When Theresa May stood on the steps of Downing Street to address the nation for the first time as Prime Minister, she identified several ‘burning injustices’, the first of which was that ‘if you’re born poor, you will die on average nine years earlier than others’.
She reiterated this in one of her first major speeches as Prime Minister, when she went on to set out a personal commitment to tackling the burning injustice of mental illness and promised to publish a Green Paper on children and young people’s mental health. Now that this has been published, how does it measure up in linking inequality and mental health?
While all children and young people can experience mental ill-health, there is an association between inequality and mental illness. Some groups of children and young people including care givers, those from poor and disadvantaged backgrounds, and from refugee and asylum-seeking families, and disabled, LGBT and looked-after children, are more vulnerable to mental health problems. This can be because of individual attributes – such as low self-esteem, difficulties communicating and physical illness – or because of their social circumstances and the environment in which they live – including poverty, poor housing, parental substance use, and family and neighbourhood violence.
Having one or more adverse childhood experiences – such as having a parent with mental illness, or experiencing neglect, abuse, conflict or bereavement – can also affect mental health and wellbeing, and predispose children to mental ill-health for many years, or even decades. This is an inequalities issue: disadvantaged and vulnerable children and young people are at greater risk of exposure to adverse childhood experiences. The Green Paper recognises this and identifies some of the groups referred to above as being at greater risk of developing mental ill health. However, it lacks an overall narrative on inequalities.
To address inequalities in mental health, a universal proportionate response is needed. This means improving access to services and promoting good mental health for all, but with an additional focus on those children and young people more vulnerable to poor mental health. Importantly, this approach should be guided by a long-term, cross-departmental strategy for child health and wellbeing.
There is also a key role for local systems to play. A range of services and organisations, including the NHS and public health services, local authorities, schools, adult education, youth justice, drug and alcohol services, and voluntary and community groups need to work together to reduce inequalities and improve child and adolescent mental health.
Again, the Green Paper recognises this, and we welcome the proposals to focus on early intervention and increase the support available in schools and colleges. It is also encouraging to see the commitment to piloting a four-week waiting target for treatment. However, this doesn’t incentivise providers to actively reach and engage with vulnerable and disadvantaged groups. Proactive case-finding is essential in reducing inequalities, as evidence shows that vulnerable and disadvantaged children and young people are less likely to access mental health services and attend arranged appointments.
Another proven, but often underutilised, way to improve access to services is by involving children, young people, their families and carers – including those who are more vulnerable and less likely to access services – in policy and research, and in the design and delivery of mental health services and care. This can be directly beneficial to children and young people’s wellbeing, and increases the likelihood of them using and benefiting from these services.
Finally, having access to up-to-date and accurate data on children and young people’s mental health is still a challenge in many areas. Understanding local demographic information, assets and need is vital. Areas need to be mindful that some routinely collected mental health data may systematically exclude more vulnerable groups, so there needs to be concerted effort to design, deliver and evaluate services appropriate for their local populations, including services for those with the greatest need.
The publication of the Green Paper brings a welcome and long overdue focus on children and young people’s mental health. However, if it is to succeed in tackling the burning injustices identified by the Prime Minister, a much stronger focus on inequalities and the causes of inequalities is required.