Written evidence submitted by the Royal College of Nursing (CYP0074)

Overview

With a membership of around 450,000 registered nurses, midwives, health visitors, nursing students, nursing support workers, nursing associates and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies, and voluntary organisations.

The Royal College of Nursing (RCN) welcomes the opportunity to feed into the inquiry looking at what progress the Government has made against the ambitions announced in the 2017 Green Paper Transforming Children’s and Young People’s Mental Health Provision.

The Covid-19 pandemic has highlighted and further exacerbated social and health inequalities and has negatively impacted the mental health and wellbeing of many children and young people. Increasing numbers of children and young people are experiencing increased social isolation due to the ongoing closure of schools, a sense of loss for the future they believed they would have, increased levels of stress and anxiety, they have also expressed increased levels of anxiety regarding family members and concern over family finances.

Whilst the pandemic required innovation, new ways of working and delivering services across healthcare, it is important that the true impact of these changes is understood and evaluated to identify any unforeseen consequences. The RCN hopes the inquiry will also consider and review the impact of any such changes within the delivery of children and young people’s mental health service to fully assess the impact, positive or negative, these have had when considering the question of system reform.

Consideration of system reforms cannot be done in isolation of robust transparent workforce planning, which will need to be at the core of any service redesign. Without intervention, existing health and care workforce gaps will continue to negatively impact upon patient care, safety, and outcomes.  The health and care service is currently being compromised due to insufficient numbers of staff. 

2.0 RCN Response to specific questions

Q1: What progress have the Government made on children and young people’s mental health, including but not limited to:

1)      the ambitions laid out in the 2017 Green Paper

1.1.1 Children and young people’s mental health services have been under scrutiny over the past decade due to issues with access to services and long wating times. The ambitions set out in the Green Paper aimed to address some of these issues, by developing Mental Health Support Teams, Designated Senior Lead for Mental Health in schools and trailing a four week waiting time.

1.1.2 Although there has been some improvement in access to services, these have not been achieved across the country, as evidenced by the Children’s Commissioner’s ‘The State of Children’s mental health services 2020/21’ report[1] . Mental health services have expanded recently, however due to the low starting point this has not been sufficient to meet the demands for children and young people’s mental health services that existed prior to the covid-19 let alone the needs of children and young people post the pandemic.

1.1.3 It is postulated that due to the disruption in education, social isolation, increasing concern and anxiety about the impact of the pandemic on loved ones, the number of children with a mental health need will have increased by approximately 50% over the last three years and equates to an increase from 1 in 9 to 1 in 61. This reflects the information the RCN is receiving from its members in relation to increased demand for, longer waiting times and increased pressure on staff.

1.1.4 our members advise us that they are seeing more and more children and young people attending emergency departments in crisis as they are unable to access appropriate services in a timely manner elsewhere. The age at presentation is also getting younger and the child / young person is more severely unwell upon presenting / requesting support.  

2)      Provision of mental health support in schools

1.2.1 The implementation of ‘Mental Health Support Teams’ [MHST] is overdue and a vision that must become a reality. With mental health nurses being at the forefront of care, they are pivotal to the delivery and success of this ambition.

1.2.2 The Government’s own response to the to the First Joint Report of the Education and Health and Social Care Committees of Session 2017-19 on Transforming Children and Young People’s Mental Health Provision: A Green Paper[2] suggested “….that at full roll-out, the brand new Mental Health Support Teams could comprise up to 8,000 new staff. This is comparable in size to the entire current children and young people’s mental health services workforce in the NHS, which is around 7,000 full time equivalent staff.” Given, the historic and chronic nursing workforce shortages the question remains where these highly skilled and experienced staff will be found.

1.2.3 The Governments ambition is to roll out MHSTs to between a fifth to a quarter of the country by 2022/23.  The pandemic has highlighted that around a third of the NHS workforce has considered leaving once the pandemic has concluded, this will become an even more ambitious target. It will be essential that this approach is carefully tested and is robustly monitored and evaluated to ensure that it is both sustainable and does not place undue additional pressure on an already over stretched workforce.

1.2.4 It is vitally important that mental health nurses are actively involved and included in such testing. The therapeutic input of care co-ordinators is a vital support for many young people, yet the interventions they provide is rarely formalised or measured. 

3)      Provision of support for young people with eating disorders

1.3.1 Evidence suggests that there has been an increase in the number of children and young people presenting with eating disorders and this needs to be fully funded and resourced.

1.3.2 Eating disorders affected both genders, yet society tends to view this as a mainly female only health condition, this perception by society needs to be challenged if younger males are to feel more comfortable seeking and accepting the support they require.

1.3.3 To promote the prevention of mental and physical deterioration, educational resources must be made available for schools and families, to help them recognise the signs of an eating disorder and how best to support the young person to seek help.

1.3.4 Inpatient and community provision needs to be more readily available to all and ‘closer to home’ to facilitate easier access. There needs to be a holistic approach - one focusing on the whole family and not just the child or young person.

4)      Addressing capacity and training issues in the mental health workforce

1.4.1 Nursing forms the largest professional group in the mental health workforce and was overstretched before the pandemic, due to widespread staffing shortages; these shortages will only become more apparent as demand for support increases. Government need to urgently address the historic and chronic underfunding in children and young people’s mental health services and the ongoing issues relating to staff recruitment and retention. One way to address this is by introducing a universal living maintenance grant that reflects student needs[3] and provide nurses with a pay award that addresses the real term decrease in salary experienced by nurses over the last decade.

1.4.2 Further, against the backdrop of covid-19 and ongoing staff shortages, nurses are increasingly struggling with their own mental health and wellbeing. It is vital that mental health nurses receive the right support, in the right way, at the right time to enable them to deliver the care and treatment our young people need and deserve. Without addressing these issues, it will become harder for services to meet the growing demand.

1.4.3 If the nursing workforce shortages are not urgently addressed then the ambitions set out in the Green paper will not be achievable, as there will be significant gaps in the highly skilled and specialised workforce that is required.

1.4.4 To ensure children and young people are assessed appropriately and receive the highly specialised care they deserve it is important that care teams have access to both specialist children’s nurses as well as mental health nurses thus allowing for age appropriate assessment and interventions.

5)      Improving access to mental health services

1.5.1 There was a 35% increase in referrals for mental health services in 2019/20. From this, approximately 4% accessed mental health services, equivalent to only 1 in 4 children and young people who had a mental health need. Access and speed of access to appropriate services in the right place needs to improve if children and young people are to receive timely and effective intervention.

1.5.2 The Nursing workforce, is a highly skilled and capable workforce and as such needs to be included not only in the delivery of care but shaping, planning, and commissioning of services

1.5.3 Information provided by RCN members highlights a focus on monitoring and feedback on waiting times, rather than on the time taken before a child or young person receives or accesses the appropriate support. Thus, meaning services are focusing their resources and time is given to assessment rather than on providing appropriate treatments or interventions.

1.5.4 RCN members have also highlight that due to staffing and capacity issues and the focus on achieving the  initial assessment, staff are being expected to take on additional duties which takes them away from their primary role, the result of which is a further delay in to the appropriate support being accessed. 

1.5.3 Any consideration of reform needs to consider the issues raised above, to ensure that children and young people’s mental health services is fully funded, and workforce shortages are addressed. 

Q2: 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

2.1 It is well recognised that inpatient admissions can be harmful. The inappropriate placements, due to the lack of suitable children and young people’s mental health beds, can further exacerbate this harm. 

2.2 We are advised by our members that they are seeing an increasing number of children and young people being admitted to inappropriate areas or wards due to the lack of Children and Young People’s mental health beds. This is distressing for the child / young person as well as for other patients on the ward.

2.3 With the insufficient number of specialist beds in children and young people mental health units to meet demand, children and young people requiring admission can often find themselves miles away from home; this creates an additional level of stress and anxiety. One solution would be to increase the number of beds available, however, this would also require an increase in the numbers of staff required to safely staff such units and this would need to be considered.

2.4 The appropriate use of physical or medical restraint, needs to be reviewed to ensure that this is seen as a last resort. Reduction could be achieved if staffing levels, i.e. the right number of staff with the right knowledge and skills, were appropriate to meet service need, thus enabling staff to provide the timely and effective care that children and young people require and deserve.   

Q3: 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

3.1 A review of services is welcomed however, in considering any reforms to the wider system consideration needs to be given to how this links with other NHS reforms, such as the recent 2021 White paper[4] and the open consultation on the reforms to the Mental Health Act[5] launched earlier this year.

3.2 Further, any such reforms cannot be done in isolation without consideration of the support that will be required for all members of the family involved. Evidence suggests that children exposed to adverse events at home are more likely to suffer from stress and anxiety and are also more likely to have long term physical and mental health needs.  Therefore, significant investment in appropriate early intervention as soon as possible could have far reaching financial and economic consequences.

3.3 Any focus on early intervention needs to also consider the efficacy to ensure it is both appropriate and safe for the child or young person. The appropriateness of care delivery setting also needs to be assessed, providing treatment at home maybe preferrable providing it is safe to do so rather than admitting a child / young person to an inappropriate area. Our members have informed us of instances where young people have been treated on adult mental health wards, due to the lack of a suitable children and young people’s mental health bed  or they have been inappropriately admitted to general adult wards rather than children’s wards or teenage units. Admission to an inappropriate area can have a detrimental effect on the child or young person and their recovery.

3.4 As nurses form the largest part of the mental health professional workforce, we would expect that any such system review / reform would actively seek to include and involve nurses at the earliest opportunity.

3.5 Importantly, in any such reforms the needs of the child or young person should be at the forefront and dictate what is required. Rather than, starting from and being constrained by issues such as workforce shortages. 

Q4: How the Government can learn from examples of best practice, including from other countries?

4.1 There are examples of best practice and Government needs to actively encourage and facilitate the sharing of this so that children and young people and their families no matter where they are based are able to access high quality care and support. Thus, putting an end to the postcode lottery in children and young people’s mental health provision.

4.2 Spending on children and young people’s mental health services varies significantly across the country. On average the amount spent is considerably less than that which is spent on adult mental health services. The Children’s Commissioner’s report provided evidence that demonstrated that where spending on children and young people’s mental health is higher, they accordingly have better mental health services.

4.3 Steps should be taken to address this variation and to ensure consistency of access to services across the system and that there is parity with adult mental health services.

Q5: What measures are needed to tackle increasing rates of self-harming and suicide among children and young people?

5.1 Evidence suggests that children and young people are accessing inappropriate and harmful material via social media, which has increased as a direct result of the pandemic.

5.2 The Government needs to urgently develop and enact the Online Safety Bill, given the duty of care and the legal obligation this places on social media providers to identify, remove and limit the spread of illegal content, including suicide material. Additionally, it needs to ensure that the secondary legislation defining what contributes harm and abuse is enacted as quickly as possible.

5.3 RCN members have advised that questioning children and young people about their internet usage should be normalised and included in all conversations and interactions, whether be they are at school, home, or healthcare environment. Thus, allowing for an appreciation and understanding of the child’s / young person’s virtual friendships.

About the Royal College of Nursing

The RCN is the voice of nursing across the UK and the largest professional union of nursing staff in the world.

For further information, please contact:

Peta Clark, Professional Lead for Children and Young People

Nursing Department

Royal College of Nursing

February 2021

March 2021