Conclusions and recommendations
Introduction
1.We welcome the publication of the Government’s Green Paper. However, we consider that it lacks any ambition and fails to consider how to prevent child and adolescent mental ill health in the first place. The narrow scope does not take several vulnerable groups into account, the proposals put more pressure on the teaching workforce without sufficient resources, and the timetable for implementation ignores hundreds of thousands of children over the next twelve years. We are also concerned that the funding for the Green Paper’s proposals is not guaranteed and contingent on an unspecified level of success. (Paragraph 7)
Development of the Green Paper
2.We believe that the Government limited the scope of the Green Paper too early by restricting the terms of the evidence review. Scrutiny of the Green Paper has been made more difficult because we did not have access to the evidence review on which it was based. (Paragraph 15)
3.We recommend that the Government publish the evidence review alongside the response to this report. (Paragraph 16)
4.Mental health sits within a complex landscape, and with this policy area as with many others, there must be effective coordination with other initiatives from across Government when building a new strategy. (Paragraph 19)
5.The Green Paper does not adequately connect to other relevant policies and we are concerned that it misses opportunities to address fragmented and, in places, poor services. (Paragraph 24)
6.When the Government publishes its response to the consultation on the Green Paper, we want to see more evidence that the changes it proposes will join up services in a way which places children and young people at their heart. The Government’s response must also address and recognise the constant change and fragmentation of both the education and health systems. (Paragraph 25)
7.The Government should also place a greater emphasis on, and provide a strategy for, prevention, early intervention and dealing with some of the root causes of child mental health problems. (Paragraph 26)
Prevention and contributing factors
8.We recommend that the Government should gather independent evidence concerning the impact of exam pressure on young people’s mental health, and what steps might be considered to build resilience to cope with it. This consultation should take into account the views of children and young people, teachers and school leaders, and health care professionals. It should consider the past 10 years, given the varied changes in examination policy in both primary and secondary schools. (Paragraph 31)
9.We also recommend that the Government commission independent research, with young people at its heart, on whether the narrowing of the curriculum from Key Stage 1 to Key Stage 4 is also having an impact on mental health. This research should be considered when considering further restrictions to the accountability of schools in relation to curriculum offer. (Paragraph 32)
10.We recommend that the Department for Education’s review into exclusions focuses on the increase in pupils being excluded with mental health needs and how the mental health needs of excluded pupils are being met. The Government’s response to the Green Paper should ensure that Pupil Referral Units have sufficient resources and capacity to meet the particular needs of the pupils who attend. (Paragraph 34)
11.Given the widespread concerns about the impact of social media, we look forward to the outcomes of the working group of social media and digital sector companies in partnership with the Department of Health and Social Care and the Department for Digital, Culture, Media and Sport. We also look forward to the report of the Chief Medical Officer on the impact of technology on children’s mental health and to the House of Commons Science and Technology Committee’s forthcoming inquiry. (Paragraph 36)
12.We repeat the recommendation of our predecessor Committees that PSHE should be compulsory in all maintained and academy schools. All schools should include education on social media as part of PSHE (Paragraph 37)
13.We recommend more co-commissioning between adult and child mental health services for the whole family, especially in perinatal mental health support. (Paragraph 41)
14.We recommend that the Government include the early years in their plans for children and young people’s mental health following the consultation. (Paragraph 44)
15.We recommend that more work is done to integrate preventative approaches with vulnerable groups into the core strategy of the Green Paper. (Paragraph 45)
16.The Green Paper fails to take fully into account the factors affecting children’s mental health and the need for preventative action in stimulating and protecting early years brain development, supporting loving and respectful inter-parental relationships and enabling secure attachments with parents and carers. (Paragraph 46)
Transition to adult mental health services, the role of further education, and key vulnerable groups
17.Young people are falling through the gaps and not receiving the services they need as they enter adulthood. It is disappointing that there are no substantive plans to deal with the transition from CAMHS to adult mental health services in the Green Paper. (Paragraph 49)
18.We recommend that the Government commit to a full assessment of the current transition arrangements between child and adult mental health services. (Paragraph 50)
19.We recommend that the Government target funding for mental health support into areas of social disadvantage and inequality. (Paragraph 55)
20.Mental health support for children and young people who move between carers and in and out of care is often patchy and disjointed, and sometimes non-existent. The proposals in the Green Paper will not meet the needs of looked after children, in fact, they may well exacerbate them. (Paragraph 59)
21.We echo our predecessor Committee’s recommendation to ensure that looked-after children and young people have priority access to mental health assessments by specialist practitioners but that subsequent treatment should be based on clinical need. We also recommend that the Government’s response to the Green Paper include a distinct and separate set of proposals for looked after children accessing mental health services. (Paragraph 60)
22.We are surprised that despite clear evidence of particular need for certain groups of young people—including the most socially disadvantaged children and young people, looked-after children, children in the criminal justice system, and NEETs—the Government has not recommended policy interventions to ensure that support is available for them. The Government should ensure that it is providing mental health support for the young people who are most likely to need it and should set out how it will reduce health inequality in the mental health of young people. (Paragraph 63)
23.The Government often referred to schools and colleges interchangeably, and did not adequately recognise the substantial differences between schools and colleges. We recommend the Government utilise the potential of a further education sectoral approach in implementation alongside other approaches. (Paragraph 66)
24.The Government should take action to ensure that apprentices also have access to mental health provision under the Green Paper’s proposals. (Paragraph 68)
Workforce
25.Effective data collection on the in-school provision and workforce for mental health support is crucial for future policy development and monitoring purposes. (Paragraph 72)
26.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. (Paragraph 73)
27.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. (Paragraph 81)
28.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. (Paragraph 82)
29.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. (Paragraph 85)
30.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. (Paragraph 86)
Implementation of the Government’s strategy
31.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. (Paragraph 89)
32.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. (Paragraph 90)
33.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. (Paragraph 91)
34.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. (Paragraph 92)
35.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. (Paragraph 99)
36.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. (Paragraph 100)
37.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. (Paragraph 101)
38.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. (Paragraph 102)
39.We recommend that NHS England commit to a mandatory child and adolescent mental health investment standard. (Paragraph 103)
40.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. (Paragraph 106)
41.The Green Paper’s proposals are fundamentally reliant on effective collaboration between multiple different services and sectors. (Paragraph 111)
42.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. (Paragraph 112)
43.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. (Paragraph 115)
44.We recommend that the Government set out how it will monitor and act to mitigate the risk of a widening inequality of provision. (Paragraph 116)
45.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). (Paragraph 120)
46.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. (Paragraph 123)
47.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. (Paragraph 124)
48.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. (Paragraph 125)
Published: 9 May 2018