Recommendations
Introduction
1. 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.
We welcome the announcement of the joint NHS England /Department
of Health Children and Young People's Mental Health and Wellbeing
Taskforce, as it endorses one of our central conclusions, that
problems with CAMHS are broadly based and not simply confined
to inpatient Tier 4 services. Many of the recommendations in this
report are therefore directed towards this taskforce as it begins
its work. In addition to this, we recommend that the taskforce
takes full account of the wealth of information contained in the
written submissions received by this inquiry, including, in particular,
submissions from service users, from their parents and representatives,
from individual clinicians working in CAMHS, from provider organisations
and from commissioners. We plan to review the progress of the
taskforce early in 2015.(Paragraph 7)
Information
2. The
Committee is deeply concerned that the most recent ONS data on
children's and young people's mental health is now ten years old,
as up-to-date information is essential for the safe and effective
planning of health services. We welcome the Government's commitment,
made during the course of this inquiry, to fund a repeat of the
ONS prevalence survey. It is essential that this survey is not
a one-off, but is repeated on an ongoing basis. We recommend that
the Department of Health/NHS England taskforce adds the issue
of the quality of ongoing data to its terms of reference.(Paragraph
23)
3. Not only is there
a lack of data on children and young people's mental health, but
also a worrying lack of comprehensive and reliable information
about children's and adolescents' mental health services, including
referrals, access and expenditure. In the words of the Minister,
CAMHS services have been operating in a "fog", and efforts
to improve data availability have been subject to delays. This
is unacceptable. Ensuring that commissioners, providers and policy-makers
have access to up-to-date information about all parts of CAMHS
services-from early intervention up to inpatient services-is essential.
We recommend that this is a priority for the Department of Health/NHS
England taskforce.(Paragraph 24)
CAMHS as a whole system
4. Whilst
most attention has so far centred on problems in accessing inpatient
treatment, 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.
It is clearly unacceptable if a child or young person cannot access
a Tier 4 service close to their home, but for every child in this
position, a further question needs also to be asked - has everything
possible been done to prevent that child from becoming so unwell
that they needed admission to inpatient services? The evidence
we have received suggests poor provision of lower tier services
may be increasing the number of children and young people requiring
admission to inpatient services. This situation must be addressed
by the Taskforce.(Paragraph 33)
Early intervention mental health services (Tier 2)
5.
We recommend that, given the importance of early intervention,
the DH/NHS England taskforce 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 including those
provided by voluntary sector partners. (Paragraph 51)
Outpatient specialist CAMHS services (Tier 3)
6. Whilst
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 monitor and increase
spending levels on CAMHS until we can be assured that CAMHS services
in all areas are meeting an acceptable standard. We welcome recent
funding announcements for mental health services but we remain
concerned and recommend that our successor committee reviews progress
in this area.(Paragraph 112)
7. Commissioners of
CAMHS services undoubtedly face a difficult task in collaborating
across a complex web of other commissioners, and overseeing a
varied patchwork of different types of providers to attempt to
commission a seamless CAMHS service. They also face challenges
in securing sufficient funding for this sadly de-prioritised service.
However, CCGs hold ultimate responsibility for commissioning community
CAMHS services, and we feel that there is a clear need for CAMHS
commissioners to be given further monitoring and support from
NHS England to address the variations in investment and standards
that submissions to this inquiry have described. We recommend
NHS England provides an action plan detailing how it plans to
do this.(Paragraph 115)
8. We heard from witnesses
that national service specifications are required, to set out
minimum acceptable levels of community CAMHS services, and we
understand that Tier 2 and 3 service specifications are now being
developed. We recommend that these specifications should set out
what reasonable services should be expected to provide. They should
cover specific clinical areas including ASDs, perinatal mental
health, and eating disorders, as well services which currently
fall between the Tiers, including out-of-hours, outreach and paediatric
liaison. We recommend that the taskforce should carry out and
publish an audit of whether services are meeting these minimum
standards. (Paragraph 116)
9. In addition to
the universal concerns expressed about CAMHS services, we also
received written submissions highlighting problems with CAMHS
services being experienced by children and young people suffering
from particular conditions, or from especially vulnerable groups
of society. Specific conditions included OCD, ASDs, ADHD and Eating
disorders; vulnerable groups included children and young people
in the care system, and those who have been adopted or fostered;
homeless young people, asylum seekers and recent immigrants; lesbian,
gay, bisexual and transgender young people; and bereaved children
and young people. The breadth of different conditions and different
populations covered in our written submissions is indicative of
the complexity but also the importance of the task facing CAMHS
services. This inquiry does not have the scope to consider all
of these issues individually, but again we recommend that the
Department of Health/NHS England taskforce takes full account
of the submissions we have received, and the wealth of information
they contain.(Paragraph 118)
10. There is unacceptable
variation in the provision of perinatal mental health services,
and we recommend this is addressed urgently. Service specifications
should make clear that these services must be available in every
area.(Paragraph 120)
Inpatient CAMHS services (Tier 4)
11. It
is wholly unacceptable that so many children and young people
suffering a mental health crisis face detention under s136 of
the Mental Health Act in police cells rather than in an appropriate
place of safety. Such a situation would be unthinkable for children
experiencing a crisis in their physical health because of a lack
of an appropriate hospital bed and it should be regarded as a
'never event' for those in mental health crisis. In responding
to this report we expect the Department of Health to be explicit
in setting out how this practice will be eradicated.(Paragraph
160)
12. Written submissions
to this inquiry have described a situation where despite the move
to national commissioning over a year ago, 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. While many of the difficulties
NHS England is now seeking to address may be a legacy from previous
arrangements, it has not, in our view, sufficiently prioritised
these problems. We note that in addition to the new capacity that
is being funded, NHS England is recruiting more case managers
to give them better control over the commissioning process, but
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 NHS England has instead presided
over a system which has resulted in children being sent hundreds
of miles to access care. We intend to review NHS England's progress
addressing these problems early in 2015.(Paragraph 162)
13. As a first step
in improving its commissioning of Tier 4 services, 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.(Paragraph 163)
14. We believe that
education is crucial to protecting the life chances of the especially
vulnerable young people who need inpatient treatment for mental
health problems, particularly as in some cases these admissions
may last many months. 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.(Paragraph 166)
Bridging the gap between inpatient and community
services
15. It
is clear from the evidence we have received that commissioning
extra inpatient capacity alone will not be enough to alleviate
the current problems being experienced in relation to Tier 4 services.
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.(Paragraph 188)
16. Looking beyond
this, we agree with the Minister that the current fragmented commissioning
arrangements make "no sense", and are "dysfunctional".
A key responsibility for the newly set up Taskforce 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, which could include liaison services in A&E
departments, and crisis resolution home treatment teams. We recommend
that the Government ensures that a substantial proportion of this
new funding is directed towards services for under-18s. (Paragraph
189)
Schools
17.
We consider that awareness of mental health issues, including
their relationship to normal child development, conduct issues,
and impact on education, is important and 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.(Paragraph
210)
18. . We 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 this 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. (Paragraph 211)
19. 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.(Paragraph 212)
Digital culture, social media, bullying and cyberbullying
20. 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.(Paragraph 227)
21. 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.(Paragraph 228)
22. 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.(Paragraph 229)
23. 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. (Paragraph 230)
General practice
24. We
ask Health Education England, together with the GMC and relevant
Royal Colleges, to provide us with a full update on their plans
for GP training in children's and adolescents' mental health.
(Paragraph 236)
National priority and scrutiny
25. 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.(Paragraph 249)
26. We 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.(Paragraph
250)
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