Written evidence submitted by Professor Angie Hart, Louise Brinton-Clarke, Vicki Dunham, Mirika Flegg, Harvey Hill, Lindsay Jones and Anne Rathbone (CYP0059)

Centre of Resilience for Social Justice www.brighton.ac.uk/crsj/index.aspx

University of Brighton and BoingBoing CiC www.boingboing.org.uk/

Blackpool HeadStart Headstart Resilience Revolution (blackpool.gov.uk)

on behalf of the Resilience Revolution www.blackpool.gov.uk/Residents/Health-and-social-care/HeadStart-Blackpool/HeadStart-Blackpool.aspx

Introduction

In this submission, we draw on our collective organisational and personal experiences, relating them to policy and practices associated with children and young people’s mental health. We are a community of academics, students, practitioners, parents/carers and young people working together to beat the odds whilst also changing the odds, as and with disadvantaged communities. As co-authors we have experience of working in, and / or receiving support from children and young people’s mental health services.

1. What progress have the Government made on children and young people’s mental health?

1a) The ambitions laid out in the 2017 Green Paper

• In 2017, 10% of children and young people (CYP) experienced diagnosable mental health difficulties. By July 2020 this had risen to 16% of all CYP . A 2020 report by the Children’s Society rated UK’s CYP as experiencing a ‘significant decrease in happiness with life as a whole’ (p.22), and having the lowest life satisfaction in Europe. CAMHS referrals have continued to significantly rise year on year. We would conclude, therefore, that the implementation of the 2017 Green Paper has made little to no impact on the mental health of CYP.

• We agree with the Green Paper’s focus on prevention and early intervention. However, we believe that the preventative focus is largely limited to individual resilience building, ignoring the causal relationship between structural inequalities and resilience. There is strong evidence that those of us who are marginalised and face multiple disadvantages in society are more likely to experience mental distress. The Boingboing approach to resilience stipulates that to increase resilience, we must ‘change the odds’ for CYP by reducing the adversities they face in the wider system as well as supporting them to ‘beat the odds’ (helping individuals thrive despite the adversities they face). Whereas the Green Paper makes specific reference to the importance of meeting the needs of vulnerable groups, this will only ever have limited, if any, impact without any focus on wider systems change to reduce health and social inequalities.  
• Elements of the Green Paper which had the potential to move away from traditional mental health models have been neglected in the roll out. For example, peer support was identified by young people as being important but has failed to become embedded into CAMHS. Young people recommended the new Mental Health Support Teams (MHST) be multi-disciplinary and multi-skilled, in an effort to move away from the medical model of mental health. Young people say they would like open access to community-based services where they can talk to a trusted adult. It is disappointing that an opportunity to implement much needed CAMHS transformation and better resourcing of grass roots support for young people has resulted in more of the same traditional clinical services.
• The Green Paper lacked ambition and leadership when it talked of co-production with CYP, leaving it up to local areas how to proceed. The lack of importance given to co-production, the absence of specific guidance and the tacit collusion with significant disparity in standards between areas undermines the vital importance of co-production in service development. From our own personal experience, being involved in coproduction is beneficial for our mental health as it makes us feel valued and empowered. However, whilst other organisations continued to successfully co-produce during the Covid pandemic, we experienced co-production in CAMHS been quickly withdrawn, illustrating how co-production in CAMHS is still considered an additional extra rather than an essential part of service delivery. Without truly embracing co-production in service design, planning and delivery, CAMHS will maintain the unhelpful expert / patient model and continue to fail to provide an effective and impactful service to those most in need.
• We welcomed the Green Paper’s commitment to improve the evidence-base by funding further research into CYP mental health, which has previously been neglected. To date, research has focused on psychiatric and psychological interventions for a clinical population which concludes current interventions are beneficial only for a minority (and not those most in need). There is overwhelming evidence that CYP who are most at risk of developing mental health problems are often excluded from traditional mental health services and, have poorer outcomes when they do access services. We know of the therapeutic qualities of accessing green space, arts and culture, social connectedness, volunteering, social action, music and community engagement but these areas are currently under researched. We hope the government will acknowledge these significant limitations and now fund much-needed research from other disciplines to widen our understanding of what works for CYP’s mental health.
• The impact of the Green Paper remains limited as other government policies, for example in education, continue to exacerbate CYP mental health. While we recognise the importance of education and the benefits it can yield, the stress and pressure of academic expectation directly compounds existing mental health difficulties. Evidence consistently highlights that CYP facing adversity are more likely to achieve poorer academic results and be excluded from school. Action to reduce inequalities in the education system therefore would improve CYP mental health. It should be a matter of priority for the government to address these inequalities and shortfalls in the current education system, in order to prevent mental health problems in CYP.
• Whilst CYP have reported varying experiences in regard to their mental health during Covid-19 pandemic, there is strong evidence that those who are the most marginalised and disadvantaged in society have experienced the severest decline in their mental health during this time. This includes CYP with pre-existing mental health difficulties, young carers, care leavers, LGBTQ+, CYP from BAME backgrounds, disabled and those living in poverty. For some groups, this may illustrate the importance of peer support which has been curtailed by lockdown. We will see the real limitations of the Green Paper in the aftermath of the pandemic due to its failure to pro-actively address structural inequalities.

1b) Provision of mental health support in schools

• MHST’s are to be rolled out in 1/5 of all CCGs by 2022/23. There hasn’t been any revision of these plans and timescales since the onset of the Covid-19 pandemic, which has had a significant impact on disadvantaged CYP’s mental health. Given the unprecedented pressure both school staff and pupils have been placed under, revisiting of these plans (and how they are to be resourced) should be an urgent priority.

• One function of MHST, is to provide evidence-based intervention to CYP experiencing mild to moderate mental health difficulties. CYP IAPT (Children and Young People’s Improving Access to Psychological Therapies) is the chosen evidence-based intervention. As current limited research into CYP mental health has predominately focused on ‘treating’ a clinical population (i.e. through provision of medication and individual therapy), CYP IAPT is defined as an evidence-based intervention. This is not because it is the best intervention, but because this intervention has got some form of evidence. The over emphasis on the CYP IAPT model of service delivery has resulted in a ‘one size fits all’ approach which ignores the complex and multi-faceted nature of mental health. Due to the clear limitations of CYP IAPT, it should only ever be considered as ‘part of the solution, not the whole solution’. What we need is a multi-layered, responsive and needs led approach to supporting those most in need. We are deeply concerned that the proposal to recruit and train 8000 new mental health practitioners in CYP IAPT is based on this biased and limited evidence, with seemingly little attention paid to the mental health benefits of more community based or community led alternatives including peer support.
• There is strong research regarding the importance of a positive relationship with a trusted adult, regardless of the therapeutic model. We consider committed and positive relationships a central component of the BoingBoing Resilience approach and believe a sense of belonging to be central to recovery. This is something that many disadvantaged CYP lack, which is highly detrimental to emotional wellbeing and development (Hart, Blincow and Thomas, 2007). Time-limited and goal-orientated interventions such as CYP IAPT, do not permit the development of positive, trusting and committed relationships. It would make more sense for CAMHS to train, supervise and support school staff, who are in the position to commit to long term relationships with CYP and more able to provide the required targeted support. In the BoingBoing approach to resilience, we call this embedded therapy, and we understand that it can often be the small everyday interactions and connections, that has the greatest impact. This would require additional funding for schools who, over the last 10 years, have experienced significant funding cuts.
• The MHSTs have three main functions – to support schools in embedding a ‘Whole School Approach’ to mental health (WSA), to train and offer consultation to school staff and provide evidence-based early intervention for mild / moderate mental health difficulties. In reality, early intervention has taken priority over prevention. We view this as a political move so the government can show it has met the target of providing CAMHS intervention to an additional 70,000 CYP by 2020/21.

2. 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?

• We are greatly concerned that CAMHS inpatient care continues to run on an overly medicalised model. In our experiences of working or being patients in CAMHS inpatient units, we regularly see an over-emphasis on medication to ‘cure’ the patient. It is now widely accepted, that the majority of paediatric anti-depressant trials were industry sponsored, often with manipulated efficacy outcomes, that glossed over the adverse side effects. We witness the negative impacts that this medication has on CAMHS patients, from rapid weight gain, extreme drowsiness, nausea, lack of concentration and increased suicidality. We are not saying that there is no place for medication, but that there should be alternative treatments available.

• Continued staff shortages continue to impact on the quality of patient care, as appropriate staffing levels are vital to keep both patients and staff safe. Staff shortages have been identified by a number of Trusts, as contributing to increased violence on wards and in one case even a homicide. As a result, staff are exhausted; 49% of generic acute ward staff met the threshold for burnout on the emotional exhaustion scale resulting in high staff turnover and a greater reliance on agency staff, who often have less training. Indeed, CYP struggle to form therapeutic relationships with staff who are anxious, overworked and lacking in training and where there is high staff turnover. Furthermore, staff shortages often result in decreased provision of activities for CYP, including reduced opportunities to utilise section 17 leave and is inevitable that the CYP’s mental state will deteriorate as a consequence.
• The ‘Child and Adolescent PICU service specification’ explicitly states that PICU admissions should not last longer than 6-8 weeks. However, the reality is that many patients are staying in the highly restrictive PICU environment beyond this. The NHS Benchmarking CAMHS report (2016), noted the length of stay had increased in the year prior. In our experiences of working in CAMHS PICU, we have seen many patients staying in a PICU for more than 9 months to even a year. It is a great failing of the UK mental health system that CYP are growing up in this traumatising environment.
• CYP are still often placed many miles from home, and we witnessed patients who are placed over 200 miles from home, much to the anguish of their supportive family. Research has shown that tapping into good influences and keeping relationships going are key to developing resilience. However, such long distances inevitably put a strain on supportive family relationships.
• In our experience of working or being patients in CAMHS inpatient units it is evident that there is a fundamental absence of non-medicalised therapy available to patients. One inpatient told us that ‘[the staff] put you in a room with soft edges and expect you to get better’. When therapy is available, it is generally not satisfactory, often lacking trauma awareness. In our daily working lives we see inpatients offered little to no therapy who are engaging in high-levels of self-harm, resulting in frequent physical restraint. In turn, patients who often have PTSD as a result of childhood abuse and neglect are re-traumatised through physical restraint on (in some cases) a daily basis.

• Although we appreciate the progress already made through the Transforming Care agenda, CAMHS inpatients with learning disabilities and those on the autistic spectrum are still being shockingly failed. The shortages of staff, the lack of training, and the clinical inpatient environment, means that patients with additional needs often do not have these needs met. The lack of sensory stimuli or over-stimulation that occurs due to the loud noises from other patient’s distress can exacerbate these patients’ mental health issues. In our experience, we have witnessed blanket-rules for all patients to be locked out of their bedrooms for set periods during the day. Patients with ASD are likely to struggle in communal areas with no escape from sensory overload, which puts them under additional stress.
• In light of all the concerns noted above, we believe inpatient care can be fundamentally transformed by adopting a resilience-building approach. An increase in funding and staff training is required to enable CYP to be adequately cared for, with a focus on safe transfer of care to the community as soon as possible. The harmful use of medication and restraint requires an immediate review.

3. 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

• As we have outlined above, an individualised approach to improving CYP mental health will only ever have limited impact and the BoingBoing approach to resilience strongly endorses a systemic approach. Whilst we recognise the need for targeted intervention, prevention remains the goal and the best way to promote good mental health is to invest in protective environments . Unfortunately, this investment has not been prioritised by the government, the example being that £166m has been deducted from Blackpool Councils budget, despite it being one of the most deprived Local Authority areas in England across many indicators.
• We believe that effective mental health support needs to be community led, offering choice and flexibility. Blackpool’s ‘Resilience Revolution’ encompasses a whole town approach to resilience, and is an example of a system-based approach to building community resilience and supporting CYP mental health. It has co-production at its heart and a focus on ‘beating the odds whilst also changing the odds’ for CYP facing adversity.
• Boingboing’s Resilience Framework and Resilient Therapy (published in 2007 and written by CAMHS specialists including a psychiatrist) demonstrates through the evidence-base at how supporting every aspect of the system around a child builds resilience. The Resilience Framework focuses on the whole individual, as well as what is required in order to foster resilience and overall wellbeing: Basics (such as housing, money and diet); Belonging (having meaningful relationships and experiences); learning (academic resilience, future plans and life skills); Coping (problem solving and positive interests); and Core Self (hope, understanding and responsibility). All these need to be considered for overall wellbeing, meaning wider systems changes need to occur (such as ensuring safe housing and enough money). This asset-based approach requires collaboration between CYP and families, health, education, local authorities and community organisations and represents the growing move away from an individualistic medical model in the resilience and mental health evidence base.
• A systems approach would challenge the current silo working practices that we currently have (where on one hand the Green Paper seeks to reduce CYP mental health difficulties, within an education system that increases these problems). All government policies have the potential to negatively impact CYP highlighting the need to totally reform all the system.

3. Recommendations

A) Short term recommendations:

• Reducing inequalities has to be a government priority if we are to improve CYP mental health post Covid pandemic. We endorse the immediate implementation of the ‘Build Back Fairer’ recommendations including a permanent extension to the additional £20 Universal Credit.

• Suspend SATS and national testing and undertake a full review on the implication of the national curriculum on CYP’s mental health.

• Review the current MHST impact and accelerate and extend roll out plans if the findings are positive. Pilot a model where CAMHS train, supervise and support school staff who are in the position to commit to long term relationships with CYP and who are best placed to provide the required targeted support (with increased funding to schools).

• Provide a clearer directive to support schools develop a Whole School Approach, using evidence-based systems-focused models such as the Academic Resilience Approach.

• Increase funding into prevention and community-led supports and services (especially for young people facing multiple systemic disadvantages), for example, youth services, early years support and the voluntary sector.

• Conduct an immediate review of all CAMHS inpatient services, to include the dangers of the medicalised model and length of stay. Increase 1-1 support, access to trauma therapy and occupational therapy programmes; and provide greater support for staff to reduce high staff turnover.

• Confirm plans to fund mental health research from other disciplines, to widen our understanding of what works for CYP’s mental health.

B) Longer term recommendations:

• Undertake a commitment towards a ‘whole government approach to children and young people's mental health’, where children and young people's mental health is considered in every national and local government decision and policymaking.

• Tighten accountability for CAMHS to co-develop and co-deliver services with children, young people, parents/carers and partner organisations, and in particular young people facing the most systemic disadvantages.

• Integrate services supporting children and young people, with a parity of funding between health, local authorities, and community organisations.

• Review the National Curriculum with a specific focus on reducing inequalities in attainment, significantly reducing national testing and more flexibility in the curriculum in order to respond to CYP varying needs, talents and development potential.

• Address the enormous gap in supporting the mental health needs of children and young people with learning difficulties.

February 2021