Annex
1. Services Development and the National Service
Framework
The Department of Health should make clear the
strategic process by which it intends to performance manage systematic
improvement in child and adolescent mental health services.
We are particularly concerned that the National
Service Framework for mental health is focused almost exclusively
on adults and that there appear to be no plans for the development
of a comparable framework either for child and adolescent mental
health services, or for child health services more generally (which
could include mental health).
It is not easy to discern a convincing justification
for why the framework does not apply to children. (We note that
when Mrs Wise asked Department of Health officials in March why
children had been excluded from the framework, the question went
unanswered in the ensuing discussion.) While we fully understand
that not every aspect of health care can be improved simultaneously,
and that it takes time to develop a National Service Framework
in any particularly field, we feel that the long-term strategic
thinking with regard to the development of child and adolescent
services must be made clear.
As with adults, the delivery of effective mental
health care to children and adolescents is very complex and cuts
across a range of agencies. At a time of such significant organisational
change and uncertainty within the NHS, where there is a significant
risk of the further fragmentation of child and adolescent mental
health service, it seems even more crucial that a concerted attempt
is made to define the sorts of standards of care and service delivery
that children, young people and their families should be entitled
to expect.
In saying this, we are acutely conscious of
the fact that report after report1, 2, 3 (most recently the Audit
Commission, last September) has found that child and adolescent
services are not only patchy, but are also commonly based on historical
practice rather than a coherent assessment of local need. This
seems all the more reason why the development of appropriate national
standards for child and adolescent services should be prioritised
rather than deferred.
That considerably less attention should be paid
to the systematic, standards-driven development of child and adolescent
services seems particularly perverse when we know that many acute
mental health problems and disorders start to manifest themselves
during childhood and adolescence.
Ministers and officials have suggested that
the current mental health strategy is a 10-year strategy. We would
like to see the Department also map out, in a clear and transparent
way, what its plans are for developing children's mental health
services over that same period. We accept that, because children's
services are generally even more poorly developed than adult mental
health services, a longer timescale might be required. But failure
even to define a timetable seems to us to be fraught with risk.
As part of a clearly stated long-term strategy
for the development of child and adolescent mental health services
we would like to see the Department of Health supporting the piloting
of standards-based approaches, perhaps through Health Action Zones
or joint HAZ/Education Action Zones or initiatives such as the
NHS Beacons. This strategy could include the development of, say
in three or four years time, either a National Service Framework
for child and adolescent mental health services or for child health
services more generally including mental health. (An alternative
might be a revised National Service Framework for mental health
which includes children and adolescents.
2. Workforce Planning Issues
The Government should establish a Workforce
Action Team or a Care Group Board (as referred to in the Government's
consultation document on workforce planning) to look specifically
at manpower planning issues in relation to Child and Adolescent
Mental Health Services as soon as possible.
We note the work of Sue Hunt and the Workforce
Action Team. However, we understand that this initiative is linked
to the development of the National Services Framework and we are
unclear about the extent to which this initiative will also address
the acute shortages of skilled staff within child and adolescent
mental health services. The already existing shortages have been
aggravated by government policies which, while very welcome, rely
on access to skilled and qualified staff within these services
in order to maximise their potential eg Quality Protects, YOTs,
Connexions. The issue of manpower planning further underlines
the need for a longer term strategy for child and adolescent service
development. We are particularly anxious that some admirable and
welcome initiatives should not be undermined by the non-availability
of properly trained staff.
3. Relationships between the NHS and DfEE
Any standards-based approach must include the
development of clear protocols for how NHS mental health services
should support and work with schools; we would also welcome a
joint Inquiry by the Health Committee and the Education and Employment
Committee into the linked problems of poor mental health and school
indiscipline.
While we appreciate that the focus of the Committee's
current Inquiry is on NHS mental health services, we are deeply
concerned that not enough attention is being paid to the problems
which children suffering from mental health problems are likely
to face within the education system, which is driven by a quite
different philosophy to one of health-benefit. The services available
to schools are in many areas minimal.
In saying this, we are mindful of the fact that
it is now widely accepted that at any one time, one child in 10
is suffering from a diagnosable psychiatric disorder3 which will
significantly affect day-to-day functioning, while one child in
five will have some form of mental health problem.
In particular, we believe it is critical that
in developing a standards-based approach for child and adolescent
mental health services (as described at 1 above), priority must
be given to developing a clear framework for how schools and health
services should work together to help children and young people
with problems. A systematic and determined attempt needs to be
made to develop effective ways of working, perhaps through the
use of HAZs and EAZs.
We are also disappointed that no progress has
been made (as far as we know) on the suggestion made by the Health
Committee in its report on child and adolescent mental health
services in 1997, that consideration should be given to a joint
inquiry by the Health Committee and the Education and Employment
Committee into "the linked problem of school indiscipline
and exclusions".
In that report, published shortly before the
dissolution of Parliament, the Health Committee concluded that
unsatisfactory arrangements for the needs of excluded children
"may well contribute not to reducing but to perpetuating
patterns of conduct disorder and anti-social behaviour".
We are also mindful that in a report earlier
this year of its Inquiry into the management of dangerous people
with severe personality disorder, the Home Affairs Committee recommended
that the Home Office, the Department of Health and the Department
for Education and Employment should collectively examine the benefits
of "identifying in early adolescence individuals who may
develop a personality disorder and become dangerous".
A Joint Inquiry by the Health Committee and
the Education Sub-committee could be an invaluable starting point
for encouraging a thorough and long-overdue debate about the sorts
of support which schools and teachers need from NHS child and
adolescent mental health services in order to support and educate
those children and young people who are experiencing problems
and distress, including the sort of anti-social behaviour which
leads to exclusion, interrupted learning, poor educational achievement
and continuing problems in adult life.
4. Data Collection and the Prevalence of Mental
Health Problems
The Government should commission a regular national
survey to indicate the extent of serious mental health problems
among children and young people.
We are aware that the Committee has already
expressed some dissatisfaction at the extent of the relevant data
collection with regard to the treatment of children and adolescents
with mental health problems.
But we believe it also has to be an integral
part of any coherent strategy to improve the mental health of
children and young people that Government and policy-makers should
be informed by an up-to-date picture of the mental health of the
nation's youth. We therefore applaud the Department of Health—and
the Scottish Office and Welsh Office (as then were)—for
having commissioned the first-ever national survey of the extent
of psychiatric disorders among children and adolescents. This
was published by the Office for National Statistics on 30 March
this year.
However, we believe it would be immensely helpful
if the Government were now to make a commitment to repeat that
psycho-morbidity study at least every five years in order to provide
an on-going, long-term indicator of the mental health of the nation's
children and adolescents.
We are conscious here, for example, that the
Government's commitment to reducing drug misuse among young people
is underpinned by a plan to conduct a survey every two years of
the extent of drug misuse among 11-15 years olds, as part of Keith
Hellawell's 10-year anti-drugs strategy.
5. Review of the Mental Health Act
Sufficient time must be allowed to examine in
full the implications for children and young people of the Government's
proposals for reform of the Mental Health Act.
While we agree with the proposal (made both
by the Expert Committee and within the Green Paper itself) that
children should be subject to the provisions of any revised mental
health legislation, we are extremely anxious that the Government
is moving too fast in this area and that the Department of Health
has not thought through, with anything like the attention to detail
that is needed, the implications for children and adolescents.
While we understand the Minister's desire to act sooner rather
than later, and that any proposed new legislation will be subject
to scrutiny during its passage through Parliament, we are very
concerned that not enough time has been devoted to the implications
for the Government's proposals for children and young people.
While we recognise that a balance must be struck between careful
consideration and the need for action, we have concerns that if
not enough time is spent now on thinking through the implications
for children and adolescents, the new legislation may do little
to improve things and could conceivably make matters worse.
We believe there should be a discrete section
within any new Act which specifically addressed the particular
needs of children and young people who fall within the legislation.
At present, there is considerable confusion among practitioners
about when to use the Children Act and when to use the current
Mental Health Act. New legislation must help to ease that confusion,
rather compound or perpetuate it.
Some areas which require much more careful consideration
are firstly, the issue of capacity. We believe it is a very important
principle, in spite of its complexities. Capacity applies as much
as to young people as it does to adults. Secondly, we believe
it is essential that compulsory powers in any new Act must be
linked to a substantive concept of "health benefit"
as put forward by the Richardson Committee. Thirdly, the right
to a mental health assessment is extremely important—(a
proposal also made by the Richardson Committee). We would like
the opportunity to use legislative powers to ensure that people
get help at the time when they most need it rather than waiting
until problems become so serious that compulsory powers are needed.
Shortage of services means that such an assessment can be hard
to obtain particularly for adolescents.
Finally, the issue of advocacy is very important
in relation to children and adolescents. We would suggest, for
example, that a Guardian ad litem who has experience of
working with children is appointed in all cases where compulsory
powers are being considered.
REFERENCES
1. Kurtz, Z, Thornes, R, Wolkind, S (1994).
Services for the Mental Health of Children and Young People in
England: a national review. Department of Public Health, South
Thames (West) Regional Health Authority.
2. Health Advisory Services (1995). Together
We Stand: Thematic review on the commissioning, role and management
of child and adolescent mental health services. HMSO.
3. Audit Commission (1999). With Children
in Mind: child and adolescent mental health services.
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