There are serious and deeply ingrained problems with the commissioning and provision of Children's and adolescents' mental health services. These run through the whole system from prevention and early intervention through to inpatient services for the most vulnerable young people.
The Committee draws conclusions and makes recommendations for action in the following areas:
· The lack of reliable and up to date information about children's and adolescents' mental health and CAMHS means that those planning and running CAMHS services have been operating in a "fog".
· Ensuring that commissioners, providers and policy makers have up-to-date information about children's and adolescents mental health must be a priority for the Department of Health/NHS England taskforce.
· Compelling arguments have been made to this inquiry that the focus of investment in CAMHS should be on early intervention-providing timely support to children and young people before mental health problems become entrenched and increase in severity, and preventing, wherever possible, the need for admission to inpatient services. However in many areas these are suffering from insecure or short term funding, or being cut altogether.
· Health and Wellbeing Boards, and the transfer of public health budgets to local authorities, both represent significant opportunities for health issues to receive higher priority within local authorities. We have been told of some areas where these opportunities are beginning to be exploited, but this is patchy and progress remains slow. We have also heard that in times of financial constraint, some local authorities do not consider CAMHS early intervention services as "core business".
· We recommend that, given the importance of early intervention, the DH/NHS England task force should have an explicit remit to audit commissioning of early intervention services in local authorities, and to report on how best to improve incentives in this area. They should also look at the best mechanisms to provide stable, long term funding for early intervention services.
Outpatient specialist CAMHS services (Tier 3)
· Providers have reported increased waiting times for CAMHS services and increased referral thresholds, coupled with, in some cases, challenges in maintaining service quality. In the view of many providers, this is the result of rising demand in the context of reductions in funding. Not all services reported difficulties-some state that they have managed to maintain standards of access and quality-but overall there is unacceptable variation.
· Young people and their parents have described "battles" to get access to CAMHS services, with only the most severely affected young people getting appointments; they also described the devastating impact that long waits for treatment can have. Even amongst those providers implementing quality and efficiency improvement programmes there was concern that improvements were being stalled or even reversed because of increasing demand and reduced funding.
· While demand for mental health services for children and adolescents appears to be rising, many CCGs report having frozen or cut their budgets. CCGs have the power to determine their own local priorities, but we are concerned that insufficient priority is being given to children and young people's mental health. We recommend that NHS England and the Department of Health should monitor and increase spending levels on CAMHS until we can be assured that CAMHS services in all areas are meeting an acceptable standard, and for NHS England to give CAMHS further monitoring and support to address the variations in investment and standards that submissions to this inquiry have described. Service specifications for Tier 2 and 3 services should set out what reasonable services should be expected to provide, and NHS England and the Department of Health should carry out a full audit to ensure all services are meeting these. We welcome recent funding announcements for mental health services, but we remain concerned and recommend that our successor Committee reviews progress in this area.
· In addition to the universal concerns expressed about CAMHS services, written submissions highlighted problems with CAMHS for children and young people suffering from particular conditions, or from especially vulnerable groups of society. We recommend that the DH/NHS England taskforce takes full account of the submissions we have received detailing these problems.
· Transition from CAMHS to adult mental health services has been described by NHS England as a "cliff edge", and the stories we heard from young people bear this out. We plan to review progress in this area early in 2015.
· As well as the transition to adulthood, a crucially important time for promoting good mental health is the perinatal and infant period, but there is unacceptable variation in the provision of perinatal mental health services, and we recommend that this is addressed urgently.
Tier 4 inpatient services
· There are major problems with access to Tier 4 inpatient services, with children and young people's safety being compromised while they wait, suffering from severe mental health problems, for an inpatient bed to become available. In some cases they will need to wait at home, in other cases in a general paediatric ward, or even in some instances in an adult psychiatric ward or a police cell. Often when beds are found they may be in distant parts of the country, making contact with family and friends difficult, and leading to longer stays.
· The Committee is particularly concerned about the wholly unacceptable practice of taking children and young people detained under s136 of the Mental Health Act to police cells, which still persists, with very few mental health trusts providing a dedicated place of safety for children and young people. In responding to this report we expect the Department of Health to be explicit in setting out how this practice will be eradicated.
· Alongside problems with access, we also heard from young people and their parents, as well as those who work with them, of quality concerns in some inpatient services; NHS England reported that over the past year some inpatient services have in fact been closed owing to quality concerns.
· Concerns have also been raised about the quality of education children and young people receive when they are being treated in inpatient units. It is essential that clear standards are set for the quality of education provision in inpatient units, and that there is clear accountability and ownership for ensuring that these standards are upheld. As a first step towards this, we recommend that OFSTED, DFE and NHS England conduct a full audit of educational provision within inpatient units as a matter of urgency.
· Despite the move to national commissioning over a year ago, we have been told that NHS England has yet to 'take control' of the inpatient commissioning process, with poor planning, lack of co-ordination, and inadequate communication with local providers and commissioners. NHS England is now recruiting more case managers. However, while many of the difficulties NHS England is now seeking to address may be a legacy from previous arrangements, we are disappointed that during its first year as a commissioner of inpatient services, many of the perceived benefits of national planning have not been realised, and we intend to review NHS England's progress addressing these problems early in 2015. In particular, we recommend that NHS England should introduce a centralised inquiry system for referrers and patients, of the type that is already in operation for paediatric intensive care services.
· NHS England has announced 50 extra inpatient CAMHS beds, but by its own admission, it is not clear how many beds are needed to provide sufficient Tier 4 capacity. It is essential that the extra beds are commissioned in the areas which need them most, and are supported by an improved system of case management.
Bridging the gap between inpatient and community services
· Out-of-hours crisis services, paediatric liaison teams within acute hospitals, and Tier 3.5 assertive outreach teams can have a positive impact, including reducing both risk and length of inpatient admission; however availability of such services is extremely variable. The experience of care reported by those young people suffering a mental health crisis remains extremely negative.
· Perverse incentives in the commissioning and funding arrangements for CAMHS need to be eliminated to ensure that commissioners invest in Tier 3.5 services which may have significant value in minimising the need for inpatient admission and in reducing length of stay. The Department of Health and NHS England must act urgently to ensure that by the end of this year all areas have clear mechanisms to access funding to develop such services in their local area, where this is appropriate. A key responsibility for the newly set up task force will be to determine a way in which commissioning can be sufficiently integrated to allow rational and effective use of resources in this area, which incentivises early intervention. The Government has recently announced extra funding for early intervention in psychosis services and crisis care; we recommend that the Government ensures that a substantial proportion of this new funding is directed towards services for under-18s.
Education and digital culture
· We heard from young people that while some teachers and schools provide excellent support, others seem less knowledgeable or well trained, and can even seem 'scared' of discussing mental health issues. The launch of MindEd, together with new guidance for schools on mental health, are both welcome steps towards addressing this. However, with both of these, the onus is on individual schools and teachers to find time to prioritise this, and within a sea of competing priorities, it may be difficult to ensure that all schools and teachers use these tools.
· We recommend the Department for Education looks to including a mandatory module on mental health in initial teacher training, and should include mental health modules as part of ongoing professional development in schools for both teaching and support staff. We also recommend that the Department for Education conducts an audit of mental health provision and support within schools, looking at how well the guidance issued to schools year has been implemented, what further support may be needed, and highlighting examples of best practice. OFSTED should also make routine assessments of mental health provision in schools.
· It is clear that education about mental health could and should contribute to prevention and support for young people. We recommend that the Department for Education consult with young people, including those with experience of mental health issues, to ensure mental health within the curriculum is developed in a way that best meets their needs.
· For today's children and young people, digital culture and social media are an integral part of life; whilst this has the potential to significantly increase stress, and to amplify the effects of bullying, the internet can also be a valuable source of support for children and young people with mental health problems. We have not investigated the issue of internet regulation in depth. However, in our view sufficient concern has been raised to warrant a more detailed consideration of the impact of the internet on children's and young people's mental health, and in particular the use of social media and the impact of pro-anorexia, self-harm and other inappropriate websites, and we recommend that the Department of Health/NHS England taskforce should take this forward in conjunction with other relevant bodies, including the UK Council for Child Internet Safety.
· Children and young people also need to know how to keep themselves safe online. It is encouraging that e-safety will now be taught at all four key stages of school education. We recommend that as part of its review of mental health education in schools, the Department for Education should ensure that links between online safety, cyberbullying, and maintaining and protecting emotional wellbeing and mental health are fully articulated. We recommend clear pathways are identified for young people to report that they have been sent indecent images of other children or young people, and that support is provided for those who have been victims of image sharing. Pathways should also be established for children and young people who have experienced bullying, harassment and threats of violence.
· CAMHS providers may also need further support-both in helping the children and young people they treat to cope with the challenges of online culture and manage the impact it might have on their mental health - and so that they themselves are better able to use online means of communication for reaching out to young people. We recommend that the Department of Health/NHS England taskforce should also investigate and report on the most effective ways of supporting CAMHS providers to do this.
· We have heard that many GPs currently feel ill-equipped and lacking in confidence in dealing with mental health issues in children and young people, and that their current training does not prepare them adequately for this. We therefore ask HEE together with the GMC and relevant Royal Colleges to provide us with a full update on their plans to enhance GP training in children's and adolescents' mental health.
National priority and scrutiny
· It is clear that there are currently insufficient levers in place at national level to drive essential improvements to CAMHS services. These have received insufficient scrutiny from CQC and we look to review progress in this area following their new inspection regime. The Minister has argued that waiting time targets will improve CAMHS services but we recommend a broader approach that also focuses on improving outcomes for specific conditions in children's and adolescents' mental health.
· We therefore recommend the development, implementation and monitoring of national minimum service specifications, together with an audit of spending on CAMHS. We recommend that the Department of Health/NHS England taskforce look to remove the perverse incentives that act as a barrier to Tier 3.5 service development and ensure investment in early intervention services. There must be a clear national policy directive for CAMHS, underpinned by adequate funding.