Written evidence submitted by the Royal College of Psychiatrists (CYP0090)

Summary

Even before the pandemic there was a mental health crisis developing among the country’s children. In 2017 one in nine children aged between 5 and 16 in England had a mental disorder. During the peak of the pandemic this had increased to one in six[i]. Referrals to children and young people’s mental health services have doubled since 2012-13 and are currently at the highest level ever leading to rising average waiting times (benchmarking data).

There have been increased investments and improvements in children and young people’s mental health services since the Green Paper was published in 2017 but we have not yet made some of the big steps needed to ensure that action matches the rhetoric.

To fully match the ambition to ensure that every child with a mental illness gets the help they need. We need to see:

• Regular detailed data on both the scale of mental health problems with children and young people and the support they are receiving. This should include an annual prevalence survey, use of services, and potential risk and protective factors that may affect mental health problems.
• After the failure to meet workforce targets set out for the Five Year Forward View for Mental Health, we need a clear detailed workforce plan to ensure we meet the further ambitions set out in the 10-year plan
• Investment in prevention and early intervention, including the early years.

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

1. The ambitions laid out in the 2017 Green Paper

In some ways the Green Paper may seem ambitious but that is only because the amount of support available for children with a mental illness was so pitifully low.

In 2019/20 NHS England was aiming to provide community mental health support for 34% of children and young people with a diagnosable mental illness. They beat this target providing care for 36.9% of children and young people who need it. This shows the investment is having an impact but also shows how far we still have to go. It is important to remember that even these low targets are based on how many children had a mental disorder in the 2016 prevalence survey. The most recent survey in October showed there were significantly more children need help.

This shows why we need regular detailed data to know what the real need is for CAMHS and to update our targets and plans accordingly.

2. Provision of mental health support in schools.

The Green Paper proposed the establishment of Mental Health Support Teams (MHST) linked to schools. The RCPsych supports these proposals but we were disappointed by the speed of the Government’s plans to roll them out. The original plan was that the roll-out would be done by area with some schools not getting a MHST until 2028 – leaving a generation of children without support. In some areas those aged eight when the Paper was published will be 18 by the time it reaches their school.

The pandemic may also have significantly delayed the creation of these teams at a time when they are likely to be more needed than ever. It would be good if the Committee was able to establish the current timeline for plans to expand these teams and update on the evaluation process.

The Green Paper said that all schools should have a ‘Designated Senior lead for mental health’. It was not however compulsory for all schools and there was only £7.6m allocated for training for every single school and up to £15-20m each year from 2019 to cover costs until all schools and colleges have had the opportunity to train a Lead (assumed five years for modelling purposes). It would be helpful to have an update on how many schools have created a designated lead and what steps the Government are taking to support the children in schools without one.

3. Provision of support for young people with eating disorders

Investment in children and young people’s eating disorders services has made a big difference but we still have not been able to keep up with demand. In quarter one of 2020/21 87.8% children and young people with an eating disorder are receiving treatment within one week in urgent cases and 86.8% within four weeks for non-urgent cases. Both of these waiting time measures have improved from around 65% in the first quarter of 2016/17.[ii]

NHS Digital showed that hospital admissions for eating disorders have risen by more than a third (37%) across all age groups over the last two years showing the need to do significantly more to prevent eating disorders developing.

One way to ensure that we react earlier to the signs of a developing eating disorder is to ensure that more medical staff are trained to identify and support children with eating disorders. The GMC has recently surveyed medical schools and have confirmed previous findings by Ayton & Ibrahim (2018) that medical students receive less than two hours of training on eating disorders over four to six years of undergraduate study and one in five medical schools do not offer any training on eating disorders at all.[iii]

To cope with this rising demand we need to expand the eating disorder workforce. Our 2019 workforce census found that 15.6% of consultant ED posts are unfilled. We urgently need to see efforts to improve the recruitment and retention of psychiatrists[iv].

We also need to significantly invest in research into eating disorder treatments to give us a much better idea of what works. There needs to be funding for at least twenty university departments, by establishing flexible training pathways for clinical academics, through funded MSc, MD, PhD training, by developing strong links with the NHS, and by building interdisciplinary research in Biomedical Research Centres. Future research will need to harnesses routine NHS data collection, and that frontline NHS services receive appropriate support to collect good quality data and integrate research into clinical practice.

Addressing capacity and training issues in the mental health workforce

As Simon Stevens said to the Committee recently, we need to expand the mental health workforce or the Government’s mental health plans are ‘for the birds’[v].

The Five Year Forward View for Mental Health included plans to expand services, with HEE saying we would need to recruit an extra 100 consultant psychiatrist to specialise in helping children and young people by March 2021. Unfortunately, since then the numbers have fallen with the latest figures from November showing that there were 26 less consultant CAMHS psychiatrists than in March 2017 (the baseline the Government is using for the Five Year Forward View for Mental Health)[vi].

The more recent Long-Term Plan for the NHS includes proposal to further increase the target for how many CAMHS psychiatrists the NHS employs. It is important that we learn the lessons from the failure to meet the previous ‘Stepping Forward’ targets and take more bold action to recruit more psychiatrists and retain the ones we have.

Our 2019 workforce census found that the rate of unfilled NHS consultant psychiatrist posts in England has doubled in the last six years. Around one in eight (12.14%) of child and adolescent psychiatrist vacancies in England are unfilled.[vii]

The latest data from the RCPsych run the Quality network for inpatient CAMHS (QNIC) shows that around four in ten children’s inpatient wards did not have enough staff to meet their needs. The network covers over 95% of all CAMHS inpatient wards and each year they set standards about how many staff are needed to give children the recommended level of care. In 19/20 56% of wards that responded to the survey reported that they lacked staff in at least one of the professional groups needed. The biggest shortage was in social work with around one in three wards not having enough social workers and over two in ten wards not having enough clinical psychologists[viii].

4. Improving access to mental health services

Demand for services

During the first lockdown referrals to CAMHS fell but have since risen to record breaking levels. The latest NHS figures showed the number of children referred to child and adolescent mental health services (CAMHS) was 4,615 per 100,000, the highest on record and up nearly 20 per cent on last year.[ix]

A survey by the Royal College of Psychiatrists in September 2020 found that over half of child and adolescent psychiatrists saw an increase in emergency care compared to the same time last year, while 48 per cent reported an increase in demand for urgent.

Waiting times

The 2017 Green Paper contained an ambition to improve waiting times for children and young people. It included plans to pilot a four-week waiting time standard in a number of areas with the commitment to role this out nationally if it was shown to improve care.

In the long run the Mental Health Support Teams (MHST) included in the Green Paper may reduce the demand for CAMHS services as children get support early. The impact report for the paper however made clear that when they are initially being set up they are likely to increase demand for CAMHS as they identify more children that need help[x]. As these MHST are rolled out over ten years this means that it is likely they will gradually identify more an more children who need help before you are likely to see a positive impact of cases being prevented.

The data collected by the Children’s Commissioner shows that we are still a long way from all children needing care getting it quickly enough. On average children are waiting 45 days between referral and their second contact with specialist services, which is the generally used measure to show when they have accessed treatment.[xi]

Spending on CAMHS

When analysed at the national level, the trajectory for investment in mental health services for children and young people (CYP) appears to be extremely positive. Total reported expenditure by the 191 CCGs in operation during 2019/20 on CYP MH services (excluding eating disorders) was £791.377m, compared to £702.704m in 2018/19 (12.6% increase). Moreover, planned CCG investment for the 2020/21 financial year amounted to £872.263m, a further increase of 10.2% if realised in the outturn data.

For CYP eating disorders specifically, reported spending by CCGs decreased from £50.593m in 2018/19 to £49.955m in 2019/20 (compared to a planned spend for the latter of £52.087m), a reduction of 1.3%. Planned spending for 2020/21 was £61.611m, which would be a 23.3% increase on the previous year if realised.

Combined spending over these two areas was therefore £841.333m in 2019/20 compared to £702.755m in 2018/19, an increase of 19.7%.

This however masks continued inconsistencies in reporting by CCGs, which prevents parliamentarians and researchers from being confident in the figures being published at the local level. The NHS England Mental Health dashboard has now aggregated the spending data for the areas covered by the 135 CCGs in operation until April 2021, so the numbers and percentages below are based on those figures.

For example, 16 CCGs (11.9%) reported spending less on CYP and CYP ED services combined in 2019/20 compared to the previous year in cash terms, with seven of those areas having a reported spending cut of at least 11.8% or more. 34 CCGs (25.2%) had a reported reduction in investment for CYP eating disorders, including 16 areas with a decrease of 22% or more in its investment level.

At the other end of the scale, 12 CCG areas (8.9%) reported combined spending having increased by more than 30% in a single year, with reported spending in NHS St Helens CCG increasing by 502%.

Operational Planning and Contracting Guidance from NHSE tells every CCG that they must increase the proportion of their overall budget that they spend on CYP mental health. It is therefore concerning that 13 CCGs (9.6%) are planning to spend less on CAMHS than their actual spend from the year before, according to the latest NHSE Mental Health Dashboard data, with only two of those also reporting a reduction in total planned spending on mental health (NHS North East Hampshire & Farnham CCG, NHS Thurrock CCG).

We know that the spending reported on CYP mental health should exclude reporting on learning disability and eating disorders, but it is possible that some CCGs include eating disorders in the figures they report for CYP mental health services despite the separation in the dashboard data.

The reiterated commitment in the Operational Planning and Contracting Guidance from NHSE for 2020/21 (prior to the guidance being suspended because of the pandemic) to increasing investment in services for children and young people year-on-year is of course extremely welcome, nevertheless this must be matched with more robust and consistent financial reporting.

In the same way that the mental health dashboard reports on whether each CCG has met the Mental Health Investment Standard, it should also report on whether each CCG has increased the proportion that they are spending on CYP mental health. If any CCG fails to increase the amount they spend it would be helpful if a short summary of the cause was also reported, for example it may be because of a non-recurrent funding pot coming to an end.

Supporting the mental health needs of those with a Learning/Intellectual Disability

There are clear pathways and services in most areas for the assessment of ADHD and ASD to identify all Children and Young People with these disorders and then offer management and treatments. However, there are no Learning/Intellectual Disability assessment services in the absence of co-occurring mental health or behaviours. The provision of Learning/Intellectual assessment services are required to identify those with a Learning/Intellectual Disability to ensure their needs are identified, are met lifelong and disability rights are promoted.

There are no national minimum standards for Children and Young people with Learning/Intellectual Disabilities regarding community mental health/behaviour/crisis services to meet the assessment and management needs. There is a postcode lottery for accessing local specialised care both in the community and within inpatient settings. To address this, we need a clear national strategy to set a minimum community service provision to meet the mental health and behaviour needs of children and young people with Learning/Intellectual Disabilities with requirements for commissioners to provide these locally.”

Inequalities in provision of Children and Young People’s mental health services

Like all NHS services there are significant inequalities in CAMHS services. To help commissioners tackle these inequalities the RCPsych has worked with NHE England to develop the Advancing Mental Health Equality (AMHE) resources. These are tools help commissioners to map which different groups need help in your area and how to work with these communities to improve services.

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

Restraint and prone restraint unfortunately remains high in children and young people’s mental health services and is, on average, over 5 times higher than the adult equivalent according the NHS Benchmarking data. While some wards have done well to reduce the use of restraint there is a wide variation in the rates of restrictive practices amongst different children’s wards.

The SafeWards initiative has been used nationally within the adult inpatient settings to great benefit, and restraint has been a focus of national benchmarking. This has resulted in significant decreases in restraint and particularly prone restraint for adults. Improvements within the CYP estate is likely to be enhanced by monitoring of restraint through the National Clinical Reference Group. 

Provider organisations must have oversight of the levels of restraint and segregation using per occupied bed days rather than the raw number and a target to reduce restraint and segregation in young people to the same, if not better level than in the adult inpatient population. This should be regularly reported at Board Level.

The Reducing Restrictive Practice programme was launched in November 2018 by the National Collaboration Centre for Mental Health (NCCMH), part of the Royal College of Psychiatrists. Of the 38 wards they worked with 5 were CAMHS wards[xii].

The programme involves those closest to the issue – staff, service users and carers - to identify and test new ideas using data to understand which ideas are working. It aims to change behaviours and attitudes on wards so that they focus on prediction and prevention rather than restraint.

All of the wards in the scheme saw improvement in at least one area including two who saw reduced the use of physical restraint, four cut down on the use of seclusion and four reduced the use of rapid tranquilisers. Overall, the CAMHS wards reduced the use of restrictive practices by 29%. It is important now that the lessons of this project are learnt and best practice is shared with all CAMHS wards.

This work has influenced the guidance published by the Government on Reducing the Need for Restraint and Restrictive Intervention[xiii]

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

Back in 2015 the Department of Health published a comprehensive plan called ‘Future in Mind’ to reform children’s mental health services which included a strong focus on early intervention. Unfortunately, much of these promises have not been acted on. For example, the closure of 1,000s of sure start centres surely goes against the principles of early intervention set out in Future in Mind.

In 2019, NHS Benchmarking estimated that the annual cost of operating a CAMHS inpatient bed is £219,000, and the average amount per 100,000 (0-18 year olds) on community CAMHS was £5.4 million[xiv]. If you consider that the most recent prevalence survey estimated that one in six children (5-16 year olds)[xv] had a probable mental disorder you can see that they are spending roughly around £324 per child with a mental disorder. The figures published in prevalence data is for 5-16 while the funding is for 0-18 so not directly comparable but it is enough to give you an idea of the scale of the different spend on community and inpatient care.

Staff inpatient CAMHS units tell us that in recent years in the severity of the mental health problems faced by the majority of children in their wards. This is largely driven by the difficulty of accessing these services so only those with the most serious cases are admitted to inpatient wards. Between 15/17 and 19/20 there has been a 12% increase in the number of children being detained under the Mental Health Act so more children are reaching crisis before they are able to get help[xvi], [xvii].

The NHS Long Term Plan proposes for young people an “integrated approach across health, social care, education and the voluntary sector, such as the evidence based ‘iThrive’ operating model”. The plan does not however say how the systems approach will be realised and funded as it needs cross sector investment including social care and appropriate education provision.

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

The 2018 NHS Benchmarking compiled an International Comparisons of Mental Health

Services for Children and Young People[xviii] showed some areas of concern for the UK nations.

The UK nations had the lowest number of children admitted to mental health beds per 100,000 population. With England admitting 33 children less than a third of the median number of the other nations. England and Wales have significantly higher average length of stays for CAMHS inpatient wards than other comparative nations. This seemed to be driven by a small number of wards which had very long lengths of stay.

The Benchmarking report also showed that England had a below average number of staff working in CAMHS (59 per 100,000 compared to an average of 67) and a below average number of consultant psychiatrists in both the community and a below average number per 100 inpatient beds.

A study of 28 European countries CAMHS services found that the UK had one of the lowest number of CAMHS Psychiatrists per head, ranking 21st with 4.5 psychiatrists per 100,000 compared to 36 in Finland or 23 in Sweden[xix].

As well as learning from other countries it is important that mental health trusts learn from each other. That is why the RCPsych set up the CCQI (College Centre for Quality Improvement). CCQI runs two networks one for children and young people one inpatient and one for community CAMHS.

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

The scale of the problem

Data from the Millennium cohort study found that pre pandemic 24% of 17-year olds had self-harmed in the previous year and that 7% of said they had harmed themselves “on purpose in an attempt to end your life”.[xx]

The COVID crisis has added to mental health difficulties faced by children and young people. NHS Digital have reported that the prevalence of mental health disorders amongst 4-16 year olds has increased from 1 in 9 to 1 in 6[xxi]. A review of likely child suicides in England during the COVID-19 pandemic raised a concerning signal that child suicide deaths may have increased during the first 56 days of lockdown in March to May 2020, but that the risk remained low and the numbers were too small to reach definitive conclusions.[xxii] It is important to acknowledge the complex reasons underlying cases of likely suicide, and there is no evidence of a simple link between the pandemic and any possible increase. It is important to continue to monitor this possible development particularly for vulnerable children such as those with autism.

Preventing self-harm and suicide in the community

When we are talking about community prevention, we need to remember that a large part of many children and young people’s community is online. The RCPsych recommends that psychiatrists ask young people about their online behaviour to get a better understanding if they might have a contribution to their problems. The College has also put together a position statement on ‘Technology use and the mental health of children and young people’ where we set out clear recommendations for how the new regulatory powers set up by the planned Online Harms Bill could help protect children from the most damaging content online[xxiii].

It is important that all staff who work with children are trained to spot signs of self-harm or suicidal thoughts. The National Collaborating Centre for Mental Health (NCCMH) based at the Royal College of Psychiatrists has developed a series of Self-Harm and Suicide Prevention Competence Frameworks for Health Education England (HEE) to support people who self-harm and/or are suicidal. One of these frameworks is particularly aimed at people who work with children.

The competency frameworks help, to makes suggestions about best practice in the light of current understandings of the effectiveness of approaches and interventions. One of the key recommendations from the frameworks is a move away from a risk assessment model to a risk reduction model. Risk assessments are failing to identify who is likely to die by suicide, so we need to look at how we reduce the risks for everyone in contact with mental health services and not just focus on those who have been identified as a high risk. It is important that the curriculum and training for the Mental Health Support Teams and School Designated Leads for Mental Health training and curriculum needs to take on board the recommendations of the competency framework for suicide prevention in children and young people.

When children and young people are in a mental health crisis, they need to be able to quickly access help. As different local areas have taken different approaches to providing crisis care the crisis line where staff need to have a good understanding of what services are available. This is probably best managed through investment in the 111 system so it is fully integrated into the healthcare system rather than trying to set up a new national mental health crisis line. We are pleased that the NHS Long Term Plan commits for all children to be able to access crisis care through NHS 111.

Once a someone gets through to a crisis line, they often need to be referred to somewhere and unfortunately crisis services are often patchy throughout the country.

The transfer between CAMHS and adult mental health services

In 2018 the Healthcare Safety Investigation Branch examined the link between suicide and the transfer between CAMHS and adults’ mental health services.  Their research found that few of the 25,000 transitions were ideal. They recommended that we need a flexible, managed transition to adult mental health services which has been carefully planned with the young person, provides continuity of care and follow-up after transition[xxiv].

The RCPsych is putting together a paper on how we can better manage this transition, from this work it is clear that as different local areas have different structures already in place there is no one model for 18-25s but all areas need to follow the principles set out by the work of the Safety Investigation Branch.

Preventing self-harm and suicide in inpatient wards

In-patient admissions for young people with repeat self-harm should be avoided as far as possible except where the potential benefits of admission clearly outweigh the risks. Admission should have clear goals with the shortest possible length of stay, with the close involvement of all stakeholders prioritising resolution of safety issues in community settings to enable discharge in a timely manner.

When a child is admitted for self-harming they should have their own individual plan on how to minimise the risk of suicide and further self-harm. The main barriers to this happening now is the lack of well-trained staff to carry this out.

The CQC’s State of Care report on mental health found that many mental health wards are unsafe and provide poor quality care in old and unsuitable buildings. The CQC argue that the design of many of these buildings do not permit staff to observe all areas easily and many wards contained fixtures and fittings that people who are at risk of suicide could use as ligature anchor points.[xxv]

Preventing self-harm and suicide after patients leave hospital

The time where children and young people are at most risk of suicide is the first weeks post discharge. A study of children who had been in psychiatric inpatient care in found that those who were given intensive community treatment were significantly less likely to have needed to return to hospital after six months[xxvi].