Written evidence submitted by Youth Access (CYP0085)

About Youth Access

Youth Access exists to make sure all young people have somewhere to turn to, and someone to talk to, wherever and whenever, they are in need. Along with our network of 160 ‘Youth Information, Advice and Counselling Services’ (YIACS), we champion young people’s right to access high-quality local services which offer a range of support to help young people tackle the diverse challenges they face as they move into adulthood.

The YIACS model

YIACS are organisations rooted in local communities all over the country that provide free, easily accessible and age-appropriate support to young people aged 11-25 with a wide range of issues.

Youth Access YIACS recognise and respond to the particular challenges faced by teenagers and young adults, from mental health to housing, money and benefits and sex and relationships. Taking a young person-centred approach, YIACS are driven by the rights and needs of young people and target support at those who would otherwise fall through the gaps between children and adult’s mental health services.[i]

Introduction

While young people have faced the sharp edge of the ‘mental health crisis’ for some time, with the widest ‘treatment gap’[ii] and steadily inclining needs,[iii] the Covid pandemic has created a treacherous and uncertain terrain for those making the journey into adulthood.

In recent years, we have welcomed the political drive to put mental health into focus and to address the inequalities in access and experience faced by children and young people. Now, especially in light of the immediate and longer-term effects of the pandemic, this review is an important opportunity to examine what has worked and where there are improvements to be made in the provision and approach to youth mental health.

The pandemic makes clearer than ever before that mental health does not exist in a vacuum. Young people lead complex lives and are navigating specific challenges for the very first time, all of which depend upon, as well as affect their mental wellbeing. To address these challenges, and stay mentally well, young people need support across all areas of their life, not just their mental health diagnosis.

Current commitments in the Green Paper and the NHS Long Term Plan have the potential to take us a long way towards a system that meets young people’s rights to the help they need to stay well, but to truly move to a system which prioritises prevention and early intervention, the Government needs to look beyond medical models and take a joined-up approach across multiple departments to address the social and economic factors impacting on young people’s lives and wellbeing.

Summary

-          Young people have the right to the best possible standard of mental health and to be involved in decisions about what that looks like and how it should be achieved, at both the individual and the system level.

-          Mental health does not exist in a vacuum. Young people are clear that they want mental health support that responds to their ‘whole life’, and which helps them to address the various social, economic and emotional challenges along the journey into adulthood.

-          The commitments outlined in the Green Paper and the NHS Long Term plan do not go far enough in offering this ‘whole life’ support for young people’s wellbeing, though both pose important opportunities to tap into the skills and community connections of voluntary sector services and thus to cater to young people outside of medical and educational settings.

-          Voluntary and Community Sector (VCS) services are well-placed to respond to the diverse range of needs facing young people. Many local services, such as those in the Youth Access network, already play an essential role bridging the ‘cliff edge’ between children’s and adults services and in serving young people who typically face poor access, experience and outcomes in statutory provision.

-          Investment in ‘one-stop-shops’ such as Youth Access YIACS was recommended in Future in Mind, but funding remains patchy and unsustainable, with no accountability on any agency to ensure the full model of open access Youth Information and Advice is provided.

-          The implementation of the ‘0-25’ offer outlined in the NHS Long Term Plan poses another opportunity to genuinely centre prevention and early intervention through investing in this model of open access, young person-centred support. However, accountability must go beyond the health system and budget should be drawn from both children’s and adults’ provision.

-          Plans for the expansion and training of the mental health workforce should mirror this ‘whole life’ approach; capitalising on the diverse professions in the voluntary sector, such as counselling, youth work and advice as well as peer support from young people with lived experience.

-          All future planning and decision-making for the mental health system should put the voices of children and young people at the centre, creating more accessible opportunities for young people who face inequalities and are typically underrepresented to be heard.

1.       Young people’s rights and vision for the mental health system

1.1   Youth Access takes a rights-based approach to our work standing up for the needs of young people and the services that support them with the journey into adulthood.[iv]

1.2   The UN Convention on Economic, Social and Cultural Rights (ICESR) specifies the rights of all people to “the highest attainable standard of physical and mental health”[v], while the UN Convention on the Rights of Persons with Disabilities (UCRPD) emphasises the need for a fundamental shift away from diagnostic biomedical approaches, which favour medication and institutionalisation; moving instead towards an asset-based approach, whereby the individual (including children and young people), along with the family and communities involved in their care, are treated as knowledgeable and equitable partners in the decisions affecting them.[vi] Furthermore, the UN Convention on the Rights of the Child (UNCRC)[vii] underlines children’s fundamental right to have their views heard and given due weight.

1.3   A human rights-based approach, therefore, should focus on progressing person-centred care and inclusive methods of co-production and participation in the system at large.

1.4   Over 2020, we worked with partners in each nation of the UK to support young people to define their vision for a mental health system that meets the principles of the human right to mental health.

1.5   Young people in England created the ‘Our Minds Our Future manifesto’[viii], which outlines the following seven priority areas:

-          ‘Experts who understand’ – Young people want respectful, knowledgeable and non-judgemental practitioners who can help them navigate the unique and intersecting issues facing young people in today’s world, including social and economic factors. Importantly, they want more schemes to support young people with lived experience to access training and join the mental health workforce.

-          ‘Services made for us’ – Young people want a range of services tailored to the specific preferences and challenges of young adulthood. This should include in-person as well as online, dedicated support in schools, colleges and universities, and accessible support in informal settings like youth clubs, drop-ins services and text-based support.

-          ‘Services made with us’ - Young people should be meaningfully included in any decisions being made about their own mental health care, as well as supported to co-design services and the wider system. They are willing and eager to engage with policymakers, commissioners and service providers to ensure their diverse lived experience can be applied to building a system that works for all young people.

-          ‘Equity, diversity & accessibility’- Young people are not a homogenous group, so services, and the information about them, should be tailored to specific needs and preferences relating to gender, culture, race, sexual orientation, ability and other characteristics in order to cater to those facing inequalities or marginalisation. This should include diversifying the mental health workforce as well as the points of access for services (ie not solely in clinical settings, which can be stigmatising).

-          ‘Help when we need it’ – A diverse range of services - including drop-in and out-of-hours support - should contribute to reducing the barriers to young people accessing appropriate and timely support. Young people should not be placed on long waiting lists without transitional support. Where possible, services should be flexible and accessible by self-referral, so that young people are not cut off from support when they are ‘too old’ for children’s services, or told they are ‘not sick enough’ due to thresholds outside of their control.

-          ‘Education & training for all’ – All professionals working with young people, as well as young people themselves, should be educated in mental health wellbeing, and where to access support. Mental health professionals should have specific training to understand the issues faced by minoritised groups and how to work with young people from those communities.

-          ‘A ‘whole life approach’ to mental health’ – Mental health doesn’t exist as a simple diagnosis in a vacuum. Young people lead complex lives, often facing multiple disadvantages which affect, and are affected by, by their mental wellbeing. Mental health support should be tailored to the individual, looking not just at their diagnosis, preferences and lived experience, but also the other areas of their life, such as education, housing, relationships, money and benefits. Stronger links should be made within and between statutory health systems and youth services, community-based organisations, and schools, to ensure no young person falls through the gaps.

2.       Progress on the Green Paper

2.1   Youth Access delivered part of the consultation with young people on the Green Paper Transforming children and young people's mental health provision.[ix] While the participants welcomed the proposals set out in the Green Paper, they raised concerns that rollout was slow and that the narrow focus on educational settings would not work for many of them, due to:

-          Stigma or bullying in school

-          Low attendance due to illness or caring responsibilities

-          Being over 18 and not in education

2.1   Some key suggestions from young people included:

-          Mental Health Support Teams (MHSTs) should ensure support is accessible outside the school setting

-          Local voluntary sector community-based organisations (such as their local YIACS) should be involved in MHSTs

-          Additionally, that mental health workers within schools should come from a community-based organisation, so that young people can access support in either setting, at any age up to 25

-          Young people should be well represented in the decision-making structures (eg the 16-25 partnership)

-          Services and the broader strategy also need to address the root causes of mental ill health, such as debt, employment, housing and benefits as well as addressing inequalities faced by groups such as Black and Minority Ethnic (BAME) communities, young carers and care leavers.

2.2   The Government has not responded adequately to the concerns raised in the consultation to make the roll out of the Green Paper’s proposals truly transformational. In addition to the concerns raised by young people, we are yet to see a clear role for voluntary sector services in the delivery of MHSTs and school-based support.

2.3   We have been somewhat reassured, however, since the development of the NHS Long Term Plan, that there is a growing acknowledgement of the needs of young adults and a comprehensive offer that spans a young person’s adolescence from age 0-25, in addition to the involvement of some of our member services in the design and delivery of MHSTs.

Recommendations:

-          The roll out of Green Paper commitments should be based on feedback gathered from young people as well as professionals, in a genuinely inclusive way, focusing on those who face inequalities.

-          The design and delivery of MHSTs should provide a meaningful role for voluntary sector providers who provide a wealth of knowledge on the local community and can provide access to a range of psychosocial support for young people outside of educational and clinical settings and over the transition into adulthood.

3.       Improving access: the case for the YIACS model of open access one-stop-shops

3.1   Despite the commitments in the Green Paper and the NHS Long Term Plan, the Children’s Commissioner for England recently reported that one million children would still go without the mental health support they need.[x] Additionally, these plans do not provide detail on how the system will address key access issues for young adults (aged 16-25) who face the widest gap between support needed and support accessed.[xi]

3.2   For young people around age 18 who face major upheaval such as leaving education, leaving home or the care system, joining the workforce and gaining financial independence, this also comes hand-in-hand with losing access to vital support from various children’s agencies.[xii] For every local area to have a truly inclusive offer for all young people up to age 25, plans must go beyond schools and CAMHS, so that young people are given a bridge, rather than a cliff edge as they approach adulthood.

3.3   To help young adults through this specific life phase, mental health support for this age group must also be accompanied by a range of social and practical support to help address the social determinants of mental health, such as financial and job insecurity, discrimination and poor living conditions.[xiii] This is even more important when seeking to address socio-economic inequalities, many of which have been exacerbated by the Covid-19 pandemic.

3.4   In order to improve access, experience and outcomes for people from communities facing inequalities and multiple disadvantages, evidence-based recommendations[xiv] back up what young people tell us:[xv] Mental health support should be flexible, offered through local services rooted in the community - rather than clinical or educational settings which can be stigmatised – and should offer a range of support in one place.

3.5   A rapid review of the evidence on remote mental health support[xvi] showed that, while remote services are important in reducing barriers to access for many young people, reliance on digital interventions can pose barriers and exacerbate inequalities for others and should complement, rather than replace an in-person offer.

Future in Mind: ‘One-stop-shops’

3.6   In 2015, the children’s mental health strategy Future in Mind[xvii] made a commitment to make mental health support more visible and accessible for children and young people. The report highlighted the importance of incorporating open-access, community-based services into every local offer; recommending that Local Transformation Partnerships (LTPs) invest in “one-stop-shops” and capitalise on the existing network of Youth Access member services which offer Youth Information Advice and Counselling Services (YIACS) to cater to a range of emotional and social needs under one roof. 

3.7   Following that recommendation, many of our members played a meaningful role in shaping local plans for improving access for young people, and many have seen an increase in funding through CAMHS to allow them to offer their model of person-centred, holistic support to more local young people.

3.8   This success has, however, been limited in its reach and sustainability, as voluntary sector services such as our members consistently report challenges with tendering processes, being excluded from local decision-making, and being offered last minute, short term contracts which prevent them from investing sustainably in their staff and services.

3.9   Since the YIACS one-stop-shop approach sits across health, social welfare, justice and youth provision, there is no clear accountability for funding the full service model. Thus, often the socio-economic elements of support, which are vital to supporting the prevention of, and recovery from, mental illness, are frequently under resourced.

3.10                        Even within the health system, the inflexibility of the statutory model often poses barriers to YIACS’ potential to offer truly effective, person-centred care to more young people. For example, the delineation between children’s and adults’ services at age 18 leaves voluntary sector providers with CAMHS contracts falling short on funding for their clients aged 18-25. They may also be limited to offering a set number of talking therapies, or to only serving young people with postcodes that fall under the remit of a certain CCG.

‘Open Access Hubs’ as part of a 0-25 offer

3.11                        There is growing consensus in the sector that the system requires a strategic investment in open access drop-in hubs such as those in the YIACS network.[xviii] These hubs should offer a range of services under one roof, such as psychological therapies, housing advice, youth work and sexual health, on young people’s own terms via self-referral, rather than based on the thresholds set by the system.[xix]

3.12                        The implementation of ‘open access hubs’ would require partnership between the NHS, local authorities, the voluntary sector and digital providers. To avoid the same barriers faced with Future in Mind playing out again, it will require national oversight of the roll out of early intervention, young person-centred services, paired with clear accountability and transparency on which agencies are responsible for ensuring adequate provision. [xx]

3.13                        We are also keen to see a more defined role for the voluntary sector in local decision-making structures. While the NHS Long Term Plan makes some recommendations for the involvement of the VCS, this should be formalised to ensure they can play an equitable role and ensure that decisions about service provision consider the needs of VCS services, as well as, crucially, the young people they serve. Vitally, this must be inclusive of small VCS organisations, as well as larger or confederated providers.

3.14                        In fleshing out the proposed changes to NHS structures and procurement processes, the Government should seek to make it easier, rather than harder, for VCS agencies to take part in the design and delivery of service provision in their local area.

3.15                        Good practice in Norfolk and Waveney: Meaningful involvement of the VCS in system design

MAP (Mancroft Advice Project) is a Youth Access YIACS offering counselling, advice, youth work and social action projects for 11-25 year olds across Norfolk.

The service has been included in the new alliance model for CYPMHS in the region, giving them equal representation with other providers on the Executive Management and Clinical Reference Groups. This enables the organisation to communicate not just the value of their young person-centred approach but also to support the local system to respond more effectively to the priority areas for improvement identified by the young people they serve.

MAP have also been commissioned to lead the participation strand of the development of a new service. Thus, they are able to facilitate the inclusion of a diverse range of young voices in the ongoing transformation of local provision.

Recommendations:

-         Progress the implementation of the 0-25 offer in every local area as a priority.

-         Create dedicated budgets for young people’s mental health services that are distinct from child and adult budgets.

-         Join up commissioning across both age (children/adult) and service needs (mental health, housing, employment, youth services, sexual health) in order to meet the needs of young adults in a coordinated way. Ideally there should be nationally driven strategic investment in open access hubs such as Youth Access YIACS.

-         Set clear expectations for system engagement with the voluntary sector.

4.       Capacity & training issues in the mental health workforce

3.1  We welcome the ambitious targets for workforce expansion set out in the Green Paper and the NHS Long Term Plan, though we would encourage an approach focused on transformation of the approaches and skillset of the workforce, rather than solely on increasing numbers of existing clinical roles.

3.2  While NHS England have consistently cited workforce as the greatest challenge to improving access to services,[xxi] voluntary sector services such as Youth Access YIACS benefit from a diverse workforce with skills that span across counselling, youth work, advice and guidance.

Counselling

3.3  The counselling workforce offers a wealth of expertise and well-regulated professional skills. Research conducted over several years in Youth Access member counselling services demonstrated that these voluntary sector services achieved similar clinical outcomes compared to CAMHS and school-based counselling, but with young people reporting significantly better experiences.[xxii]

3.4  Recent research from the Institute of Public Policy Research[xxiii] found that only 48% of schools offer on-site counselling services – fewer than in 2010. Some counselling services have been commissioned as part of the MHSTs, including agencies such as Youth Access members 42nd Street in Manchester and Croydon Drop-in, which offers a promising model for a system which can offer multiple access points for support, rather than only in school.

3.5  Northern Irish and Welsh school and community counselling models provide choice of setting and offer important learning as we shape our approach to MHSTs and early intervention in England.

Advice

3.6  Our analysis of data from the Ministry of Justice’s Legal Problem Resolution Survey, 2017, showed that 57% of young people with mental health problems reported legal problems. They were more likely than older respondents to have issues related to housing, employment, neighbours and debt[xxiv] – issues which, without appropriate support, can put added pressure on the criminal justice system,[xxv] the NHS[xxvi] and social services,[xxvii] costing thousands of pounds per case.

3.7  Young people are also clear that they want to be able to help themselves, but that might mean being able to access expert, independent advice, advocacy and representation. They want workers they can trust and who understand the issues they face as young adults, and can help them to take appropriate steps before their issues reach crisis point.[xxviii] Importantly they don’t want to be passed around the system to get the help they need – they see mental health as an issue interwoven with every element of their life, warranting a ‘whole life approach,’[xxix] and would prefer to be able to access advice on issues like debt, employment, benefits etc alongside counselling and therapeutic interventions, drug and alcohol support and other wellbeing services.

3.8  The help that YIACS provide through their advice services to address housing and money problems has been found to be highly effective, and cost-effective, at improving young people’s mental health.[xxx]

3.9  The recognition of these diverse professional skills will be vital to any workforce strategy that can truly meet the needs of all young people, as early as possible, and in a way that is responsive to the range of social and economic factors that come hand-in-hand with their wellbeing. Looking solely at clinical or siloed mental health roles, or focusing on delivery through statutory services risks missing an opportunity to develop a transformational national approach to personalised care.

Lived experience & peer support

4.1   Young people want to see their diverse lived experiences reflected in the mental health workforce. [xxxi] This means creating more opportunities for training and career development for young people and other groups who are typically underserved by the mental health system and underrepresented in the mental health workforce.

4.2   People with lived experience by definition can face significant challenges related to their mental health, discrimination and marginalisation. For the mental health workforce to benefit from the full potential of practitioners who bring such a wealth of personal experience and understanding, there must also be measures to support those staff to stay well.

4.3   Our members report that clinical or professional supervision is a vital part of their approach to supporting staff to cope with the wide range of challenges and personal triggers that come up in their interactions with young service users, but this is often poorly understood and undervalued by commissioners, leading to poor resourcing.

4.4   Good practice in Bristol: Anti-racist reflective practice supports therapeutic staff to draw on lived experience in their practice

Off The Record in Bristol is a youth service and social movement in the Youth Access network. After the death of George Floyd and the race equality demonstrations over the summer of 2020, many of the staff were struggling with the impact of these events on their personal wellbeing, as well as in supporting young people who had been affected or traumatised.

As part of an organisational anti-racism strategy, the service has started to hold regular reflective practice sessions for the entire therapeutic team; creating a space whereby practitioners of all races and identities can share challenges related to their lived experience and get support from their peers.
 

Educating the wider workforce

4.5   Young people also want to see education on mental health, and the support that is available, provided as standard to a broader range of professionals, such as teachers, social workers and youth workers.[xxxii] This approach would benefit from the engagement of community-based organisations, which have a depth of understanding and expertise on local communities, and thus, the workers, community leaders and gatekeepers who could help to connect young people to appropriate support.

4.6   Good practice in Croydon: Community Development Workers improving access, experience and outcomes of mental health support for the local Black community

Off the Record is an established and highly regarded local service that has been offering a range of accessible, free support services to young people in South London for over 25 years. 

Their Community Development Worker (CDW) service was created as a result of a national government attempt to reduce the inequalities in mental health service experiences and outcomes for Black and Minority Ethnic (BME) communities. The CDWs work on an outreach basis acting as a bridge between statutory mental health services and local BME communities.  Their work involves changing attitudes towards mental health amongst BME communities; improving BME access to, and experience of, existing services; building capacity within community organisations and developing mental health services.  

The CDW team, with their roots in the heart of Croydon’s Black community, identified that Black young men feel significant stigma and distrust of traditional mental health services and talking therapies. On the other hand, the barber shop is a community hub, frequented often by young men to talk and get support from peers in an informal setting.  

They therefore  developed mental health awareness sessions for groups of barbers in the area, which is delivered in partnership with the local social prescribing programme. They also run ‘Trim ‘n’ Grin’ – back-to-school engagement events for pupils which take place in barber shops in Croydon and Merton. During the 2020 lockdown, they ran the #NoTrimChallenge, a video challenge for young men unable to get to the barbershops.[xxxiii]
 

Recommendations:

-          Health Education England and the Department of Health and Social Care should develop an overarching plan to develop the workforce in youth mental health and wellbeing.

-          A cross-departmental plan should be drawn up to enhance the skills of the wider youth workforce to better respond to mental health needs.

-          NHS England should give explicit permission and encouragement to local health systems to look beyond clinical professions in their local planning for workforce expansion to benefit from diverse professions including counselling, youth work and advice.

5.       Wider system changes

5.1   Without taking a ‘whole life’ approach, which responds to the wider social determinants and inequalities surrounding mental health, any strategy to improve the wellbeing of children and young people will be inefficient. It is also of vital important that this ‘whole life’ approach centres the voices of young people, as experts by their own experiences of tackling life’s challenges and accessing support.

5.2   The Government needs to take a cross-departmental approach to look at all policies with a lens to mental health and the effect on young people. Likewise, local systems must be held accountable to investing in prevention and early intervention and catering to the needs of young people as a specific cohort, distinct from children and adults.

5.3   These systems and processes should include a meaningful role for young people to shape decisions and design services, with a focus on those who typically experience poorer access, experience and outcomes from mental health services. This should be a standard and obligatory requirement in both national and local decision-making structures, and should draw on the expertise and connections of the voluntary sector to those communities of young people who are perceived as ‘hard to reach’ by other parts of the system.

5.4   Further, the Government should follow the lead of Scotland and Wales, by committing to put into domestic legislation the commitments to which it is already beholden in international law, which would enshrine the rights of children, young people and those with lived experience of mental illness to participate meaningfully in the co-production of a mental health system that is equipped to keep them as well as possible and give them the best possible care when required.

5.5   Recommendations:

-         The Minister for Mental Health, Suicide Prevention and Patient Safety should convene a cross-departmental review into the impact on youth mental health of existing policies and new proposals in the wake of the pandemic, with focus areas identified by young people.

-         NHS England should ensure that guidance for Integrated Care Systems incudes expectations to involve young people and communities facing inequalities in local decision-making.

-         The Ministry of Justice should use the review of the Human Rights Act as an opportunity to strengthen to UK’s commitment to fulfil to rights of children and young people, and those with mental health conditions, by translating key UN Conventions into domestic legislation namely:

• The UN Convention on the Rights of the Child
• The UN Convention on the rights of Persons with Disabilities
• The UN Convention on Economic, Social and Cultural Rights

February 2021