Written evidence submitted by the Children’s Commissioner for England (CYP0109)

About the Office of the Children’s Commissioner for England:

The role of the Children’s Commissioner was initially established under the Children Act 2004 which gave the Commissioner responsibility for promoting awareness of the views and interests of children. The Commissioner’s statutory remit includes understanding what children and young people think about things that affect them and encouraging decision makers to always take their best interests into account. Her unique data gathering powers and powers of entry to talk with children and gain evidence, enable her to help bring about long-term change and improvements for children, particularly the most vulnerable.

The Children and Families Act 2014 further strengthened the remit, powers and independence of the Commissioner, and gave her special responsibility for the rights of children who are in or leaving care, living away from home or receiving social care services.

The current holder of the office is Anne Longfield OBE, her tenure ends on the 28th February 2021. Dame Rachel de Souza takes office on the 1st March 2021.

The Children’s Commissioner’s Work on Children’s Mental Health

The Children’s Commissioner undertakes an annual consultation with children to inform her annual business plan. Mental health has consistently been the top issue raised by children, in a variety of different settings.

Since 2017 the Children’s Commissioner has produced an annual briefing on the state of Children’s mental health services which assesses the provision of NHS children’s mental health services (CAMHS). This briefing is compiled using data from NHS England and NHS Digital, under Section 2(F) of the Children Act 2004. The latest briefing covers the financial year 2019/20 and is available here: cco-the-state-of-childrens-mental-health-services-2020-21.pdf (childrenscommissioner.gov.uk)

In addition, we have utilised Section 2(F) to undertake a nationwide survey of low-level mental health provision (pre-CAMHS), to see both what is provided, and how this burden is shared between CCGs, local authority children’s services departments and local authority public health teams. This is available here: Early access to mental health support | Children's Commissioner for England

We also undertake a regular programme of visits to children’s mental health inpatient units, undertaken under Section 2E of the Children Act 2004, which gives the Office of the Children’s Commissioner a right of entry to such premises. This has informed several published pieces of work, including a 2019 report focusing on the experiences of children in in-patient learning difficulty units: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/05/CCO-far-less-than-they-deserve-2019.pdf

A note on this submission: In order not to repeat work published elsewhere, this submission is deliberately short and focused on questions posed by the Committee. However, this only represents a fraction of the overall work of the Office of the Children’s Commissioner, and we remain more than willing to provide supplementary oral or written evidence on any of the points if it would be helpful.

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

1. The ambitions laid out in the 2017 Green Paper and improving access to mental health services.

Our 2020 briefing on children’s mental health finds that the Government is on track to meet the treatment targets outlined in the 2017 Green Paper. Whether it is will also meet the treatment targets in the NHS Long Term Plan is less clear. The technical report that accompanies our briefing assesses various scenarios: cco-the-state-of-childrens-mental-health-services-2020-21-tech-report.pdf (childrenscommissioner.gov.uk)

However, while we find that services are improving (both in terms of access and waiting times), we find they are still inadequate when compared to the needs of children, especially given increased rates of mental health issues resulting from the pandemic. Children are more aware of their mental health, and feel more empowered to seek help. This is positive, but services are not expanding at a sufficient rate to be there for children when they do need help. In the year before the pandemic (2019/20), there was a 35% increase in referrals to the NHS, but only a 4% expansion of treatment places.

The more fundamental question was whether the initial targets were ever ambitious enough, and the position of the CCO is that they were not. We think the approach adopted by NHS England in devising these targets was the wrong one. It is our view that NHS England established a model and then the pace at which this model could be expanded determined the overall rate of service expansion. We would have preferred NHS England to have accepted the failures in CAMHS access as a problem which required more creative solutions, and greater ambition. In particular, we have been consistently critical that there are not greater roles for in-school counselling, the voluntary sector and digital service provision within the NHS CAMHS model.

Moreover, a consistent finding of our annual mental health briefings is huge local-level variation between areas. There is no clear pattern to this variation: adjacent CCGs consistently have widely different performance. This suggests that it is local level prioritisation of children’s mental health services, as much as national capacity, which is the biggest constraint on improving services. Our research suggests that there are a group of around 20-30 CCGs (and this number is expanding rapidly) which are investing in CAMHS and improving services far beyond national expectations.

2. Provision of mental health support in schools.

We have not conducted a large-scale survey of mental health provision in schools, so we cannot say whether provision has changed since the DfE’s survey of in-school provision[1].

But our observation from our regular programme of engagement with children is that more children are mentioning in-school lessons and are feeling positive about the skills these are giving them to talk about their mental health.

However, we encounter a huge divide amongst children in terms of access to additional help through school. Our experience is that children are very much aware of this. Where children can access counselling in or through their school, they regularly mention this and, even if they have not accessed the service themselves, feel more confident because this option is available. In contrast, when an in-school counselling option is not available, children are regularly critical of this failing, and are angry that this means the have to go through CAMHS assessments and waiting lists, potentially unnecessarily. The quotes we have included in our 2020 Mental Health Briefing illustrate this divide.

The Children’s Commissioner has consistently advocated for every child to be able to access mental health support through school, and believes this should be an NHS commitment. Children repeatedly tell us that they want to be able to access support on their terms, and with minimum fuss. For most children this means an in-school offer. Where this is available children overwhelmingly support this.

To this end we strongly support the introduction of Mental Health Support Teams. We think these are the right model, but we think the target to have them in a minimum of 20% of areas by 2022/23 was under-ambitious. We would like to see a clear commitment to have them in all areas, and we believe a more flexible approach, with a bigger focus on the voluntary sector which can help deliver this.

3. Provision of support for young people with eating disorders.

Our annual briefings show a more significant rate of progress in eating disorder services than general CAMHS services, with the introduction of waiting time standards that are broadly being met, and capacity being increased at a (relatively) faster rate. However, as with general CAMHS services, there is a concern as to whether the system has capacity to meet the steep rise in referrals caused by Covid-19.

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

We have not undertaken systematic research into the workforce. However, these are observations drawn from existing work:

1)      Given that NHS England have consistently cited the workforce as the biggest limiting factor in terms of expanding CAMHS services, we would expect to see exponential growth in CAMHS provision, as reforms introduced through Future in Mind and the Green Paper deliver an expanded training provision. As our 2020 technical report explains, we are not seeing this. This would suggest insufficient attention has been paid to expanding the workforce[2].

2)      Through our regular engagement with mental healthcare providers (NHS and voluntary sector) we have discussed issues with expanding the workforce. Given the demands of this, it is largely dependent on being able to upskill/retrain staff with an existing training in therapeutic work - particularly social workers, mental health nurses and those working elsewhere in mental health services. The following issues are regularly raised:

1. The MHST model, with a reliance on an entirely new Band-5 level position, has been criticised for being overly prescriptive. The requirements to design, and then implement, a new training regime has significantly slowed down roll-out. The demand that this be a Band 5 role means that existing professionals would not consider it for re-training. It also precludes existing registered psychotherapists working in-school or in the charitable sector. We have encountered services which have been decommissioned because their staff are ‘over-qualified’ to work as part of MHSTs.
2. The routes for re-training existing professionals into Band 6/7 roles seem to be inconsistent. Some areas report this being a real strength of their model, others criticise the lack of training opportunities for Band 6 roles, and incentives for other professionals. Several areas have told us they have not been able to establish the same training programmes/pathways with university partners as they have for adult services.
3. Because adult services are expanding at a greater rate than child services, there is more possibility for advancement and promotion in adult services, which can undermine efforts to retain staff.

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.

There are two separate, but interrelated issues which we believe need to be addressed here:

1. The accessibility of children’s inpatient units and the relationship between inpatient mental health care and children’s social care.
2. The quality of mental health inpatient units, and the use of restraint.

We would strongly urge the Committee to examine both issues.

The accessibility of children’s inpatient units and the relationship between inpatient mental health care and children’s social care.

There are a group of children in England who have both challenging behaviour/self-harming and mental health issues who are not well provided for within either social care or mental health care. Our report ‘The children no one knows what to do with’ examines how the state responds to these children, and the frequent disputes between children’s social care and mental health as to who should take responsibility: The children who no-one knows what to do with | Children's Commissioner for England

The Children’s Commissioner receives an increasing number of Family Court judgements which highlight the plight of these children.

“It is plain that, despite the issue being highlighted in multiple court decisions since 2017, and by the Children’s Commissioner, the shortage of clinical provision for placement of children and adolescents requiring assessment and treatment for mental health issues within a restrictive clinical environment, the shortage of secure placements and the shortage of regulated placements remains. In this context, children like G with highly complex needs and behaviour continue to fall through the gaps that exist between secure accommodation, regulated accommodation and detention under the mental health legislation.” - Lancashire CC v G (Unavailability of Secure Accommodation) [2020] EWHC 2828 (Fam)

This more recent judgement highlights a case where there was serious dispute about what the most appropriate kind of care is for a child with a mental disorder, and where ultimately only a place in an unregistered setting could be found, as neither a Tier 4 mental health bed nor secure children’s home bed could be found:

                   “On 13 January 2021 a Mental Health Act 1983 assessment hereafter (MHA) of E was undertaken.  The MHA resulted in two clinicians completing medical recommendations in support of the detention of E under s.2 of the Mental Health Act 1983, although at this time there were no Tier 4 Psychiatric beds available. […]  In E's case the AMHP declined to apply for the admission of E, considering that secure accommodation under s. 25 of the Children Act 1989 was more appropriate in light of the risks presented by E.” A Borough Council v E (Unavailability of Regulated Placement) [2021] EWHC 183 (Fam) (05 February 2021)

The Children’s Commissioner’s Office regularly sees such cases, and such judgements. This shows both that there is a shortage of Tier 4 beds for critically ill children, but also that there is confusion and dispute as to where children with severe mental health difficulties, including those at risk of taking their own life, should be cared for. If a child does not meet the criteria for detention under the Mental Health Act and yet is clearly at high risk, too often it appears that there is nowhere appropriate. There is limited information about the number of children in this situation. We know that over the course of 2019/20 there were 327 children deprived of their liberty under the inherent jurisdiction of the high court – this is used when a child is deprived of liberty but not in any formally designated secure accommodation, either because none is available or because non-secure accommodation is preferable. We know that some of these children end up in makeshift, unstable places – for example, one child living in a holiday cottage which she had to vacate as it had been let out for the weekend. These issues are examined in more detail in our report into children detained by the state: https://www.childrenscommissioner.gov.uk/report/who-are-they-where-are-they-2020/ 

While the fault for this is shared between the NHS and social care, one immediate problem is the failure of NHS England to provide proper mental health care for children in care. About 80% of children’s homes are privately run, and these homes specialising in providing care for highly vulnerable children tend to provide mental health care ‘in-house’,  provided by the private company and commissioned by the local authority. This means both that these very vulnerable children miss out on NHS care (something they are entitled to under the NHS covenant) and that their treatment is not overseen either by the NHS (who neither commission[3] or provide it) or the CQC (because the home is registered as a children’s home not a hospital). Where homes do not have in-house provision, children in care must access it through their local GP, where the children’s home is located. If this is a placement out of area, children start all their treatment again when moving home, and can find themselves at the back of a CAMHS list. Instability is so high in these homes that we have met children who have been moved several times and each time go to the back of the CAMHS waiting list, never accessing treatment. There is a commitment in the NHS Long Term Plan to improve provision for these children, but the Children’s Commissioner has not seen progress towards this.

We would like to see the NHS commit to providing specialist treatment for children with challenging behaviours and self-harming within children’s social care. The Secure Stairs model, designed by NHS England for the youth justice estate, could form the basis of a clinical model for this.

For further information on the children detained across either secure welfare, secure mental health or deprived of liberty in some other setting, please see our annual report ‘Who are they? Where are they?’:

cco-who-are-they-where-are-they-2020.pdf (childrenscommissioner.gov.uk)

The quality of mental health inpatient units, and the use of restraint.

During 2020 the Children’s Commissioner’s Office has published two reports into children’s experiences within inpatient mental health settings. The first looks specifically at the response to Covid-19, and the degree to which support for children was maintained during the first Covid-19 lockdown. This can be read here:

https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/10/cco-inpatient-mental-health-wards-during-covid-19.pdf

The second was a more general survey of the experiences of children in mental health wards prior to Covid-19 and can be read here: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/11/cco-childrens-experiences-in-mental-health-wards.pdf

It shows that some children felt that inpatient admission was essential for them, and some spoke about receiving good care from staff. However, it highlights the profound impact of restraint on children:

“When you know those nurses are coming into the room it’s a wave of terror because you know that it’s happening and I do everything I can but when there’s like seven people on top of you trying to hold down each limb of your body, it’s the worst thing. I just cry – don’t do it.”

Particularly for those who found it to be a re-traumatising experience:

“They would grab me and I’d instantly start screaming my head off because I’m straight back to that place that I don’t want to be at. They grab you and it takes a lot of people for me to be restrained.”

The report particularly focused on the differences between children admitted ‘informally’ (through their consent or the consent of a parent) and those admitted under section. While we acknowledge that for some children making the decision themselves can be empowering, many felt either coerced into consenting, or had no choice as it was decided by parents. We are therefore very supportive of suggested reforms of the Mental Health Act which would guarantee advocacy for informal patients, and it is essential that this is not made subject to funding availability.

The full report can be read here: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/11/cco-childrens-experiences-in-mental-health-wards.pdf

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.

In 2019 we published a survey into low-level mental health provision in England. The Children’s Commissioner’s research is the first time any organisation has collected data to show how much is being spent by areas in England on low level mental health. It reveals that local areas, which included both local authorities and NHS spending, allocated a total of £226 million for low-level mental health services in 2018/19, just over £14 per child.

The report shows there were wide variations between areas in how much funding is available: the top 25% of local areas spent at least £1.1 million or more, while the bottom 25% spent £180,000 or less. Within this, there is also significant variation as to how much is contributed by the NHS and how much by local authorities, and how this composition has changed over the last 3-years. Full details are available here: Early-access-to-mental-health-support-Technical-report.pdf (childrenscommissioner.gov.uk)

This points to a fragmented system whereby responsibility for early provision is contested and inconsistent.

As outlined above, we would like a significant shift to community-focused mental health treatment which is more flexible and meets children on their own terms. This means in-school, online and open-access options for children. We support the Thrive model of interventions and are pleased to see NHS England commit to it, but there is a lot of work to do to see this model realised in national and local commissioning. We see MHSTs as an important part of this, but this needs to be in all areas of the country. As we have outlined above, the system currently lacks flexibility and overall rates of access are so low that children repeatedly tell us about battles to access services which exacerbate existing problems.

We would also like to see a much greater focus on the mental health of younger children (aged under 12). We frequently encounter young children with emotional health problems and challenging behaviour who have been told that they are not meeting thresholds for CAMHS because they do not have a clearly diagnosable condition. We believe that too often adult definitions are being applied to children.

We are also concerned about inconsistencies in the offer to young children, in particular:

• Access to family-based therapies
• Access to specific types of therapies which are more accessible for younger children, including play therapy and art therapy. Recent international evidence reviews[4] have established that these are highly effective, and this should be reflected in English commissioning policy.

We are concerned that NHS England do not have a clear expectation as to what should be provided in this regard and do not have adequate data about what is provided in different areas and how many younger children and families are accessing it. This is one area where we have witnessed a good offer in other countries, including France and Australia.

It is also one area where we would have liked to see more in the NHS Long Term Plan. The Long Term Plan contains clear commitments on perinatal mental health, including a plan to look at more innovative therapeutic approaches for children up to 24 months, but the Children’s Commissioner would like to see the same commitment for children 2-12yrs.