHS Long Term Plan to accompany a full People Plan.
- We welcome research from 2019 which found that there had been a 23% growth in the NHS Children and Young People’s Mental Health workforce in the previous three years, largely in community-based services. The percentage of vacant posts had decreased from 12% to 9% over the same period. There was not enough data to make comparisons with the local authority and voluntary sector workforce but there is evidence that growth exists. However, there is much more to do given the ambitions of the NHS Long Term Plan, the extent of unmet need prior to the pandemic and the forecast that an additional mental health need among children and young people as a consequence of the pandemic.
- The Conservative manifesto committed to an extra 6,000 GPs and 50,000 additional nurses. Of the 50,000 nurses, only 4,000 are set aside for mental health against 7,000 needed. More positively, the Government introduced nursing maintenance grants of £5,000, plus another £3,000 for shortage areas such as mental health and learning disabilities. Additionally, the retention programme led by NHSE/I role has led to a 1.2% improvement in retention of mental nurses.
- There is evidence of huge interest in careers in mental health in the popularity of Think Ahead social care and Mental Health Support Team roles, along with oversubscription to clinical psychology posts. Health Education England should work with the wider mental health sector to develop a mental health careers campaign, encompassing the full range of roles available, including those in CAMHS, setting out a clear narrative on career pathways and opportunities for progression. This should involve partnership working with schools, colleges and universities and promote roles in social care and the VCSE, as well as in the NHS.
- Key to both recruitment and retention of the mental health workforce is high quality support for staff wellbeing. Even before the pandemic, people working in mental health services reported high levels of work related stress. Since the Covid-19 outbreak, numerous surveys have shown health and care staff reporting depression, anxiety, stress, burnout, emotional distress or other mental health problems related to their work. This crisis offers an opportunity for a reset moment for mental health support, building on the Wellbeing Hubs set up during the crisis to identify and roll out evidence-based, effective interventions, with staff mental health and wellbeing strongly linked to safety. There also needs to be a bigger focus on presenteeism, the costs of which are much higher than sickness absence, but which has received much less attention.
- Beyond specific interventions, there needs to be significant culture change based on compassionate leadership, tackling issues such as long working hours, poor physical workspaces, and lack of management support that have the most negative impact on staff mental health and wellbeing. All employers across NHS and social care settings should adopt the Mental Health at Work Commitment.
- The Royal College of Psychiatry’s publication ‘Going for Growth’ makes recommendations to support staff during and after the pandemic, while Mind, Samaritans and Shout! set up Our Frontline, a service for frontline health, care, emergency, education and key worker. This offers round-the-clock one-to-one support, by call or text, from trained volunteers, plus resources, tips and ideas to look after their mental health.
- Health Education should urgently take forward the recommendations in the Pearson Review (NHS Staff and Learners Mental Wellbeing Commission).
Improving access to mental health services for children and young people
Access to mental health services
- Mind welcomes the commitments in the 2017 Green paper and the NHS Long Term Plan to prioritise children and young people’s mental health, including:
- A four-week waiting time target for children and young people who need specialist mental health services
- 70,000 more children and young people accessing treatment each year by 2020/21
- 100% of children and young people who need specialist care can access it by 2029.
- Ensuring an additional 345,000 children and young people aged 0-25 can access NHS mental health services and school or college-based support via Mental Health Support Teams.
- Mind is however concerned that many targets and commitments are not ambitious enough and currently may still not be met, particularly with rising need as a consequence of the coronavirus pandemic.
- There is currently huge variation in services for low-level Children and Young People’s mental health services (formerly ‘tier 1’ CAMHS) and specialist services (formerly ‘tiers 2-3’ CAMHS) partially due to lack of standard models, meaning that what young people are able to access locally varies dramatically.
- We are concerned that the NHS Long Term Plan commitment to a 100% access rate for those who need specialist support by 2029 must not be achieved by raising the already high thresholds for accessing support, but by ensuring specialist services are well-funded and thriving. Currently a high rate of referrals to specialist mental health services are rejected. A lack of national service specifications for specialist services allows for the possibility that providers narrow their eligibility criteria so that many young people do not meet the threshold for help, ensuring targets are met while children are being turned away. Despite the government’s ambition to transform children and young people’s mental health services, 26% of referrals to specialist mental health services were rejected in 2019, and children in some parts of the country are waiting as long as six months to get support. On top of this, in 2019 reported that 81% of Mental Health Trusts felt unable to meet the demand for community CAMHS services, putting further pressure on the service overall.
- In some areas, community support services are not available so if a young person is not accepted into specialist services there may be nowhere else for them to go, leading to many young people falling through the gaps in the system. This is partly due to confusion as to who should be providing the low-level help – schools, councils or the NHS – which would be clarified if it was made clear what support ‘specialist services’ were supposed to provide and therefore what everything else should cover. A national service specification for specialist CAMHS services should be considered.
- Targets to ensure higher rates of access to mental health services, should also not be ‘met’ through using mediums that don’t work for people, such as digital models. Since the coronavirus pandemic there’s been a necessary shift away from providing services face-to-face and a move to phone or online. This however should not be a permanent shift that doesn’t consider the needs of the many young people this does not work for. Against the assumption that many young people will prefer services online, Mind’s survey of 16,000 people found that young people were nearly twice as likely to say that they feel uncomfortable using phone or video-call technology to access mental health support. Almost a third of young people (30%) who accessed or tried to access support said that the technology was a barrier to doing so, in comparison to 17% of adults. Concerns about privacy appear to be a particular issue for young people. This has been echoed in research by Young Minds and in a Mind research about accessing support by phone or online, due to be published in the Spring.
Transitions between Children and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS)
- We welcome the national commitments to move towards 0-25 models of care, given that we know that transitions to adult services are reported to be poor with high drop-out rates. However, this remains a challenge, with again large variation between areas on what age services are commissioned to and different threshold criteria between young people’s and adult’s mental health services. Despite broad consensus to provide 0-25 models of care in mental health services for some time, progress on this has been slow. More needs to be done to support new commissioning arrangements to deliver these models.
- Whilst the current Government reform programme for mental health services for children and young people is welcome, there is a lack of focus on expanding access to early intervention support beyond schools and the NHS and into community settings. While a focus on schools is important, for many young people this won’t be the best place for them to access support. Whilst some areas have already invested in such ‘upstream’ community-based services in the form of ‘open access hubs’ or ‘one-stop shops’, this is far from a standard provision. Efforts to increase this provision is hampered by the lack of a dedicated funding stream for local areas to provide services of this kind.
- Mind and other’s in the sector are calling for the roll out of inclusive, open access mental health drop in hubs for children and young people across England. Open access hubs are designed to 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. The hubs would be co-designed with young people locally, to reflect the needs of individual communities. Such hubs would greatly increase access to mental health support which intervenes early in the development of difficulties. To ensure that the hubs are sustainable, they should be rolled out alongside continued investment in statutory CAMHS as well as improving support for mental health in schools.
Improving inpatient care
- If children and young people become acutely unwell, a stay in an inpatient setting may be needed. It is vital that these are safe, therapeutic, suitable for their age and close to home. In 2019/20 3,582 children and young people were admitted to inpatient wards. 1,771 of these admissions were under the Mental Health Act.
- We support the government’s commitment to end ‘Inappropriate Out of Area Placements’ (OAPs) for children and young people, and the increased funding for new beds brought in, in 2017. We are concerned however, that funding for inpatient CAMHS services is still not adequate, leading to inappropriate care for young people including staying in adult inpatient wards or in wards far from home.
- The Mental Health Act puts a duty on the NHS to provide ‘age appropriate’ care to patients under 18, and makes clear that no child should be placed in an adult ward except in an emergency or an atypical circumstance (e.g. being very close to an 18th birthday). Between 1st January 2020 and 31st March 2020 there were 205 children admitted to adult mental health wards.
- On March 31st 2020, of the 944 children living on inpatient wards, 190 (21%) were living over 50 miles from home, with the median distance being 21 miles. 7% (60 children) are staying more than 100 miles away from home, with a further 22 children living over 150 miles from home. For young people, being away from family and support networks can be particularly traumatic, and can worsen chances of recovery.
- As part of improving inpatient care, broader work needs to be done to address inequalities in use of the Mental Health Act in regards to ethnicity. The Children’s Commissioner has identified that compared to their White peers, Black children are less likely to be admitted informally; are more likely to be held in low/medium secure/PICU units; and are slightly more likely to be admitted from criminal justice related sources, though the proportions of admissions are small. We are hopeful that the roll out of the Patient and Carer Race Equality Framework (PCREF) should begin to address this, and hope that the engagement work continues to explicitly address the needs of children and young people.
Reducing the use of physical and medical restraint
- Mind has long been campaigning for a reduction of restraint in mental health settings. An experience that can be scary, humiliating and cause unnecessary distress. Restraint can include physical restraint, mechanical restraint, chemical restraint and seclusion. Reducing restraint can be achieved when wards addressing ward culture. Creating environments that are calmer and safer places, where staff and patients know each other better, and where there is a determination not to rely on force. A range of best practice has shown that this can be done, including the following:
- APi National Involvement Standards
- No Force First
- Positive and Safe Champions Network
- Restraint Reduction Network
- REsTRAIN YOURSELF
- While we support government guidance on reducing restraint on children and young people in a range of settings, we are concerned that there is currently no law or statutory guidance that addresses this. The statutory guidance on the Mental Health Units (Use of Force) Act 2018 (known as ‘Seni’s law’) is due to be published for consultation in 2021. We hope this will provide statutory guidance on reducing restraint and restrictive practice on children and young people in mental health settings.
 NHS Digital (2020) Mental Health of Children and Young People in England, 2020: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2020-wave-1-follow-up. Accessed February 2021.
 Kessler, R. C. et al. (2005) Lifetime prevalence and age-at-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Volume 62, pp. 593-602.
 Centre for Mental Health (October 2020) Covid-19 and the nation’s mental health Forecasting needs and risks in the UK: October 2020. www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-october-2020. Accessed February 2021.
 Department of Health and Social Care and Department for Education (2017) Transforming children and young people's mental health provision: a green paper: www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper. Accessed February 2021.
Mental Health Foundation (January 2021). Teenagers' mental health under severe pressure as pandemic continues: www.mentalhealth.org.uk/news/teenagers-mental-health-pandemic. Accessed February 2021.
 NHS England has begun using Children and Young People’s Mental Health Services (CYPMHS) rather than Children and Adolescent Mental Health Services (CAMHS) after a consultation with young people which highlighted confusion about the term ‘adolescent’ in reference to CAMHS. Given that both terms are still in use, both are used in this submission document.
 YoungMinds, Schools need urgent funding to prevent mental health crisis – new report:
https://youngminds.org.uk/about-us/media-centre/press-releases/schools-need-urgent-funding-to-prevent-mental-health-crisis-new-report/. Accessed February 2021.
 Mind, Educating Mental Health: an inquiry into mental health schools: www.mind.org.uk/news-campaigns/campaigns/educating-mental-health-minds-inquiry-into-mental-health-in-schools. Accessed February 2021. Results of this research are due to be published in the summer of 2021.
 NHS (July 2019) NHS Mental Health Implementation Plan 2019/20 – 2023/24: www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf. Accessed February 2021.
 NHS Benchmarking (July 2019) Children and Young People’s Mental Health Services Workforce Report for Health Education England: www.hee.nhs.uk/our-work/mental-health/children-young-peoples-mental-health-services. Accessed February 2021.
 NHS Staff Survey 2019: www.nhsstaffsurveyresults.com/homepage/national-results-2019/breakdowns-questions-2019/. Accessed February 2021.
 Curated by Mind, supported by The Royal Foundation and our partners: www.mentalhealthatwork.org.uk/commitment. Accessed February 2021.
 Royal College of Psychiatrists (May 2020) “Going for Growth” An outline NHS staff recovery plan post-COVID19 (outbreak 1): www.rcpsych.ac.uk/docs/default-source/about-us/covid-19/going-for-growth-version-3-05-05-20.pdf?sfvrsn=7cf71c97_4. Accessed February 2021.
 www.mentalhealthatwork.org.uk/ourfrontline/. Accessed February 2021.
 Health Education England (February 2019), NHS Staff and Learners Mental Wellbeing Commission: www.hee.nhs.uk/sites/default/files/documents/NHS%20(HEE)%20-%20Mental%20Wellbeing%20Commission%20Report.pdf. Accessed February 2021.
 Mind (2020) A review of mental health services for children and young people (2020): www.mind.org.uk/media/6865/briefing-on-cyp-mhs-2020-final.pdf. Accessed February 2021.
 Education Policy Institute (2020) Access to child and adolescent mental health services in 2019: https://epi.org.uk/wp-content/uploads/2020/01/Access-to-CAMHS-in-2019_EPI.pdf. Accessed February 2021.
 NHS Providers (March 2019) Mental Health Services, addressing the care deficit: https://nhsproviders.org/media/606029/mental-health-services-addressing-the-care-deficit.pdf. Accessed February 2021.
 Young minds (2020) Coronavirus: Impact on young people with mental health needs (March 2020 and Summer 2020 surveys): https://youngminds.org.uk/about-us/reports/coronavirus-impact-on-young-people-with-mental-health-needs/. Accessed February 2021
 Broad, K., et al. (November 2017). Youth experiences of transition from child mental health services to adult mental health services: a qualitative thematic synthesis, BMC Psychiatry, 17:380: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1538-1.
 Children’s Commissioner (2020) Who they are? Where they are? 2020. Children Locked up: www.childrenscommissioner.gov.uk/wp-content/uploads/2020/11/cco-who-are-they-where-are-they-2020.pdf. Accessed February 2021.
 Children’s Commissioner (2020) Who they are? Where they are? 2020. Children Locked up: www.childrenscommissioner.gov.uk/wp-content/uploads/2020/11/cco-who-are-they-where-are-they-2020.pdf. Accessed February 2021.
 Mind and NSUN (2015) Restraint in mental health services, what the guidance says: www.mind.org.uk/media-a/4429/restraintguidanceweb1.pdf. Accessed February 2021.
 Further details of these initiatives can be found in - Mind and NSUN (2015) Restraint in mental health services, what the guidance says: www.mind.org.uk/media-a/4429/restraintguidanceweb1.pdf. Accessed February 2021.
 Department for Education and Department of Health and Social Care (June 2019) Reducing the need for restraint and restrictive intervention: www.gov.uk/government/publications/reducing-the-need-for-restraint-and-restrictive-intervention. Accessed February 2021.