Written evidence submitted by NHS Providers (CYP0068)

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. NHS Providers has all trusts in voluntary membership, collectively accounting for £92bn of annual expenditure and employing more than one million staff.

 

Key messages

 

 

 

 

 

 

 

 

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

 

The ambitions laid out in the 2017 Green Paper

 

  1. The government’s 2017 Green Paper on transforming children and young people’s mental health provision brought a welcome focus on the earlier identification, treatment and support for children with mental health needs, and emphasis on quicker referral to NHS specialist services. However, the limited scale and pace of plans to increase access to improved mental health services was a key concern that we continue to hold. While our aspirations as a healthcare system are growing – supported by politicians and senior healthcare leaders – there remains a stark difference in the level of aspiration around meeting the needs of those with mental, as opposed to physical, health conditions.

 

  1. We acknowledge the progress that has been made to begin training a new workforce of Education Mental Health Practitioners and developing mental health support teams in selected areas, as well as testing approaches that could deliver four week waiting times for access to NHS support, ahead of introducing new national waiting standards for all children and young people who need specialist mental health services. It is important to recognise that there has also been progress made by the sector in important related areas to the core proposals of the Green Paper, notably in perinatal mental health. Trusts are doing all they can to expand services and provide the best possible care with the staff and resources available.

 

  1. The four week waiting times pilots are part of a broader move to extend the breadth of the mental health standards. Trust leaders support this work, seeing it is an important step towards parity of esteem in providing more information and data about the demand for mental health services. Hopefully, it will also help shift the current perverse incentives linked to the current mental health investment standard which – although there is evidence that investment is starting to flow better – still does not always enable funding to reach the frontline as intended.

 

  1. Areas implementing the core proposals of the Green Paper have faced a number of challenges. For example, where pilots have been carried out to implement four week waiting times for access to NHS support, challenges have included: workforce capacity, measuring activity and outcomes, identifying and managing internal waits, and ensuring ease of access and re-entry for children and young people to services. The crisis pathway for children and young people is less well developed than for adults, which is a key issue as is the broader need to invest in building up community provision. The digital capability of mental health trusts is further key challenge. Due to the nature of the referral-based approach, and timescales in the proposed standards, there is work to do locally between primary and secondary care providers around information sharing and data governance, and the time and resource implications also need to be considered. As the rollout of mental health support teams continues, it will be important to ensure mental health trusts are fully involved to ensure the service implications, particularly relating to the workforce, are fully taken into account.

 

  1. The COVID-19 pandemic meant a necessary degree of re-prioritisation and adaptation of plans for 2020/21 had to be undertaken which has had an impact on progress. We understand that, while as much work as possible to establish mental health support teams continued in 2020, some adjustments were made to the delivery model and the timeframes for recruitment and implementation of new teams in light of the challenges posed to services and wider society. NHS England and NHS Improvement also recognised some areas working as part of the four week waiting time pilot may have had to pause this work where it was not operationally viable at the peak of first wave pressures. It is important that the impact of the pandemic on the delivery of ambitions is recognised and adequate support and resources are made available to ensure it is still possible for subsequent milestones to be met. It is also important that a condensed timeframe for those areas piloting implementation does not compromise the dissemination of key learnings and successful wider roll out.

 

  1. Looking ahead, there remains significant unmet need and we need to see support for prioritising mental health services for children and young people provided to local areas that are not piloting implementation. Otherwise, there remains a risk of reinforcing the inequalities in quality and access to specialist mental health services that were already a serious concern prior to the Green Paper’s publication, which the impact of COVID-19 risks exacerbating further.

 

  1. Furthermore, whilst 345,000 additional young people will have access to treatment under the NHS Long Term Plan by 2023/24, this needs to be matched with a significant increase in the provision of specialist services. Otherwise, the children with the most complex needs will still not receive the help they require. The accessibility and responsiveness of NHS children and young people’s mental health services is significantly challenged by a combination of rising prevalence and acuity of mental health conditions among children and young people, in addition to workforce shortages and funding not reaching the frontline.

 

  1. The issues faced take on even greater salience given the current, and future anticipated, impact of COVID-19 on children and young people’s mental health. While mental health trust leaders have told us it is difficult to evidence the extent and drivers of the current pressures, they have emphasised the acute, complex and risky nature of presentations, coupled with it being harder to safely discharge people from services, especially when individuals were living in less stable or multiple occupancy households. Reduced family, social and community support as a result of the pandemic and the corresponding lockdowns and restrictions are key factors driving both the increase in acuity of patients coming through to services and the challenges trusts are facing around discharge.

 

Addressing capacity and training issues in the mental health workforce

  1. Workforce shortages have been a key, longstanding reason why mental health trusts have struggled to meet local demand. While we have seen some progress, the shortfalls both in the number and skill-mix of staff in the mental health sector remain the most pressing challenge to the sustainability and accessibility of services for children and young people, and one which will take the longest to resolve. The shortages will clearly have an impact on the service’s ability to respond to the ambitions of the Green Paper, for example, in meeting the needs of those children identified through the schools-based services as requiring early access to specialised services.

 

  1. Community mental health services are an area of note, with positive developments in numbers and skill mix. According to latest analysis from the NHS Benchmarking Network, the number of staff working in community mental health services for children and young people has been increasing over recent years and skill-mix is rich. The network also found growth in the number of staff working in inpatient children and young people settings over the last year.

 

  1. However, there remain significant workforce gaps with vacancy levels in mental health trusts particularly high and variation locally, which the impact of the pandemic on the current and future pipeline of staff risks increasing further. The Royal College of Psychiatrists concluded from its most recent workforce census, in 2019, that there was not enough of a reduction in the vacancy rate for CAMHS consultants to alleviate the pressure on services, and it remained one of the highest vacancy rates of all the psychiatric specialities. The college’s census also showed trusts remain unfavourably reliant on employing locum or agency staff. We need to continue to build on the work to retain specialised roles and encourage foundation year doctors into psychiatry, alongside nurses and the professionals in other disciplines who we know are critical to the delivery of effective services.

 

  1. The inpatient workforce skill-mix is a cause for concern: effective mental health services depend on multi-disciplinary teams with the right expertise and experience to meet individuals’ care and treatment needs. There therefore remains a need to focus on diversifying the skill mix of the workforce, particularly in inpatient settings but also in primary care with mental health nurses or social prescribers for example. Taking this forward requires greater clarity on how local bodies work together here, as well as full funding to cover the full costs of employment.

 

  1. Trusts have been working hard over the years to meet the workforce gaps they face, by using new roles, changing skills-mixes, and pursuing a range of recruitment and retention initiatives. However, the impact of the steps trusts are currently taking are limited without greater national progress on growing and funding the domestic pipeline.

 

  1. One trust leader told us last summer that demand increases were not being matched by investment and there will be workforce gaps, which are most pronounced in CAMHS, even if the funding is provided. Moreover, the impact of the pandemic on the current and future pipeline of staff risks increasing the workforce challenge. Mental health trust leaders are deeply concerned about existing staff wellbeing, stress and burnout, following the pandemic. One mental health trust leader told us its staff are already extremely stressed from overwork, and increased demand stemming from the outbreak will make that worse. They added they will need “well over 100% (of capacity) to keep pace” moving forwards, but staff are tired and “in chronically short supply”, especially the highly trained staff they need for the more complex cases they are now seeing.

 

  1. We need to see a fully funded plan to help address the impact of workforce issues on the broader health and care agenda. This needs to include adequate investment at a national level to maintain and build on the steps being taken to grow the mental health workforce, which was already identified as fundamental to meeting the ambitions set out in the NHS Long Term Plan. Trust leaders also need resources and support to give staff the time they need to rest and recover from the pandemic, and trusts need the autonomy to move at their own pace, given the variable impact of the outbreak across the country.

 

Improving access to mental health services

  1. There has been progress made on improving access to mental health services, including early achievement of the national children and young people’s access ambition as set out in The Five Year Forward View for Mental Health 2016. Our analysis of the most recent NHS statistics available shows the number of children and young people in contact with mental health services has risen considerably, with the average number of individuals in contact each month 80.6% higher in 2020 than in 2017. Our analysis also shows the number of completed pathways for urgent and routine referrals of children and young people’s eating disorder services has increased by 128% and 71.5% respectively between Q3 2017/18 and Q3 2020/21.

 

  1. However, despite services reaching more individuals than ever before, there remains a substantial treatment gap and barriers to accessing help. Prior to the pandemic, services were at full stretch and access thresholds in many places were too high, creating long waits and contributing to deteriorating mental health for many individuals. Eight out of 10 trust leaders told us they were not able to meet demand for community CAMHS and over half of trusts reported that waiting times for community CAMHS were increasing. Three out of 10 trusts also told us they were not able to meet demand for inpatient CAMHS and a third of mental health leaders said that children and young people were increasingly waiting longer to access treatment in inpatient services. Longstanding challenges we need to overcome to address the treatment gap and barriers to accessing help include: stigma, historical under-provision, the physical location of services, the need for more training in evidence-based interventions, and service pathways based around diagnosis rather than need.

 

  1. During the first wave of the pandemic, the number of referrals for CAMHS services fell but activity has since returned closer to pre-pandemic levels, with evidence of CAMHS bed occupancy being one of the fastest to rebound. Since the easing of the first wave pressures, mental health trusts have been focused on meeting a series of important objectives and targets set centrally for the remainder of the 2020/21 financial year, which include maintaining the growth in the number of children and young people accessing care as well as retaining the 24/7 crisis lines for children and adults rapidly set up at the very start of the outbreak. However, not all trust leaders felt these were achievable at the outset and depended largely on the scale of: winter pressures; further COVID-19 waves; and surges in demand for mental health services. Trust leaders also stressed the need for clarity on funding and investment for the sector. One trust leader stressed the quality of services was very much "subject to funding keeping pace with demand".

 

  1. Demand for services for children and young people is widely expected to increase further in the months ahead due to the direct and indirect impact of the COVID-19 pandemic. Mental health trusts are having to factor in providing services for a new and unknown level of mental health demand and meeting this on top of existing demand will be extremely challenging, as we warned earlier in the pandemic. In our latest survey of mental health trust leaders, only three out of 10 told us they were confident that their trust had the capacity to meet demand for mental health services over the next 12 months. The needs of mental health services must be adequately prioritised in future plans. This means fully and promptly funding, on a sustainable basis, the rapid expansion of services needed to meet the extra demand for mental health care and support.

 

  1. Demand for services is a complex issue: it is both a reason for, and result of, the care deficit permeating mental health services. If we are to address this, we need to see national policy moving in the same direction with increased support for both mental health and public health – local authority services are a key element in both meeting current need and preventing future demand. We also need realism about levels of demand and what is needed to meet it, given the impact of raised awareness of mental health issues and wider socio-economic factors on demand for services. Better demand and capacity planning with inputs from both trusts, commissioners and the national bodies is also crucial.

 

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

  1. The majority of NHS child and adolescent mental health wards are providing good care, with 66% of core services rated as good and 24% as outstanding by the Care Quality Commission as of 22 February 2021. However, trust leaders were raising concerns prior to the pandemic about being able to maintain the quality of services given the pressures on capacity, and there are a range of complex challenges facing trusts that impact on their ability to provide the right level and nature of support for children and young people consistently. These include workforce shortages – particularly of specialist staff – as well as increasing demand and severity of cases, which is partly attributable to individuals having to wait longer to access the services they need resulting in some needing more specialist, longer-term care as a result.

 

  1. A further complex challenge is placing individuals out of area. Trust leaders are acutely aware of the impact of out of area placements (OAPs) on the overall quality of care and have repeatedly expressed concern that they are having to do this as an absolute last resort because of a lack of inpatient mental health beds in their local area. In the past, six out of 10 trust leaders have told us they are having to resort to OAPs for those children and young people with the most serious mental health conditions. Further factors contributing to trusts’ reliance on OAPs include: the increasing severity of inpatients’ conditions which means they need to stay longer; low levels of investment from clinical commissioning groups; the use of block contracts to pay for services; lack of specialist provision; insufficient community-based services; and accommodating changes to the use of Section 136 (whereby police have the power to take, or keep, an individual in a place of safety) of the Mental Health Act. Infection prevention and control measures during the pandemic have put further constraints on inpatient capacity.

 

  1. There is a welcome national focus and work underway to improve current specialist children and young people’s inpatient mental health services, including work to ensure trusts consistently develop quality improvement plans so action is taken where needed. The development of a new service framework is also planned, which will set out what high quality services should look like, taking into account learnings from responding to COVID-19. It is clear that there is a great deal to deliver in order to improve inpatient care for children and young people, but as this work progresses we would note the need to be realistic about how quickly progress can be made given capacity and resource constraints.

 

  1. Mental health trusts also need capital investment, allocated quickly, fairly and transparently. The under-prioritisation of investment in the mental health estate is having a real impact on trusts’ ability to ensure a safe and therapeutic environment. Mental health trust leaders have specifically highlighted that a mental health trust’s physical environment affects an individual’s rehabilitation and recovery. It is important to remember that individuals are often accessing inpatient services at an incredibly vulnerable and difficult point in their lives, and having high quality therapeutic environments is particularly important given the length of stays typical in mental health settings.

 

  1. The longstanding neglect and underinvestment in the mental health estate is rooted in the historical, structural disadvantage the sector has suffered compared to physical health provision. This was exemplified by the prime minister's announcement last year on investment in new hospitals that almost entirely overlooked the needs of mental health trusts, and the delay in allocating the funding to eliminate mental health dormitory wards which has made it harder for mental health trusts to plan effectively and deliver maximum value for patients given the money still needs to be spent in-year.

 

  1. Trust leaders have also stressed to us the importance of the right training and staff having time for supervision and reflective practice to reducing the use of restraint and other restrictive practices. There has been a national programme of work, the Reducing restrictive practice (RRP) collaborative programme, underway since 2018 with the aim of supporting wards in a select number of trusts to reduce the use of restrictive practice and significant improvements have been seen as a result. However, as CQC’s interim report on its thematic review into restrictive practices made clear, while the day-to-day responsibility for quality of care sits with managers and staff, shared learning and effort is needed across the health and care system in order to tackle the inappropriate use of these practices in all settings in every part of the country.

 

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.

  1. There are significant, systemic challenges to providing the right level and nature of mental health support for children and young people consistently. Trust leaders have stressed to us their concern about the impact of COVID-19 on waiting times for children and young people’s mental health services and that the need for a more effective model of care for children and young people is greater than ever.

 

  1. The nature of demand across local systems is not straightforward with increasing numbers of children and young people having complex needs that can require a response from multiple services. We therefore need to address in the round how mental health services and other colleagues, including in the voluntary sector, are resourced, commissioned, funded and paid for. At the moment, the system struggles to consistently intervene early enough to prevent more serious mental illness developing amongst individuals. Trust leaders have also stressed the importance of public health leaders at a national and local level developing prevention strategies which align with their inpatient and community pathways. Planned changes to the organisation of public health at a national level offers a window of opportunity to rethink the way population mental health, health inequalities and public health services are coordinated and delivered to the benefit of children and young people’s mental health.

 

  1. It is important to take a balanced approach with appropriate emphasis on delivering greater prevention, early intervention and community-based care, alongside ensuring continued funding for, and access to, inpatient services that children and young people with severe and enduring mental health conditions may need. A further aspect here is the need for mental health expertise in all parts of the system. The NHS Long Term Plan made welcome commitments here, for example to build the mental health response competency of ambulance staff and to make mental health liaison services available in all acute hospital A&E departments. With adequate resourcing, this comprehensive approach would better position the healthcare system to respond quickly and appropriately to the needs of children and young people.

 

  1. The advances in the use of digital technologies made by services during the pandemic period may offer a way of improving aspects of the current model of care and aiding earlier intervention. Many services plan to continue to use technology to improve choice and access. However, trusts leaders are conscious that there are still significant barriers to overcome – including accessibility, information governance issues and the appropriateness of a digital setting for some therapeutic interventions and each individual’s needs – and of the need to assess and evaluate the effectiveness and impact of delivering services digitally properly over the longer term.

 

  1. System working is a key vehicle for supporting local health and care organisations to improve and co-ordinate local planning, better integrate services for children, and to maximise the use of collective resources. We have welcomed the government’s ambitions as set out in the February White Paper to create a flexible, permissive legislative framework that aims to remove barriers to collaboration and enable more joined up care.

 

  1. However, in the meantime, without sufficient, dedicated funding for services for children and young people, there will be a limit to how much value these partnerships can add for patients and their families or for staff under considerable pressure. We also remain concerned about the current fragmentation of the commissioning structures for services. For most local services, the integrated care system (ICS) may not be the natural footprint on which to plan or deliver specialised services until much more resource can be found to invest in the community-based workforce that can support children closer to home. NHS-led provider collaboratives in mental health, where providers hold control of the tertiary commissioning budget, have proved an effective model for better joined-up commissioning of services, improving timeliness of access, reducing out of area placements and enabling reinvestment of funds back into local community care services to improve early intervention. However, the experience has shown that it is vital that trusts are adequately funded and resourced to manage these new care budgets effectively.

 

  1. Efforts also need to extend to addressing the lack of coordinated planning around the needs of particular groups and vulnerable children, where there is a higher prevalence of mental health problems than in the general population. Multiple adverse childhood experiences are strongly correlated with higher risk of a child developing serious physical and mental health problems in adult life. Many of the problems that children with complex health needs face are often practical ones related to the accessibility and responsiveness of services. These are consequences of underfunding and insufficient joined-up working between the many different services that they and their families and carers need. Local systems need to be resourced effectively and enabled to work more collaboratively in supporting children with the most complex needs and improving their physical and mental health. Attention also needs to be given to addressing the link between social circumstances and mental health in children, such as variation in access thresholds and the scale of cutbacks to social services for the most vulnerable children.

 

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

  1. The rise in self-harm and suicide amongst children and young people in recent years is a key concern. Suicide prevention is a complex system-wide challenge which requires close working between the NHS, public health and partner organisations and evidence of what works to be tailored to local needs and determinants. The National Confidential Inquiry into Suicide and Safety has set out 10 clear evidence-based ways to reduce suicide rates for patients in touch with mental health wards, including approaches specific to children and young people. It is important that providers are supported to implement all of these approaches. 

 

  1. We welcome the national work underway to support a number of local areas to develop multi-agency suicide prevention action plans to reduce suicide and self-harm, and foster a shared learning culture across the country. There is further welcome work planned or in train to improve mental health services – from 24/7 crisis care for all ages available via 111 to improving the therapeutic environment in inpatient settings – which will also support suicide prevention. However, these areas will need to receive adequate resources and support in line with the new context the sector is operating in as a result of the COVID-19 pandemic.

 

  1. Progress has been made against the previous Secretary of State’s ‘Zero Suicide’ ambition for mental health inpatients, with all mental health trusts developing Zero Suicide plans. The Zero Suicide Alliance, which includes over 200 trusts as well as other partners in the health and care system, has been playing a role in identifying, devising and sharing best practice on suicide prevention, which includes training modules and resources for trusts. The alliance has recently made a renewed call for all NHS providers to join and work together to resource, refresh and reinforce its approach to suicide prevention.

 

  1. It is too early to examine the full impact of the direct and indirect impacts of the pandemic, particularly economic adversity, on mental health and suicide. However, we would encourage close attention to emerging evidence, including looking at a level of detail sufficient to pick up any variation between communities and population subgroups, given the uneven impact of the pandemic to date. Suicide is likely to become a more pressing concern as time goes on, given the mental health consequences are likely to be present for longer and peak later than the COVID-19 pandemic itself.

 

 

March 2021