Eighth Report - Children and young people’s mental health

Children and young people’s mental health is an all-society issue. The problems discussed in this report can only be addressed by Government departments, local government and the health system acting together to promote good mental health and prevent new crises emerging. We recommend setting up a Cabinet sub-committee to bring together different departments to make sure this happens.

Although the full long-term impact of the coronavirus pandemic on the mental health of children and young people under the age of 25 is as yet unknown, it is already clear that the mental health needs of these groups have been much exacerbated by the pandemic. This has been supported by NHS data from July 2020 which shows that one in six young people now have a probable mental health disorder. But the impact of this has not been even across different children and young people, with older teenage girls, for example, particularly affected by the rise in eating disorders. In order to understand the level of need in children and young people’s mental health as well as the inequalities that continue to exist, more regular and accurate prevalence data is urgently needed.

The gap between the 2004 and 2017 NHS Digital Mental Health Surveys was too long, and this must not be repeated. We recommend that NHS Digital regularly collect and publish robust prevalence data for mental health conditions every three years, starting from the end of 2021 disaggregated by age, ethnicity, sexuality, gender, and condition, alongside a plan to address any disparities uncovered. Such a study should also examine both unmet need and the risks of overmedicalisation of minor issues.

During the pandemic, children and young people’s mental health has significantly worsened and the scale of the backlog mean that the NHS will not be able to treat its way out of this crisis. The need for early intervention and prevention in children and young people’s mental health has been consistently overlooked by successive governments and although there has been a significant expansion of services recently the pace of change has not been keeping up with increases in demand. Still today too many children and young people are reaching the point of crisis before they can access any mental health support. This compounds stress not only on the individuals affected, but across society more widely. The lack of adequate protective support and early intervention create unnecessary pressure across the entire healthcare system, from GP appointments to A&E presentations and NHS inpatient services.

The Department of Health and Social Care—in partnership with the Department for Education and all other relevant Government departments—must take radical steps to shift the focus in mental health provision towards early intervention and prevention. This must ensure that all children and young people under the age of 25 can receive mental health support as early as possible and no young person is turned away from mental health support for not being ill enough. The Department must focus its attention on: Children and young people’s mental health 55 a) the faster roll out of Mental Health Support Teams, as detailed in Chapter 3 of this report; b) a network of community hubs based on the Youth Information Advice and Counselling service model detailed in Chapter 4 of this report and; c) digital support, as detailed in Chapter 4 of this report.

We expect a full and comprehensive update from the Department on what measures it will implement, how this work will be funded and a timeframe for key outcomes relating to increased early intervention and prevention. We expect this information by the end of January 2022. (Paragraph 36) Increasing access to mental health services

Commitments in the 2017 Green Paper and the NHS Long Term Plan have been taken seriously by NHS England and led to a significant expansion of provision. We are, however, concerned that many commitments may not yet be ambitious enough to ensure every young person with a diagnosable mental health condition can access care. Currently, waiting times for accessing children and young people’s mental health services remain far too long, and too many referrals to specialist services are inappropriately rejected. We are also concerned that, despite the NHS Long Term Plan committing to improve access to specialist support for all children and young people aged 0–25, children below the age of three have largely been overlooked to date. The Early Years Health Development Review provides an opportunity for Government to ensure a more consistent offer for families to help strengthen parent-infant relationships which are a key foundation for good mental health.

We recommend that NHS England & Improvement set out a clear action plan including key milestones, deadlines, and funding for how they will meet their target set out in the NHS Long Term Plan of 100% access to specialist support for all children and young people aged 0–25 by 2029, without raising the already high thresholds for accessing support.

We further recommend that NHS England & Improvement hold Clinical Commissioning Groups, which have consistently failed to meet national expectations, to account on key measures such as expenditure, waiting times and access rates. National ambitions should be raised in line with the best performing areas so that best practice becomes universal practice. This is essential to ensuring that provision of children and young people’s mental health services does not remain a ‘postcode lottery’.

We welcome and support the proposals in the recent access and waiting times consultation that concluded on 1st September, including crisis response times and a four-week waiting time limit for children and young people, and call on NHS England to publish a detailed roadmap as to how it will be delivered including the additional funding requirements.

It is clear that young adults between the ages of 18 and 25 face some of the widest gaps between the support that they need and the support that is available to them. 56 Children and young people’s mental health We welcome NHS England & Improvement’s commitment to shift away from the current model of care towards one that provides for those aged 0–25. However, we have heard progress on this has been slow, with large variation between areas on what age services are commissioned to. Lucas’s story provided a stark reminder that the transition to adult services remains poor for many children and young people, with high rates of drop-out from services in this period. It is essential that young people do not experience a sudden drop in their support at the age of 18.

NHS England & Improvement must accelerate the implementation of the 0–25 offer in every local area as a national priority so that young people do not continue to face a cliff edge in accessing the care they require as they transition from children to adult services.

One of the largest barriers to increasing access to mental health provision for children and young people remains the size of the mental health workforce. We have seen that children and young people’s mental health practitioners face staff shortages, increasing demand and high levels of work-related stress which in turn leads to more part-time work and increased early retirement. We have already made recommendations to the Department on providing mental health and wellbeing support to NHS staff in our previous Report into workforce burnout and resilience in the NHS and Social Care. In particular, we are clear that: • Integrated Care Systems (ICSs) must be required to facilitate access to wellbeing support for NHS and social care workers across their systems, and that they are accountable for the accessibility and take-up of those services. (Workforce burnout and resilience in the NHS and Social Care, Second Report of Session 2021–2022, Paragraph 39); and • the level of resources allocated to mental health support for health and care staff must be maintained as and when the NHS and social care return to ‘business as usual’ after the pandemic; and that the adequacy of resources allocated to that support be monitored on a regular basis. (Workforce burnout and resilience in the NHS and Social Care, Second Report of Session 2021–2022, Paragraph 40).

In addition, it is paramount that a plan is implemented to increase the size and wellbeing of the children and young people’s mental health workforce based on independently verified estimates of the number of people needed in different disciplines and the training places required to deliver them. The strategy should include an assessment of how the skill mix of the workforce can be developed to include other expert professionals such as speech and language therapists, social workers, youth workers and the importance of a diverse workforce in improving outcomes for minority ethnic groups. The Department of Health and Social Care should work with Health Education England to develop this plan to build on the steps already taken to expand the workforce and enhance the skills of the wider workforce. (Paragraph 68) Mental health support in schools

We have seen that Mental Health Support Teams, where they have been rolled out, are well-placed to facilitate early intervention for children and young people as part Children and young people’s mental health 57 of a whole school approach. They appear to have delivered positive outcomes for children and young people where they are up and running. We welcome the fact that under the current trajectory the commitment of 20% to 25% coverage will be delivered a year ahead of schedule and we welcome the commitment that the Government and NHS England & Improvement have shown to deliver this roll out. But reaching only around half of children by the end of this Parliament shows the original ambition is too low and it should be increased, at a minimum, to reaching two thirds of schools by the end of the Parliament if we are to reduce referrals for severe conditions by as much as needed.

We therefore recommend that the Department of Health and Social Care fully fund and scale up the roll out of Mental Health Support Teams to cover two thirds of schools in England by 2024/25 and 100% by 2027/28.

Furthermore, in light of the rise in both prevalence and severity of children and young people’s mental health difficulties, the training of Education Mental Health Practitioners should be reviewed to integrate their skills into a new psychological professions structure. This must include training experienced practitioners in more sophisticated psychological therapy so that they can work with more complex cases such as eating disorders and self-harm.

A whole school approach to mental health and wellbeing should include the promotion of good mental health as well as the early identification of those who are at risk of mental health difficulties. Designated Senior Leads for mental health can have an extremely important role in overseeing and leading this whole school approach but they need to be adequately trained, particularly in how to identify and intervene in emerging cases of mental health problems. Given the worrying signs that more children and young people are turning to self-harm as a coping mechanism and more are struggling with eating disorders, it is extremely concerning that training for Designated Senior Leads appears to have been paused and has not yet been rolled out four years after the Green Paper committed to do so.

It is vital that the Department rolls out the training for Designated Senior Leads to all schools urgently with a commitment to completing the roll out before the end of the current Parliament. Moreover, given the worrying trends in self-harm and eating difficulties among children and young people, it is essential that this training includes sufficient training specifically for the early identification of self-harm and eating disorders as well as mild to moderate mental health problems generally. We expect a comprehensive update on work towards this ambition by the end of December 2021.

Whilst Mental Health Support Teams and Designated Senior Lead training is being rolled out, the Department of Health and Social Care and the Department for Education should work closely together with all schools to ensure that they have the support they need in order to offer a whole school approach, including: access to digital self-help support; school counselling for every child who needs it; and good guidance on best practice for staff on how to provide the most appropriate support in schools. (Paragraph 93) 58 Children and young people’s mental health Importance of community-based and digital mental health support

For some children and young people where schools are not their preferred place to access support, drop-in hubs that operate on an open access, self-referral basis provide a valuable alternative opportunity to access help. We have heard that the large-scale roll out of a similar style system has improved outcomes for children and young people in Australia. Where these hubs already exist in the UK, based on the Youth Information Advice and Counselling model, they fill a vital gap in the health system and are perceived as accessible to young people. They are also capable of reaching those who may be less able to access traditional services. However, while these have been rolled out in some areas of the country, we have heard that this is subject to local funding priorities and is far from a standard provision. Access to these drop-in services should not be dependent on where a young person lives but should be available nationally.

We recommend that the Department of Health and Social Care fund and roll out open access models to every area across the country so that there is a consistent, comprehensive community offer to complement available school-based and clinical support across England. The hubs should also offer outreach support to vulnerable groups and should be integrated with specialist children and young people’s mental health services with a clear step down/step up relationship. National standards for the provision of support should be published so hubs adhere to clinical standards.

The social care sector is essential to the provision of mental health services to children and young people and it is essential that it is funded to do so as part of the forthcoming social care white paper.

Equally vital is the role of the new Integrated Care Systems and it is essential they publish detailed plans with timescales as to how community provision for the mental health needs of children and young people will be improved working jointly with the local social care system.

For those children and young people who prefer accessing help online, digital services can be an important way of reducing barriers to access so it is important that a digital offer should be available for all young people. To prevent over-medicalisation of mental health conditions this should include self-help options as well as digital counselling offers. However, digital support options are not appropriate for all children and young people, and in fact can pose barriers and exacerbate inequalities for some. Therefore, targets for improving access to services should not be met by over-reliance on digital support. These models should complement, rather than replace the existing in-person offers. (Paragraph 117) Inpatient care

Inpatient units have a role to play in treating some of the most severe and complex mental health conditions, especially those that are resistant to community treatment. However, in most cases the most compassionate and effective care for children and young people is provided in the community–and increasing its provision must be the overall aim of the Department and NHS England & Improvement. We have Children and young people’s mental health 59 set out the benefits of Trieste model of care in more detail in our report into The treatment of autistic people and individuals with learning disabilities. We believe that the principles of this model of care are also appropriate for children and young people’s mental health treatment.

We therefore recommend that the Department accelerates the shift towards increased community-based provision and a reduced inpatient bed base as a national priority to ensure that children and young people with the most complex needs receive good quality care in a setting that is right for them. A national strategy should be set out to establish jointly commissioned health and social care services. To ensure children and young people are not ‘parked’ in inappropriate in-patient care, an independent psychiatrist should sign off the need for inpatient provision on a monthly basis for all young people who have stayed for longer than three months in a mental health hospital. This should be backed up by legislative changes. It should equally apply to those with a learning disability, autism, or both.

In order to achieve this shift towards community-based care, every area should have a community service for children in crisis which is available 24 hours a day, seven days a week. A clear map is needed of where current gaps in this provision are and a plan should be in place to ensure these services are available in every area. This should include 24/7 all age liaison psychiatry in hospitals, crisis services in the community, and 24/7 crisis support teams in all areas. These should have specialist expertise in preventing admissions and supporting children and young people with autism, a learning disability or both.

For those children and young people for whom inpatient admission cannot be avoided, a continued focus is needed to increase the quality of this care. As well as much improved data collection, this should include access to therapies, activities and education, including from private sector providers. It should include a stronger voice for children, young people and their families through access to advocacy for all children and young people.

It is disappointing that the Government’s 2021 Mental Health White Paper leaves expanding the legal right to support from an advocate to all children and young people subject to future funding availability. There is a compelling case that Independent Mental Health Advocates have a valuable role in helping inpatient children and young people understand their rights and raise any concerns that they may have. It is nonsensical that this resource is denied from children and young people admitted informally, who are often living under the same conditions as those admitted formally.

The Department should commit to expanding Independent Mental Health Advocates support so that all children and young people admitted to hospital informally have the same legal right to an Independent Mental Health Advocate as those admitted under legislation without qualification. This advocacy should all operate on an opt- out basis.

We welcome the Government’s commitment to reducing the use of seclusion, segregation and restraint for children and young people in inpatient units and the Mental Health Units (Use of Force) Act in particular. However, we have heard that 60 Children and young people’s mental health restrictive interventions, and particularly restraint, are still used excessively and avoidably against children and young people in inpatient settings and in transit. We are particularly concerned about the continued use of prone restraint on children and young people, despite guidance stating that prone restraint should be avoided due to the increased risk of death from this position. It is extremely worrying that restraint, and particularly prone restraint, is being used on children and young people at a much higher rate than in adult services.

In addition to our recommendations on the use of restraint that we set out in our report on the treatment of autistic people and people with learning disabilities, the use of prone restraint on children and young people should be banned in all inpatient settings and in transit. Further action should be taken with all inpatient and transport providers to minimise restrictive practice by sharing best practice from programmes such as the SafeWards approach with all children and young people’s inpatient units nationally. In line with requirements to report incidents of restraint in inpatient settings and children’s homes, all organisations involved in the transportation of children should be required to report such incidents so that these can be monitored and acted upon where necessary.

It is vitally important to be able to monitor the experiences of children and young people in inpatient care, particularly how often restraint is used in each setting and whether there is appropriate access to advocacy. This is key to ensuring individuals in inpatient care are receiving quality support and treatment, and to avoid the lowering of the standard of care. It is therefore highly concerning that the data currently available on the use of restraint in inpatient settings is incomplete and of very poor quality, while there is no publicly available data at all on how many children and young people have a legal right to an advocate. Failure to understand the current experiences of children and young people in inpatient units only provides a further hindrance to the Government’s and NHS England and Improvement’s plans to improve the care provided in these settings. Higher national standards in data collection should be set by NHS England and Improvement and services that consistently fail to meet these standards should face greater accountability.

In addition to the recommendations on data we set out in our report on the treatment of autistic people and people with learning disabilities, we further recommend that NHS England and Improvement regularly collect and publish high quality data including from private sector providers on: • the basis of children and young people’s admission to inpatient units; • the number of children and young people not accepted into units; • the waiting list for children and young people waiting for adequate community provision; • the number of children and young people receiving advocacy support; • the number of children placed out-of-area; and • the length of their stay in inpatient units. (Paragraph 155) Children and young people’s mental health 61 Self-harm and suicide prevention

We are deeply concerned about the increasing numbers of children and young people who experience self-harm and suicide and the quality of care they are able to access. Much more needs to be done to tackle suicide and self-harm amongst children and young people. In particular, given the link between self-harm in children and young people and later suicidality, any suicide prevention strategy must include improving the support available to those who self-harm. We have heard that too often, children and young people’s mental health services are not commissioned with self-harm in mind. It is essential that self-harm is not used as a reason to reject referrals to mental health services. While we welcome the inclusion of self-harm in the National Suicide Prevention Strategy, we are clear that support must be available earlier to these children and young people, before they reach a crisis point.

We recommend that the Department implement a new system of early intervention to support children and young people who self-harm and are at risk of committing suicide. Educational settings, as a universal provision, can have an important role to provide effective early intervention to pupils who may be struggling with self-harm before the mental health need becomes more acute. Mental Health Support Teams are well placed to deliver these interventions and an accelerated roll out of these teams would increase the capacity of schools and colleges to support those children and young people who may be struggling. Education Mental Health Practitioners must be trained in self-harm and suicide prevention specifically.

For those children and young people for whom school is not the most accessible place to seek support, there must also be a community-based offer. This could be based on the network of drop-in hubs outlined in Chapter 4 of this report, which provide open- access mental health support without the requirement for a referral or high thresholds for access.

Preventing the worst mental health outcomes means first creating the conditions across society that are conducive to good mental health and wellbeing. We welcome the support provided by the former Minister for Patient Safety, Suicide Prevention and Mental Health to a ‘cross-governmental’ strategy to prevent the worst mental health outcomes for children and young people as well as her recognition that mental health should not be only the concern of the Department of Health and Social Care. The complex, multifaceted nature of the causes of suicide and self-harm necessitates a public health approach to suicide prevention that involves cooperation between Government departments, local government, education and the care sector. Given that self-harm is often used as a coping mechanism for other forms of severe emotional distress, the wider points made on public mental health in Chapter 1 of this Report will also help to prevent it.

We recommend that each Government Department, led by the Department of Health and Social Care should set out specific, measurable objectives for mental health promotion in each policy area. This should include policies that aim to build mental health resilience in the population as a whole, as well as specific interventions targeted at those who have the greatest mental health need. (Paragraph 173) 62 Children and young people’s mental health