Select committee inquiry
Mental health services for children and young people inquiry
Closed
What the inquiry looked at
“Scope of the inquiry Only a quarter of children and young people who require mental health support can access the services they need. Demand for these vital services is increasing: according to government estimates, the number of children and young people with a mental health condition is likely to be higher in 2018, compared to the last time data was collected in 2004. The Government committed an additional £1.4 billion to children and young people’s mental health services between 2016-17 and 2020-21. It aims to treat an additional 70,000 children and young people per year between 2015-16 and 2020-21. However, a recent National Audit Office report found that even if current Government initiatives are delivered as intended, there would remain significant unmet need for mental health services amongst young people. There has been slow progress on increasing the mental health workforce in England: planned NHS recruitment was below target by 1,000 staff in March 2018. The report also found significant weaknesses and unreliability in government data. With the last estimate of children and young people with a mental health condition carried out in 2004, there is a risk that the Government does not understand how many need treatment. If new estimates, expected late 2018, are 50% higher than in 2004, the NHS would have to treat an additional 186,000 young people to meet their targets. The Committee will question the Department of Health and Social Care and NHS England on how additional funding for mental health services for children and young people has been spent. It will also examine the reliability of government data and whether NHS targets will meet the increasing demand for these services. Chair's comment Chair of the Public Accounts Committee, Meg Hillier MP, said: “The Government’s ambition of parity between physical and mental health services has a long way to go. The Government urgently needs to set out how departments, and national and local bodies, are going to work together to achieve its long-term ambition.””
The committee's words, from the inquiry page on parliament.uk ↗.
What it found
In the committee's words, from the summary of 72nd Report - Mental health services for children and young people ↗
In 2017–18 only three in ten children and young people with a mental health condition received NHS-funded treatment, and many more faced unacceptably long waits for treatment. The government has committed to providing ‘parity of esteem’ between mental and physical health services, but it is still unclear what it means by this in practice.
It also has no comprehensive, long-term plan for how it will fulfil its commitment to implement Future in Mind, which set out a cross-sector vision for how to support children and young people’s mental health. There is now a welcome focus on improving NHS mental health services for children and young people, but there are still significant gaps in the data to monitor progress. Recently published figures have underlined the scale of the task faced: one in eight (12.8%) five to 19 year olds have a mental health disorder. There has also been a marked increase in the number of five to 15 year olds who suffer from an emotional disorder: the figure now stands at 5.8% in comparison to 3.9% in 2004. Work to increase mental health staff numbers and develop the right skills has also progressed more slowly than planned. The recurring issues with recruitment and retention of NHS staff remain unchanged and it is clear that the government’s inability to increase the number of mental health nurses is a roadblock to progress in this area. New and important ways of supporting young people’s mental health through prevention and early intervention, particularly in schools, are now being developed.
The government must make urgent headway on all these fronts if it is to provide the mental health services and support that young people need.
What the government said
No government response is linked to this report.
How the inquiry ran
Each dot is a dated item listed on this page, from the inquiry's opening on 19 September 2018 to 11 January 2019.
- Oral evidence 31 Oct 2018
- Report 11 Jan 2019
- Correspondence 2 letters
What it recommended 1 recommendation · 20 conclusions
1Most young people with a mental health condition do not get the treatment they need,...
Concluded (the committee's words)
Most young people with a mental health condition do not get the treatment they need, and under current NHS plans this will still be true for years to come, while many face unacceptably long waits for treatment. The NHS’s Five Year Forward View for Mental Health (Forward View) aims to increase the proportion of children and young people with a diagnosable mental health condition who access NHS- funded treatment from an estimated baseline of 25% to 35% by 2020–21: this would still leave two-thirds of young people in need without NHS treatment. Similarly, the Green Paper plans to introduce new mental health support in schools will only cover up to a quarter of the country by 2022–23. The NHS estimates that just 30.5% of children and young people with a diagnosable mental health condition accessed NHS-funded treatment in 2017–18. We heard numerous examples of families unable to access the treatment they need or having to wait too long for treatment. Preventing and intervening early in mental health conditions is thought to reduce the need for more specialist services and reduce future costs. Yet children and young people are being turned away from NHS services because their condition is not considered severe enough to warrant access to overstretched services. There is a clear risk that young people reach crisis point if they do not get help but the NHS has limited sight on what happens to children and young people turned away from NHS services.
2Recommendation: From April 2019 to April 2022, the Department and NHS England should provide annual...
Concluded (the committee's words)
Recommendation: From April 2019 to April 2022, the Department and NHS England should provide annual updates to the Committee on: • the number of young people who: Ȥ request or are referred for treatment (i.e. number of young people who request a CAMHS appointment); Ȥ whose requests/referrals are accepted; and Ȥ who subsequently receive treatment, and how long they had to wait; • the proportion of young people with a diagnosable condition who receive NHS- funded mental health services; • waiting times across the range of children and young people’s mental health services; and • progress in implementing and evaluating the pilot schemes for the Mental Health Support Teams in schools. The first update should also include current understanding of the financial and human cost, and longer-term impacts, of providing no, or delayed, treatment for children and young people, and the steps being taken by the Department and NHS England to address these impacts. 6 Mental health services for children and young people
3Getting the right workforce in place is the biggest barrier to the government’s ambitions for...
Concluded (the committee's words)
Getting the right workforce in place is the biggest barrier to the government’s ambitions for children and young people’s mental health services. NHS England says that workforce is the single biggest risk to achieving its Forward View ambitions, and other stakeholders have raised similar concerns. Health Education England has limited information to develop its mental health workforce plan, which include an ambition to increase the children and young people’s mental health workforce of around 11,300 by a further 4,500 staff. It still has no data specifically for the children and young people’s mental health workforce to measure progress against expansion plans. Available data on the overall mental health workforce suggests little change in numbers since Future in Mind was published in March 2015, with just a 1% increase overall between April 2015 and September 2017. Given the length of training times (a minimum of three to four years), Health Education England’s short-term focus is on retaining current staff and re-recruiting staff who have left the NHS. It estimates that, if the retention of nurses had remained at the 2012 level, then 50% of current nursing vacancies would not exist today. A range of factors, for example the removal of the nursing bursary and the cost of living in some areas, are affecting both recruitment and retention. In addition to increasing numbers, there are challenges in increasing the skill set of the existing workforce: for example, the Royal College of Nursing says that the removal of continuing professional development for nurses has made it harder to provide them with mental health training.
4Recommendation: As part of the annual update to the Committee, the Department, NHS England and...
Concluded (the committee's words)
Recommendation: As part of the annual update to the Committee, the Department, NHS England and Health Education England should report on its progress in expanding the children and young people’s mental health workforce, setting out any changes they may have made to plans or targets and knock-on effects to other parts of the Five Year Forward View. It should also include an update on recruitment and retention rates for the mental health workforce and make an assessment on any knock-on effect on other professions e.g. nursing and midwifery.
5Tackling mental health issues among children and young people requires significant cross-departmental co-operation, but current...
Concluded (the committee's words)
Tackling mental health issues among children and young people requires significant cross-departmental co-operation, but current approaches do not ensure that this co-operation happens in practice. The government is committed to delivering the cross-departmental vision set out in Future in Mind but has not set out the actions and budget required to deliver it in full, or any measurable objectives or targets. In practice a number of separate work programmes, largely NHS-led, are implementing parts of Future in Mind. There are no cross-departmental accountability arrangements in place for delivering it, or for children and young people’s mental health support more generally. The Department does not intend to revisit Future in Mind when planning future improvements for children and young people’s mental health services, although NHS England is developing a ten-year plan which is likely to prioritise mental health services for children and young people. The Department does not intend to create a corresponding cross-departmental plan but says it will instead take a similar approach to its joint working on the Green Paper with the Department for Education, working on a one-to-one basis with at least five departments. It is not clear how certain cross-departmental issues, for example housing for mental health staff, will be addressed. Mental health services for children and young people 7
6Recommendation: By April 2019, the Department should lead on co-ordinating a comprehensive, practical and long-term...
Concluded (the committee's words)
Recommendation: By April 2019, the Department should lead on co-ordinating a comprehensive, practical and long-term cross-departmental plan which sets out how the government will achieve the improvements to children and young people’s services and support, as envisaged in Future in Mind. This does not need to be delivered as a single programme of work but should clearly set out what each department is responsible for and be specific enough to hold the contributing departments to account for the delivery of the plan.
7Action to improve prevention and early intervention, which are vital in tackling mental health problems...
Concluded (the committee's words)
Action to improve prevention and early intervention, which are vital in tackling mental health problems among children and young people, have been slower than work to improve NHS treatment. Preventing mental health conditions, or tackling them earlier, is thought to be better for young people and their families and more cost effective since it can reduce the need for more intensive services later. However, many areas of government that provide preventative or early intervention services, for example schools and local government, face significant funding challenges and so have reduced non-statutory support in recent years. For example, the number of school nurses, who are local authority-funded, has declined significantly, despite the fact that NHS England sees them as important to the mental health system. There is limited information about what support is available outside the health sector or understanding about the impact of cuts to such support on the demand for NHS services. A further challenge to implementing prevention and early intervention initiatives is the limited knowledge about which approaches are most effective. The Green Paper aims to improve prevention and early intervention but, as it will only be rolled out from 2019, this will come too late to make a significant difference to the current programme to improve NHS services.
8Recommendation: As part of its cross-government planning, the government, led by the Department, should prioritise...
Concluded (the committee's words)
Recommendation: As part of its cross-government planning, the government, led by the Department, should prioritise specific improvements in prevention and early intervention, including, and in addition to, the work currently being undertaken on the outcomes of the Green Paper, taking an evidence-based approach. They should also monitor changes in other departments policies (for example, the Ministry of Housing, Communities and Local Government and the Department for Work and Pensions) to anticipate their impact on children’s mental health.
9The NHS has committed to achieving ‘parity of esteem’ between mental and physical health services,...
Concluded (the committee's words)
The NHS has committed to achieving ‘parity of esteem’ between mental and physical health services, but has not defined what the practical, meaningful outcomes are in terms of access to services, waiting times, or patient outcomes. For example, it has not yet determined what percentage of young people in need would access mental health services under full ‘parity’. So far, the Department and NHS England have taken a pragmatic approach to identify what they think they can achieve with available funding, rather than considering what improvements are required to support all children and young people in need of mental health support. New estimates, published in November 2018, show that the number of children and young people (five to 15 year olds) with a mental health condition increased from 10.1% in 2004 to 11.2% in 2017. This will impact how long it will take and cost to achieve full ‘parity of esteem’ between physical and mental health. The NHS will be producing its ten-year plan by the end of 2018 and mental health services for children and young people is expected to be one of the priorities in this plan. 8 Mental health services for children and young people
10Recommendation: In or alongside its ten-year plan, the NHS must set out clearly what it...
Concluded (the committee's words)
Recommendation: In or alongside its ten-year plan, the NHS must set out clearly what it wants to achieve for children and young people’s mental health services, including defining clearly what ‘parity of esteem’ means in practice, the criteria it will use to measure progress and what data/information it requires.
11Significant data weaknesses hamper the NHS’s understanding of progress against its current improvement programmes.
Concluded (the committee's words)
Significant data weaknesses hamper the NHS’s understanding of progress against its current improvement programmes. At the start of the Forward View, the NHS lacked the necessary baseline information to measure progress against its plans, for example, on the number of children and young people receiving NHS treatment. The NHS intended that the new Mental Health Services Data Set would provide much of this information but this is behind schedule: for example, reliable data on patient outcomes are not expected until 2019. NHS England commissioned a one-off data collection for 2017–18 to understand how many children and young people were accessing NHS services, but it still does not have the data to understand growth rates in patient access to services. It now intends to repeat the one-off collection for 2018–19. In 2014 and 2015, the government committed to providing an additional £1.4 billion of funding specifically to transform children and young people’s mental health services, but a lack of reliable financial data up to 2016–17 means that NHS England cannot be sure that clinical commissioning groups spent all their additional funding as intended. It has since worked to improve financial information and spending controls, and gave us its commitment to ensuring that the £1.4 billion will be spent as intended by 2020–21.
12Recommendation: By April 2019, the NHS should set out to the Committee what arrangements are...
Recommended (the committee's words)
Recommendation: By April 2019, the NHS should set out to the Committee what arrangements are in place to collect the data it needs to: • set up a robust baseline, and monitor progress on children and young people’s mental health services in the ten-year plan for the NHS; • reliably measure patient outcomes; and • fully evaluate approaches in the Green Paper pilot areas to inform the national roll-out of services, including information from outside the NHS. Mental health services for children and young people 9 1 Current NHS performance
13The Department told us it does not intend to use Future in Mind as the...
Concluded (the committee's words)
The Department told us it does not intend to use Future in Mind as the basis of its future plans to improve services and support for children and young people’s mental health. NHS England is developing its ten-year plan which is likely to prioritise mental health services for children and young people within the NHS, but the Department is not preparing a corresponding cross-departmental plan. Instead, the Department told us it would take a similar approach to its joint working on the Green Paper with the Department for Education; working on a one-to-one basis with at least five departments. However, it is not clear how some cross-departmental issues affecting children and young people’s mental health services will be addressed, for example affordable housing for staff.26 Prevention and early intervention
14Preventing mental health conditions, or addressing them earlier, is thought to be better for young...
Concluded (the committee's words)
Preventing mental health conditions, or addressing them earlier, is thought to be better for young people and their families and more cost effective since it can reduce the need for more intensive services later on. Many areas of government that provide preventative or early intervention services sit outside the health sector, for example schools and local government. However, these face significant funding challenges and many bodies have reduced non-statutory support in recent years. One example of this, given by the Royal College of Nursing, is the significant decline in the number of school nurses (which are local authority-funded). The Royal College of Nursing told us that school nurses are ideally placed to support children and young people’s mental health in schools because of their training in child development. The number of school nurses has declined (falling by 16% between April 2015 and January 2018) despite the fact that NHS England sees them as an important part of the mental health system.27
15There is limited information about what mental health support is available for children and young...
Concluded (the committee's words)
There is limited information about what mental health support is available for children and young people outside the health sector, and limited understanding about the impact of reductions to such support on the demand for NHS services. NHS England told us it 25 Q232; C&AG’s Report, para 1.10–1.11, 1.13, 3.18–3.19, figures 4, 5, 18 26 Qq85, 88, 121–122, 154–155, 222–238; C&AG’s Report, para 1.13, figure 1; Letter from the Department of Health & Social Care, para 2, 19 November 2018 27 Qq 2, 7, 11, 28–29, 33, 36, 43–46, 86, 89, 100–111, 124, 126–133, 149; C&AG’s Report, para 1.15, 2.27–2.28, 3.22–3.24, figures 3, 18; Children and Young People’s Mental Health Coalition (MHS0001) para 2.3, 2.4 14 Mental health services for children and young people is working with the Children’s Commissioner and others to improve its understanding. A further challenge to implementing prevention and early intervention initiatives is the limited knowledge about which approaches are effective. Under its Green Paper proposals, the government aims to improve prevention and early intervention and the Department told us it will test what school-based approaches work best, and whether they reduce the demand for more specialist NHS services. But since it will only start to roll out services from 2019, this will come too late to make a significant difference to the current programme to improve NHS services.28 28 Qq89, 149–151; C&AG’s Report, para 1.15–1.16, 2.27–2.28, 3.22–3.24; Letter from the Department of Health & Social Care, para 5, 19 November 2018 Mental health services for children and young people 15 3 Future NHS plans Parity of esteem
16The government has acknowledged that, prior to 2011, mental health services had been seen as...
Concluded (the committee's words)
The government has acknowledged that, prior to 2011, mental health services had been seen as of secondary importance to physical health services. However, as set out in the Health and Social Care Act 2012 and the NHS Constitution, the government has committed to providing ‘parity of esteem’ for mental health and physical health services. This means that mental health is valued as much as physical health, though that does not necessarily equate to equal funding and staff numbers. In fact, the government has not specified what achieving full ‘parity of esteem’ would mean in practice, for example in terms of patient access to services, waiting times or patient outcomes. The Forward View sets the ambition for 35% of children and young people with a diagnosable mental condition to access NHS-funded treatment by 2020–21. But neither the Department nor the NHS have specified what percentage would access services under full ‘parity of esteem’.29
17The Department and NHS England have taken a pragmatic approach to identify what they think...
Concluded (the committee's words)
The Department and NHS England have taken a pragmatic approach to identify what they think they can achieve with available funding, rather than considering what long-term improvements are required to support all children and young people in need of mental health support. New estimates, published in November 2018, show that the number of children and young people (five to 15 year olds) with a mental health condition increased from 10.1% in 2004 to 11.2% in 2017.30 This will impact how long it will take and cost to achieve full ‘parity of esteem’ between physical and mental health. For example, the National Audit Office estimated that, if prevalence was 50% higher than the 2004 estimate, the NHS would either need to treat an additional 186,000 young people over and above current planned, to meet its present target of treating 35% with a mental health condition; or else it would need to reduce its target (as indicated in the Forward View). In either case, there would be implications for the workforce, time, and money required to achieve ‘parity of esteem’ with physical health services.31 The NHS expects to publish a new ten-year plan in December 2018 and the recent budget suggested that there will be at least £2 billion additional funding earmarked for mental health services. NHS England did not specify how much of this will be allocated to children and young people’s services but expected that those services will be one of the priorities in its plan.32 Data weaknesses
18At the start of the Forward View, the NHS lacked the necessary baseline information to...
Concluded (the committee's words)
At the start of the Forward View, the NHS lacked the necessary baseline information to measure progress against its plans. For example, two important targets in the Forward View were to treat an additional 70,000 children and young people per year by 2020– 21 (compared to 2014–15) and an associated target to increase the access rate (i.e. the proportion of children and young people with a mental health condition who receive treatment) from 25% to 35% by 2020–21. However, there was no robust national data collection for 2014–15, so the NHS has not been able to report progress directly against the number of additional children and young people treated. Instead it focuses on achieving 29 Q 84–90; C&AG’s Report, para 1.3, 1.5 30 NHS Digital, Mental Health of Children and Young People in England, 2017 [PAS], 22 November 2018 31 Qq 34, 89, 154, C&AG’s Report, para 1.4, 1.12, 1.15, figure 6 32 Qq 79, 85, 88–89, 121–122, 243–244; C&AG’s Report, figure 1 16 Mental health services for children and young people the access rate target, assuming that if it achieves its access rate target it will also achieve its target to treat an additional 70,000 children and young people. However, this assumption may not hold, since calculations of the two targets are based on different estimates of the number of children and young people who require treatment.33
19NHS Digital introduced the new Mental Health Services Data Set in January 2016.
Concluded (the committee's words)
NHS Digital introduced the new Mental Health Services Data Set in January 2016. It is designed to be the first-ever comprehensive data set that includes children and young people’s mental health services. The NHS intended that this data set would provide much of the information it needed to understand progress against key objectives, including providing the number of children and young people accessing services from December
20Going forward, NHS England told us the Green Paper will test which prevention and early...
Concluded (the committee's words)
Going forward, NHS England told us the Green Paper will test which prevention and early intervention services in schools are effective, including how they impact on the demand for more specialist NHS services. Since these new services are only being rolled out across 20–25% of England at the pilot stage, it will be important that these pilots are set up from the start to generate sufficient data to inform the approach towards a later roll- out for the rest of the country.35
21In 2014 and 2015 the government committed to providing an additional £1.4 billion of funding...
Concluded (the committee's words)
In 2014 and 2015 the government committed to providing an additional £1.4 billion of funding to transform children and young people’s mental health services. In the Forward View, the NHS set out is intention to invest £1.4 billion in these services in addition to existing investment, largely through clinical commissioning groups. However, a lack of reliable financial data up to 2016–17 means that NHS England cannot be sure that clinical commissioning groups spent all the additional funding provided for children and young people’s mental health services as intended, prior to 2017–18. Since 2015–16, NHS England has worked to improve data on clinical commissioning groups expenditure on children and young people’s mental health services, by clarifying guidance and carrying out more intensive quality checks. It considers 2017–18 expenditure data to be much more reliable. From 2018–19 NHS England expects clinical commissioning groups to spend additional funding provided for children and young people’s mental health services on those services; and will monitor this as part of its annual planning process. Despite the uncertainty over expenditure prior to 2017–18, NHS England gave us its commitment that it would ensure that all the £1.4 billion committed to children and young people’s services will be spent as intended by 2020–21.36 33 C&AG’s Report, para 2.4–2.5, figure 8 34 Qq160–162, 184–187; C&AG’s Report, para 11, 2.4–2.6, 2.8, 3.10–3.11, 3.14–3.17, figure 8 35 Qq89, 149–151; C&AG’s Report, para 1.15–1.16, 2.27, 3.22–3.24 36 Qq188–194; C&AG’s Report, 1.10, 3.7, 3.11–3.12, figure 15 Mental health services for children and young people 17
Evidence
Oral evidence sessions 1
- 31 Oct 2018No witnesses recordedparliament.uk ↗