1.On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), NHS England and Health Education England on mental health services for children and young people. We also took evidence from the Royal College of Nursing, NHS Providers, the Children and Young People’s Mental Health Coalition and the Children’s Commissioner for England.
2.NHS survey figures, published in November 2018, estimate that one in eight (12.8% of) five to 19 year olds have a mental health disorder. The figures showed that the number of five to 15 year olds with a mental disorder has increased over time: rising from 9.7% in 1999 and 10.1% in 2004 to 11.2% in 2017. There has also been a marked increase in the number of five to 15 year olds who suffer from an emotional disorder: the figure now stands at 5.8% in comparison to 3.9% in 2004. More than half of all mental ill-health starts before the age of 14 and three-quarters has developed by the age of 18. Mental health issues affect the life chances of affected individuals in many ways, including their physical health, education and work prospects, their chances of committing a crime and even how long they live. Despite this only three in ten children and young people with a diagnosable mental health condition received NHS treatment in 2017–18.
3.The Department is responsible for mental health policy. NHS England oversees the commissioning of NHS-funded services, either directly or through local clinical commissioning groups. In 2017–18 NHS England and clinical commissioning groups spent around £1 billion on children and young people’s mental health services. A range of other bodies—including in schools, public health, local authorities, social care and youth justice services—also have an important role to play in supporting children and young people’s mental health. In March 2015, the government set out its cross-departmental vision for children and young people’s mental health services and support in Future in Mind. The main programmes currently taking forward Future in Mind’s ambitions include: the NHS’s Five Year Forward View for Mental Health (the Forward View); the accompanying workforce development programme Stepping Forward to 2020/21 (Stepping Forward), led by Health Education England; and joint work by the Department and the Department for Education in response to Transforming Children and Young People’s Mental Health Provision: a Green Paper (the Green Paper). The latter commits a further £300 million, and has a focus on developing the links between schools and health services.
4.Services for children and young people with a mental health condition will not reach most of those who need help. The Children and Young People’s Mental Health Coalition and the Children’s Commissioner for England told us that NHS services are turning away many children and young people because their condition is not considered severe enough to warrant access to overstretched services, even though it can later deteriorate to a point of crisis. This corroborates other evidence from a number of MPs who gave us examples of problems their constituents have experienced in accessing treatment, either waiting a very long time or not yet getting treatment. These problems in getting treatment are occurring despite the fact that intervening early in, or preventing, mental health conditions is thought to reduce the need for more specialist services and reduce future costs. Added to this, it is difficult to know what happens to these children after they are denied access to treatment. The Children and Young People’s Mental Health Coalition told us it was concerned that, in many cases, when a young person was turned away by NHS services because their condition did not meet the threshold for treatment, those services did not direct them to other services that might be of help.
5.The NHS’s Forward View programme aims to increase the proportion of children and young people with a diagnosable mental health condition who receive NHS-funded treatment, from 25% in 2016–17 to 35% by 2020–21. It estimates that this equates to an increase of 70,000 children and young people accessing services per year, by 2020–21. For 2017–18, the NHS reported that it was on track to meet this target, with 30.5% of children and young people with a diagnosable mental health condition accessing NHS-funded treatment. However even if the 2020–21 target is reached, two-thirds of children will not have access to such treatment.
6.The Green Paper sets out how the government will improve mental health support in schools. Two key elements are: new senior mental health leads in schools and mental health support teams. The latter support teams will require a new (NHS-funded) workforce, who will work closely with schools and deliver interventions to address mild and moderate mental health conditions, under the supervision of NHS staff. These proposals have not yet been implemented and the government intends to begin ‘trailblazer’ pilots, covering 25 areas and 59 new support teams, in 2019. The Department estimates that the initial pilots will cover approximately 5.8% of children and young people in England. Like the Forward View, the Green paper work only covers a minority of children and young people who may benefit from help; the government expects the proposals to be rolled out across 20% to 25% of England, by 2022–23.
7.In terms of early-year strategies (covering zero to five year olds) for mental health, NHS England told us that it commissions mental health services “across the life course” and, in collaboration with Health Education England, has developed a competency-based education programme for early-years practitioners. We note in particular that a great deal of onus is being placed on local authorities, who are themselves under funding pressures. The Department highlighted that local authorities are responsible for commissioning prevention and early intervention services for zero to five year olds. It also stated that the NHS has “promoted joined-up working between clinical commissioning groups and local authorities to deliver early years services” through the annual local transformation plans for children and young people’s mental health services, which were introduced in 2015. These transformation plans, however, have very limited national oversight.
8.NHS England told us that ‘getting the workforce right’ was the single biggest risk to achieving its Forward View ambitions. Other stakeholders, including the Royal College of Nursing, the Royal College of Psychiatrists and the British Association for Counselling and Psychotherapy, have also raised concerns with us about the workforce for children and young people. Health Education England leads the main mental health workforce strategy (Stepping Forward) which supports the Forward View. Stepping Forward includes an ambition to increase the children and young people’s mental health workforce from 11,300 full time equivalent staff in 2016–17 to 15,800 full time equivalent staff by 2020–21. This planned increase of 4,500 staff was to include 200 additional doctors and 1,200 additional nurses. It also covered both staff employed directly by the NHS and staff providing NHS-funded services but not employed directly by the NHS. However, Health Education England had very limited information when it developed this plan, particularly on the staff not directly employed by the NHS, and it still has no reliable data specifically for the children and young people’s mental health workforce. This means that it is unable to measure progress against expansion plans.
9.Available data on the overall mental health workforce (not just the children and young people’s mental health workforce) suggest there has been little change in numbers since Future in Mind was published. Between April 2015 and September 2017, there was a 1% increase in the whole mental health workforce, with some variation between different groups of staff: for example, a 2% decrease in mental health nurses, but an 8% increase in therapeutic staff, such as psychologists. Health Education England told us that the number of mental health nurses had been falling until last year, when there was an increase of 250 nurses. It hopes that this represents the end of the longer-term decline in numbers but acknowledges the increase is very small. Health Education England claimed that the number of people starting registered nurse training programmes for mental health increased by 13% between 2013–14 and 2017–18. It also told us that it had launched a new trainee nursing associate role, with 14% of all trainee nursing associates working in mental health (although Health Education England does not know how many of these are in children and young people’s mental health services). We have not seen evidence supporting either of these statistics. The Royal College of Nursing told us there was a ‘huge shortage of nurses’ in mental health.
10.Health Education England told us that, given the time needed to train staff (a minimum of three to four years), its short-term focus was on retaining current staff and re-recruiting staff who have left the NHS. It told us that if the retention of all nurses had remained at the 2012 level then 50% of current nursing vacancies would not exist today. Health Education England told us that, as part of these efforts, it was running a return-to-practice programme that had brought 5,000 nurses back into training to return to nursing, although it did not know how many of these were mental health nurses.
11.NHS England and Health Education England told us that many factors, including some outside the control of the NHS, are affecting both recruitment and retention. The removal of the nursing bursary may have an impact on the recruitment of mental health nurses. It has coincided with fewer mature students entering undergraduate nursing training, and historically older students have been more likely to specialise in mental health nursing. Health Education England also believes the higher cost of living in London and the South of England means it is harder to recruit there than it is in the North of England. NHS England also told us that under current pension rules, mental health nurse matrons can incur tax penalties on their pension by the age of 55, and therefore have an incentive to retire early. In addition to maintaining and increasing staff numbers, there are challenges in increasing the skill set of the existing workforce. For example, the Royal College of Nursing told us the removal of continuing professional development for nurses has made it harder to provide non-mental health nurses with basic mental health training.
1 Report by the Comptroller and Auditor General, , Session 2017–19, HC 1618, 9 October 2018
2 NHS Digital, , 22 November 2018
3 , para 1.6–1.7, 2.6
4 , para 1.8, 3.18, figure 18
5 , para 3, 1.10, 3.4, figure 4
6 Qq2, 12, 15, 28, 68, 75, 85, 163, 238–239
7 Qq28–29, 43–44, 85, 116; , para 1.16, 2.28; Children and Young People’s Mental Health Coalition () para 2.3, 2.4
8 Qq12–14, 19, 123–125
9 , para 2.4–2.6, figure 8
10 A third element is trialling a new four-week waiting time standard for children and young people’s specialist mental health services
11 , para 6, 19 November 2018
12 , para 7, 19 November 2018
13 Q97, , para 1.10, 2.23, figure 4
14 , para 18, 19 November 2018
15 Qq29, 99, 100
16 , para 19, 19 November 2018
17 , para 3.4, 3.6
18 Qq29, 175; , para 2.19; , pp 2–3; The British Association for Counselling and Psychotherapy ()
19 , para 2.13, 2.16, figure 10
20 Qq29, 73, 196–198; , figure 4, para 2.18
21 Qq203–205; , para 3, 19 November 2018
22 This arises because mental health staff can be eligible for mental health officer status. After 20 years of mental health officer status, pension benefits accrue at double the existing rate.
Published: 11 January 2019