Education Committee
Health Committee
Oral evidence: Transforming children and young people’s mental health provision, HC 642
Tuesday 30 January 2018
Ordered by the House of Commons to be published on 30 January 2018.
Members present:
Education Committee: Robert Halfon (Chair); Lucy Allan; Michelle Donelan; Trudy Harrison; Ian Mearns; Lucy Powell; Thelma Walker.
Health Committee: Dr Sarah Wollaston; Luciana Berger; Dr Lisa Cameron; Rosie Cooper; Diana Johnson; Andrew Selous; Dr Paul Williams.
Questions 1 - 75
Witnesses
I: Anne Longfield OBE, Children’s Commissioner for England; Dr Pooky Knightsmith, Vice Chair, Children and Young People’s Mental Health Coalition; and Rowan Munson, former member, Youth Select Committee.
II: Paul Whiteman, General Secretary, National Association of Head Teachers; Stuart Rimmer, CEO and Principal, East Coast College; Dr Bernadka Dubicka, Chair, Child and Adolescent Faculty, Royal College of Psychiatrists; and Professor Tamsin Ford, Professor of Child and Adolescent Psychiatry, University of Exeter Medical School.
Written evidence from witnesses:
– Children’s Commissioner for England
– Children and Young People’s Mental Health Coalition
– National Association of Head Teachers
– Royal College of Psychiatrists
Witnesses: Anne Longfield OBE, Dr Pooky Knightsmith and Rowan Munson.
Q1 Chair: Good morning. Thank you for coming. For the benefit of those watching and for the recording, could you kindly give your titles, from our left to right, and say where you are from?
Dr Knightsmith: I am Dr Pooky Knightsmith. I am the vice chair of the Children and Young People’s Mental Health Coalition, but I am also representing the Fair Education Alliance and the Partnership for Well-being and Mental Health in Schools today.
Anne Longfield: I am Anne Longfield. I am the Children’s Commissioner for England.
Rowan Munson: I am Rowan Munson. I was a founder member and alumnus of the NHS Youth Forum and am a former member of the House of Commons Youth Select Committee on Mental Health.
Q2 Chair: Thank you. Because we have a lot to get through, can we try, very gently, to be succinct? We have a lot to ask you. Can I start off by getting your general views of the Government Green Paper? Anne, do you want to start?
Anne Longfield: I welcome the Green Paper. It has a lot in it that I wanted to see. I particularly welcome early intervention and the work within schools. It is something that young people have said they wanted to see. I welcome the move on waiting lists.
However, in broad terms, if you were to ask me whether I could go back to the hundreds of children who have come to me over the three years—and, indeed, professionals too—and say, “Will this transform things and give you the help you need when you need it?”, in all honesty, I would have to say no. On that ground, I think it is not nearly ambitious enough.
There are three pillars, but the element that is missing is the fourth pillar, which is the framework of expectations, the measurement, the benchmark and the accountability. We need to look at the scale of change we have seen in the adult mental health service around IAPT, see what is possible, take that framework and benchmark, and translate that to children. The Minister herself talked about the journey that is needed to get the seismic shift in mental health support. This takes a good step, but without that pillar it is a series of interventions. My fear is that, if the pillar is not there, it will fall over and we will not reach the scale of change that children clearly need.
Rowan Munson: It is a step in the right direction, but it underestimates an awful lot of the challenges presenting themselves, such as the culture of the education system. PSHE education and the particular issues around young adult care and the 16 to 25 transition period are not covered enough. It also does not take account of some of the first points of contact, perhaps around GPs and school nurses, and the cuts that are imposed on local authorities and how those are affecting the mental health care of young people at the moment.
Q3 Chair: By the way, is it okay to call you by your first names?
Dr Knightsmith: Yes. We are cautiously optimistic. We are hugely supportive of the coming together of health and education in this way, and we think this is a really positive step forward. We have been grateful to the Department for Education and the Department of Health for actively engaging with us in the consultation process. We worry about whether there is enough money. We do not think there is enough money. We are concerned about how that is going to find the right places, and how and if there is any manner of ring‑fencing. We also think there is a huge amount of good that has already happened or is already happening and that this is sitting in a bit of a silo. We would like to see it set within a broader strategic landscape.
Another major concern from members is that there are more questions than answers in the Green Paper. We appreciate that it is a consultative process. However, we think it might mean that, for some areas that might consider wanting to be a trailblazer area, for example, there is not enough there for them to understand whether this is something that they could do. It might rely on areas that are already more advanced in their thinking to pick this up and run with it.
Q4 Chair: The Royal College of Psychiatrists says: “By the Government’s own estimates, a quarter of a million children and young people who could be helped by a Mental Health Support Team will be missing out in five years because of the time it takes to roll out the proposals.” Is what you are saying that it is a good intention, but it is too tortoise‑like and there is not enough clarity on the training and the resources? You are not against any of the proposals, but there are just not enough clear, defined steps forward in training, resources, implementation, monitoring and so on. Would that be the summary?
Dr Knightsmith: That is a fair summary. It is just not ambitious enough. We think it is really exciting. We understand the hesitation and not wanting to roll out things that do not work, but taking an iterative but really ambitious approach is what we should be doing now, because we worry about the three in four young people who will not even be touched by any of this by the end of the five‑year period.
Anne Longfield: I completely agree. The will to make this work is enormous. Professionals want to be working within a clear framework, but it is that framework of operation that will set really clear expectations, deliver the consistency that children need and also the reassurance that they can get help swiftly. So, there is a time issue; there is a consistency issue; and then there are the clear expectations of what children can get and when they can get them. We should not forget that three out of four children are not getting help now, and they need to get help as soon as possible because we need to avoid a situation where children become adults and have mental health problems.
Rowan Munson: You have three issues: timescale, resource and that the proposals themselves are not going to meet the problems that we are going through at the moment.
Q5 Chair: Do you feel that the commitments are backed up by proper resources?
Anne Longfield: We simply do not know, because clearly there are some elements of funding that have been announced but we do not know what is spent already. It is not clear what new funding is going to be introduced. One thing that would be very helpful would be to get the NAO to do a survey of funding, possibly linked to the new prevalence figures when they come out later this year, but to be very clear about the level of funding and the level of spend on children’s mental health, which we know is tiny—just 6% compared with adults, and children are 20% of the population. There is already a huge gap between what is spent on children and what could and should be spent.
Q6 Chair: I am going to pass over to my Co‑Chair of this event, but I just want to confirm that you are saying the National Audit Office should assess the actual resources needed to implement the Green Paper proposals.
Anne Longfield: Also the current spend. That would be very helpful.
Q7 Dr Wollaston: There is a huge dispute about exactly how you track spending.
Anne Longfield: It is very unknown.
Q8 Dr Wollaston: Your recommendation would be to ask the NAO to look in detail at this.
Anne Longfield: Absolutely.
Q9 Dr Wollaston: Thank you for that very clear recommendation. Can I ask about another pillar that some people might feel could be added, and that is around the role of prevention? It was very interesting to hear you, Rowan, talking about the cuts to local authorities and that the prevention roll‑out in communities comes through voluntary groups. I am seeing that in my own constituency with cuts to certain voluntary groups in Brixham, for example. Do you feel that there should have been something more specific about prevention in this and a “what works” role in prevention?
Rowan Munson: Yes, there should have been. There was a report by the Children’s Society that showed that there was a 40% real‑terms cut in spending on early intervention between 2010‑11 and 2015‑2016 in local authorities. One of the real issues is that the cuts that we are imposing on local authorities are disproportionately hitting young people’s preventive mental health services, and then, of course, we are seeing an increase in spending of 7% on later interventions services, when those young people have got to crisis point, with the kind of constantly increasing thresholds that we see. I welcome a little bit of emphasis around the waiting times and how those are going to get to young people faster, but one of the voluntary sector providers that I was working with locally said that they felt that there was really no point referring to the local CAMH service unless the child they were working with was literally about to throw themselves off a bridge.
Q10 Dr Wollaston: Thank you for that, but my question more specifically was on prevention. Anne, thank you for reflecting the recommendations of our predecessor Committee in your own report about the importance of early intervention, and we really welcome that; but it was even a step further back from that. We heard powerfully from young people from a school in east London yesterday about some of their whole‑school approaches to prevention. Perhaps Anne and Pooky could come in on this. Do we know what works in whole‑school prevention—specifically looking at prevention rather than early intervention?
Anne Longfield: Increasingly, we have evidence of what works, and some of that will be in school, but, also, we need to go back before that. There will be children with vulnerabilities. I have a major piece of work on vulnerable children, collecting data on who they are, and there are huge gaps. But we certainly know that there are interventions, for instance, when children at the age of 2 are going into school. We have 40% of the most vulnerable children with places at the age of 2, but that is not used as an opportunity to identify those who have additional needs, which may not even be linked to mental health issues at that point, and then used as a trigger to offer additional support.
In a way, we have a system that is fragmented and is not working together to identify children early, and then add additional support as they grow up. While these are very good proposals around intervention, if they are in isolation, they cannot look at addressing the needs to the scale required. That needs much more of a whole‑system approach—yes, in school, but across a local area around the child as well.
Q11 Dr Wollaston: Pooky, do you want to come in on that point about prevention?
Dr Knightsmith: Yes. Briefly, we see this as an evolving picture. On the situation with young people right now, we would hope that, with the implementation of the kind of things outlined in the Green Paper, prevention would become more of a key part of that. At the moment, early intervention—and late intervention—is, sadly, hugely needed.
One thing that we think should be addressed in the Green Paper, which is missing, is the age group 0 to 5 and thinking about prevention there, and also thinking about maternal mental health. Another big thing that came through from members in our consultation yesterday was the role of the mental health of the school staff themselves and parents—that we should be thinking about their mental health and making sure that they are able to act as positive role models, quite aside from all the other issues that having poor mental health as a teacher may bring.
Q12 Luciana Berger: Reflecting on the Green Paper, there is only one paragraph, section 118, that makes any passing reference to the under-fives and to babies, and it just mentions in passing adverse childhood experiences. What do the panellists think about what more could and should be in this Green Paper, if anything at all, about how it prevents those adverse childhood experiences and what impact that might have on children later on as they grow up?
Anne Longfield: I would like to see a comprehensive starting point that looks at children from birth and pre-birth onwards, and recognises that problems develop along the way; and the earlier and the nearer to home they can be treated, the better it is going to be for the child. I would want to see that reflection, but there is a bigger point there about having a wider strategy around vulnerability that goes across all Government Departments. Certainly, there are many points where you can intervene to identify those children who have additional needs and that they can be helped, and some of these can be prevented. Schools are a great place where children can get access, yes, of course, but that does not mean that there cannot be work beforehand and it should be within that.
Q13 Lucy Powell: Briefly, following on from that, about perinatal mental health as well, although we are trying to address this in Manchester with the devolution of health, something I see is that perinatal health is totally separate from the effects that has on the child. There is not a joined‑up commissioning approach there at all about problems that a new mum might be having and the impact on the child. It is totally separate commissioning. Do you think that is something that could have been looked at in this and in general?
Anne Longfield: Yes.
Dr Knightsmith: Yes, absolutely. It is a key point that is being missed. We talk about wanting to look at the child from 0 to 25, but increasingly we are thinking pre-birth as well and the health of the mother. It is a broader picture.
Anne Longfield: Certainly, in the vulnerability figures that I published last year, there were almost 700,000 children who lived in homes where parents had particular, extreme problems with drug and alcohol abuse, violence and mental health for the majority of those. Clearly, they have impacts on the child. It needs to be seen within that context.
Q14 Lucy Powell: It is almost a family approach.
Anne Longfield: Absolutely.
Q15 Lucy Allan: Do you think the Green Paper focuses enough on the more vulnerable groups—the most disadvantaged groups? The predecessor of this Committee carried out an inquiry into the mental health and wellbeing of children in care, for example. Looking at what the Green Paper says about our recommendations, there is nothing coming through by way of action. There are quite a lot of suggestions about research, further surveys and so on. I want to know whether you feel that the needs of those most vulnerable to mental health conditions have been properly addressed in a specific way rather than generic provisions that would apply to all young people.
Chair: To add to that, the Royal College of Psychiatrists again has said there is not enough recognition in the report on the fact that most people from disadvantaged backgrounds have mental health difficulties.
Lucy Allan: Can we start with Pooky?
Dr Knightsmith: Our members would completely echo your concerns. We represent lots of different groups, and many of them are there particularly to represent vulnerable groups. There was a feeling that there just was not enough detail and thinking about how we are to reach those vulnerable children and vulnerable families, period. There was particular concern with the big focus on schools, which we see as a great conduit, but what about those who are not accessing school, for whatever reason? We know our vulnerable groups are more likely to fall within that. We felt there needed to be more. We welcome the idea of virtual mental health leads for vulnerable young people, for example.
Q16 Lucy Allan: Presumably, it makes sense that, if we know these vulnerable groups have greater propensity to suffer mental health conditions, we should be going straight to those groups and trying to focus on them. I do not know if you agree.
Anne Longfield: Absolutely. I would agree with that. I am always struck by the fact that when you have children who are in very vulnerable situations—they may be in care or in custody, and clearly there is much more of a likelihood that they are going to have mental health issues—they have often not received help in the past, for a start, but even when they are in those situations they are not getting that targeted support. I want to see that stitched into the package of support that they are offered.
I have heard from children who are in custody and those trying to give them help that they are struggling to get appointments on a CAMHS waiting list, just like anyone else. It has to be built in as part of the package that is offered to children in those situations. That has to be a trigger for specialist health—a part of what they are offered.
Rowan Munson: We definitely need some targeted support. The focus on schools forgets young people in those vulnerable situations who are more likely to be excluded, and in fact people just because of their mental health issues are more likely to be excluded from schools.
There is also an issue around young people getting full support when they are in those situations and linking their mental health provision with something like a housing issue or a legal issue, making sure that those services are provided alongside and that those work with the mental health provision.
Anne Longfield: One issue is that access and navigating the system is pretty complicated, even if you have parents fighting your corner, but, if you are in care or in the justice system, you are not necessarily going to have parents who are going to be able to help you navigate and access the system. There does not seem to be anything in the Green Paper that says, “We recognise that and we are going to try to address it.”
Dr Knightsmith: Absolutely. One thing that one of our members brought up yesterday, which I think really hits the nail on the head, is the idea that in doing this work and recognising issues, and perhaps generating more referrals, those referrals would not all necessarily be into the mental health system but sometimes into social care. That is really important. We would want to see more cohesive working between health, education and social care all working together, ideally with the child at the heart of it.
Q17 Thelma Walker: Talking about young people accessing mental health services, would you say that it is an entitlement, and really this is about social justice? When we are looking at the trailblazer areas that are piloting, where would you want those to be?
Anne Longfield: In geographical terms, I want consistency across the country as early as possible, because there is a responsibility that we all hold to offer help as early as possible for all children who need it. While I accept that there is a role in piloting, moving swiftly and testing out, I want to see this as quickly as possible, which is why I look again at what has happened in IAPT and the speed at which that has been able to roll out, to get to 1.5 million people in 10 years, and now there is a consistency, expectation and a clear accountable framework there for people to know where they are.
Q18 Chair: Do you see any joined‑up thinking between this Green Paper and the social mobility report that came out just before Christmas and the opportunity areas?
Anne Longfield: I would like to see a lot more. I think the opportunity areas, and any place‑based approach, are a real opportunity to provide that joined‑up thinking across all areas of children’s lives as they grow up. I am keen not to look at education in isolation, or indeed health in isolation. I would like to see the opportunity areas being bold and ambitious, and looking at embracing all these opportunities together, because the more things can join up, and the more there can be a series of interventions around a child’s life, the better we are going to be able to see the difference.
Q19 Thelma Walker: Just to come back on the trailblazer point, would you agree that the areas that should be targeted are the ones where it is not working well currently?
Anne Longfield: I would like to see targeting in broader terms around areas where there are particular problems and high levels of disadvantage, because there you are going to get the children with the most needs. The places where we clearly need to move fastest are where children are not getting help and support, but it is also important to see what does work. I think there are some very good examples—
Q20 Thelma Walker: It is what works for the most deprived children and young people. That is what I am suggesting.
Anne Longfield: Yes, but models and approaches that work, which are about being joined up, reflecting and listening to what children need and helping them design that system for them; but it needs to be geographically in the areas where children have the greatest need.
Q21 Andrew Selous: Good morning. Apologies for being late, but I have been speaking in a Westminster Hall debate. Anne, you were talking about every area of the child’s life. Could you say a little on your take about what we can do to help children within the family situation? Perhaps if there are issues between the parents—I think there is some evidence that unresolved, low‑level conflict between parents can be very damaging to children—what more can we do? You mentioned IAPT in particular, and I am a great fan of that. I am a bit worried, though, that it all seems to go on cognitive behavioural therapy, and the couples counselling for depression seems to be squeezed out a little in some areas. What is your take on what we can do to help the home and family situation to improve children’s mental health, please?
Anne Longfield: We have now got to a stage where there is good evidence of what works with families, and that is around the whole joined‑up approach. I would like to see children’s centres working much more with families in a broader context, and there are some really good examples of family hubs that are working with children from birth upwards and their families. That is around all aspects, around parents who might have particular issues and problems, but also building strong relationships, supporting good parenting and the like. I think there is a real opportunity around children’s centres and family hubs.
You mentioned IAPT again. I have been really impressed by going to the website, putting your postcode in, seeing what is available and having clear information on that. Some of those who are working there have said to me that they are fed up with helping parents or talking to adults who have issues such as fear of flying, when they know that around the corner there are children who are self‑harming, suicidal and the like and not getting that help. It is that disparity between what we have there, what we know can be done, relatively swiftly, and what children are faced with.
Q22 Luciana Berger: I have a comment on that and then I will come back to the question I was due to ask. On the point you just made, Anne, about children’s centres, the Green Paper says that the Government want to commission further research into interventions that support parents and carers to build and improve the quality of attachment relationships with their babies. Do you not think that work is already being done through the Sure Start centres and children’s centres and that we will just be reinventing the wheel?
Anne Longfield: There is a base in children’s centres, and there are still 2,000‑odd of those that are around the country in the most disadvantaged areas. They are a resource that is already doing very important things, which could be a positive springboard to really help families, linking very much with this Green Paper to provide that link across different services and different elements of the family.
Q23 Luciana Berger: We know from the Centre for Mental Health that children from the poorest 20% of households are four times more likely to have a mental health difficulty than those from the wealthiest 20%. You said that the trailblazer areas could focus on that disadvantage. Are there other things in this Green Paper that you would like to see address that inequality that we see with mental health in children from the most disadvantaged backgrounds?
Anne Longfield: I would like to see targeted help towards the most disadvantaged areas in terms of early intervention. Rowan mentioned early intervention and some of the reductions. The LGA tells us that, in terms of its estimates of the shortfall in funding, the figures are going to be around £2 billion in the next three years. We know the areas where funding is being reduced at early intervention, and that is the area where we know local authorities will struggle to provide their part of this strategy.
Yes, I would like to see additional support in that area, additional help in getting the infrastructure in place, but also potentially something like transition funds that would help them maintain and build early intervention and support the poorest communities to enable them to get to the place where they can access it.
Q24 Chair: Given what Luciana has just said and my previous question, going back to the social mobility report published by the DFE, do you not think—because it is very much a silo, and we have a mental health Green Paper—that it should be much more joined up? Do you think the social mobility report missed an opportunity to link all this together, given the impact on the disadvantaged that mental health has?
Anne Longfield: Yes. I do think that social mobility should have a much broader brief. An opportunity will have been missed if we do not stitch together the whole range of interventions and knowledge around vulnerable children, and that is why there has to be a strategy across all Government Departments that looks to reduce it.
Q25 Chair: It seems astonishing that we have trailblazers for this and then opportunity areas for education.
Anne Longfield: I am forever bumping into opportunity areas from different Departments.
Q26 Ian Mearns: I am sorry, Anne, I have gone on about this a few times, but are you not a little surprised that the methodology that has been used to pick the opportunity areas on the aftermath of the social mobility report has missed out the entirety of the north‑east of England?
Anne Longfield: You have raised that with me before, Ian. All I can say is that I do not think that 10 opportunity areas deliver the change needed. I am not aware of how they were picked. I think there should be one in the north-east, and it seems very strange there is not one. I think you should just pitch for one in the north‑east and go for it.
Ian Mearns: Oh I am.
Q27 Chair: At every Committee meeting. There is no better representative of the north‑east than Ian. Pooky, you want to come in.
Dr Knightsmith: I want to talk about the trailblazer areas. This was a topic of great discussion for us yesterday. In our final submissions we will put in some recommendations specifically about trailblazers, but our thinking on this is still evolving. While we think it is important that we are recognising the more disadvantaged areas, we would welcome a very wide range of different sizes, geography and type of area being represented. What we want to see more than anything else is a rapid, iterative, well‑evidenced and outcome‑focused response. We want to see what is working rolled out rapidly to as many people as possible.
Rowan Munson: That is why you need to be looking at maybe some areas that are examples of good practice at the moment and see what they could do further as well as focusing on the most disadvantaged areas, because the learning is transferable, and the more diverse data we have the better the intervention will be.
Anne Longfield: You could do both, could you not, if you actually have a coherent approach? You can look in terms of mental health at the actual things that we need to learn about in a very specific way but stitch it into a wider intervention around disadvantaged areas, such as around early intervention, and do them all at the pace needed to get to the seismic shift that we need to see.
Q28 Dr Wollaston: I want to ask your views about areas that traditionally do not do terribly well under the formula because much of the area could be deemed as having few people who, for example, qualify for pupil premium, but within that wider area they can have pockets of severe disadvantage in many of our rural counties. Those are the areas that often do not have any resource to be able to put in extra mental health resources and bring in others to help them. Would you like to see some of these trailblazer areas particularly look at those areas that do not have existing funding to be able to bring this in but do have pockets of severe disadvantage?
Anne Longfield: Yes, completely. There was an approach with Sure Start that did just that. It looked at the areas where there were large numbers of the population who were disadvantaged but then also had a phase that looked at pockets within. There is a methodology there that is useful, and it would be interesting to look at that, but, of course, that needs—
Q29 Dr Wollaston: They can often be hidden, particularly in rural areas, where people assume everything is fine but in fact they are not.
Anne Longfield: That is right. Then the disadvantage can be even—
Q30 Dr Wollaston: It can be doubled.
Anne Longfield: Absolutely, so you have a shortage of transport and high costs and the like.
Q31 Dr Cameron: My question is about an important issue of transition from CAMHS to adult services, hearing that that is not seamless in the way that it should be, and that children and young adults are falling through gaps. When they get to the other service it might be configured entirely differently from the one they have come from, which can then make transition very difficult, and at that crucial point in development maybe losing attachments and supports they have developed over a number of years. What more should be done to improve transition and to make sure that it is fit for purpose in that sense—that people are not falling through gaps? Should it be a more developmental approach than chronological, for instance? I do not know who wants to answer first.
Dr Knightsmith: We have two takes on this. One is that a lot more definitely needs to be done around transition. There is quite a lot of focus on that at the moment. We think there needs to be a lot more joined‑up thinking.
We think there is a particular role for colleges and the thinking there. The references to colleges throughout the Green Paper were welcome but somewhat tokenistic and do not recognise the unique challenges of colleges. But we would welcome the broadening of that and welcome the further focus in the future on 16 to 25s.
However, we think that focusing in on the transition from CAMHS to adult mental health services only paints a small part of the picture because it does not account for all those young people who are not in services at all, and some of our most vulnerable young people are completely missing off that radar all together. We want to see something that takes into account all the young people as they are moving into young adulthood and thinking about how we can meet their needs, not just those struggling with the transition to adult services.
Anne Longfield: At the moment, it is children who are navigating the system. The system needs to join up in a way that does not put the burden on children. That means that you have to look at the 0 to 25s. That is very interesting and there are very good examples of how that is happening in practice in ambitious areas around the country, but acknowledging that lots of times children will be only starting to get the help, if at all, when they are 16, 17 or even on waiting lists. A lot of children I speak to are very anxious about that change, and certainly at a key time it adds levels of anxiety and stress in a way that is unacceptable.
We have to take responsibility, I think, for the system and ensure that the system works in whatever way that is, but also look at how we can get help and identification for those children who are not getting the support—as you say, the three out of four. There has to be something that is more systematic about getting to children across the board rather than just looking at those who are already on the waiting list.
Rowan Munson: This was particularly one of the areas of the Green Paper that I felt was almost optimistic about the situation as it is. There was a study that found that a third of young people dropped out of mental health care all together at this stage, with a further third experiencing an interruption in care, and only 4% experiencing an ideal transition.
Having said that, we do have some elements of good practice. Things such as service user passports or the “Ready Steady Go” programme over at Southampton Children’s Hospital are great examples of where transition is working well at the moment. I would support a 0 to 25 approach. In young people, the adolescent brain is still developing. There are lots of changes in a young person’s life at the age of 18, if you are moving away from home and going to university.
In fact, on that particular point for myself accessing mental health care, you can only be registered with one GP. I am at university half the year and at home the other half, so that means I am only getting half the support I could be getting, even if it was perfect. Frequently, it is described as a cliff edge. At 16 to 24 you have between 10% and 20% of those young people having mental health issues, and we need to strengthen those legal rights, increase services up to 25, and ensure that both child and adult mental health commissioners have a remit to engage in transition. At the moment some of the child mental health services are doing their best, but they are not being picked up properly by the adult services and it is that link that we are seeing a real issue with.
Q32 Dr Cameron: It is a crucial developmental time in terms of particular types of mental health and the difficulties that can arise, and that particular time is when it is most difficult, it seems, for young adults to be in services.
Chair: Can we have brief, succinct answers as we have a few more bits to go through, thank you?
Dr Knightsmith: It is important to note the specific challenges faced by young people with additional needs and, in particular, learning difficulties, both as they transition into adult services, which is a particularly difficult time for them, but also throughout. We felt that was something there was not enough of in the Green Paper.
Q33 Diana Johnson: I am particularly interested in the good examples—the good practice that you have talked about—Southampton being one. I also wonder about the role of universities. We have talked about colleges, but if we are serious about going from 0 to 25 that does involve universities. Rowan, in particular, do you have a view about what more universities could contribute to the wellbeing of young people?
Rowan Munson: All universities need a counselling service that works alongside the mental health provision that is provided at that point by the NHS. We need some more training for people in universities who engage with young people, people such as personal tutors, to be spotting those mental health issues. It is probably worth noting that we already have resources such as MindEd, which I was surprised to see was not in the Green Paper itself, which are available for that very purpose.
Q34 Lucy Powell: My question is mainly for you, Rowan, slightly backpedalling a little to something you said right at the beginning, and it builds on from what Sarah was saying about prevention, but it is particularly around causes and what some of the current drivers are of mental health, stress, anxiety and so on in young people.
First, do you feel that the Green Paper or this whole agenda in general is saying enough about some of the root causes? You referred earlier to the current exam pressure—the current school system. Do you want to expand on that a little further, because that has come through very strongly from the young people we have spoken to? What do you think can be done to link up education more strongly with that preventive, deep, root-cause issue?
Rowan Munson: It was something we saw come out in our closed evidence session on the Youth Select Committee. If you were to imagine a workplace where there was a hierarchical relationship that was repeatedly enforced, where individuals were required to publicly display their knowledge or ignorance, or highlight their performance deficits in front of a team, and not always in that supportive, encouraging and nurturing manner, where the staff had little control over their workplace or where it was extremely difficult to change line managers or jobs, the Health and Safety Executive would judge that to be a highly stressful work environment, but for many young people that is their reality every day at school.
We heard that current education was a real cause of people’s anxiety—exams and fear of failure—and lots of people are given the sense that there is almost no hope for the future because they are constantly reinforced with the idea that they have to do well, they have to study hard and they have to revise or they are going to fail.
It is worth noting with the vulnerable young people as well that, where young people have behavioural difficulties, the guidance at the moment is showing a kind of almost antagonist approach to be taken by schools, whereas lots of the health advice is that you need to be positive, nurturing and supporting young people rather than just constantly battering them down again.
Another aspect of that is the shame that comes with admitting that you have a mental health problem. The stigma is one of the biggest battles in mental health. The recommendation from the Youth Select Committee was that anti‑stigma campaigns should be developed with young people, and increasing mental health literacy and peer support are integral to what we need to be offering.
Q35 Lucy Powell: What about teacher stress? Do you think that sits alongside some of this overall stressed environment?
Rowan Munson: Yes, of course, teachers are subject to their own work pressures and have their own mental health pressures, with that constant focus on exam grades and league tables. Teachers are visibly stressed in lessons. I even know of one teacher at a local school who had anxiety issues and had a panic attack in the middle of the class, which was both very distressing for the teacher concerned and even more distressing, I would say, for the year 8s—I think it was—in that class.
Q36 Chair: I know we have asked Anne this before, but, Pooky and Rowan, what about the impact of social media as drivers?
Rowan Munson: The Green Paper focuses on the negative aspects of social media, and we know that there is a link between social media and poor mental health. We do not know whether people’s mental health is worse because of the social media or whether social media is their coping mechanism for their mental health, but we are missing the positive aspects that maybe were covered in “Future in mind.” They suggested things such as a kitemarking scheme for resources. So, the real problem in that issue is sorting the wheat from the chaff, and I would support, going forward, some kind of recommended and supportive resources by the NHS.
We have seen NHS Go, which was developed by the Healthy London Partnership; it is a really popular app among young people. Although it is a general health app, one of their most frequently accessed areas is mental health. They have promoted it, I thought very innovatively, with YouTubers. So social media is positive and negative.
Dr Knightsmith: I would agree with Rowan. Often, we miss out the positives. For some of our more vulnerable groups, children on the ASD spectrum, for example, this is the one place where they can make meaningful relationships that they might struggle to make face to face.
When it comes to social media, there is a lot more that needs to be done in educating both young people and the adults who work with them. Setting this in a wider context, we would expect social media to form part of any compulsory statutory PSHE curriculum, which we would welcome the introduction of, but that is a wholly separate consultation process going on. We think more needs to be done to understand it, but it should be certainly something that young people, their teachers and their parents are learning about and learning to navigate in a safe and positive way.
Q37 Luciana Berger: I have a very quick question, and forgive me for coming back to the point about transition, because it was in the “Future in mind” document that was released by the Government in March 2015, which advocated the 0 to 25 approach. Are you disappointed perhaps, or not, as the case may be, that the Green Paper seeks to re‑entrench the 16 to 25 separate approach to transition rather than looking at that 0 to 25 approach?
Dr Knightsmith: We are a little ambivalent. We want a 0 to 25 approach. However, we welcome a particular focus on 16 to 25 and think there are challenges there that need to be looked at specifically. We also appreciate that, the bigger we make the scope of this paper, there is not necessarily going to be more money, and so there is an argument for doing less but doing it well; but at the same time our members come back again and again saying 0 to 25, absolutely, and even pre-birth, as we discussed.
Anne Longfield: There is an opportunity missed if you do not look at this within the context of transition and the fact that actually there are young people who will become young adults with particular mental health issues. It has to be a system that is co‑ordinated, worked out and does not allow children just to find their own way through. As with the wider issues around linking this with the broader strategies in all aspects, there is an opportunity lost if it does not do that around 0 to 25.
Q38 Thelma Walker: I would like to go back to teachers, schools and support services, and the idea of having a designated person responsible for mental health and the training for that person, remembering that we already have a designated person in school for safeguarding and that teachers have a pastoral role for the care and wellbeing of young people. In terms of the training for that designated person and the quality assurance of the nature and consistency of the training, who is going to provide it and how is it going to be provided? Alongside that is the question of increased pressure on individuals in school to deliver it.
Anne Longfield: Those are the unanswered questions in there. My view is that it should be compulsory to have a designated lead; it cannot just be added on to someone else’s job, and it has to be someone who has the particular ability to be able to work with health teams. What we do not want to put in place is yet another opportunity for children to fall through those gaps. There needs to be statutory guidance around there and whole‑school training as well to back that up. It is a really crucial role and it is a good aspiration, but it is crucial that we get this right.
Q39 Thelma Walker: Talking about liaising with health teams, the chief executive of YoungMinds reported to the Health Committee last year in November that “We have low morale in our CAMHS workforce. They are overwhelmed. They do not want to turn people away, but they have to—just to cope.” That was November.
Anne Longfield: Again, none of this is going to happen by itself, which is why the issue of resources is so important. It cannot just be a stitching together of what already exists, because we know access levels are so poor that there needs to be a rapid and dramatic improvement there. This is only going to happen if it is made to happen, which is why you need specialist people around the designated lead but also specialist health teams there within the health agencies as well.
Q40 Thelma Walker: But if you have overstretched CAMH services going in to support teachers who are—
Anne Longfield: I agree. That is why, again, I am arguing the case that there needs to be additional funding in there to be able to boost the numbers that are available to work with children. Again, going back, we know that only 6% of the mental health budget at the moment is spent on children. That is an urgent area that needs attention. If it was trebled or quadrupled, it would only start to become proportionate to the number of children, and it could be argued that in preventive terms we should be investing more in this age group because it is now that we need to prevent these issues from escalating.
Chair: We will have one final question from Luciana before we wrap up this session.
Q41 Luciana Berger: Further to that, we know from some freedom of information requests that the NSPCC did over the last two years that more than 100,000 children have been rejected for mental health treatment, which equates to about 150 rejections per day. According to the Green Paper, the Government seek to provide treatment for an additional 70,000 children by 2021. Do you think that is going to meet the needs of the children who currently do not access treatment? Is that ambitious enough to reach the children who need support?
Anne Longfield: From my point of view, this is not nearly ambitious enough. As to the fact that three out of four children do not get treatment at the moment, we do not know an awful lot about that; we do not know the ones who get turned away, the waiting list times and the like. I would be very happy to undertake a study on waiting lists to provide more information. We simply do not know enough—the data is not there. Again, I get children raising these issues all the time. It has to be much more ambitious. A seismic shift is needed. These are issues that are not going to go away. There needs to be urgent action. The scale of change needed is incredible and it is one that I think should be a priority across Government to deliver.
Dr Knightsmith: We know far too little, as Anne says, about exactly what need is out there. There is so much that is hidden, which is not understood at the moment, but we do know that there is a huge amount of need not being met. The way we are going to meet that is only going to be by social, health and education working together with the child at the heart, and stepping back and remembering that we are talking about individual children’s lives and not just data points. When we look at the Green Paper and at how much it is trying to achieve in how much time, just imagine that the three and four whom it does not touch are your own children.
Q42 Chair: If you had to sum it up, it would be, “These are good intentions, but where is the beef of the whole thing?”
Dr Knightsmith: We welcome the joint working between health and education. We are really excited to continue to work together on this and on rolling it out. We hope that it will be done in an iterative way so that as much can be done as quickly as possible. We think more money is needed and that there need to be careful safeguards in place to ensure that the money that is spent is not spent on things that are already happening but on stuff that is genuinely innovative, new and makes an impact on young people.
Anne Longfield: We know through other priorities that action of this scale can be delivered. IAPT, again, really shows that it can be done. There will be a question of why that cannot be broadened as the approach in terms of children, but when you look at issues such as extremism and CSE, there we have a real focus and priority to push that through. This needs and demands that level of priority.
Rowan Munson: The real issue is that we are not talking to children and young people enough. We need more data from the clinical side, but the Green Paper was not written for young people. It was very tricky for me to read, and I have the experience of being on the Youth Select Committee and such like. Most of the questions are not accessible, for one thing. You would not be able to understand them as a layman, but we need to be asking where the first point of contact is, how we get that right, what works for you, very simply, and developing that so that we do have young people at the heart rather than the system.
Q43 Chair: Thank you, first, for the incredible work you do. You are an incredible representative of young people, I should say. This is two Committees that have come together because we really believe it is incredibly important and we are doing everything we can to try to hear the voices of young people. We had two schools in yesterday for an informal session. Thank you to all of you and we look forward to working with you over the months ahead.
Anne Longfield: Thank you.
Rowan Munson: Thank you.
Examination of witnesses
Witnesses: Paul Whiteman, Stuart Rimmer, Dr Bernadka Dubicka and Professor Tamsin Ford.
Q44 Chair: Good morning. Thank you very much for coming to our session today. For the benefit of the recording and the audience watching, from our left to right, could you kindly give your name and title?
Dr Dubicka: My name is Dr Bernadka Dubicka. I am chair of the Child and Adolescent Faculty of the Royal College of Psychiatrists.
Paul Whiteman: I am Paul Whiteman. I am the general secretary of the NAHT.
Stuart Rimmer: I am Stuart Rimmer, the principal and chief executive at East Coast College, and also the chair of the Association of Colleges’ mental health policy group.
Professor Ford: I am Tamsin Ford. I am a child psychiatrist from Exeter medical school.
Chair: The acoustics are not fantastic, so bear that in mind when you give your evidence. We have quite a lot to get through, so can we, kindly, try to be as succinct as possible?
Q45 Dr Wollaston: It is great to have such expertise from across mental health and education, and we are really looking forward to hearing your views. I would like to start with your overall views about the Green Paper, what you see as the main pros and cons, and particularly around having the three‑pillar approach and what is missing, starting with yourself, Bernadka.
Dr Dubicka: First, the Royal College of Psychiatrists very much welcomes this paper. We welcome the focus on child and adolescent mental health by the Government, and we particularly welcome the coming together of these two Departments. Seeing this Committee sitting together in the same room is such a fantastic blueprint and model for how services should be working in the communities. It starts from the very top. If we can see this cross‑governmental working between Departments, that will be very important in making sure that approach is consistent in the community.
We welcome the fact that the paper addresses the spectrum of disorder, from early intervention prevention to serious mental health problems, and we welcome the bold ambition to try to reduce waiting times, which are currently scandalous in child and adolescent mental health services.
Moving on to the cons, having said all of that, there are some caveats, and we have heard very eloquently from the previous panel about what some of those concerns might be. Our overriding concern is workforce recruitment and retention. Since 2013, there has been a reduction of child psychiatrists by 6.6%, and it is an ongoing challenge to recruit and retain. The college is doing what it can with its “Choose Psychiatry” campaign, and recently we have had a lot of applicants for our run‑through training scheme, but we will not be able to deliver the high‑quality care that young people need, particularly when they are referred to CAMHS, without an adequate workforce and without child psychiatrists in place.
We welcome the notion of a mental health lead within schools. However, as previously mentioned, we believe that should be mandatory as well, otherwise the paper will fall apart.
We want some thinking around the parameters about how these mental health teams will work. There is a discussion about the fact that they will see mild to moderate disorders. However, we know that moderate disorders can become quite complex and risky. Without being clear about the training of the mental health teams and the level of expertise they will have, we need to be very clear about what they can and cannot do, and at what point they should be expected to refer to more specialist services.
We also have some concerns about the consistency of training for mental health leads. The paper suggests that schools should be able to pick and choose those approaches. However, although we appreciate there is some excellent local practice and local need should be taken into consideration, there should also be some guidance nationally about the best-quality training that is available and that should be rolled out nationally so that standards are consistent.
The other issue, which is touched upon in the impact assessment but only lightly in the main report, is that there is not a huge expectation that there will be an increased demand in CAMHS. However, our members are very concerned that what is likely to happen is that these mental health teams will pick up all this unmet need. We know the current ambition is only to treat 35% of young people by 2021. That represents 65% unmet need. We know that CAMH services have increased their threshold hugely, and there will be an awful lot of young people with quite significant problems and high levels of risks who will not be accepted by CAMHS. The danger is that these mental health teams will be expected to manage them, which could adversely affect morale, recruitment and retention.
It is important to think about how that increased demand might be addressed and to think about how CAMHS will link in with these mental health teams. Again, we welcome the fact that the ambition is to have closer working between CAMHS, the mental health teams and the mental health leads within schools. We think that is really important, but we do need to think about things such as clinical notes, how they will be kept and shared between systems, and how we can have seamless transition between the teams and between CAMHS, and not create further barriers.
Dr Wollaston: Thank you.
Paul Whiteman: We too welcome the Green Paper from the school point of view. We welcome the co‑working and think it is the thing that is missing most at the moment in terms of schools being able to get access to and help from mental health services.
We are concerned about the pace and scope of the proposals. We do not think they go far or fast enough, and therefore there are questions for us around the amount of money and resources available.
We welcome the recognition of the central role that schools can play in identification and support of children with mental health issues. So, we accept and welcome the acknowledgement that schools can promote good mental health and wellbeing across a whole‑school context, and we welcome the brief reference in there to the mental health and wellbeing of teachers and school leaders as well in terms of being role models and promoting the whole culture.
We understand that we have a unique position in identifying emerging mental health needs of children who are in the care of our members. Where we worry is that the Green Paper begins to give a nod towards diagnosis and treatment from the leads that are to be identified, and we do not think there is a place for education professionals to do that. That should be in terms of working with others who have that expertise. We believe we should refer and then support the interventions that are made by the health professionals. So, we broadly welcome all of that.
The other thing that is worrying our members a great deal is the evaluation and accountability that will stem from this. We work in a system at the moment that is high stakes and our members suffer terribly at the hands of the accountability system. We worry that this is just another stick with which to beat school leaders and teachers rather than it being a serious and positive intervention to look after children’s mental health.
Stuart Rimmer: Certainly, we welcome it broadly as a group of colleges, and we have seen a step change in the fact that colleges, as a previous person who gave evidence said, had been excluded from previous pieces of work. The fact they have been included in the Green Paper should be welcomed.
Colleagues of mine have made a point, though, that we feel it is time that colleges could be dealt with separately, rather than just being “schools and colleges” or “colleges and universities.” There is an opportunity here, with three quarters of a million 16 to 18‑year‑olds in colleges right now, which is a significantly higher proportion than find themselves in schools at that age. There is also the advantage in that, in terms of scope and pace, we feel that colleges could mobilise much faster. We would not have to wait for some of the timelines outlined in the programme. There are only 300 or so colleges nationally, and that mobilisation can happen very quickly. We feel there are some missed opportunities in using colleges.
Likewise, we have previously given evidence and talked about that transition period of 16 to 25 and feel that is an important period. We certainly get reports from colleagues in colleges where that is a bottleneck that happens, and it feels like the Green Paper does not go far enough in understanding what might sit behind the bottleneck.
Certainly, colleges have a slightly different structure in terms of college environment than schools, and therefore some things that may work in schools will not necessarily work in colleges. For example, we acknowledge the role of PSHE in schools and the role of people such as school nurses. Neither of those facilities exists within the college structure, nor college funding at the moment, and we think we can do some heavy lifting for Government within this arena, but funding would have to follow from that.
Also, probably more work needs to be done around the disadvantaged. If you are from a disadvantaged postcode, you are more likely to find yourself in a college than in a school or university environment, and, therefore, once again disproportionately, colleges experience students with mental health difficulties. The college sector, it is worth noting, has done a lot of work in this arena and switched on really quickly to this work. There is a lot of good practice out there existing already, and I would welcome the opportunity at some point to explore some of that good practice with you.
The role of the designated senior person is very familiar to us in terms of the safeguarding lead, so this is not a huge leap. However, it is about defining exactly what that role would be and how it would operate. The nervousness of colleagues that I have spoken to across the country in preparation for this is around the blurring of the lines between clinician and educator. That probably needs a bit of unpacking.
Certainly, as colleges, we welcome the creation of the national strategic partnership group. We have already had some good conversations with Universities UK and so on.
Professor Ford: I totally back up my colleagues. Without repeating a lot of what they have said, certainly I am seeing enthusiasm at every single level for joint working with education, but I worry about where social care is, particularly for those with the most complex needs. There is only so much that health and education can do together.
I would reiterate my colleagues’ call that the training courses offered need to be consistent across the country and of high quality. We need to make sure that the designated mental health leads are properly trained, comfortable with their role, have time to carry out their role and are supported to do so by the mental health teams and by CAMHS outside that; and that the mental health teams are delivering interventions to children that are evidence based, monitoring their outcomes, and reflecting and improving based upon that. Anything else I would say would merely repeat what my colleagues have said.
Q46 Chair: Before I pass over to Paul, can I come back to you, Stuart, on further education? Given that you have said that a significant number of disadvantaged people go to FE, and given that FE has fewer resources than other parts of the education sector, do you think there is anything in this report that would make a real difference to you as to what is being proposed and what should happen? Could you set out how far you think mental health difficulties with students in FE colleges have increased over the past few years and the pressures that the FE college sector has to bear in this?
Stuart Rimmer: Thank you. You point out the funding inequality that exists anyway, and certainly I have found, and as a college principal have lived with the fact, that I have had to cut support services to students year on year as the funding does not quite stretch as far. Predominantly now, we are having some quite difficult conversations about whether to protect the educational character of the institution or support services.
The Association of Colleges did a mental health survey; we have done two so far. The last one last year showed that 80% of colleges had seen a significant increase in mental health services. I can give you an example from my own college. This year there have already been 622 separate referrals—and that is a medium‑sized college; we are not that big—which include the complexities of mild and moderate mental health difficulties, from suicidal ideation, self‑harm, suicidal intent and eating disorders. We have seen a huge rise in that, and that is an exponential rise year on year with little or no future resource to solve this.
Coming back to the issues surrounding people taking a whole‑college approach, we certainly would do that. We have trained all our staff, not just one person in an institution, and we need to do that in order to get under the complexity of colleges. At the same time, we have seen the gap being at CAMHS. That is the sticky point. Unless there is significantly more resource put into that, we are still going to see the bottlenecks. Most of those occur around assessment first and then treatment. Unless significant work is done to address that bottleneck, we will still be seeing it.
I would say that colleges have been very proactive out of their own coffers to address and support. I certainly will not wait four weeks for a young person to get help. We do it on day one. If that costs the college money, that is what we are prepared to do. That does not make economic sense from the college’s perspective, but it is certainly a moral imperative that we will not turn back on.
Q47 Dr Williams: Headteachers in my constituency have particularly highlighted gaps in services for children with suspected or diagnosed autism. What do you think about what the Green Paper has to say in those areas?
Paul Whiteman: The whole situation is characterised by a lack of resources. We know in terms of how the Green Paper addresses the whole subject that, when we look at referral to support services, we are waiting months rather than days or weeks for intervention and support. Local headteachers will use their own budgets, in common with the evidence given about colleges, to fill the gap sometimes, but against already stretched budgets that is becoming harder. Without this working, I suspect that the reports from headteachers will simply get worse about intervention across the whole sphere of support that is needed.
Bringing all the agencies together—education and health together—is the right thing to do, but we worry very much about whether there is sufficient resource there and whether the correct support will be brought in without more resources.
Stuart Rimmer: From my point of view, we have seen an increase in students with educational healthcare plans. With the volume of high‑needs learners coming through, the imminent issue for colleges around that is that funding works on a lagged basis. You are working 12 months behind, as a minimum, and therefore you do not always have the right resource to put in place for the learners you have on the deck in that academic year.
Professor Ford: From talking recently with teachers working with and supporting children with autism, the problem is that people often feel they have a dilemma between mental health access and support in special education or attainment for those children who are high functioning with autism who may well cope in the classroom because it is structured but struggle with the social environment in the school. We need to be better able to support them.
That has implications in special educational needs training and resources, teachers understanding autism and how it presents. You may have a child who in the classroom seems to be doing fine, and may well excel, but who is completely unable to cope with break or lunchtime, or particularly in a college where it is even more unstructured. Parents should not have to choose between their children’s mental health and academic attainment.
Q48 Dr Williams: What do you think the answer is?
Professor Ford: The answer is adequate support for those children to cope with the social structures, and that might mean having a TA with them through break. That is very difficult for schools and colleges to do because TAs often need to go off and have breaks. That means training those working around the child to understand autism and that children with autism can end up with secondary depression or anxiety around the difficulties of fitting in, particularly in the teenage years where they begin to understand that they are different, and that they should have access to prompt support at whatever step of the scale they need it so that they can carry on functioning.
Dr Dubicka: I see the extreme end of that. I work in an in‑patient service, and, increasingly, over the past few years we are having more young people presenting in crisis with autism because they have not had the support that people are talking about here and it is an absolute tragedy to see them presenting with self‑harm. Families are not able to cope any more. They do not have anywhere to live, social services do not have anywhere to place them, and they sit for inordinate periods of time inappropriately in in‑patient units while we are trying to get the right resource in the community, which is very few and far between.
Professor Ford: You do not have to stop very many of those admissions, which cost several hundreds of pounds per week, to be able to pay for a team to support children properly in the community, which would be better for them, their families and for everyone else. If you go to most university departments of physics or firms of accounting, you will find quite a lot of people who would tick boxes on the autism spectrum. If you can get them through school and get them qualified, then when they leave school they choose their own niche and find somewhere they fit, but schools are very social places so are very challenging for people with autism.
Paul Whiteman: It is worth adding that the support that is needed takes away from the debate that is in the report in the Green Paper. This is about basic funding as much as funding around the support we are discussing here. The funding issues around the number of TAs that we can have in place at the moment is a real stretch, even before you get into the other services around it and the removal of support. The amount of one‑to‑one care that we are losing in that context at the moment is only going to put more pressure on the services that we are talking about here in this Green Paper.
Q49 Dr Williams: Even if the Green Paper said something more strategically around autism, if it is not backed up with the resources required across the whole system, it would not help if the resources—
Dr Dubicka: I do not think that is strictly true because there are things that can be done within schools, and I think we mention in our response that the particular behavioural approaches that young people with autism or a learning disability might need are going to be different from those of other pupils. There are certainly interventions that can be done in school to try to make schools better places to learn for those young people.
Q50 Trudy Harrison: With regard to children and young people who are disadvantaged, to what extent do you feel that the Green Paper addresses those needs? I am speaking really with particular reference to young people in the criminal justice system or looked‑after children.
Dr Dubicka: We heard from the previous panel a lot of discussion around that, with which I would broadly agree. The introduction to the Green Paper talks about these disadvantaged and vulnerable groups, and recognises those needs, but, as you say, there is not much substance later on in terms of what is going to be done for them. So, it is a concern that we share and they are questions that we would like to raise, because we know that it is the most disadvantaged groups that are most likely to have mental health difficulties and need a disproportionate amount of mental health input.
In addition to that, the previous discussion that we had was that it is not just the disadvantaged vulnerable groups but also the early years. There is no mention of nurseries within this Green Paper, but, if it really wants to be ambitious in trying to do as much prevention work as possible, it needs to target those disadvantaged groups as well as the very young children.
Professor Ford: I would add that the focus on schools is very welcome, but those particularly disadvantaged groups who are particularly likely to have not only mental health problems but complex and severe mental health problems are much less likely to be in school in the first place. I worry that they may be missing out without something extra.
Stuart Rimmer: NEET learners, for example, are excluded, broadly, linking back to Robert’s point in the last session. A better connection between the social mobility report, published last November, would certainly be welcome to explore some of these groups. One of the sticky points on a practical level is probably around the new GDPR legislation that is coming through and how support services and agencies will share data around this, for example, with youth offending teams, housing officers and broader social supports. There is a kind of puzzle there to be unlocked.
Q51 Chair: I believe the Education Committee, separately to Health—and, as you know, this is a joint inquiry—is doing its own inquiry into exclusions and alternative provision. Is your feeling that there are more children with mental health difficulties being excluded from schools?
Paul Whiteman: The issue about exclusion is a difficult one because there are so many factors. I suspect, if we went and got our statistics, that, yes, we would find there are more children with mental health issues who are experiencing exclusion from schools. Therefore, it takes us into the area that we have just discussed about what the Green Paper really says about that, and then those conversations would be around prevention.
We would like to see the detail behind that focus in those groups and to see what else can take place within schools, but that takes us to our central concern about the designated lead, how far that lead goes and what the responsibilities of that lead are in schools tacked into the debate around exclusions and how that reflects on the rest of the school.
Q52 Chair: You talked about the resources for TAs, which of course is important, but there is that need for more resources. If you had to choose, would you say it was better to spend the money on Place2Be? Obviously, you do not want to have to make that choice, but, if you did, which would you see as a more effective way of helping those children in schools, FE and so on?
Paul Whiteman: I do not think it is a choice we can make, I am afraid. I understand you are inviting me to make the choice, but I genuinely don’t think it is a legitimate choice to ask schools to make. Both are as important as each other. If we get the provision in schools correct, then perhaps we will avoid some of the issues that arise, but once they have arisen we have to look after people. I do not think it is a legitimate choice.
Q53 Thelma Walker: We took evidence and spoke with some wonderful, articulate young people yesterday. When I asked them about when they feel the most stressed, when do they get really down, many of them who spoke to me said they feel the pressure of the targets, the tests, passing exams, feeling a failure if they do not achieve their target. I want your thoughts on whether it is the culture, if we are looking at early intervention and causality, of why there is an increase in problems with mental health and children facing these challenges, and also in that culture I am thinking about the professionals’ mental health and wellbeing. There is discussion today around the creative curriculum and that broad and balanced curriculum—the curriculum diet, if you like—that we are offering children and young people.
Chair: Could I ask everyone to speak loudly into the microphones, thank you?
Stuart Rimmer: Can I jump in straight away there because I think you are absolutely right that at the moment we have a culture of failure? If you think that half of the young people at the age of 16 are told they have failed because they do not achieve the five GCSE gold status, it feels as if there is a deficit model running already. We would certainly call for other elements of Government policy to connect to this agenda in other parts of policy generated out of the DFE. For example, the maths and English resit is something we have reported as causing an increasing amount of anxiety and stress in young people in colleges that we are then having to deal with.
Q54 Chair: Do you have evidence on the impact of that in terms of their mental health?
Stuart Rimmer: I do not have it with me today, but I can provide that.
Chair: If you could supply that to the Committee, it would be very helpful.
Stuart Rimmer: I can certainly do that. The other connection you quite rightly make is to staff. Staff in the further education sector do a stunning job on a day‑to‑day basis, but there is that sort of tension between the call and drops on other services in terms of social work and housing services that they are picking up as well as being the educators that they are proud to be.
Q55 Michelle Donelan: Following on from that point, another thing that came out of our session yesterday was that some of the young people I met were saying that they are two different people—one person in school, if you like, and another person at home. Is it not the fact that we need to invest a lot more and give schools more powers and ability to reach out to parents to educate them on what to spot and how to look out for these things? A lot of these anxiety disorders can be very hard to pick up and to know what they are, and we should also deal with parents’ stigmas around mental illness.
Paul Whiteman: I will try to deal with both points, if I can, because they lead into each other. Teachers and school leaders do all they can to remove the testing and exam pressure that is in the system, but we do have a high‑stakes system at the moment for children and schools. No matter what school leaders and teachers do to remove that pressure, it is pervasive, it goes right the way through, and parents see it as well in terms of what they read in the press about results, league tables and everything else, and where their child should sit in their development for their age. There is this whole competitive environment that certainly has an impact.
School leaders whom I speak to on a daily basis tell us about how they react to pupils being away during SATs and things like that, and the impact that will have on the school’s results, if it was a particularly gifted child. This whole system that sets itself up for either success or failure is not helpful, and it does go through.
As to talking to parents and reaching out, we have to begin to understand the limits of what schools can do. Although we see them as having a central part—and it is correct to have a central part—their job is to educate children and then to rely on the services outside the school gate to give support to families outside. They cannot do absolutely everything and they are not resourced do everything either. Have that collaborative approach, yes, but we have to take some care not to overload the education system.
Dr Dubicka: Can I speak to that as well to build on your point? As to the culture, there are the external pressures but also there are vastly different cultures within schools. I see that all the time in my dealings with schools. Some value the focus on mental health and resilience, and others struggle with that concept more. The College of Psychiatrists has produced a document called “Values‑Based CAMHS” where we work with schools to think about how those sorts of joint values can be engendered within schools. It is going to be critical in being able to implement this plan that we have schools on board and all think and agree that this is an important issue to work on. With MindEd, which was briefly mentioned earlier, we have a module of training around that as well.
To pick up on your point about parenting, that is another big gap in the document. Parenting is vastly important and we know that is one of the big areas of evidence we have where it actually works. Having parenting groups for children with behavioural difficulties as early as possible, we can do an awful lot of good. The evidence shows that it works. That is missing from this document and we really need to invest in that.
Q56 Michelle Donelan: Do you think at the moment there are lots of little organisations that are trying to fill that gap and they cannot do it, because I appreciate your point that you cannot rely on the school system to do yet another thing? Would you like to see that as a co‑ordinated effort and maybe that gap filled?
Dr Dubicka: We would, yes.
Stuart Rimmer: Consistency is probably the thing that colleges would call for more. A college often sits between geographical areas as well and pulls its students from quite a broad range, some with apprentices who are working 40 or 50 miles away from their home site, so across multiple CAMHS areas and clinical commissioning groups. Therefore, for me, the document allows too much flexibility for localism, and a much more consistent national approach would be welcomed by us.
Professor Ford: Just to pick up on Bernadka mentioning MindEd, there is a whole module for parents. One thing that schools could be doing is pointing parents who are worried about their child to go and have a look at it. It is freely available for anyone who wants to use it. Likewise, there is information there that would be of use to teachers too.
Q57 Andrew Selous: Following on from that family team, I note the Royal College of Psychiatrists said in its evidence that there is little mention of early starting behavioural problems and that parenting and family‑based interventions can make a difference, and also the PPP—positive parenting programme. You say that the mental health strategy, which does not consider the crucial importance of parents in the home environment to a child’s life chances, risks missing the opportunity to tackle problems at the earliest possible moment. Could you say a little more about that and about the ways in which we can try to help deal with some of these family issues at home as well as equip parents?
Dr Dubicka: The point has been raised already. The first is the importance of having co‑ordinated parenting programmes; the second is the importance of linking in with social care, and, as has been mentioned previously, the impact on social care does not seem to have been considered in this Green Paper. There is a focus on the importance of systems, but there is no doubt it is not just CAMHS that will find additional young people they will need to see with complex difficulties, but there will be all sorts of safeguarding issues that are likely to be picked up—children from disadvantaged backgrounds, the troubled families, who will be referred to social care as well. So, we need a seamless joined‑up approach with social care, and the impact on those services needs to be considered.
The other thing that was mentioned earlier was the importance of routine inquiry into childhood adverse experiences. I know that has been looked at in the Science and Technology Committee, but, if we can pick up children where those sorts of adverse experiences are happening early on and can intervene earlier, hopefully that will improve their chances later on in life.
Q58 Andrew Selous: I will come to Tamsin in a second, but that is an interesting point, because I understand that Wales, Scotland and Northern Ireland are moving ahead with the WAVE Trust adverse childhood experiences work slightly faster than England is, so I am pleased you picked that up. Tamsin, you want to respond.
Professor Ford: I would add to what my colleagues said and what the earlier panel brought up about the importance of health visiting and support for women having babies, picking up post‑natal depression, and depression in parents who are older, which is toxic to kids’ own mental health, but also support for parents who have children with mental health problems, because all of us want our children to do well. This goes both ways: making sure that parents can get the mental health needs that they have met as well as their children is really important. It is worrying to see health visiting services being cut back in some areas, because they are vital.
Q59 Andrew Selous: Do you share my worry about the low level of provision of couples counselling for depression within IAPT inasmuch as it can have a serious impact on children’s mental health within these families?
Professor Ford: It is an issue. There are some voluntary agencies that do fantastic work not only between couples but also sometimes with children—Relate, for example—but often you have to pay to access it. I do think support for families is key and particularly families at the transition. We know that pregnancy is a very big risk factor to mental health, and we know also that young women with babies may become isolated. Health visitors are very well-trained and well-positioned professionals to pick that up and make sure those mums—and dads—get the treatment that they need before the children are impacted. All that happens before they come into school.
Q60 Lucy Allan: Do you feel that the Green Paper covers provision for 16 to 25-year-olds sufficiently? For example, if a young person is not in higher education, if they are leaving care or are moving on from CAMHS, do you feel that within the Green Paper that challenge is adequately addressed?
Dr Dubicka: As was said previously by my colleagues—Rowan described it as a cliff edge, and that is frankly what it is—we need to reduce the blockades that exist to transitioning young people. As previously mentioned, it is not just about the mental health services and the transition into that but about transition to other services, whether it is social care and other support provision for young people. So, no, it does not say enough about that.
I welcome the fact there is going to be a working group and a survey. However, we need action now. Every day I see the impact of that. It is very difficult for us to transition young people into adult mental health services, even when they have been admitted with suicide attempts to an in‑patient unit. Similarly, it is very difficult often to get the social care that they need on leaving that service, and those, by definition, are the most risky and most complex young people whom we deal with.
Professor Ford: I would add to that that, again, the most vulnerable people are not likely to be in schools, colleges or universities. Wherever there is an interface, there are going to be difficulties potentially, with services that span that vulnerable time between 16 and 18, where most people leave home, which is a transition. They may move away from their social networks, and that is another transition. If you then add transitioning between multiple support services, that just stacks risk factors on people who are already vulnerable.
Q61 Lucy Allan: What would you like to see in the Green Paper to address that?
Professor Ford: There is quite a lot of research and practice—sort of grey literature—around what makes an optimum transition, so transfer of information, information flows that are made to work. Sometimes the best way to do that is to have a transition officer who can flit between the services and physically take the conversations. What is lost is shared knowledge that is not necessarily written down in files. Also, if I walk into the waiting room, I expect to see a child; they may be 17 and a half or 17 years and 11 months, but maybe a month later they are sitting in an adult clinic where the adult psychiatrist going to pick them up from the waiting room is expecting to see an adult, and people feel that. We are social animals and we make attachments, so they need something that helps them bridge that gap when maybe trusting people and making relationships might be big issues for them. Transition officers, which have been trialled in some areas, are hugely effective because they can ease that transition.
Then there are tensions around the role of parents. Quite often the parents feel completely blocked out of adult services, but for some young people—say, young people with ADHD—parents are the social secretaries who get them to the appointment. By its very nature, ADHD makes it hard for you to organise yourself, and then if you miss a couple of appointments you are seen as not wanting to engage and are discharged. Then you do not get your medication and your college life goes a bit messy. You can see how parents are crucial, but adult services are not used to dealing with parents in the same way. So, we need joint working, joint adult and child psychiatrists or mental health practitioners seeing people together as well as the information flows around everybody working around that young person.
Stuart Rimmer: Dividing by chronology at 18 does not make sense. If you talk to 18‑year‑olds, it is interesting that funding tends to split at those ages, but if you think about what most young people are going through at 18, 19 and 20, there is a huge pinch point in their lives socially, but also it does not make any sense to them transitioning between services at that time at all. I would be bolder and call for it to run to the age of 25.
It is also good to be mindful that 50% of people do not go to university. Of those, 10% stay in higher education or go to a further education setting. Sarah asked right at the start what was missing from the Green Paper. There is no mention of apprentices at all through the Green Paper, and yet there are 90,000 16 to 18‑year‑olds on apprenticeship programmes who are working in the workplace. While there is a paragraph on workplace mental health, much more needs to be done to strengthen that.
Chair: I think you just read my mind as I was going to ask you about apprenticeships and what happens to them, whether they are looked after by the college or the workplace, or the training provider or the workplace. That is an incredibly important point you have just made.
Q62 Luciana Berger: I have two questions about the impact assessment that was done on the Green Paper. Can I ask a specific question, please, to Dr Dubicka first? You mentioned in your opening remarks the issue about the reduction that we have seen in the number of CAMHS psychiatrists over the last seven years. The Green Paper impact assessment on page 3 highlights a risk in the increased demand for CAMHS treatment as more children with severe needs are identified through mental health support teams and designated leads. That was the document that came out in December.
A few months before, Health Education England produced a workforce plan for mental health until 2021. I note that within it there are no plans to create any additional child and adolescent psychiatrists in the community, and yet the document itself identifies that there are 70 existing vacancies within the sphere. What are your views on whether we will be able adequately to meet the needs of children across the country in light of there being no plans to introduce any further child and adolescent psychiatrists in the community?
Dr Dubicka: Thank you for raising that point. It is on my list. It is absolutely of huge concern. Health Education England is planning to increase child psychiatry by 100, but they are all for specialist services, so there will be no additional capacity to meet this anticipated need within the Green Paper, which is going to be hugely important. We would ask the Government to reconsider that.
The other thing to say is that, as a college, we are trying to do what we can to increase recruitment. One thing we have discussed is perhaps thinking a bit more about the curriculum, making education more of a specialism, and trying to attract child psychiatrists to that particular specialism, because in some countries, such as the US, that exists. That is something for us to be thinking about as well, but, absolutely, we will not be able to fulfil all the intentions of this Green Paper unless we increase the workforce, and, from our point of view, child psychiatrists are going to be really important in that.
As to the impact assessments, the other thing is that they are based on an awful lot of assumptions and we do not have accurate data to predict what the impact is going to be. I would make the point around that, which was previously raised. If we want to have good figures and good data on what the unmet need is out there, we have a prevalence survey coming up, so we will find out what the current level of disorder is in the community. However, that survey is not going to be repeated for seven years, and in the meantime we will not know what is happening to those children. Will those identify a disorder? Will their needs be met? Will their outcomes improve? Will they access services? What sorts of services will they access?
There is a unique opportunity here to get that data robustly from a national project if the Government will agree to fund follow‑up studies year on year between now and in seven years’ time. Then we would have answers to all those questions you were asking earlier. We just do not know what that level of need is; that impact assessment is based on figures plucked out of the air. But we could have that data and know what impact this Green Paper is having. I would call on the Government to consider investing—it is not much money—on that annual follow‑up of those young people.
Q63 Luciana Berger: Is there anything you want to add?
Stuart Rimmer: One real concern for colleges is the unintended consequences. As was raised before, all the colleges have been proactive, my own—East Coast College—included, where they have developed mental health literacy in students, and enabled them to talk and be eloquent around their own mental health, and they have increased awareness with staff through staff training and whole‑college approaches. What you find then is an increase in referrals as you start to hit that untapped need.
The unintended consequence of the great work that is flagged in the Green Paper is that we are going to see a short‑term burst probably around tiers 2 and 3. One difficulty, as colleagues identified, and certainly we have seen in Norfolk, is that there are not enough tier 4 beds available and tier 3 practitioner services, which is pushing tiers 1 and 2 fully into the hands of colleges and we simply do not have the clinical expertise sometimes to deal with those.
Paul Whiteman: To echo that, the main concern coming from our members about all this is that we are not coming from a strong starting point. There are not enough resources there already. Once we begin to develop an identification of a further need, it is just going to create more frustration within the system, and that frustration of itself will cause more problems.
Professor Ford: Can I add to that? When I had a look at some national data from CORC about tier 2 and tier 3 services a couple of years back, there was no difference in the level of severity of the difficulties for the children going to those two services, although one is supposed to be milder problems. That is a reflection of the level of need and the level of provision.
The other thing leading on from that, to echo Bernadka’s point about data going forward, is that it would be so much better to have a national level of data from which we could plan more effectively rather than the data used in the impact assessment, which is over a decade old.
Q64 Chair: That is a major thing. I am astonished that the data is so weak, the surveys so outdated and that this is not done regularly.
Professor Ford: It is not for the want of trying. The adults have been surveyed every five years.
Q65 Lucy Powell: Following on from that about the impact assessment and demand, it links in part to something Thelma was asking earlier. You said, Stuart, for example, that you have seen a significant increase in need in your college. That is before all these referral things. Could you say a little more about what some of those causes are? I think you were listening earlier to Rowan, who gave a fantastic viewpoint of a young person, and particularly that context of the school climate, or the school system at the moment, and I know there is obviously a balance there. I am a pushy parent myself of a very lazy teenager, so we do have to push our kids, but do you think that balance has gone too far the other way?
Chair: Because of time, could you answer as succinctly as you can?
Stuart Rimmer: I would suggest that there needs to be significantly more work about understanding what the barriers currently are. As I said earlier, it is connecting different elements of Government policy that can negatively influence.
The issue around accountability probably needs unpacking a little more, as Paul has said, and dare we mention Ofsted at this point, for haste? But often there is an unintended measure created, and I think there is a real balance going on in colleges if we are going to be inclusive for educational attainment versus supporting young people’s mental health.
Q66 Lucy Powell: Why do you think you have seen such a big increase in the last couple of years?
Stuart Rimmer: I think it is because we have raised awareness of our staff through training. The other thing is that, where austerity cuts have hit other Government services and local services, we are starting to see a sort of push‑through; college is the last place for some of these people to get help, especially where we are working in socially deprived areas such as I work in.
Paul Whiteman: It is worth adding that in the school context we are already stepping into the void that is left by retreating social services and other care services. That is coming out of the resources that are already there. If we then begin to add another accountability measure around this, schools can only be as successful as the services that they can access, and we could be caught in a vicious circle of argument rather than what we are trying to achieve here, which is to break some of the barriers and get some of the cross‑departmental working that will take us forward.
Q67 Dr Wollaston: Obviously there is a great deal of focus on trailblazers within this. Do you have any thoughts to add to what the previous panel was saying about how those should be selected?
Dr Dubicka: We were discussing this yesterday, and perhaps the panel could look at what the CQC did in selecting its sites, but there should definitely be a cross‑section of sites from areas that are doing well and areas that are struggling. Part of the discussion yesterday was that probably we should not be choosing sites where they will inevitably fail. Therefore, there needs to be some level of commitment and interest in making this happen.
One point I would raise as to the trailblazer sites and how we are going to measure success and outcomes, and make this happen, is that the Royal College of Psychiatrists has a quality improvement network. That is something that could be considered and modelled on in terms of how schools can support each other. We are pleased that the paper recognises the college’s suggestion that schools work in clusters. Also, as to modelling, at the royal college, for example, with in‑patient units, we have a peer‑to‑peer review system; we visit other units and give advice on what is working well. It is a supportive process and a learning process. That is something that could be considered in trying to support these trailblazer sites and networks, and how schools can support and learn from each other and learn from best practice.
Q68 Dr Wollaston: Can I go back to a point you mentioned right at the beginning? Don’t choose areas where it is inevitably going to fail? Is this not one of the problems. Sometimes we roll things out in areas where everyone is already working well together but then expect it to succeed in poor areas? Is there a case for saying quite the opposite—that you should be exploring what works in underperforming areas?
Dr Dubicka: That is a subject for discussion, I think.
Q69 Dr Wollaston: How otherwise are we ever going to tackle those areas where there is a complete failure?
Dr Dubicka: There was a concern yesterday during the discussion I attended at the Coalition that we want to make sure that we target best practice but recognise where schools are struggling as well and where there are challenges. It is a point of debate as to those areas we select that have challenges, but I guess, in schools where there is no enthusiasm, culture or interest in pushing these forward, it would be a concern that if we had too many of those sites the whole project would fail. That is up for discussion and debate. I do not have an answer to that.
Professor Ford: I would add that, having tried to get research about parenting groups and teaching groups going, I was targeting, initially, the places where I thought they really needed it and not getting very far. You do need a mix. You need some of the people who are real champions, because those who are reluctant or sceptical can see where it works and then come on board, although often it is the areas facing real challenge where people are absolutely amazing because, frankly, they have to be. So, I do not think it is necessarily about the challenges in the area. It is sometimes the context of services.
Q70 Dr Wollaston: Do you think there needs to be a specific piece of work about what you can do in the areas that are really failing, where you say there is a complete—
Professor Ford: Absolutely, but I think it is slightly separate.
Q71 Dr Wollaston: Your point is about having the range.
Professor Ford: Yes.
Stuart Rimmer: I have to admit that I would challenge the Committee to be a bit bolder perhaps in trailblazing; rather than defaulting to geography as a way of tackling it, perhaps you could look at sectoral approaches. As I said in my opening remarks, there are three quarters of a million 16 to 18‑year‑olds in the FE sector. There are only 300 colleges, the mobilisation of which could be very quick, and when I talked to colleagues we were talking months, not years, to do that.
Dr Wollaston: They are keen to engage. They just want to be asked, so it would be a sectoral approach plus maybe looking at all of the above.
Q72 Luciana Berger: I have a very brief question to Paul and Stuart. To what extent do you believe that the plans as outlined in the Green Paper seek to replace things that have already been lost in educational settings over the course of the past few years? Things that come to mind include pastoral care support, peer mentors, counselling and support services. You might not think that is an issue, but I am keen to know the thoughts of your members if you do.
Paul Whiteman: I do not think the Green Paper does seek to replace any of that. The way we are approaching this is that it is more about identification and intervention rather than the other approaches that might be more preventive in terms of those support areas. There is still lots more work that is not tackled in the Green Paper around that. Our members are obviously active in all those areas, but it is more difficult as the support services for that are in retreat too.
Stuart Rimmer: My answer is a brief yes. I think they do seek to replace some things that have already been lost or where previously there was capacity within local budgets to address some of these issues directly.
Q73 Lucy Powell: As a follow‑up, a slightly wrapping‑up kind of question, do you think another way of looking at some of these prevention and causality issues is to have an approach, which I think we are losing a little from childhood in schools at the moment, about what makes kids happy rather than just dealing with why they are sad?
Stuart Rimmer: Hugely. The deficit model is the clinical model that we have often applied. Certainly, my college has done some work with the Action for Happiness group, and we have worked on how you build resilience and discuss positive psychology models with young people in order to generate resilience and help them to get a toolkit to work through. As I said, though, that is out of our own funding. We are going to have to try to find ways of maintaining that in an ever‑increasing pinch.
Q74 Chair: I have one final question to wrap up. Going back to the apprentice issue, are there figures on the number of apprentices in terms of mental health difficulties, and do you feel that it will be better for the training provider or the workplace to deal with problems when they occur?
Stuart Rimmer: At the moment, Robert, it is probably fair to say it is a fairly inconsistent approach across access for apprentices to support services. As you are aware, there is a high proportion of apprentices in independent training providers, and I do not think there is a holistic dataset that would support it one way or another.
Q75 Chair: Is there any requirement on the independent providers to provide mental health support, apart from safeguarding?
Stuart Rimmer: Yes, around safeguarding arrangements, and, obviously, as an employee, the apprentice is covered by workplace safeguards as well from the employer’s side of things, but it is an area where we should be doing much more work if it remains a Government priority.
Chair: Clearly we need figures, not from you but from somewhere. Can I thank everyone again for outstanding evidence? Some of you have sent in evidence to the Committee. We look forward to working with you on this. I also thank my colleagues, and particularly Sarah, my Co‑Chair of the Committee. Thank you.