Written evidence submitted by YoungMinds (CYP0066)
Dear Jeremy Hunt MP,
1.0) I am writing on behalf of YoungMinds to provide a submission to your Committee’s inquiry into children and young people’s mental health.
1.1) As the Committee has recognised in its inquiries over the course of the past year, the impact of the COVID-19 pandemic on all areas of our daily lives is not to be underestimated. In the case of young people’s mental health, the pandemic has served to highlight existing issues in terms of both access to mental health support and the factors that can lead to mental health problems.
1.2) As the terms of reference of this inquiry acknowledge, while there have been real strides to improve access to NHS mental health services, it is vital to take a holistic approach to analysing existing and necessary improvements to services for young people.
2.0) Our key recommendations are:
COVID-19 and wider context
3.0) The COVID-19 pandemic is the biggest health crisis for generations and is having a devastating impact on the lives of people across the world. In 2017, 1 in 9 children and young people were estimated to have a diagnosable mental health condition. Since then, the pandemic has created a new crisis for our nation’s mental health, with recent data from NHS Digital from July 2020 suggesting that 1 in 6 young people now has a probable mental health disorder[i].
4.0) YoungMinds has carried out a series of surveys with young people with a history of mental health needs over the course of the pandemic[ii]. In summer 2020, 80% of respondents said that the COVID-19 crisis was having a negative effect on their mental health. 87% agreed that they had felt lonely or isolated during the lockdown period, while many respondents also stated that they felt demotivated and lacking in purpose.
4.1) In our most recent survey[iii], carried out in January - February 2021, 75% of young people with mental health needs reported that the current lockdown is the hardest to cope with, while 67% believed that the pandemic will have a long-term negative effect on their mental health. Many expressed a sense of frustration, uncertainty about the future and a loss of hope. Some young people said that they had started self-harming again, having panic attacks or having suicidal thoughts.
4.2) It was clear that the lockdown itself was causing additional pressure for a wide range of reasons, including isolation, a loss of routine and challenges accessing mental health support. Most young people who were at school or college also cited academic pressure as a major factor that was affecting their mental health.
4.3) While mental health professionals across all sectors deserve huge credit for adapting to the challenges of the pandemic, our surveys also suggest significant gaps in support:
4.4) Barriers to support during the pandemic included:
4.5) For those respondents who were at school or college in January 2021 (either home learning or attending), 55% said that there was a counsellor or mental health support team available in their school, 23% disagreed. Almost half (48%) did not think that their school was focusing more on wellbeing and mental health than usual.
5.0) It is important to stress that the crisis pre-dated the pandemic: research by UCL shows that in 2018-19, almost a quarter of 17-year-olds (24%) had self-harmed in the previous year, and 7% of 17-year-olds had attempted suicide at some point in their lives[iv]. While there has been an impressive swathe of efforts to improve the delivery of mental health support for young people across the country, such sobering statistics show that there is a long way to go before all young people are able to access the support they need to stop their needs escalating.
Improvements in NHS mental health support
6.0) Prior to the pandemic, the Government had made real strides to improve access to, and the quality and experience of, NHS services through Future in Mind, the Five Year Forward View for Mental Health, the Green Paper on Children and Young People’s Mental Health and the ambitious proposals in the NHS Long-Term Plan.
6.1) Through these, progress had been made to increase young people’s access to mental health support. For example, recent data from NHS Digital suggests[v] that in 2019/20, 538,564 children were referred to NHS mental health services for help. This represents an increase of 35% since 2018/19, and nearly 60% since 2017/18. Despite this increase in referrals, NHS mental health services have been able to maintain and improve access rates.
6.2) However, while recent data from NHS Digital suggests that average waiting times have decreased and are now 43 days (approximately six weeks), there is significant variation across the country, with some areas reporting average times from referral to treatment of over three months. These average waiting times exclude children and young people still waiting at the end of the year – and so the true figures may be higher. There continue to be examples of children and young people facing very long delays, including cases identified through our surveys where young people have waited over a year for support.
6.3) Despite recent initiatives, including those outlined in the NHS Long Term Plan, just over one-third (36.9%)[vi] of children and young people with a diagnosable mental health problem currently receive NHS support. A recent report by the Children’s Commissioner[vii] suggests that this may represent just 1 in 4 when using the most recent prevalence statistics from July 2020[viii]. Therefore, we would welcome the Government outlining how it plans to meet the target contained in the NHS Long Term Plan - that over the coming decade 100% of children and young people who need specialist care can access it.
7.0) One of the biggest barriers to increasing provision concerns increasing the mental health workforce. We support the recommendation by the Children and Young People’s Mental Health Coalition that Health Education England and the Department of Health and Social Care should develop an overarching children and young people’s mental health and wellbeing workforce plan to expand the workforce and enhance the skills of the wider workforce. This plan should encompass the whole children and family’s workforce, not just staff working in NHS mental health services.
7.1) Given the need to maintain social distancing, the most prominent medium of delivering mental health support during the coronavirus pandemic has been virtual and digital support. This can be a lifeline for some young people and allows them to continue the treatment that they need for their mental health. It may also provide a more accessible way to access support for young people who live in remote areas, who may face accessibility issues, or those who experience stigma or shame related to their mental health or related to challenges linked, for example, to their gender identity or sexuality[ix].
7.2) For other young people, digital and virtual support is not always appropriate or accessible. This may be due to not having access to the technology to utilise digital and virtual forms of support or concerns about privacy when accessing virtual support in the home. Additionally, some young people have told us that it is not always as easy to build relationships when support is being carried out remotely. As research by The Early Intervention Foundation highlights, there is evidence to indicate that the quality of relationships is positively correlated with improving outcomes across a range of therapeutic approaches and mental health issues[x].
7.3) Therefore, digital and virtual support should not be seen as a straightforward replacement for face-to-face mental health support for children and young people, but should be maintained so that young people can access it if they think it works best for them. Additionally, efforts should be made to involve young people in the design of services to ensure that the platforms meet their needs. Help should also be given to young people to navigate the types of digital and virtual forms of support.
7.4) A further area of consideration is the support that is provided to 16-25 year olds and those that are required to transition from children’s to adult mental health services. Past research, by Singh and colleagues[xi], suggested that up to a third of young people are ‘lost from care’ during their transition between CAMHS and AMHS, at age 18, with an additional third experiencing an interruption in their care.
7.5) Further, young adults (aged 18-25) have been found to experience a treatment gap in their care, with research suggesting that 64% of this age group with a mental health condition were not receiving any mental health support from services[xii]. Our work with young people also suggests that many young adults, and particularly those whose mental health needs are not suitable for adult IAPT services, are facing significant barriers to access services to meet their needs. Therefore, we are very welcoming of the steps that NHS England has taken to improve the availability of mental health support for young adults by trialling different models to support 18-25 year olds in 12 areas across England. We would encourage this work to proceed with pace and to be rolled out to other areas at the earliest opportunity.
Early intervention and young people’s mental health
The need for further early intervention
8.0) In order to reduce the pressure on NHS mental health services, we would urge the Government to invest in early forms of mental health support.
8.1) As previous research shows, half of all mental health problems manifest by the age of 14, and 75% by the age of 24[xiii]. These difficulties can have an impact across a person’s life course on educational outcomes[xiv][xv], employment[xvi] [xvii], an ability to maintain relationships[xviii], likelihood of engaging in risky behaviours[xix], and life expectancy[xx]. A failure to provide high-quality mental health interventions before age 25 creates significant risks for long term social and health outcomes.
8.2) Additionally, inadequate early intervention builds pressure across the whole system from GP appointments to NHS mental health services. For some young people, this also means turning to A&E because they don’t know where else to go for support. This is reflected in NHS data, with the number of A&E attendances by young people aged 18 or under with a recorded diagnosis of a psychiatric condition having tripled between 2010 and 2019[xxi]. Further to this, following an inquiry by the APPG on Self Harm and Suicide Prevention, it was reported that “the single most important potential change to the system of support offered to young people who self-harm would be earlier intervention”[xxii].
8.3) In 2018/19, expenditure on early intervention mental health services in England was £226 million. Research by the Children’s Commissioner for England[xxiii] showed that whilst the total reported spend on this kind of service has risen over the last two years, over a third of local areas saw a real-terms fall in spending -with nearly two-thirds (60%) of local authorities seeing real-terms cuts on preventative mental health programmes and early intervention for children and young people.
8.4) Evidence compiled by the Early Intervention Foundation clearly shows the economic cost of insufficient access to early intervention. It concludes that the combined cost of what it terms to be ‘late intervention’ on young people’s hospital admissions for mental health and self-harm alone totalled £465 million in the years from 2016/17[xxiv]. The decline in local authority budgets and spending on children and young people’s mental health is a concerning trend when considering the significant pressure that NHS Child and Adolescent Mental Health Services (CAMHS) are likely to be under as we recover from the COVID-19 pandemic.
Open access mental health services
9.0) One approach that has been taken to accommodate for this in the UK and internationally is open access mental health services. Open access mental health services offer easy-to-access, drop-in support on a self-referral basis for young people who do not meet the threshold for children and young people’s mental health services or with emerging mental health needs, up to age 25. They can be delivered through the NHS, in partnership with local authorities, or through the voluntary sector depending on local need and existing infrastructure. A mix of clinical staff, counsellors, youth workers and volunteers can provide a range of support on issues related to wellbeing, while additional services can be co-located under one roof; offering wrap-around support across, for example, psychological therapies, employment advice, youth services and sexual health.
9.1) Building on the existing evidence base for these services in the UK and internationally, the hubs would reduce pressures on the NHS and improve young people’s life chances by providing a community space to access flexible support for emotional wellbeing. This would sit alongside advice about sexual health and access to education or employment.
9.2) Previous evidence from the UK, Australia, Denmark and Ireland demonstrates that open-access mental health hubs can reduce psychological distress amongst young people[xxv] [xxvi]; attract young people that are less likely to engage with NHS mental health support[xxvii] and save costs to a range of services across the health system and more widely[xxviii] . Additionally, the services should link to existing digital resources and services where available, to build an element of digital support into their design. This would improve access and increase flexibility for young people who feel that they have benefited from online support during the pandemic.
9.3) Research conducted on a form of open access mental health services in the UK called YIACS[xxix] has shown that the services are more able to engage with ‘older’ young people, as well as higher proportions of LGBT+, young BAME people[xxx]. This is important when considering that BAME communities are proportionally more likely to be impacted by mental health conditions, but less likely to engage with NHS mental health services[xxxi]. We welcome the work of NHS England to reduce inequalities in NHS accessing mental health through the Advancing Mental Health Equalities Strategy[xxxii]. Alongside this work, we believe the open access mental health services model presents a viable way to reach young people who are already facing greater social and health inequalities.
9.4) Therefore, we are calling for the Government to roll out open access hubs to every area across England. In providing a comprehensive early community support offer to complement available school-based and clinical support, adopting the open access hub model will provide significant benefits for young people, both those with and without existing mental health needs, while also relieving pressure on the current mental health system.
Youth Sector and voluntary support
10.0) YoungMinds’ insight work with young people indicates that barriers around reaching out for support when young people first begin to struggle with their mental health include stigma or fear about asking for help and not knowing where they can access support.
10.1) Youth services and voluntary organisations play a vital role in building resilience, supporting young people at risk and signposting young people to mental health support. The development of young people’s resilience occurs through the experience of risk or protective factors, with risk factors leading to vulnerability and protective factors being more likely to increase resilience. Those protective factors which have the most significant impact are most often those around the child, namely a secure attachment experience, a positive environment which enhances belonging and connectedness, affection, having a belief in control and a wide network of support[xxxiii]. This points to the fact that relationships with trusted adults or peers are fundamentally important in the development of children and young people.
10.2) According to new research by UK Youth[xxxiv], two thirds (66%) of youth organisations reported an increase in demand for their services during the COVID-19 pandemic. Despite this, 83% reported that their income decreased and more than half (57%) report that the cost of delivering their services to young people has increased since COVID-19 hit. Similarly, Pro-Bono Economics has recently reported that almost half of charities saw a decrease in their income in 2020.The impact of this was particularly felt for small charities[xxxv]. Therefore, the Government must provide financial support to ensure that the charity and youth sectors are able to continue support young people, including with their mental health.
Mental health in schools
School-based mental health support
11.0) Schools play a critical role in providing wellbeing and mental health support, especially low-level support, to young people – through access to counsellors, pastoral staff and other trusted adults.
11.1) We welcome the steps that the Government has taken to increase the provision of mental health support in schools through the 2017 Green Paper on Children and Young People’s Mental Health, incentivising schools to have a Designated Senior Lead for Mental Health and rolling out Mental Health Support Teams to some schools in England. However, while these are positive developments, the scale of the rollout is concerning, given that there is currently only a commitment for Mental Health Support Teams to reach a fifth to a quarter of the country by 2022/23[xxxvi]. Further to this, partially due to the COVID-19 pandemic, training for Designated Senior Leads for mental health in schools has been delayed.
11.2) The closure of schools during and after lockdown effectively acted as a barrier to access to mental health support[xxxvii]. Many young people who were receiving some form of support through schools, for example through school counsellors, have had this support disrupted or cancelled during the pandemic. While some young people are now, or have been, receiving online support from school counsellors, this has sometimes not been possible because of logistical or safeguarding concerns. In other cases, young people have been offered online counselling but been unable to access it because of concerns about privacy at home, or because of a lack of access to appropriate technology. When schools reopen, there will need to be clear plans in place to ensure that in-school counselling services can operate safely and reach students who have lost access to support, as well as those who now require support as a result of the pandemic.
11.3) YoungMinds has welcomed the Government’s response to the return to school, including initiatives such as the £8 million Wellbeing in Education Return scheme, the offer of online psychological first aid training for adults who work with children and the recent announcement of £500m for NHS mental health services in November’s Spending Review. The recent establishment of the Mental Health in Education Action Group is a particularly positive step.
11.4) However, given that the existing scale of young people’s need has been exacerbated by COVID-19, we urgently need to see further resources made available for young people as they enter the next term of the 2020/21 school year. We welcome the £1.7 billion catch-up fund, but note that none of this has been specifically allocated for wellbeing or mental health initiatives; and, while schools have some flexibility over how they use some of this funding, the guidance on the Department for Education’s website – and the Government’s messaging – has strongly stressed the need for it to be used to catch-up on lost learning, rather than on pastoral support.
11.5) Recent research has shown that only one in five (19.5%) teachers thought they had appropriate mental health services in schools to support returning pupils[xxxviii], while a study by the Institute for Public Policy Research showed that only half of teachers surveyed thought their school could offer pupils on-site mental health counselling in the wake of the pandemic[xxxix].
12.0) In response, YoungMinds is calling for immediate ring-fenced funding for in-school mental health support for all young people who need it, delivered through a whole school approach to meeting their needs through tried and tested best practice. Depending on the needs of the school, this may include increased hours for key staff across the school, evidence-based interventions or resources, and/or the use of school counsellors, online counselling services or partnerships with voluntary sector providers.
12.1) There is a strong evidence base[xl] outlining the benefits that a whole school approach to wellbeing and mental health has for staff and students alike. The support that is available within the school environment in the immediate- and longer-term should reflect the fact that young people will, in many cases, be experiencing trauma, and should be flexible enough to meet the diverse needs of the young people who will be accessing it.
12.2) A further priority is ensuring that the roll-out of Mental Health Support Teams continues at pace, alongside training for Designated Senior Leads in Schools. Mental Health Support Teams must sit alongside other forms of support – for example, school counsellors, who will be more likely to provide one-to-one support - particularly given the limited reach that they will have in the short- to medium-term future. The roles of other professionals such as school nurses must also be taken into account.
Academic pressure and mental health
13.0) Due to the terms of reference of the inquiry, this submission will not focus on the wider impact of the school system on young people’s mental health. However, it would be remiss to discuss school-based mental health support without alluding to the impact of academic pressure on young people’s mental health.
13.1) Emotional issues, particularly stress, have been directly attributed by young people to difficulty coping with academic aspects of school such as too much homework and too many exams. In research undertaken by the Office for National Statistics (ONS) prior to the pandemic, young people noted that the amount of schoolwork they are given did not allow them much free time to do the things they value and enjoy[xli].
13.2) Further findings in the ONS data alluded to lack of availability of school counsellors, even before the onset of the COVID-19 pandemic, and that for some young people mental health concerns were met with stigma or ‘insufficient support’[xlii].
13.3) From the evidence cited throughout this submission, it is apparent that in many cases there was not sufficient support for young people’s mental health prior to the pandemic. Additionally, young people often felt overwhelmed by academic expectations in the school environment.
13.4) There is a large body of evidence to point to the exacerbation of both of these factors in the 2020/21 academic year, and possibly beyond, as young people navigate academic catch-up alongside the both personal and educational disruption that they have experienced over the past year. It is therefore imperative that measures are implemented to provide additional support to young people in, as well as outside of, the school environment.
The need for a whole system approach to mental health support
14.0) Our research and that of others suggests that the pandemic is likely to have a long-term impact on the mental health of young people and their lives more broadly. A whole-system approach that spans clinical, community-based, school-based and digital delivery of mental health support is vital to ensure that all young people are able to get the support they need, when they need it.
14.1) Therefore, we are calling for a new young people’s mental health strategy from the Government that looks across the whole system to increase mental health support for children and young people. This should include additional support for schools to prioritise mental health, a commitment to roll out open access hubs across the country, and action to address the factors that can lead to mental ill health.
14.2) Research has shown that the pandemic and measures taken to respond to it have increased risk factors associated with mental illness, including increased exposure to trauma or adversity, loneliness and social isolation and higher numbers of young people with low wellbeing. Groups that were already marginalised or disadvantaged are likely to have been disproportionately affected given the unequal impact that the pandemic has had on different groups including black and minority ethnic communities and people who have disabilities[xliii].
14.3) Creating a truly whole system approach to mental health support includes acknowledging existing inequalities, and how existing inequalities prevent young people accessing mental health services. Mental health services are not equally accessible to every young person; and diversity in terms of both the support offer and how it is delivered is a crucial part of creating a mental health system built on equity of access.
14.4) The rising prevalence of mental health problems means that current plans to meet the needs of young people will not be enough. In order to truly meet the needs of young people and provide them with the support they need, when they need it, we need to reimagine our systemic approach to mental health: taking into account clinical, community and school-based support.
15.0) If you would like to discuss any of the points raised in this submission, then please do not hesitate to get in contact. Additionally, we would encourage you to ensure that young people with lived experience of mental health problems are included in any evidence sessions that the Committee undertakes as part of this inquiry. We would be delighted to work with you to involve YoungMinds’ Youth Activists as part of this engagement.
Charlotte Watson and Emily Dobson
Policy and Parliamentary Officers
[ii] During the pandemic we have carried out four surveys with young people, one survey with parents and carers, and one survey with teachers and school staff.
[iii] This survey took place between 26th January and 12th February 2021, during a new period of national lockdown, when schools, colleges and universities were closed to most students.2,438 young people aged 13-25 who have looked for mental health support at some point in their lives took part.
[vi] NHS Mental Health Dashboard Q1 2020/21.Data available at: https://www.england.nhs.uk/publication/nhs-mental-health-dashboard/
[xi] Singh SP, Paul M, Ford T, Kramer T, Weaver T. Transitions of care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK Study): a study of protocols in Greater London. BMC Health Serv Res. 2008 Jun 23;8:135. doi: 10.1186/1472-6963-8-135. PMID: 18573214; PMCID: PMC2442433.
[xii] Knapp M, Ardino V, Brimblecombe N, Evans-Lacko S, Iemmi V, King D, Snell T (2016) Youth Mental Health: New Economic Evidence. LSE Personal Social Services Research Unit.
[xiii] Kessler RC et al. (2005). ‘Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication’.
[xiv] Green H, McGinnity A, Meltzer H et al (2005) Mental health of children and young people in Great Britain, 2004. London: Office of National Statistics
[xv] Esch P, Bocquet V, Pull C et al (2014) The downward spiral of mental disorder and educational attainment: a systematic review on early school leaving. BMC Psychiatry 14:237
[xvi] Ormel J, Oerlemans AM, Raven D et al (2017) Functional outcomes of child and adolescent mental disorders. Current disorder most important but psychiatric history matters as well. Psychological Medicine 47:1271-1282
[xvii] Fergusson DM, Boden JM, Horwood J (2007) Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes. British Journal of Psychiatry 191:353-342
[xviii] Copeland WE, Wolke D, Shanahan L et al (2015) Adult functional outcomes of common childhood psychiatric problems: a prospective, longitudinal study. JAMA Psychiatry 72:892-899
[xix] Nearly half of 17-19 year olds with a diagnosable mental health disorder has self-harmed or attempted suicide at some point. NHS Digital (2018) ‘Mental Health of Children and Young People in England, 2017’ Available at: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017
[xx]Hayes JF, Marston L, Walters K et al (2017) Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000-2014. British Journal of Psychiatry 211(3):175-181
[xxiv] Chowdry, H. and Fitzsimons, P. (2016)'The Cost of Late Intervention' Early Intervention Foundation.
[xxviii] The Legal Problems and Mental Health Needs of Youth Advice Service Users: The Case for Advice, Balmer, N.J., and Pleasence, P., Youth Access, 2012.
[xxix] Youth Information Advice and Counselling Services. For more information see: https://www.youthaccess.org.uk/our-work/yiacs-model
[xxxiii] Public Health England ‘The mental health of children and young people in England’. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/575632/Mental_health_of_children_in_England.pdf
[xl] Weare, K and Nind, M (2011) Mental health promotion and problem prevention in schools: what does the evidence say?, Health Promotion International, Vol. 26 No. S1 Oxford: OUP
[xli]https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/childrensviewsonwellbeingandwhatmakesahappylifeuk2020/2020-10-02 The findings reported stem from discussions with took place between September 2019 and February 2020, with the last focus group held a few weeks prior to the national lockdown associated with the coronavirus (COVID-19) pandemic.