The Government’s Green Paper on mental health: failing a generation Contents

6Implementation of the Government’s strategy

The level of prevalence and demand

87.Both Committees have previously raised concerns at the lack of up to date prevalence data, which is now fourteen years old. We look forward to new prevalence data from the Office for National Statistics due this autumn, as understanding the level and nature of demand for children and young people’s mental health services is crucial to development and delivery of effective and proportionate policies. However a prevalence survey every seven years will not be sufficient to assess the impact and effectiveness of the Green Paper proposals. Dr Dubicka recommended regular shorter follow up studies between prevalence surveys to ensure that the proposals can be properly evaluated and told us that “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”.97

88.We aware that new data may have serious ramifications, especially as Jonathan Marron, Director General of Community Care, Department of Health and Social Care told us that “I do not think anybody is expecting prevalence to go down”.98 The nature of the proposals in the Green Paper, the costing and funding of the proposals, and the calculation of the workforce required to meet demand, are all based on data that is well out of date.

89.We are pleased that the Government will soon publish new prevalence data, and has committed to regular updates. However, it is not sufficient to repeat the survey every seven years.

90.The Government must set out how it will ensure that prevalence data is sufficiently robust in between the full seven year prevalence surveys. We recommend that the Government undertake regular follow-up studies of the impact of the Green Paper proposals on the nature and prevalence of demand for children and young people’s mental health services between the upcoming prevalence survey and the following survey in seven years’ time.

91.The assumptions underpinning the Green Paper have been based on out of date prevalence data, and there is a widespread expectation that the level of demand will prove to have been underestimated.

92.We recommend that following the release of new ONS prevalence data the Government fully recalibrate the Green Paper proposals which are contingent on the updated understanding of demand. This assessment should include matters of funding which have been costed using existing prevalence assumptions.

Funding and training

93.The Ministers from both the Department for Education and the Department of Health and Social Care told us that funding for the Green Paper’s proposals would be with additional money. Jackie Doyle-Price said that:

The Department of Health and Social Care contribution to this is £200 million and that is all funded from within the Department of Health’s budget, but it is additional money for the purpose of mental health.99

Nick Gibb indicated a similar situation for the Department for Education. He said that the money will “come from within the DfE budget, but it is additional money for this particular purpose”.100 When asked to clarify where in Departmental budgets this “additional money” was coming from, we were told that “that is for us [the Department] to deal with”.101 Further, this money is only guaranteed until 2020/21. We are concerned about the unspecified opportunity cost of the Green Paper on other Departmental programmes, which, as currently explained to us, represents diversion of existing resources rather than additional ‘new’ resource.

94.Stakeholders raised concerns in written evidence that existing Government funding for children and young people’s mental health services was failing to be delivered at the local level. NHS Providers told us that “money earmarked for Future In Mind spending is being diluted”.102 Anne Longfield, Children’s Commissioner for England, told us that “one thing that would be very helpful would be to get the NAO to do a survey of funding”, a suggestion similar to a recommendation made by a previous Health Committee.103 The Education Policy Institute observed that:

The £1.4 billion originally committed to the CAMHS transformation has not been ring-fenced, and much of it is not reaching frontline providers. EPI has previously reported that, of the £250 million expected to be released in 2015/2016, only £75 million reached local clinical commissioning groups (CCGs), and there is no transparency in how funding is allocated on to frontline providers.104

95.In February 2018, it was announced that “each CCG must meet the Mental Health Investment Standard (MHIS) by which their 2018/19 investment in mental health rises at a faster rate than their overall programme funding”.105 However, the MHIS refers to overall spending on mental health and not specifically to funding for children and young people’s mental health services.

96.Professor Tim Kendall was clear that “there should not be any other call on this money”.106 The Health Minister told us that Ministers “firmly believe” that ringfenced funding would be “overly prescriptive”.107 However there is substantial evidence that without protection, allocated resources are not being consistently delivered. The funding must be given adequate protection, and the governance throughout the funding chain—said to need “real expertise and really smart processes”—must be sufficiently robust to ensure delivery of the Government’s policies.108

97.Despite there not being sufficient detail about some of the Green Paper’s proposals, there has been costing analysis published. There is a risk that the delivery of the proposals will be stunted by the amount of funding currently allocated. For example, it was clear from evidence from Nick Gibb that the exact nature, level and length of training for the Designated Senior Lead role in schools and colleges has not been decided upon, as it “will be for specialists to determine”.109 The allocated funding may unduly influence the level and length of the training delivered, if the training is developed to fit the budget, rather than sufficient funding being allocated for a well-developed training package. Professor Tim Kendall told us:

I think you are right that this is not two days training. I absolutely don’t think it is two days. We are talking about someone who is going to be reasonably skilled in recognising mental health.110

The lack of information provided about the training for the Designated Senior Lead role is unacceptable. It is concerning that the level of funding available may result in low quality training for such a vital role.

98.Nick Gibb also indicated that part of the funding will be used in “backfill” to cover the cost of the lead spending time on training.111 However, the impact assessment indicated that the opportunity cost had not been quantified since “we do not yet know how much time leads will spend training” nor has there been a quantified opportunity cost analysis for the time spent delivering the role itself.112 It seems likely that the long term costs of delivering this policy will fall on schools and colleges.

99.We recommend that the Government publish details of the source of the funding for the policies outlined in the Green Paper, including details about how other health and education services will be adversely affected. We also recommend that a training package for the Designated Senior Lead role be developed so that the Government can ensure that sufficient funding will be available for all teachers taking up that role.

100.In regard to the four-week wait times that the Green Paper recommends, Tim Kendall indicated “these are meant to be trialled. We do not know at this point exactly how that is going to work out.”113 We recommend that appropriate resource is made available to ensure that the implementation of the four-week waiting time target does not have any unintended adverse consequences on those accessing CAMHS services by making the threshold for accessing services even higher.

101.We are pleased that the National Audit Office has launched a value for money study into mental health services for children and young people and that it will include an assessment of accountability for spending. We look forward to the publication of the study.

102.We welcome NHS England’s announcement that every clinical commissioning group must meet the Mental Health Investment Standard in 2018/19, but we are concerned that this does not protect spending on services for children and young people.

103.We recommend that NHS England commit to a mandatory child and adolescent mental health investment standard.


Accountability in local and regional areas

104.The Health Minister told us that the Mental Health Support Teams will be clinically supervised by CAMHS, that they will be employed by the NHS, and they “will be working for clusters of schools”.114 In written submissions, stakeholders indicated concern about the lack of clarity on local-level responsibility and accountability, and the need for rigorous and well-understood monitoring and evaluation methods. The Local Government Association concluded that:

The green paper indicates that the funding and responsibility to deliver these interventions will go to the NHS, without sufficiently mapping out the relationship between the NHS, schools and local authorities. This is concerning given that local authorities are responsible for overseeing local schools and have responsibility for vulnerable children and young people and will be instrumental in achieving early intervention and prevention successfully.115

105.Ofsted also indicated concerns over local responsibility:

For example, clarity would need to be given about who has the final say when leaders from education and health do not agree on priorities and/or the threshold to access the Mental Health Support Teams. Clarity about who has overall responsibility for budget and implementation would help to clarify who should be held accountable.116

Given that the Green Paper proposes a collaborative approach, there should also be collective accountability and evaluation in place, so, for example, in considering the role of mental health support team action in schools, the accountability does not fall solely upon that school, or solely on health services. Paul Whiteman noted that “schools can only be as successful as the services that they can access”, and that the education sector was concerned that this strategy could become “just another stick to beat school leaders and teachers”.117

106.We recommend that the accountability structures for the Mental Health Support Teams and the work of trailblazers be defined to ensure clarity on local responsibility, and to mitigate the risk of gaps in provision.

Effective collaboration between services

107.The success of the Green Paper’s strategy is contingent on successful collaboration and integration between all local health and education services. We recognise the intention of the creation of trailblazer areas to ensure that provision is built around the needs of the local area and demographics. However, the fragmentation of both the health and education services means that ‘local’ can mean something very different within various areas. Local authorities do not manage all schools; Stuart Rimmer told us that a college “often sits between geographical areas” and students and apprentices can cut “across multiple CAMHS areas and clinical commissioning groups”.118

108.From the perspective of health services, Clinical Commissioning Groups can straddle local authority areas and some spread across multiple NHS Regions.119 In practice this means that trailblazer areas may add an additional, fragmented understanding of ‘local’ on top of the jigsaw. They will need clear collaboration links and legal frameworks (for example, for data-sharing, which must only be used where it is in the best interest of children) to work effectively across a variety of disparate and mismatched authorities, as well as clear lines of accountability for further monitoring and evaluation purposes.

109.NHS Providers told us of the “fractured national and local commissioning structures”, and the clear need for better integration of education and health services, since “academies can opt out of local CAMHS arrangements”.120 The Association of Child Psychotherapists told us that

There is also an assumption that the kind of inter-agency and cross-organisational collaboration and joint working envisioned is unproblematic when all experience of such work is that it is fraught with operational challenges and complex dynamics.121

110.The Green Paper’s strategy will require information and data on the mental health conditions and care of children to be shared. Appropriate data-sharing and safeguarding frameworks will be needed across all the disparate services for the Green Paper’s strategy to operate. We commend the aim to “make seamless the pathway through to CAMH services”, but it is our understanding that the full portfolio of required data sharing agreements and memoranda of understanding may not stretch across all schools, local authorities, Clinical Commissioning Groups and NHS services.122 Dr Bernadka Dubicka warned that

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.123

111.The Green Paper’s proposals are fundamentally reliant on effective collaboration between multiple different services and sectors.

112.We recommend that the Government should commission an independent review of the data sharing and collaboration frameworks that will be necessary for the proposals to work optimally and in the best interests of children. The required data sharing frameworks must be in place as the Green Paper’s proposals are rolled out to best support collaboration and implementation.

Trailblazer areas

The inequality of provision

113.The Government plans to begin rolling out its new approach with a number of trailblazer areas, operational from 2019, which will be supported by robust evaluation so that the Government understands what works. We are concerned that the use of trailblazer areas may result in unforeseen negative consequences. There is already wide variation in the quality and levels of service provision for children and young people’s mental health in different areas. The use of trailblazers may cause the gap, or inequality of provision, to widen if staff move to work in areas where staffing levels and services are better. The National Association of Head Teachers warned that

There is a danger that areas where provision is working fairly well improve further, and areas where provision is currently poor will not catch up; maintaining, and perhaps widening, inequality of access to provision based on a post code.124

Considering the anticipated pace of rollout, this widened inequality of access has the potential to last for years, since only 20–25% of the country is anticipated to benefit from additional support by the end of 2022/23.125

114.Trailblazer areas risk destabilising provision in surrounding areas. Children and young people in those surrounding areas may be directed to the trailblazer, which would artificially raise the level of demand and cause unanticipated stress on the experimental system.

115.The trailblazer approach, while useful in developing evidence of best practice, may inadvertently lead to a wider gap of inequality between areas of good provision and those which struggle across the country.

116.We recommend that the Government set out how it will monitor and act to mitigate the risk of a widening inequality of provision.

The choices of trailblazer areas

117.There has been a lack of information from the Government about the criteria for the choice of trailblazer areas and how they will be chosen. During our inquiry, we heard varied opinions on the criteria which should be used. Dr Pooky Knightsmith told us:

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.126

Nick Gibb said: “I suspect we will ensure that those trailblazer areas incorporate a number of opportunity areas” (referring to the Department for Education’s social mobility opportunity areas).127 It is essential that the Government incorporates areas of social deprivation, for example rural coastal areas. Doing so will ensure that evidence is gathered from the start on effective practice in disadvantaged areas where we are aware that mental health concerns can have higher rates of prevalence.

118.It is positive that through joining up with the Department for Education’s Social Mobility opportunity areas, areas of social deprivation will benefit from the early effects of the trailblazer strategy, and that evidence of best practice will be developed for further rollout to other disadvantaged areas. However, we on the Education Committee have already raised our concerns with Ministers on numerous occasions about the lack of opportunity areas in the North East, and there has been no guarantee that this situation will be remedied.128 The lack of opportunity areas in the North East is of even greater concern if the trailblazer areas will reflect the currently announced opportunity areas.

119.There is significant pressure focused on the performance of trailblazer areas to demonstrate effectiveness over a short period of time between 2019 and the 2020/21 Spending Review. We are concerned that this may unduly influence the choice of trailblazers to areas with good existing provision; placing an interest in quick returns above the need for wide evidence across a variety of areas.

120.In considering the trailblazer criteria, we recommend that a wide range of different areas be represented. These areas should include trailblazers with both poor and effective current provision, rural and urban areas, different types of school and college provision, and areas with social deprivation (for example, through ensuring that a selection of social mobility opportunity areas are represented).

Implementation timeframe

121.Gathering evidence of best practice across trailblazers will take time. But we agree with the Children and Young People’s Mental Health Coalition that there is a “lack of urgency and ambition for implementing the vision”.129 The implementation timetable currently follows a linear progression, which “risks leaving thousands of children waiting too long for the support they need”, only reaching 20–25% of the country in five years.130 Using trailblazer areas to explore multiple methods of delivery opens the door to more iterative and agile implementation approaches, which could incorporate wider roll-out and faster timeframes.

122.The Spending Review places overly high stakes on a fledgling system, especially given that the trailblazer criteria, methods, and accountability and evaluation measures have yet to be developed or communicated. The Green Paper’s implementation strategy must provide ways to develop evidence of best practice. It must have the time and support from the Government to succeed.

123.The long timeframes involved in implementing the Green Paper’s proposals will leave hundreds of thousands of children and young people unable to benefit from this strategy over the next few years. Rolling out the plans to only “a fifth to a quarter of the country by 2022/23” is not ambitious enough. We advocate more widespread implementation and iterative learning methods to inform best practice across the piece.

124.The Green Paper notes that the precise rollout of its proposals will be determined by the success of the trailblazers, and securing funding after 2020/21 (the end of the Government’s current spending period). The long-term success of the Green Paper will rely on adequate funding being made available beyond 2020/21. We recognise the limited time frame for the Green Paper’s proposals to be implemented with the currently allocation of funding, and have concerns that attempts to secure longer term funding could result in pressure for short-term delivery, before 2020/21. We caution the Government against attempting to ensure short-term, rather than long-term success of the Green Paper, by choosing only high performing areas for the trailblazers.

125.We recommend that the Government reconsider how it chooses to review progress and extend the period of time to monitor progress of trailblazer areas beyond the 2020/21 Spending Review.

97 Q62

98 Q192

99 Q154

100 Q152

101 Q155; Q156

102 NHS Providers (SGP0040)

103 Q5; Health Committee, Third Report of Session 2014–15, Children’s and adolescents’ mental health and CAMHS, HC 342, para 250

104 Education Policy Institute (SGP0007)

105 NHS England and NHS Improvement, Refreshing NHS Plans for 2018/19, February 2018, page 20

106 Q121

107 Q207

108 Q122

109 Q158

110 Q137

111 Q157

112 Department of Health and Department for Education, Impact Assessment: Transforming children and young people’s mental health provision: a green paper, 4 December 2017, page 17

113 Q140

114 Q196; Q197; Q198

115 Local Government Association (SGP0021)

116 Ofsted (SGP0031)

117 Q66; Q45

118 Q56

119 Office for National Statistics, ‘Clinical Commissioning Groups (April 2017)’, accessed 2 May 2018; Office for National Statistics, ‘NHS Commissioning Regions (April 2015)’, accessed 2 May 2018; Ordnance Survey, ‘Election Maps’, accessed 2 May 2018; Office for National Statistics, ‘NHS Regions (Geography) (April 2016)’, accessed 2 May 2018

120 NHS Providers (SGP0040)

121 Association of Child Psychotherapists (SGP0002)

122 Q93

123 Q45

124 National Association of Head Teachers (SGP0003)

125 Department of Health and Department for Education, Transforming children and young people’s mental health provision: a Green Paper, December 2017, para 64

126 Q27

127 Q149

128 Q202

129 Education Policy Institute (SGP0007); Children and Young People’s Mental Health Coalition (SGP0016)

130 National Children’s Bureau (SGP0010); Department of Health and Department for Education, Transforming children and young people’s mental health provision: a Green Paper, December 2017, para 64

Published: 9 May 2018