In December the House of Commons Health and Education Select Committees launched a joint inquiry to scrutinise the government’s green paper on mental health provisional for young people.
‘Transforming Children and Young People’s Mental Health Provision: a Green Paper’ is focused on increasing the capacity of schools and specialised care providers to respond more promptly and effectively to children and young people (CYP) experiencing mental health difficulties.
EPI welcomes the Government’s commitment to addressing the issue of CYP mental health, as well as acknowledging the important role that schools can play in being part of an overall system that supports young people’s mental health.
We have identified five key points on the scope and implementation of the CAMHS Green Paper’s proposals:
The Green Paper proposals respond to some problem areas in CAMHS provision
- The Green Paper proposals include incentivising all schools to identify a Designated Mental Health Lead and establishing Mental Health Support Teams linked to groups of schools. These actions would go some way toward addressing the fragmentation in CAMHS provision and lack of response capacity in schools, identified by the Education Policy Institute, the Children’s Commissioner and the Care Quality Commission as barriers to effective care delivery.
- The proposal to introduce a four-week waiting time standard for treatment addresses another ongoing and significant problem with current CAMHS provision for CYP with high-level need. EPI has previously made the case for a national waiting time standard.
However, it is unclear to what extent these actions would close the treatment gap
- Currently, only a quarter of CYP with a diagnosable condition are accepted into specialist care; the Department of Health and Social Care aim to increase this to a third by 2020/21. While any move to increase the proportion of young people accessing specialist support is welcome, nationally representative findings show that diagnosable mental health conditions in CYP have increased significantly over the last decade (national prevalence estimates will be updated this year).
- There are several reasons why the actions laid out in the Green Paper may not have the desired impact on the treatment gap.
- Schools will be incentivised, not required, to establish a mental health lead. This will therefore depend on individual schools’ commitment to addressing pupil mental health, against a backdrop of a real-terms drop in funding per pupil.
- There may be risks associated with giving schools extra responsibilities to provide support for CYP with lower-level mental health needs. Schools lack the expertise, capacity or democratic accountability of Local Authorities – who no longer have the capacity to provide these services – which could result in poor decision-making that adversely affects pupils. This will largely depend on the level of supervisory involvement of NHS CYP mental health staff with the Mental Health Support Teams, which is not made clear in the Green Paper.
- The paper does not specify if the four-week waiting time standard refers to time to assessment or start of treatment. Moreover, the introduction of the standard could result in an increasing number of referrals being refused at the assessment stage, as providers increase thresholds to meet these new targets. Both these issues should be explicitly addressed.
- It is unclear precisely how piloting the proposals in trailblazer areas will facilitate a national roll-out, particularly in areas and schools with the most limited capacity.
- Finally, the wider actions reviewed in Chapter 4, including the Youth Mental Health First Aid training programme, the anti-stigma Time to Change campaign and family-level interventions to reduce inter-parental conflict, are too disparate to comprise a comprehensive strategy. It is unclear if or how these actions will impact the treatment gap.
The scope of the Green Paper is reactive and does not address the determinants of young people’s mental health and wellbeing
- The Green Paper focuses on improving the response of schools and specialist care providers to CYP with mental health difficulties. However, to effectively tackle the rising prevalence of mental health difficulties in CYP– and to deliver on the vision laid out in Future in Mind, including preventing mental health problems from arising – the Government must address the wider determinants of mental health and wellbeing.
- Evidence suggests that socioeconomically disadvantaged children and adolescents are two to three times more likely to develop mental health problems. When a family’s socioeconomic position worsens, the risk of maternal and child mental health difficulties increases; child poverty is projected to climb to 37% by 2022. Socioeconomic disadvantage acts as a psychosocial stressor, and can work through poor housing and unsafe neighbourhoods to negatively impact young people’s mental health and wellbeing. It limits the ability of children to participate in activities with their peers. It is associated with worse parental mental, which is, in turn, a strong risk factor for poor child mental health and wellbeing. It exacerbates the effect of adverse childhood experiences, and is associated with inter-parental conflict, gang membership and NEET status – all identified in the Green Paper as risk factors for CYP mental ill-health. There is also evidence that some biologically heritable mental health conditions may only develop with exposure to certain adverse environments or social triggers, including those listed above.
- Given this, the trickle-down effect of social and economic policies on CYP mental health should be considered. Austerity measures have had the biggest impact on families with children, in terms of a reduction in real income and living standards, unemployment and cuts to local services, and have been linked to worse mental health and wellbeing.
- If upstream social determinants are addressed, there is less need for interventions that target more proximal risk factors, including inter-parental conflict or family ill-health. Furthermore, interventions targeted at an individual risk factor for CYP mental ill-health often overlook how multiple disadvantages can overlap or interact. For example, programmes aimed at reducing unemployment ignore that two thirds of children living in poverty are part of families where at least one parent is working.
- Recent evidence has shown that few factors affect child mental illness and wellbeing in the same way. Among 11-year-old children in the Millennium Cohort Study (MCS), school-related factors were more important for promoting wellbeing, including whether a child liked and engaged with their school, and bullying was identified as a key risk factor for poor wellbeing (while the home environment, family health and relationships were more important predictors of mental illness). An in-school approach may therefore be more effective at supporting pupil wellbeing, rather than preventing or addressing mental illness; this may mean re-focusing efforts to prevent the development of mental illness in CYP on the home environment.
- The paper’s evidence review concludes that there is little indication that universal prevention approaches for specific mental ill-health outcomes are effective. However, there is good evidence for the positive effect of social and emotional learning interventions, not only on mental health, but educational attainment and later life outcomes. Given this, social and emotional learning should be considered as part of the support provided to pupils in school.
The Green Paper does not address how the proposals will be implemented in light of existing and significant barriers
- It is unclear how the three actions, along with the CAMHS transformation overall, will be implemented given funding issues and a significant CAMHS workforce shortage.
- The £1.4 billion originally committed to the CAMHS transformation has not been ring-fenced, and much of it is not reaching frontline providers. EPI has previously reported that, of the £250 million expected to be released in 2015/2016, only £75 million reached local clinical commissioning groups (CCGS), and there is no transparency in how funding is allocated on to frontline providers; only half of CCGs responding to an FOI request issued by the charity Young Minds in 2016-2017 had used the additional funds for CAMHS provision in 2016/17. Meanwhile, 40 per cent of mental health trusts have faced year-on-year cuts since 2011. Theextra £300 million announced to fund the Green Paper’s proposals has also not been ring-fenced.
- There are significant shortages in the CAMHS workforce including 5000 fewer mental health nurses since 2010. Recent EPI research found recruitment difficulties in NHS mental health trusts and a deterioration of workforce standards in inpatient care. The Royal College of Psychiatrists 2017 workforce census shows a rising vacancy rate in CAMHS consultant posts. The recruitment and retention of Mental Health Support Team staff and the wider CAMHS workforce must be addressed if these proposals, along with existing commitments – including treating at least an additional 70,000 CYP annually – are to be successfully implemented.
The implementation timeline means that most local areas will see no change in current provision
- According to the implementation timeline, the majority (75 to 80 per cent) of local areas will not see any change to their CAMHS provision in accordance with the proposals in the next five years. Furthermore, this will be contingent on the outcome of future spending reviews. The rest would only see changes fully rolled out by 2022/23.
- The Green Paper’s strategy is misaligned with need right now. Referrals to CAMHS services increased by 64 per cent over the two years to 2014-15, and the majority of children with a diagnosable condition continue to not receive treatment. The prevalence of mental health problems in young people has risen substantially: findings from the nationally representative Millennium Cohort Study show a 12 per cent prevalence of mental health problems in boys and girls aged 11, and 12 and 18 per cent respectively in boys and girls aged 14 (the prevalence of high-level depressive symptoms among 14-year-old girls in the MCS is 26 per cent). The Adult Psychiatric Morbidity Study found a prevalence of common mental disorders in 26 per cent of females and 9 per cent of males aged 16-24. With the release of updated national prevalence estimates this year, the Government strategy should be reconsidered.