69.Some witnesses were concerned that the Green Paper aimed to replace services that had been lost through school and health service cuts in recent years. The British Psychological Society wrote that “between 2008/2009 and 2012/2013, CAMHS funding dropped by 5.4 per cent in real terms so that in 2012/2013, only 6 per cent of the total NHS mental health budget was spent on CAMHS”. The Association of School and College Leaders told us that “our survey of school leaders in January 2016 found then that half of respondents had to cut back on mental health support services”. Stuart Rimmer said “I think they [the Green Paper plans] 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”. We raised this concern with the Minister, who did not accept it.
70.Professor Bayliss-Pratt, Chief Nurse and Interim Regional Director for London and the South East, Health Education England, was asked whether she knew how many roles (including peer mentors, counsellors and educational psychologists) have been cut in schools. She responded:
The data quality around health and social care and children and young people is difficult to track [ … ] We do not currently get that data, so we need to understand that, find that data, challenge it and work through what the solutions are. To be absolutely honest with you, no, we do not have that granular data from local authorities as it stands.
71.To effectively evaluate the success of the Green Paper’s approach, we must have a clear picture of the current level of mental health services provided by schools and colleges, how much has been cut in the past seven years and how that provision is balanced with NHS resources and demand. We are aware that schools and colleges have already reduced the amount they have invested in mental health services. We are concerned that an unintended consequence of the Government’s proposals would be that financially stretched schools and colleges could further cut their current provision of mental health support, assuming that Mental Health Support Teams will be there instead. Given the delays inherent in the proposed timeframes for implementation of the Government’s strategy, this would leave institutions with less support than before and further increase the demand on NHS services. To measure the impact of the Green Paper, we need to know what schools currently provide, what their previous peak level of provision was and to monitor for any deterioration of the existing, baseline service level.
73.We recommend that the current level of pastoral care and mental health support provided by schools and colleges be documented and kept under review, including the number of counsellors, educational psychologists, peer mentors, and other pastoral care workers.
74.Both health and education services are under great strain with significantly stretched resources, and workforce recruitment and retention concerns. To deliver the Green Paper’s proposals effectively, the Government must take account of and mitigate against workforce pressures. The proposals cannot be effective if the workforce, including teachers and CAMHS practitioners, does not have the capacity and capability to deliver.
75.The Green Paper proposes utilising the current education workforce in schools and colleges to deliver the Designated Senior Lead for Mental Health role. We are not convinced that the existing significant and complex pressures on school and college staff have been sufficiently taken into account by the Government. Contributors to our inquiry referred to the pressures of the existing high-accountability system, combined with a stretched teaching workforce. As Rowan Munson told us, “teachers are subject to their own work pressures and have their own mental health pressures”. It is not clear whether the education workforce in schools and colleges has the capacity to deliver this proposal. The National Association of Head Teachers and the Association of School and College Leaders advocated for further recognition and support of the mental health and wellbeing of teachers, given the level of high-stakes pressure on that profession.
76.Paul Whiteman, General Secretary of the National Association of Head Teachers, said:
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.
The effective delivery of this role across the country relies on ensuring that school and college staff have the right support, sufficient time and resources, and a defined remit. Staff need support within their school or college to ensure that their role is balanced with their normal duties. A clear vision of what this role seeks to deliver is required to ensure that teachers are not put into a position where taking on too great a responsibility without the training to match, could inadvertently jeopardise a child’s care.
77.We are concerned about the support outside of schools and colleges, especially the additional pressures placed on the wider system by the slow implementation timeframe for trailblazers. The majority of schools and colleges will not benefit from the external support of Mental Health Support Teams active in trailblazer areas. Staff will therefore lack the “community of practice” that Professor Bayliss-Pratt advocated when questioned on school and college capability.
78.The Designated Senior Lead for Mental Health role is currently envisaged as voluntary and has not been made mandatory for all schools and colleges. The voluntary nature of the role demonstrates a lack of ambition and commitment. Given the complex pressures outlined, the voluntary nature of the role may result in poor take up across the country. However, making the roles mandatory will only be possible if there is additional recognition of the support required for school staff taking up this role. Further, the Impact Assessment for the Green Paper notes that “there is an opportunity cost of the time teachers or other school/college staff (acting as Designated Senior Lead) spend on training and delivering the Lead role”, but that it is “not possible to robustly estimate this”, because the role is voluntary and the time spent would be determined by individual schools. The Government needs to provide greater clarity about how they will make this an attractive role for teachers and what will be done in the event of low take-up. The Government should explore providing an additional responsibility payment for teachers who take on the Designated Senior Lead role.
79.The Designated Senior Lead for Mental Health role has significant potential. However, the unspecified level of demand to be placed on teachers undertaking this role, without sufficient resources to support them, mean that already stretched teachers will have additional pressures. The Government must commit to ensuring adequate support for teachers and school staff to deliver this role. If the Government cannot do so, it should provide additional funding to schools and colleges so they may hire a professional to fulfil this role.
80.Stakeholders have highlighted existing staff shortages within CAMHS. They raised concerns that these shortages might not only impede implementation of the Green Paper proposals, but that attempts to deliver these proposals given current workforce pressures may jeopardise the care of children and young people with the most severe needs. The Education Policy Institute said:
There are significant shortages in the CAMHS workforce including 5000 fewer mental health nurses since 2010. Recent EPI research found recruitment difficulties in NHS mental health trusts and a deterioration of workforce standards in inpatient care. The Royal College of Psychiatrists 2017 workforce census shows a rising vacancy rate in CAMHS consultant posts. The recruitment and retention of mental health support team staff and the wider CAMHS workforce must be addressed if these proposals, along with existing commitments–including treating at least an additional 70,000 CYP annually - are to be successfully implemented.
81.We recommend that the Government set out and publish plans to ensure that the existing workforce is not overburdened by the demands of the Green Paper, and that the risks are understood. It should set out how it plans to make the Designated Senior Lead for Mental Health an attractive role and what it will do in the event of low take-up. In its plans, the Government should set out an assessment of the feasibility of providing an additional responsibility payment for teachers who take on the Designated Senior Lead role. The Government should develop contingency plans to ensure the role could be delivered by qualified professionals. The Government should consider in its plans whether the role being delivered by qualified professionals rather than teachers should be its first course of action rather than the contingency plan.
82.The most recent workforce plan published by NHS England in July 2017 aimed for an expansion in CAMHS Psychiatrist roles but none in CAMHS community services. We recommend that Health Education England set out how they will address the questions raised about the impact of the Green Paper’s proposals on the entire CAMHS workforce in its upcoming workforce strategy, due for publication in July 2018.
83.We heard evidence that existing staffing shortfalls pose other risks to the implementation of the Green Paper. The Centre for Mental Health told us that “recruiting and retaining people to work in the proposed new Mental Health Support Teams will be a major challenge given the wider pressures on the health workforce”.
84.Stakeholders raised concerns about the potential scope of the Mental Health Support Team role. The British Psychological Society reported that they are uncertain as to whether the “huge remit” outlined for these teams is “viable or sustainable”. Written submissions also highlighted potential issues with the expected competency of the teams. The British Psychological Society stated that they have “concerns regarding the suggestion that non-specialists will assess and triage children” and believes that “this will be beyond the competence of a non-specialist”. They also raised concerns about the capacity of these teams to manage demand, particularly when the level of need remains uncertain. The Association of School and College Leaders summarised the issue:
There remain real concerns about how this will work and who will form these teams; how they will be supervised and what professional level of personnel will make up the teams. In order to comment on the potential success of this aspect of the proposals we will need to see much more detail, including the expected professional qualifications and experience of team members and whether the teams will have sufficient capacity to deal with the likely workload.
85.We are concerned that the Departments are anticipating significant weight to be borne by the Mental Health Support Teams, despite the fact that there is very little detail about how the teams will work in practice, and the range of skills and professional expertise that will be represented.
86.The extent of the disquiet raised in evidence about the 8,000 people that the Green Paper sets out will be working in the Mental Health Support Teams suggests that engagement with stakeholders was lacking prior to the publication of the Green Paper. We recommend that the Departments carefully examine the feedback received in their consultation and the evidence we have received in our inquiry as they make progress on this proposal.
81 British Psychological Society ()
82 Association of School and College Leaders ()
87 National Association of Head Teachers (); Association of School and College Leaders ()
90 Department of Health and Department for Education, , 4 December 2017, pages 13, 17
91 Education Policy Institute ()
92 Centre for Mental Health ()
93 British Psychological Society ()
94 British Psychological Society ()
95 British Psychological Society ()
96 Association of School and College Leaders ()
Published: 9 May 2018