Written evidence submitted by the National Children’s Bureau (CYP0079)

About the National Children’s Bureau
The National Children’s Bureau (NCB) is a leading charity that champions the rights of children and young people. We bring people and organisations together to drive change in society and deliver a better childhood for the UK. We interrogate policy, uncover evidence and develop better ways of supporting children and families.

About Young NCB and FLARE
This submission draws on NCB’s previous consultations with young people from Young NCB and FLARE around mental health and wellbeing. Young NCB is a free membership group for children and young people to speak out about the important issues and decisions that affect them. It is open to all children and young people who live in England and Northern Ireland who are aged 18 and under, or up to 25 for those with special educational needs or disabilities (SEND). FLARE, based at the Council for Disabled Children, is a group of 13-25-year-olds with SEND from across England, who bring information from a range of young people and work with Government to make sure their voices are heard.

Reason for submitting evidence
Improving wellbeing and mental health is one of NCB’s key priority areas. The NCB Family includes a wide range of networks and programmes with specialist knowledge on the mental health needs of specific groups of children, including the Council for Disabled Children, the Schools Wellbeing Partnership, the Early Childhood Unit, Headstart, A Better Start, the Anti-Bullying Alliance, and the Childhood Bereavement Network. NCB was also commissioned by the Department of Health and Social Care to deliver focus groups on the Transforming Children and Young People’s Mental Health Green Paper.

Contents

1. Summary

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

Early years

Schools

Wider mental health system

Recommendations

3. 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

Recommendations

4. 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

A new vision for childhood

Prioritising early intervention and prevention

Improving access to mental health services

Delivering integrated care

Developing and diversifying the workforce

Recommendations

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

Recommendations

1. Summary
NCB believes that the threat to children and young people’s mental health is as serious a threat to long-term health as the pandemic itself. The huge scale of need was evident before COVID-19[1] [2], and a decade of austerity in public services has forced local services into a permanent state of fire-fighting with prevention and early intervention services decimated[3] [4]. Now, following a year in-and-out of lockdown, rising poverty[5], uncertainty about the future, bereavement and a host of other challenges things are far worse.

The impact of the pandemic has not been felt equally. There is emerging evidence that families with young children[6], children and young people with pre-existing mental health conditions[7] and families on reduced incomes[8] are among the worst affected. With increasing pressure on family finances, rising unemployment and housing worries, the long-term economic impact of COVID-19 may also have a knock-on effect on children and young people’s mental health which is yet to emerge.

Initiatives such as the NHS Long Term Plan and the Transforming Children and Young People’s Mental Health Green Paper were a step in the right direction but lacked ambition, leaving many children and young people without access to support, particularly our youngest children. The development of these initiatives was also based on a different landscape, before the pandemic’s impact on children and young people’s mental health and the services in place to support them.

More of the same is not an option. The pandemic provides an opportunity to think differently and take a strategic approach to improving children and young people’s mental health and wellbeing. We need a fundamental re-think of what support this generation of children and young people need, and we must start by asking them what that is. Only by working in partnership with children, young people and their families can we begin to repair the damage and help them see a brighter future ahead.

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

Early years
In recent years, there has been growing recognition of the importance of early childhood in determining outcomes in later life, particularly emotional wellbeing, as well as the potential that intervening early has to prevent costly downstream interventions[9].

Despite this, early years is often the missing piece in the Government’s response to children and young people’s mental health with much of the focus being on children over 5. For example, plans to introduce designated leads for mental health in schools do not include an equivalent for early education settings and, in 2019, Child and Adolescent Mental Health Services (CAMHS) in 42% of Clinical Commissioning Group areas would not accept referrals for children aged 2 and under[10], despite commitments in the NHS Long Term Plan to improve access to specialist services for all children and young people from 0-25.

Early years has also been left out of the Government’s response to mental health and wellbeing needs during the COVID-19 pandemic with initiatives such as the Wellbeing for Education Return programme[11] and additional support for school staff’s wellbeing[12] not including early education.

Early education and childcare

High-quality early education and childcare promotes the social and emotional development of babies and young children[13]. Government has made some progress through their focus on developing early language and literacy skills[14] [15]; having a prime area of learning on personal, social and emotional development[16]; and Ofsted recognising the need for providers to promote social-emotional development[17].
 

However, the realisation of many of the Government’s aims is largely dependent on the quality of the early education workforce to support children’s social and emotional development in settings and work with parents and other early years professionals across health and social care. Not all staff must have a qualification in early education and childcare despite evidence that level of qualification can be a key determinant of quality of early education[18] [19] [20]. There are also significant issues around workforce recruitment and retention, and a lack of training and development opportunities[21]. If early education settings are not consistently led by high-quality staff with sound knowledge of basic early childhood and brain development, children may be less likely to realise their full social and emotional development.

The Department for Education’s (DfE) current focus on the home learning environment and speech, language and communication is welcome but could do more to be an enabler of strong mental health in the early years. As part of this work, parents and all early years’ professionals must be supported to understand and talk about the links between strong language and communication skills and good mental health and emotional development.

Health visiting
Health visitors are key to improving the social and emotional development of young children. However, since 2015, the workforce has been significantly depleted with a 31% reduction in the reported workforce[22] and funding for the Public Health Grant falling by £700 million in real terms[23]. Over half (65%) of health visitors still in the service are working with caseloads of more than 300 children each and 29% report caseloads of 500+ children, double the Institute of Health Visiting’s recommended caseload of 250 children22. As a result, many children are not in receipt of their mandated checks and opportunities for early intervention are being missed.

Recent Select Committee Inquiries have also drawn attention to the need for an additional review at age 3 – 3.5 years and the need to determine if an assessment of social and emotional development prior to the fifth check should be required[24].

Specialist services
The NHS Long Term Plan committed to improving access to specialist services for all children from 0-25. However, current provision is far from this goal for children under five, with fewer than 40 specialised parent-infant relationship teams in the UK10 and very little mental health provision.
 

Schools

All education settings play an important role in supporting children and young people’s mental health and wellbeing. Commitments in the 2017 Green Paper were a step in the right direction to increase support in schools and colleges but the target to reach up to a quarter of the country by 2023 lacked ambition. Given the increasing need as a result of the pandemic, the roll-out of Mental Health Support Teams and Designated Senior Leads should be accelerated to reach the whole country urgently.

As a result of the pandemic and subsequent school closures, education settings have been less able to play their crucial role in spotting early mental health needs. Young NCB believe the pandemic is worsening an already difficult situation:

“It is clear that the existing mental health crisis has been made even worse by the pandemic. It is of utmost priority that the Government tackle this issue. Words are not enough.”

We heard from some young people that not being able to access pastoral support through their education setting has negatively impacted their mental health, especially if home life is difficult:

“It would have been so nice to have regular 1-2-1s with them to discuss how I am doing and my concerns about my college work and the future. Not only would it have helped me to talk through things with other people (hence improving my mental health) but also it would have helped my studies.”

“Especially if your home life is a bit troubled or you do not feel comfortable at home, you may have only had that one person at school who was your person and a lot of separation has not really been good for you.”
 

However, we also heard from young people that some, particularly those with SEND, will have seen their mental health improve during lockdown and may find it difficult when COVID-19 related restrictions are lifted, particularly where plans to return to education and other services are not developed in consultation with them or communicated to them clearly.

Increasing mental health needs and concerns about returning to education emphasise the need for a whole-setting approach to mental health and wellbeing to be implemented in every education setting, including early years. This involves incorporating mental health and wellbeing into the broader curriculum, prioritising play, exercise and pastoral support, training all staff and supporting their wellbeing, and listening to children and young people’s views. It also means making sure that all policies and procedures take mental health and wellbeing into account, including adopting trauma-informed approaches to behaviour. Young people also spoke about the need for wellbeing to be a focus in education, highlighting that the Government’s academic catch-up plans must not be pursued at the cost of children’s wellbeing:

“Teachers should not just be bothered about your grades but about you as a person”

“Wellbeing is as important as academic achievement”

Members of the Schools Wellbeing Partnership and the Coalition for Children and Young People’s Mental Health have noted that many education settings are struggling with capacity, limiting their ability to offer high-quality and consistent mental health and wellbeing support. They also highlighted high levels of stress and worsening wellbeing among staff which is likely to increase as the long-term and hidden effects of the current crisis emerge. In addition, the pandemic has exposed the ongoing challenges in workforce competencies around making use of the resources and services available to them, particularly as many education settings have received a greater amount of information and resources in the last year.

Part of adopting a whole-setting approach to mental health and wellbeing requires funding to train staff and boost capacity in the workforce so that they are able to identify children and young people’s needs, provide low-level support, signpost to local services and resources, and know when to refer to other services.

Wider mental health system

Access to specialist mental health services is often described as a postcode lottery because children and young people do not consistently receive the mental health support they need and their experiences vary depending on their level of need and where they live[25]. On average, children and young people go 10 years between first becoming unwell and receiving the help they need[26].

Despite record government investment in children’s mental health, including through the NHS Long Term Plan, the young people we spoke to had not felt the impact with waiting times continuing to be long and children often not being seen until they reach crisis point. In addition, those who have multiple and complex needs struggle to navigate the system and have their needs met due to a lack of joined-up care.

“Mental health services are underfunded and have long waiting lists. We need to see change.”

“So many services are already over-subscribed and this means many children

and young people are unable to access the support they desperately need

until they reach breaking point. Funding these services better would stop this

problem and allow children and young people to get the help they need at

crucial moments in their lives”
 

NHS data published this January showed that the number of children and young people being referred to mental health services is at its highest ever level, and has increased by 20%[27]. Increasing needs due to the pandemic alongside a backlog of missed appointments, an already stretched workforce, and a lack of flexibility in the system means services are concerned about their capacity to respond to this significant demand.

This highlights the urgent need for a significant boost in capacity of services, including by prioritising early intervention and prevention services, delivering integrated care, and the expansion, training and diversifying of the children’s workforce. This is covered in more detail in section 4.

Recommendations

• Government must support all education settings, including early years, to place mental health and wellbeing at the heart of education.
   
• Government must invest in training to increase the knowledge, skills and confidence of all staff working with children and young people, including in the early years, and across health, education and social care, to support children’s mental health and wellbeing. This should include recognition that working with babies and young children requires a sound knowledge of early childhood and brain development.
   
• The roll-out of the 2017 Green Paper should be accelerated across the country beyond the existing target to reach up to a quarter of the country by 2023; this will require additional investment beyond current funding.
   
• The NHS should prioritise work to increase access to mental health services and roll out services that continue to age 25.
   
• Urgent investment in the early years is needed, including through a package of support for early education settings to focus on wellbeing; investment in health visiting to reverse the cuts and make sure that every child is in receipt of their mandated checks; and improving access to appropriate specialist mental health support for babies and young children.
   
• Government and local areas must consult and communicate with children, young people and families around COVID-19 related decision-making, including where there are changes to education settings or mental health support, to reduce uncertainty and confusion.

3. 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.

Many children and young people are in restrictive institutional settings[28]. There are particular concerns about the ability for children and young people with multiple needs to access adequate community-based support, particularly for young people with learning disabilities and/or autism and mental health needs and those with behaviour that challenges, leading to a vicious cycle towards admission.

There are poorly evidenced responses for many young people, for example with behavioural interventions or treatments for mental health conditions which may not be appropriate or useful for children and young people with learning disabilities or autism and mental health needs. This includes widespread use of suicide risk assessment tools in CAMHS that do not adequately assess young autistic people’s risk of suicidal behaviour or account for its different presentations[29]. Some children’s mental health issues are not addressed appropriately because their autism is not recognised; others have been refused help from CAMHS as they did not feel equipped to support them, or told that CAMHS are not commissioned or funded to see autistic children.

This lack of appropriate and effective support emphasises a need for better community-based support and greater training and knowledge for professionals. The Lenehan Review[30] concluded that too many children and young people are moved out of their homes into residential placements, which still do not necessarily meet their need, when they could and should be supported well in their local communities. Areas with effective links between social care, SEND and youth offending teams reported positive outcomes[31], particularly where these teams were co-located, highlighting the benefits of integrated working for supporting children and young people with multiple complex needs.

There is also evidence of unnecessary and excessive use of restraint for children and young people in institutional settings, including the use of medical restraint. People with behaviour that challenges are three times more likely to be prescribed anti-psychotics, and prescriptions for anti-psychotics are made to approximately 22% of adults with learning disabilities26. The Challenging Behaviour Foundation also found that the number of restrictive interventions used against children, young people and adults is high, including 845 incidents experienced by under 18s23.

Restrictive interventions should never be used to punish or with the intention of inflicting pain, suffering or humiliation. The Restrictive Physical Intervention Steering Group emphasised that restraint should be the last response to behaviour that challenges. De-escalation techniques appropriate to the child or young person should always be used to try and avoid the need for restraint.

Recommendations

• All settings should have: a clear policy for promoting positive relationships and behaviour, including measures for understanding the causes of behaviour; evidence-based approaches to promote positive behaviour and supporting individual children and young people whose behaviour challenges; clear governance and accountability arrangements; and processes for involving all young people in decision-making.
   
• Restraint should be based on consent where possible and an understanding that all children can and do communicate. Wherever possible children should be involved in developing their behaviour support plan so that they understand the sanctions and techniques that the service will use to manage their behaviour.
   
• Figures on the issue of restrictive practices, including physical and mental restraint and segregation, must be published weekly by institutions.
   
• The Care Quality Commission should carry out all inspections unannounced and prioritise in-person inspections at institutions with a history of malpractice and those which have been rated inadequate/requires improvement.
   
• Government must invest in better community-based support for children and young people with learning disabilities and/or autism. This should include dedicated training for the children’s workforce. 

4. 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.

A new vision for childhood

Without a clear vision, the Government’s response to children and young people’s mental health needs will not deliver value for money or provide sustainable improvements to outcomes. We need a cross-Government strategy that considers the needs of all children, young people, and families from conception to age 25 with mental health and wellbeing as a key strand[32].

For this strategy to be effective, it must be co-ordinated by a Cabinet level minister, be backed by significant investment to reverse the impact of a decade of cuts, and have the voices of children, young people, parents and carers, and the children’s workforce at its heart. Listening to these perspectives at every stage of the process – from design and development to service delivery – will allow for a mental health system designed to meet the needs of children, young people and their families.
 

Prioritising early intervention and prevention

We will not break the vicious circle of increasing need and lack of provision until we take a preventive approach to children and young people’s mental health and wellbeing, starting in the early years and supporting all children and young people from 0-25 in all settings. We cannot continue waiting until children and young people’s needs escalate to crisis point before we intervene.

Specialist services cannot work effectively without universal and targeted services in place to provide a baseline level of support for all children, young people and families, identify those who need additional support, and provide low-level interventions for those with less complex needs. Investment in services for all levels of need will allow for a step-up/step-down system to provide support as needs change. Freeing up capacity in specialist services would prevent needs from escalating to crisis point, reduce referrals to costlier specialist support and allow specialist professionals to upskill those working in universal and targeted services.
 

Improving access to mental health services

Place-based, whole-system approaches are most effective at meeting children and young people’s needs, particularly for those with complex, multiple and long-term needs[33]. Services delivered in the community provide flexible and cost-effective support while reaching underserved communities due to their universal, non-stigmatising and culturally responsive approach.
 

An effective way of delivering these services could be through the delivery of open access mental health support hubs[34]. These hubs would offer easy-to-access, drop-in support on a self-referral basis for those who do not meet the threshold for CAMHS or with emerging mental health needs, up to age 25. A mix of clinical staff, counsellors, youth workers and volunteers could provide a range of support on issues related to wellbeing while additional services can be co-located, for example, employment advice, youth services and sexual health.

During national lockdowns, some services were able to adapt quickly and offer remote support with some seeing an increase in engagement due to barriers such as time constraints, travel etc. being reduced. However, where some services are only able to provide digital or telephone support during the pandemic, they have not been able to reach out to children, young people and families not already known to them. We heard from members of the Health Policy Influencing Group that both families and professionals are ‘Zoomed out’, are missing face-to-face support and that there is unequal access to digital support with some not having the digital literacy skills or technology to engage. Some young people we spoke to found digital support useful during lockdowns but would still prefer face-to-face support:

“Although I think face to face support usually works better for me as it makes it easier for me to open up to people and read body language, I found [digital support] helpful during COVID”

When COVID-19 related restrictions are lifted and face-to-face support is re-introduced, it is important to utilise learning from remote support to offer a blended face-to-face and digital offer so children, young people and families can access support appropriate to their needs and preferences.

Delivering integrated care

Children and young people’s needs do not respect service boundaries or departmental budgets. Young people have expressed challenges to accessing support in this complex system:

“I think it’s difficult because when you have a disability they don’t know which service to put you under, and it’s hard because they want to put you into a category when you’re a person not a category.”

Looking at children’s wellbeing and mental health through a single lens will not provide sustainable improvement to outcomes. Government and local systems must respond to the complex interplay between poverty, race, SEND, mental health needs, trauma, abuse, neglect and a range of other challenges if they are to improve outcomes and narrow inequalities.

Partnership working with a collective vision, shared outcomes and joint accountability arrangements is key to delivering integrated care33. Government must support all services and professionals working around and for children to align and integrate their work in order to effectively support children and young people. This includes local government, health, education, social care, and the voluntary and community sector. NCB welcomes the NHS’ vision to build effective Integrated Care Systems (ICSs) across England. However, more clarity is needed on how ICSs will function in relation to children and young people’s mental health.

Developing and diversifying the workforce
In order to support children and young people’s mental health effectively, there needs to be a diverse children’s workforce across health, education, social care and community settings who are equipped to identify needs, provide varying types of intervention and know when to refer on to more specialist support. The workforce should not just be teachers and clinical staff but all those working with children and young people. This includes health visitors, early education practitioners, social workers, youth workers, advice workers, link workers, peers with lived experience, receptionists, sports coaches, activity leaders etc.
 

The workforce should be supported to acquire the knowledge, skills and confidence needed to support and protect the children, young people and families they work with. Breaking down the historic, cultural and systemic barriers between different types of children’s practitioners must also be at the forefront of this work.

The above must be considered within the context of the pandemic which has created additional demand and placed significant pressure on the children’s workforce. Any strategy to develop and diversify the workforce must also consider how to support their mental health and wellbeing, including through effective supervision.

Recommendations

• Mental health and wellbeing must be at the heart of a cross-government strategy, co-ordinated by a Cabinet level minister, to support babies, children and young people to recover from the effects of COVID-19. This strategy must be backed by major investment at the Comprehensive Spending Review and have the voices of children, young people and parents at its heart.

• Government must develop a strategy to expand, train and diversify the children and young people’s mental health workforce across health, education and social care to tackle inequalities, create the capacity to meet increasing demand and develop leadership skills to provide a robust safety net.

• Government must provide dedicated and sustainable funding for prevention and early intervention services in local communities and education settings to relieve the pressure on specialist services and boost capacity in the system.

• Government must develop a comprehensive picture of how children and young people’s mental health has been affected by the COVID-19 pandemic, particularly where existing inequalities have been exacerbated.
• Local services must be given the time and resources to respond to changing local needs. Government should encourage education settings, specialist mental health services and community services to work together to re-assess children’s wellbeing and mental health needs in their local area and adapt their integrated local response. Consideration must be given to how Integrated Care Systems can be incentivised to prioritise children and young people’s mental health alongside Health and Wellbeing Boards.

• Government and local areas must consult with children, young people and families when planning responses to mental health needs and designing services to make sure they can access support in a way that works best for them and meets their needs.
   
• Government must support local systems to provide a clear offer for children and young people with accessible information to help them navigate a complex system and a blended face-to-face and digital offer so they can easily access support how and when they need it.

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

Research from UCL and NCB found that, even before the pandemic, 16% of 17-year-olds reported high levels of psychological distress, 24% reported self-harming and 7% reported self-harming with suicidal intent1. The research revealed stark inequalities, particularly among LGB+ teenagers who were twice as likely than their heterosexual peers to report serious mental distress (41% vs 16%) and self-harm (56% vs 24%), and three times more likely to report self-harm with suicidal intent (22% vs 7%).

NCB asked a group of 16 and 17-year-olds why they thought young people were reporting such high levels of distress:
 

“Our generation have a whirlwind of expectations around us, from social

media depicting the “perfect” life or body to exam stress. On top of that,

being from a disadvantaged background will add to the pressure. If you’re

being bullied for being LGBTQ+, or you have to worry about where your next

meal will come from, of course you’re going to be more at risk of bad mental health.”

“The fact is that [these findings] aren't particularly surprising. Those who

are disadvantaged are nearly always those who struggle the most, and

therefore have the most mental health problems.”

Young people face significant life transitions at age 17 and 18 however, many fall through the gaps between CAMHS and Adult Mental Health Services (AMHS)[35] at a time when support is most needed. These stark findings coupled with the impact of the pandemic highlight the need for an urgent response to prevent such high levels of distress emerging.
 

Recommendations
The below must be considered alongside recommendations throughout this response on prioritising early intervention and prevention and boosting capacity in the system.
 

• Young people should not face a drop in support when they turn 18. Where not already doing so, CAMHS should continue to support young people who have turned 18 and would normally be moving to AMHS.
   
• LGBTQ+ young people need better and more targeted support. Government and local areas should tackle the stark sexuality-based mental health inequalities found, through:
• Good relationships education and tackling homophobic, biphobic and transphobic bullying;
• Working with LGBTQ+ young people to ensure mental health services are designed to meet their needs and provide whole-family support;
• Including measures to reduce the risks faced by LGBTQ+ young people in national and local self-harm and suicide prevention plans.
   
• During the current crisis and given the uncertainties about the future, additional protections should be in put in place to help young people make the transition to adulthood. This could include funding services that help with planning the move into university, training or work, and providing better mental health and wellbeing support in these settings.
   

February 2021