Is the balance right?
There is widespread agreement among health, public health and social care bodies that prevention and early intervention should be prioritised in addressing the health and wellbeing of the population. This is particularly important in mental health; more than half of all mental health conditions in adulthood are established before the age of 14.
The focus on schools is a welcome starting point. Schools and primary care settings have traditionally been seen as part of the first tier of support in addressing the common problems of childhood.
The proposals reflect an ambition to create a pathway between schools, colleges and NHS children and young people’s mental health services in what could be conceived as a stepped model for addressing needs. There is an imperative to ensure there is sufficient capacity to provide the right support at each step of the pathway and, as set out below, it is not clear that the necessary workforce currently exists.
If we take the learning from development of the improving access to psychological therapies (IAPT) services for adults with depression and anxiety, there is little doubt that a large number of people have benefited from talking therapies by enabling primary care practitioners to refer people experiencing mild to moderate symptoms on to appropriate support. But an unintended consequence has been that a higher than expected number of people have been identified with more severe or complex mental health problems that deem them unsuitable for IAPT services. As growing numbers of people seek help for mental health problems, services are struggling to meet that demand.
Currently mental health services are able provide support for only 25 per cent of children and young people who need it. Plans laid out in the Five year forward view for mental health seek to expand that provision to 33 per cent by 2020/21, but this still falls far short of meeting demand. Our own research shows that NHS mental health trusts are experiencing considerable workforce pressures, and analysis by the Education Policy Institute identified workforce shortages as a major barrier to transforming children and young people’s mental health. According to the Mental health workforce plan for England, approximately 11 per cent of clinical posts in children and young people’s services are vacant. The plan accounts for expansion of therapists and supervisors within children and young people’s services but does not include growth in psychiatrists and mental health nurses. Child and adolescent psychiatrists are in short supply; Health Education England data from August 2017 showed that 52 per cent of specialist trainee posts for child and adolescent psychiatry were unfilled and efforts to recruit overseas are being negatively impacted by immigration rules.
Do the proposals go far enough?
As the Green Paper highlights, the mental health and wellbeing of children and young people is influenced by a wide range of factors, and our view is that the proposals do not address these wider factors adequately.
The biggest gap is action to tackle the factors that impact on children before they reach school and that they are exposed to beyond the school environment. Adverse childhood experiences, which include child maltreatment such as physical, sexual and verbal abuse, and adversities experienced within the home environment, including parental separation, domestic violence, parental mental illness, drug and alcohol use and parental incarceration, have a negative impact on physical and mental health throughout life. The prevalence of low mental wellbeing in adults has been shown to increase with the number of adverse childhood experiences suffered. Furthermore, the poor outcomes associated with exposure to multiple adverse childhood experiences represent risks for the next generation.
A report commissioned by the Department of Health concluded that tackling the prevalence of adverse childhood experiences was needed to reduce injury and death during childhood, premature mortality and suicide, disease, physical and mental illness as well as reducing inequalities in these outcomes. To do this requires a co-ordinated approach addressing parental and family risk factors and reducing household adversity. This is also reflected in the Thrive framework, a model developed by some of the leading figures in child and adolescent mental health which places particular focus on schools, families and communities as part of its multi-agency approach.
The proposed school and health-based interventions fit alongside planned investment in IAPT for children and young people and perinatal support for women experiencing mental health problems. But this leaves huge gaps.
A review of the evidence commissioned by Public Health England recommended that interventions to support prevention of mental health problems should include investment in health visiting and home-based family support for infants, as well as access to evidence-based support for families at greater risk in early years. Our own analysis of public health spending found that although investment in early years support remains a priority for local authorities, growth in spending has reduced. At the same time, the number of health visitors and school nurses has decreased significantly. Not only do the Green Paper proposals fail to address adverse childhood experiences in early years, existing support may also be contracting.
A further gap in the proposals is action beyond schools. The proposals reflect an ambition to signpost and/or link with organisations and professionals providing wider support. The proposed mental health support teams add another layer of support focused on the child or young person, but this is not matched by additional support for families and communities, which are the source of adverse childhood experiences. Many of the services providing support for families and issues arising at home are insufficiently resourced or have faced cuts: support has been withdrawn for women experiencing domestic violence; there are cuts of up to 30 per cent to addiction services, and a failure to address the needs of children with a parent in prison. The narrow focus of the current proposals misses the opportunity to address the significant needs identified by agencies working in these areas. It also raises questions about the wider availability of support once mental health support teams have identified a need.
Addressing health inequalities
One in ten children experience social and emotional behavioural problems at age 11, but the risk is much greater in disadvantaged children. Disadvantaged and vulnerable children and young people are at greater risk of exposure to adverse childhood experiences. In addition, some groups of children and young people, including young carers, refugee and asylum-seeking families, disabled, LGBT and looked-after children, are more vulnerable to mental health problems. Despite all this, the Green Paper lacks an overall narrative on tackling inequalities.
Addressing inequalities in mental health requires a universal proportionate response, balancing improved access to support for all with an additional focus on those most vulnerable to poor mental health. This is more important than ever. Services for children and young people have been hit hardest by year-on-year cuts to the public health budget. The failure to intervene early and support those at greatest risk is a failure of the system and also results in greater inequality. Over the past nine years there has been a steady increase in the number of looked-after children. All looked-after children have experienced at least one adverse childhood event, and it is estimated that 45 per cent have a diagnosable mental disorder. However, an inquiry by the House of Commons Education Committee found that child and adolescent mental health services were frequently failing looked-after children. The Committee’s recommendations include the need for a multi-agency team approach and for looked-after children to have priority access to mental health assessments.
Although the consultation reflects a need to test the proposed interventions and whether children from vulnerable groups can easily access the right support, it does not go far enough. The current proposals are weighted towards support for those with mild to moderate mental health issues, but without giving sufficient attention to the ability of mental health and social care services to meet the current demands of children deemed to be ‘in need’, meaning those with the greatest need will lose out.
The previous government strategy Future in mind provided an ambitious vision for children and young people’s mental health and wellbeing, but how this has translated into local improvement plans, investment and action has been variable. Unlike its predecessor, this Green Paper focuses on a small number of key deliverables creating a much-needed pathway from schools to sources of further support, most notably child and adolescent mental health services.
The Green Paper is a start, but its narrow focus leaves it falling far short of transformational. As it moves into a White Paper and into policy and practice there is a need to reflect on the scale of need and establish an appropriate scale of ambition to meet that need. That ambition should include three key areas.
First, there should be a commitment to a long-term strategy for child and adolescent mental health services. If only 25 per cent of children and young people with cancer were able to access appropriate support and treatment it would be a national scandal. Current plans to expand access to child and adolescent mental health services fall far short of meeting demand, in part due to the scale of expansion and the associated workforce required. The proposals in the Green Paper risk placing further pressure on already understaffed services and on the quality and safety of care provided. While it is recognised that the current proposals sit alongside previous commitments, the White Paper should include commitments to funding new services, a realistic workforce plan and how demand for those services will be met.
The second key area is realising the opportunity to address adverse childhood experiences. The impact of social media and influence of gang culture have garnered attention in recent years, but adverse childhood experiences remain the most prominent and well-evidenced factors that influence poor mental health and wellbeing and the development of mental illness. Tackling adverse childhood experiences has been highlighted as a key component of meeting the commitments laid out in the Well-being of Future Generations (Wales) Act 2015. There is also evidence to suggest that action can be taken to support individuals’ resilience, moderating the cumulative impact of adverse childhood experiences.
Finally, there is a need to ensure a coherent narrative around how the proposals will impact on inequalities and what measures can be taken to reduce existing inequalities.
The lives of children and young people are inherently influenced by the environments in which they grow up: their families, schools and communities. A White Paper that aims to be transformational will need to effectively address the needs of children and young people with mental health problems while capitalising on opportunities for prevention and early intervention across all of these settings.
Great blog that focuses on the big underlying issues for young people, and the continuing lack of a plan to tackle adverse childhood experiences. ACEs play such a central role underlying severe mental health issues and dependency, yet most are still denied MH interventions, either because their behaviour is too risky for IAPT services, and they often end up with a "diagnosis" of personality disorder of dependency that is most frequently a reason to exclude from MH service interventions. So many times in my work with drug & alcohol users, or working with perpetrators of domestic abuse, those folk say "why didn't they intervene and help me as a small child with what was going on at home?". Thanks for shining a light x