childrenssociety.org.uk March 2018 1

Transforming children & young people’s mental health provision

The Children’s Society’s response to the Departments of Health

and Education’s Green Paper

Summary and key messages:

The Children’s Society supports vulnerable children and young people aged 10-18 in England.

We address the mental health and well-being of the young people we support in a variety of ways.

Some of our projects are entirely focussed on mental health and well-being whereas others look

to safeguard children effectively or to support them to exercise their rights. All of our work however

supports young people to be happier and more resilient.

We provide counselling services, therapeutic interventions for children who have experienced

trauma, group work, drop-in services, advocacy and advice services and work with a range of

young people including looked after children, care leavers, young carers, unaccompanied and

asylum seeking children, children who are at risk of child sexual exploitation, children using drugs

and alcohol and those with mental ill health.

We also have an extensive programme of research, policy work and advocacy around improving

the mental health system for children and young people. We are leaders in children’s subjective

well-being and provide developing insight into the lives of children and young people facing

multiple disadvantage.

The following response to the Green Paper, ‘Transforming children and young people’s mental

health provision’ draws on both our direct practice and our research and policy work.

The Children’s Society is part of the Alliance for Children in Care and supports the submission

made by the group outlining how the Green Paper could better meet the needs of looked after

children and care leavers. We are also members of the Children and Young People’s Mental

Health Coalition which has submitted a joint response with the Partnership for Wellbeing and

Education in Schools and the Fair Education Alliance. We supports the recommendations put

forward by this large group of stakeholders working in partnership and hope it will be given

appropriate weight given the large number of expert organisations it represents.

We have addressed all the questions outlined in the official consultation in this document and

have tried to keep our response to the same order. We felt however that the consultation

document was restrictive and so ask that this response be accepted and consider in full in lieu of

the online survey.

1. Overall judgement of the proposals (Question 1)

The Green Paper must address the major problems in children and young people’s mental health

services. There are three major challenges:

Access – the system does not currently support all of the 1 in 10 young people who need help

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Unresponsive – the system is not designed with young people in mind. It lacks community and

school services, is characterised by long waiting times and high numbers of missed

appointments and does not engage young people in their own health care sufficiently

Joint working to meet the needs of the vulnerable – currently the links between CAMHS and

the rest of children’s social care are under-developed and instead of accessing early

intervention services we see late childhood presentation to services and long-term

engagement during adulthood.

The proposed measures will hopefully expand access through the Mental Health Support Teams

(MHSTs) which we hope will make the system feel closer and more responsive to young people.

The paper does not, in our view, expand the capacity, or responsiveness of current NHS services.

The paper also does not address the needs of the most vulnerable adequately. It fails to draw on

existing work streams and initiatives and implement them in a holistic and considered manner.

The proposals are somewhat undermined by the long implementation timetable which means that

the majority of 11 year olds entering year seven in September 2017 will not experience the new

system whilst in secondary school. Given the current lack of service, and the likelihood of

increasing need we expect to see in the prevalence survey, this cannot be considered good

enough for our children.

Furthermore the paper is unclear on funding. Ministers have tried to communicate what is new

funding and what is existing funding, but unless the true cost of the new system is ascertained

the Departments will risk getting an insufficient funding allocation at the next Comprehensive

Spending Review on which the national roll-out of the programme is dependent.

Within the system, and the wider children’s sector however there is the desire and the will to see

these reforms succeed. They are sorely needed. In this response, we make a range of both

tactical and strategic recommendations for the implementation of the Green Paper which we hope

are useful to the Departments. As an organisation we are keen to play a role in the implementation

of the Green Paper, especially in relation to the most vulnerable young people.

We make two strategic recommendations and one more practical recommendation at the outset:

The Departments should publish a full costing of the plans, informed by the new prevalence

survey and provide ring-fenced finance until the Comprehensive Spending Review (CSR). At

the CSR they should make an ambitious spending ask that covers the whole programme and

provides further funding for NHS CAMHS in addition to the £1.4 billion already committed in

2015. The ring-fence should be flexible so that money can be spent in schools, colleges,

universities, the community and the NHS, but it must ensure that the money goes directly to

children and young people’s mental health services.

The Departments should require trailblazers to be led by a partnership of the local authority

and the relevant CCGs. Testing a single, democratic and accountable model in multiple places

will allow the Departments to understand how to provide a robust statutory framework for

national rollout. The statutory duty all local authorities have to the welfare of children and

young people mean they must play a role.

Alongside formal monitoring and evaluation the trailblazers, after 18 months of operation,

should be subject to a Joint Targeted Area Inspection (JTAI) by Ofsted, the CQC, HMIC, and

HMIP so that the observations and expertise of the inspectorates can be utilised in roll-out.

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2. Mental health Support Teams (Questions 5-9)

The following section focuses on how the Mental Health Support Teams (MHSTs) will be delivered

within the trailblazers. Overall, we welcome the MHSTs but would wish to see them well

resourced, provide children real choices about what care they receive, and piloted in a way that

maximised learning and joint working with professionals outside the immediate school context.

Trailblazer leadership

One of the problems with reform thus far has been the focus on CCGs as the commissioning

vehicle for transformation. In some areas this has worked well, in other areas this has been more

challenging. For the trailblazer to be accountable when it is delivered at scale there is a need for

local authorities to have a role.

This is important for a number of reasons. Firstly, it increases democratic accountability. Secondly

it will increase the chances that the system will reach those most in need. Local authorities have

crucial roles in relation to children’s social care, absences from school, alternative provision,

public health functions and early years’ provision. Creating a system that can demonstrate

effective joint working with these services and utilise the local authorities’ ability to identify and

reach some of the most vulnerable young people is of critical importance.

Thirdly, we think it will increase spending accountability. It is challenging for members of the

general public to understand how CCGs spend their budgets and even more challenging to hold

them to account. Data produced by Young Minds demonstrated how, in the first year of the

additional CAMHS funding, 64% of responding CCGs used some or all of the extra money on

other priorities.1 Using the public accounting skills of local authorities, and their ability to

communicate these to the electorate, to help communicate and implement these reforms should

prove useful.

We recommend that all trailblazers are led jointly by the local authority and relevant CCGs.

We recommend that schools do not play a leading role in the commissioning and strategic

management of the trailblazers.

Already the challenges of embedding both a designated senior lead and a whole school approach

to well-being that is meaningful and effective are significant. The proposed models makes schools

the ‘customer’ of the Mental Health Support Teams (MHSTs) and there should be close joint

working at the operational level. Given schools relative inexperience of commissioning and limited

capacity for strategic leadership we recommend that schools are not required to be directly

involved in the membership of the vehicle taking a lead for commissioning.

We welcome that the consultation recognises the role that charities and community organisations

could play in delivery. Indeed, we are keen as an organisation to play a role. We would

recommend two models are tested for charity involvement by the trailblazers. One model

should test a statutory-voluntary partnership and the other should test a commissioned model

delivered by the voluntary sector, likely in a consortium.

Trailblazer joint working

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Professionals who work with the most vulnerable young people are often working in the

community. They are highly mobile and are often managing complex cases. We recommend

that professionals like social workers, youth offending team workers, and local authority

SEND teams are prioritised for joint working over staff who are based in schools like

counsellors, nurses and teaching staff. MHSTs will likely find joint working with the latter easier

simply because of closer proximity.

As part of the architecture of the trailblazers we recommend the government test out an

information sharing protocol that can be used between partners to ensure that treatment

notes, and safeguarding information can be easily shared. We would suggest drawing on the

learning from the Welsh Accord on the Sharing of Personal Information2 given the information

sharing among the CCGs, NHS Trusts, the voluntary sector and the local authority is likely to be

highly complex.

The trailblazers must also test case file storage options. In our own experience using a database

designed to meet the needs of children’s social record management can be effective, but

difficulties do arise when moving case files in and out of the NHS. The Trailblazers should look at

a variety of options and the evaluation should explicitly focus on how information moves around

the system and how good case management is ensured.

Measuring Success and understanding outcomes

Measuring the success of the trailblazers will be challenging but it must be done; it is crucial that

we understand which sites have been more effective than others. Formal monitoring and

evaluation however must also be augmented by more nuanced and embedded ways of measuring

impact and, even more importantly, spreading learning.

The most important measure is, of course, the impact the trailblazers have on children’s mental

health. We would recommend this is measured through the individual interventions provided by

the MHSTs so that we can also judge effectiveness. For example, children receiving a CBT

intervention would use tested and standardised outcomes tools throughout their intervention to

understand the impact of the therapy. This will help to inform other local areas which interventions

represent best value for money and produce the best outcomes. We do not recommend that

overall measures of effectiveness of the whole programme are used, ‘like number of children

reporting an improvement in their mental health’ for example. We would rather see robust, peer-

reviewed measures being used.

There is one important caveat however. When measuring the effectiveness of interventions the

trailblazers must also measure their popularity. Young people respond best to interventions when

they feel they have genuine choice and control, particularly the most vulnerable. We must

therefore know what interventions are offered, the uptake, dropout and completion rates

alongside therapeutic outcomes.

The big fear of expanding access through schools will likely be that it increases demand on NHS

specialist services. This must be a likely outcome given the vast numbers of young people who

we know have needs, but needs that are currently unmet by the system. The impact of the MHST

on the NHS must therefore be measured to allow accurate modelling of how demand is affected.

This will help prevent problems during rollout that are likely to occur if the ‘front door’ of mental

health services rapidly expands whilst specialist services retain the capacity they had before the

expansion.

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Alongside formal evaluation and monitoring we recommend the Departments also embeds a

programme of work to spread learning, best practice and the experience of the trailblazers

through the new system. Last year we ran an Action Learning Set for a number of NHS and

third sector providers to help them think about ways they could expand access in their own

services. This kind of iterative and reflective learning was highly effective and resulted in a number

of interesting innovations being tested across the participating areas.

As a result of this work we are currently working with the Local Government Association to run a

modified programme for eight local authorities.3 Each is struggling with a different problem within

its local children’s mental health services and will be matched with a peer who has already

successfully dealt with a similar problem.

Embedding a way of learning into the trailblazers, where first tier pilots can share experiences

and the second tier of areas can be supported during rollout could be enormously valuable and

the Departments should consider this at the outset of the programme.

Where should the trailblazers be?

The Green Paper, and subsequent comment from the Departments suggests that trailblazers will

be diverse in nature and not necessarily comparable. Each local area is different, but without

endorsing a more structured model and implementing it the Departments run a risk of creating a

new patchwork of support and services that will result in a new postcode lottery.

If a diverse range of areas are selected we recommend a focus on the most vulnerable young

people is prioritised over commissioning and organisational structures. In our experience,

whilst working across CCG or local authority boundaries can cause difficulties there are already

examples of how this has been effectively solved.

Areas of deprivation should be prioritised. Our own analysis of Understanding Society survey

data shows significantly lower wellbeing for 16-19 year olds growing up in poverty compared to

young people not living in poverty.4 The National Child Development Study found poor children

to be four times more likely to display psychological problems compared to rich children.5 The

MHSTs could address these poor outcomes by offering a new mental health service that is well

suited to their needs, non-stigmatising and easily accessible.

We also recommend that income and health inequalities are addressed. We have run a

number of local well-being assessments across the country, asking about what makes children

young people happy.6 Our findings suggest that well-being is powerfully affected by comparison.

In 4 different areas we asked about the child’s own perception of their family wealth, and their

friend’s wealth. The areas include; a coastal town, and inner London borough, an affluent home

county borough and a northern city.

From these assessments we found that;

Children who felt that their families were of below average wealth for the area had the lowest

average well-being scores and a higher percentage of children with low well-being. The

biggest difference was observed in the most affluent area, where income inequality was

greatest. For areas which had more balanced income profiles, even if they had significantly

higher levels of poverty/low income households, the difference in well-being of the children

was not as great.

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This is supported by the analysis of the question which asked the children how much they had

compared to their friends. Children who said that they had about the same wealth as their

friends had on average the highest well-being scores with children who said they had more or

less scoring lower. However, children who said they had a lot less than their friends had the

lowest well-being. We know that children want to feel like they fit in with their peers and so

being on either end of the income scale can make them feel different and may affect their well-

being.

Based on these findings we suggest that one trailblazer is situated in an area of income, and

health inequality. Exploring how to deliver interventions that reach those most affected by

inequality, without stigmatising them, and whilst still providing appropriate services to those not

affected by inequality will be a useful challenge for a trailblazer to explore.

How can children and young people inform the design of MHSTs?

The trailblazers should test co-design, and more traditional participation techniques within

both their design and delivery phases. Increasingly we see NHS Trusts adopting models of

participation from children’s social care, to great effect, within their own services.

In Birmingham we run a participation group out of our PAUSE open access hub that we deliver

as part of the Forward Thinking Birmingham 0-25yrs Children and Young People’s Mental Health

Services consortium. The value of such groups to the consortium, helping to design delivery

spaces, quality assure information and forms, train staff, and in making strategic decisions about

therapies and delivery is clear.

The group also has great benefit to young people themselves, giving them a way to gain extra

support, learn new skills, and get their voice heard. It provides a useful “step-down” when a young

person has completed, or is receiving, a therapy, but may need a little ongoing support to maintain

good mental health and well-being.

Co-design is more ambitious and we are not aware of examples where is has been successfully

used a system-level to drive delivery and change in the sphere of mental health. Learning from

children’s social care however suggests that it will work and we would be keen to see it

implemented. We are happy to provide further advice and support to the Departments to scope

and deliver this.

Our recommendations:

All trailblazers should be led jointly by the local authority and relevant CCGs.

Schools should not play a leading role in the commissioning and management of the

trailblazers.

The voluntary sector should be properly included with the trailblazers. Both a partnership and

commissioned model should be tested and compared.

Joint working arrangements with professionals largely outside the schools context should be

prioritised over joint working with professionals already heavily based in schools.

The trailblazers should test different information sharing methods between partners to ensure

that treatment notes, safeguarding information, and public health data can be easily shared.

The trailblazers should measure the impact on children’s mental health but this should be

done through measuring the impact of individual interventions so their effectiveness can be

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gauged. This must include take-up, drop-out, and missed appointment rates, so that future

areas can understand which interventions young people themselves most valued.

The trailblazers should also measure the number of NHS CAMHS referrals and other relevant

NHS performance data so that future areas to adopt the model can understand the pressures

the new system is likely to place on the NHS.

The most vulnerable children should be the central consideration of where to place the

trailblazers. The departments must prioritise areas of deprivation and areas of high income

and health inequalities.

The trailblazers should test co-design, and more traditional participation techniques within

both their design and delivery phases.

3. Piloting a waiting time standard

In 2016, we estimate that 195,000 referrals were made to specialist Child and Adolescent Mental

Health Services (CAMHS) for young people aged 10 to 17.7 After being referred these young

people waited an average of 58 days until they were assessed and then a further 41 days until

they began treatment.8 To move from an average we calculate to be around 13 weeks, to a four

week waiting time is a significant ambition that should be welcomed.

Waiting times are known to introduce pressures into stretched systems and can result in perverse

outcomes like higher thresholds, or quick assessment followed by lengthy treatment waits.

The logic in the Green Paper is that earlier intervention, through schools and the MHSTs will

result in fewer, and more appropriate referrals to CAMHS. As we set out in our impact assessment

section below, our experience does not support this logic. Expanding access through schools, at

scale, will result in the identification, at least in the short term, of more children and young people

in need of support. If the NHS part of the system is not resourced for this then waiting times will

likely rise. There could also be workforce attrition and a reduction in the quality of NHS provision.

It is critical therefore, that when the Government brings forward more detail on the waiting times

following consultation that it outlines how the waiting time will be financed if areas do struggle to

reduce waiting times as a result of the MHSTs.

Ultimately, however, trialling a four-week waiting time in a limited number of areas between now,

and the middle of next decade is not good enough for the majority of children. The Government

has a Mental Health Bill scheduled for this Parliament and we recommend that it introduce a

new statutory waiting limit for children’s mental health services and that this new

requirement in primary legislation is fully financed. The financing should be informed by the

results of the new prevalence survey so that it will support delivery based on the most recent

figures available on the level of need.

Beyond waiting times: missed appointments, workforce & further reform

The Green Paper does not set out new ambitions for NHS reform beyond the waiting time trials.

This is disappointing. There is still much to be delivered from Future in Mind9 and the Green Paper

could have been an opportunity to accelerate and expand this.

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Our latest report on NHS services focused on missed appointments. We found that children and

young people missed approximately 157,000 appointments with specialist Child and Adolescent

Mental Health Services (CAMHS) in 2016.10 As well as the direct impact of this on the children

not receiving the help that they need, they also have a substantial economic impact – costing

specialist children’s mental health services over £45m a year.11

This report also reveals that a significant proportion of missed appointments are not followed up,

and that thousands of children and young people are discharged from services as a result of

repeatedly missing appointments. We also found that 15% of missed appointments that resulted

in young people being discharged from services were not risk assessed.12

Our findings also explore the effectiveness of approaches that are currently used in areas to help

improve attendance - such as arranging appointments in partnership with children, young people

and their families, and the role of advocacy services to support young people to get their needs

heard, and to secure access to the help they require.

Such approaches have merit, For example, we found that around a fifth (19%) of providers say

they offer children and young people independent advocacy ‘most of the time’ or ‘always’. In these

areas, we estimate there were 21 missed follow-up appointments per 1000 10-17 year olds. This

is less than the national average of 28 missed follow-up appointments per 1000 for this cohort.13

The Green Paper should also have focused more on workforce development. As we outline in

subsequent sections, there are a range of professionals who would benefit from the designated

mental health leads in schools training.

Furthermore given the significant workforce shortage within NHS CAMHS the Green Paper could

have provided a useful opportunity to announce new training incentives and work force

retention schemes similar to those that have been used in nursing and teaching to secure the

long term future of the children’s mental health workforce.

Our recommendations:

The forthcoming Mental Health Bill should introduce maximum waiting time standards for an

initial assessment across CAMHS. These standards should at least match the six-week

standard currently expected for a diagnosis in physical health services.14

To support trailblazers the Green Paper response must outline the financial support available

to the trailblazers to implement the waiting time standards in way that is safe and prevents

perverse incentives.

The waiting time pilots should be rigorously evaluated – numbers of referrals, outcomes,

waiting times, thresholds, user experience and unintended consequences should all be

measured or explored with staff and patients.

All young people within local mental health services, whether NHS, community or schools

based should be offered access to an independent advocacy service to help ensure that they

get the support they need. The Department of Health and NHS England need to strengthen national guidance on Did Not

Attend cases across children and young people’s health services and on what follow up needs

to be undertaken by services.

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The Department of Health should implement and publicise a suite of interventions to expand,

improve and retain the children’s mental health workforce. Support for students, tax breaks,

continuing professional development, publicity campaigns and fast-track routes from other

professions, or for graduates, should all be considered.

4. Designated Mental Health Leads in Schools (Questions 11-12)

The model of having designated leads in school is well known and we welcome the position. The

paper does not propose any statutory backing for the position and sees roll-out incentivised

through free training. The lead will have two main roles – identifying and supporting children who

do require support with their mental health and also championing and embedding a whole school

approach to mental health. The first task will be easier than the second. In order to give leads the

prestige they need, ensure national roll-out and provide clear guidance to the lead we recommend

in the long term, once legislative time becomes available, that the position is enshrined in

primary legislation and subject to statutory guidance by the Department of Education.

The statutory guidance will be able to draw links with the designated lead on safeguarding, the

school lead for looked after children, relationships with school nursing teams and with the virtual

school head for looked after children based in the local authority.

Following consultation with children and staff we recommend that the statutory guidance is clear

that the safeguarding lead cannot also be the designated lead for mental health because of

concerns about confidentiality. The two leads will need to work closely but, as in all areas of child

protection, information should not be shared unless it poses a direct risk to a child, or the child

sharing the information has given informed consent.

We recommend a statutory footing for the role as it is the only way central government can

guarantee roll-out across the fragmented schools system. The financial incentives for

schools to identify a lead, provided through the free training course, will not, in our view, result in

permanent change across the system. Even if take up is high, turnover of staff within the school

will mean that a one-off training course will not be enough.

The designated lead training will need to provide the teacher with a range of skills. These should

include; an understanding of well-being and mental health and the differences between them; an

understanding of the most common conditions faced by young people like anxiety, depression

and low mood; the relationships between special educational needs and mental health; mental

health first aid; identifying mental ill health; the social determinants of mental ill-health; a whole

school approach to well-being; the needs of vulnerable young people (please see the list in the

vulnerable young people section of this response); the theoretical basis of the most common

therapeutic interventions like CBT; knowledge of more serious conditions like self- harm, eating

disorders, and suicidal ideation; and how to provide effective support to parents.

This level of knowledge will require a substantive course over a number of days and in order to

embed it over the long term the Departments should consider how to provide continuing

professional development (CPD). They should also consider more formal qualifications like a

masters level degree course or a general certificate in order to add prestige to the role.

The Departments should also consider making the course, or a shorter version of it, available

for other parts of the children’s workforce. Early intervention can come from any professional

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including health visitors, teaching assistants, youth workers, residential staff and foster carers,

and others like library or leisure centre staff. Having designed a comprehensive and high quality

course the Departments should explore ways to ensure the course material is widely used.

Counselling in schools

Whilst we welcome the MHSTs, we still believe there is great value in school-based counselling.

Evidence has shown that children and pastoral care staff see school-based counselling as

accessible, non-stigmatising and effective,15 with school management reporting improvements in

attainment, attendance and behaviour of young people who have accessed services.16 It has also

been found to reduce levels of school exclusion by around 31 per cent.17

The Local Government Association, and others have called for school counsellors to be included

in the Green Paper.18 MHSTs will not be based in the school as they will be working across school

clusters. The services MHSTs are described as providing are clearly, and rightly, designed to fill

the gap that exists between NHS CAMHS and current in-school provision. The Department for

Education’s review shows that school counselling is by far the preferred intervention nationally

with counselling currently in around 60% of secondary schools.19

The economic case for counselling is also clear. The estimated cost of school-based counselling

is around £40 per session. Based on this, the overall cost of a statutory provision of school-based

counselling in secondary schools in England would be around £90m per year. Given that

approximately 60% of schools already deliver this, the additional cost would be around

£36m.20 The average cost of a school based counselling session is around one-sixth of the cost

of an average single contact with a CAMHS Tier 1-3 practitioner which is estimated to be £240.21

We recommend therefore that the Government commit to ensuring that every secondary

school and college in England has a counsellor. If schools are really to embed a whole school

approach to mental health and well-being then the designated lead and a school counsellor could

prove more powerful in creating this change than just a designated lead on their own.

Whole school approaches to well-being and mental health

In many ways, the decision to embed a whole school approach to well-being and mental health

in schools is actually one of the most challenging policy changes outlined in the Green Paper.

The Departments will need to pull every policy lever at their disposal in order to see it happen.

Secondary schools and colleges in England are not benign environments. The pressure on staff

and students to achieve, the influence of the national curriculum, and the inspection regime

through Ofsted can all make schools toxic places for staff and students’ mental health.

The Children’s Society undertakes well-being consultations in schools across England. Our

consultations ask children about a number of aspects of school life and we find significant

differences between primary school and secondary school (Figure 1), between boys and girls

(figure 2), and between those with, and without, learning difficulties or other disabilities (figure 3).

The graphs are based on a sample of 21,454 students from a variety of locations across the

country.

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Figure 1: Well-being at school – differences between primary and secondary schools

Figure 2: Well-being at school – differences between boys and girls at primary and

secondary schools

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Mean score (out of 10)

Male Primary Male Secondary Female Primary Female Secondary

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Figure 3: Well-being at school for children with disabilities and learning difficulties

In consultation with girls we find increasing unhappiness with their appearance to be a significant

factor, especially so in secondary school. Often they find uniform policies and peer pressure to

look and behave a certain way particularly difficult to cope with.22

We find that there are variations between schools and have supported struggling schools to put

in place measures to improve well-being. Often this involves convincing schools that highly valued

behaviour and uniform policies need thorough review so they are more inclusive, promote positive

mental health and do not single out more vulnerable students. We have worked to make the

school day ‘poverty proof’ for example, so as to improve the well-being and integration of children

from low income families.23 We have also worked with the Church of England to consider how

well-being might be meaningful incorporated into their SIAMS inspections.24 We recommend the

whole school approach has a specific focus on gender, disability, learning difficulties and

children in low income families.

To implement a whole school approach we recommend embedding well-being and mental

health into the Ofsted inspections framework. We know that Ofsted is contentious for schools,

but its expertise from children’s social care will prove very useful in understanding the

effectiveness of the whole school approach and the inspectorate is one of the few policy levers

available to the Department to ensure this change is implemented.

Our recommendations:

The designated mental health lead in schools should be made statutory at the next

legislative opportunity and the Department for Education should publish statutory guidance

on the position. This should include a clear statement that the safeguarding lead role and

mental health lead role cannot be assigned to the same teacher.

The course for the Designated Mental Health lead should be comprehensive. A continuing

professional development framework should be provided and a higher-level qualification.

The course, in full, or shortened form, should be made available to professionals across the

children’s work force.

6.4

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0

2

4

6

8

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childrenssociety.org.uk March 2018 13

In their response to the Green Paper consultation the Government should clarify how the

Green Paper relates to the Blueprint for Counselling in schools25 and commit to a national

strategy to provide a counsellor in every secondary school and college in England.

In order to ensure children and young people can access in-school counselling the

government should use primary legislation to provide a legal entitlement for children and

young people to access counselling in schools and colleges. This entitlement must be

matched with sufficient funding for services.

The Department of Education should explore mechanisms to support schools in embedding

a whole school approach to well-being and mental health. This should include use of the

current Public Health England guidance,26 a best practice document, conferences, learning

materials and other departmental advice if required.

We recommend the whole school approach has a specific focus on gender, disability,

learning difficulties and children in low income families.

The Ofsted Inspections Framework for schools must include well-being and mental health.

5. Vulnerable young people (Questions 13-16)

Vulnerable young people, who have experienced trauma, or face other challenges due to

disability, poor physical health, or learning difficulties are all more likely to develop mental ill

health. Evidence shows that 1 in 3 diagnosable mental health conditions in adulthood stem from

childhood adversity.27 Our mental health services should be primarily designed for these children

in order to prevent poor outcomes and long-term engagement with adult services.

These vulnerable groups have been historically underserved by CAMHS. Our Access Denied

report found that a lack of personalised care pathways that properly link children into all the

support systems they are known to is letting down vulnerable groups of young people such as

children in care, young carers, and children whose parents are misusing substances or have

mental ill-health themselves.28

There is an assumption that referral, appointment and assessment procedures work for everyone

and that young people will always be ‘good’ patients, ready to engage in treatment. Too often, we

hear that the acceptance criteria for CAMHS is too restrictive. We have also found significant

variation in what is and is not deemed appropriate for intervention. For example, in some areas

CAMHS are only extended to young people once safeguarding concerns have been addressed.29

The Green Paper’s offer for vulnerable young people

The Green Paper offers an opportunity to embed joint working within the system. This is just one

of the reasons we recommend it is local authority led. Currently services like schools, social care,

and CAMHS are not integrated enough, resulting in children being passed around the system

without anyone actually addressing their needs.

The Green Paper does reference a range of vulnerable groups. A more transformative approach

to children’s mental health could have been achieved by designing the whole system around

these children, rather than around a universal service like schools. Vulnerable children often do

not succeed at school or engage well in school-based services. Indeed the most vulnerable are

often not in mainstream education.

childrenssociety.org.uk March 2018 14

An alternative approach would have been to properly integrate existing services, rights and

entitlements, and current work to transform services for these young people, into the provision

outlined in the Green Paper. This could be done through national advice clarifying roles and

responsibilities between agencies in relation to mental health and the development of

integrated referral pathways within mental health services for vulnerable groups. The paper

neither radically reforms services for the vulnerable nor adequately integrates their needs into the

proposed changes.

The Departments must recognise that the contents of the paper will be the drivers of reform locally

for the next ten years. Anything that is not included in the paper, or implemented via the same

mechanisms, is likely to receive less attention once reform trickles down to the front-line. We

recommend therefore that the recommendations of the following programmes are integrated

into the delivery plan of the Green Paper for holistic and managed implementation so that

important work for vulnerable groups does not get lost during the implementation of the universal

service elements of the paper:

the Expert Working Group for the emotional well-being and mental health of children in care;30

the Lenehan Review of residential and specialist schools and colleges;31

the new pilots for assessment of children’s health when entering care;32

any work carried out as a result of the national LGBT survey;33

the rollout of ‘Secure Stairs’ and the community forensic children and young people’s mental

health services;34

And other ongoing initiatives for vulnerable young people cited within the paper.

Quality provision for vulnerable children

We recommend that one of the trailblazers must have an explicit focus on vulnerable

children. Getting the predominantly schools based MHSTs to deliver for vulnerable young people

will be difficult. The teams will have to be able to deliver in the community as well as in schools

and will need to work closely with other services to meet need and safeguard effectively.

As we have demonstrated, there are a lot of separate initiatives currently underway for vulnerable

groups. We know from our research however that children rarely face just one disadvantage in

their lives. The most vulnerable live with multiple disadvantages and we have found that the

greater the number of disadvantages children face, the more likely they are to experience low

well-being.35 Low well-being does not necessarily mean these children will have mental ill-health

but wider literature suggests that increased incidence of mental ill-health is more common.

We welcome the Department’s suggestion that a trailblazer could look at vulnerable groups. They

must seize the opportunity to test as many of these initiatives targeted at vulnerable children in

one or two areas. This will allow us to test how they work together, gather important learning and

perhaps provide the insight required to radically redesign the system for vulnerable young people

so that it works for them.

Data collection

In order to demonstrate how the reforms are supporting the most vulnerable the MHSTs must

collect data on vulnerability. This data should be recorded so as not to hide the multiple

disadvantage many children face, as a result individual children may appear on multiple datasets:

childrenssociety.org.uk March 2018 15

Looked after children and care leavers

Children in need or on a child protection plan

Young carers

Children who have been adopted, or have a Special Guardianship order

Children currently working with Youth Offending or Troubled Families Teams

Unaccompanied and separated migrant children

Children of parents with mental ill-health

Gypsy, Roma and Traveller children

Disabled children and children with special education needs and learning disabilities

Children not in mainstream education inc. PRUs, home schooled and special schools

Children in homeless families

Children in families with no recourse to public funds

Children receiving free school meals/pupil premium

Our Recommendations:

There is a need for national advice to provide clarity around the roles and responsibilities of

health, social care and immigration services in providing integrated mental health support to

young people they work with.

All local areas must work towards developing integrated referral pathways to mental health

care for vulnerable young people that include clear routes into an out of children’s social

care and other local partners.

One or two trailblazers should have an explicit focus on provision for the most vulnerable.

They should seek to embed a range of current national initiatives alongside existing best

practice and embed this alongside, or as part of the MHSTs.

In the trailblazers focused on vulnerability, the number of vulnerable young people accessing

services must be recorded to understand reach, outcomes, and multiple disadvantage.

6. Evidencing the Impact Assessment (Questions 17-21)

Learning from PAUSE in Birmingham

The Children’s Society runs PAUSE,36 an open access drop in mental health hub for children and

young people in Birmingham as part of the Forward Thinking Birmingham Consortium37 that

delivers CAMHS for the city.

There are no waiting lists at PAUSE. Young people drop in whenever they feel ready and can

access information and advice about mental health, signposting around the services available in

Birmingham, a one off session with a mental health worker or a volunteer to discuss any

challenges they might be facing, a one off workshop, or on-going group work around a mental

health challenge they are facing. The space is young person friendly and based in the city centre.

In the first year PAUSE had 7,191 visits made by 3,595 unique users. In the first month, footfall

was just over 200 people, the largest group being aged 18-25, followed by children aged 11-17,

parents and health professionals, of which there were roughly equal numbers.38

By March the following year footfall had increased to around 1,000 a month. Over the course of

the year both teenagers aged 11-17 and parents grew as cohorts, to match the size of the 18-25

cohort. The number of primary aged children increased to around 100 a month. More

childrenssociety.org.uk March 2018 16

professionals were also seen over the course of the year.39 Within the year, 1,330 young people

received one to one therapeutic sessions.40

The lessons may not be applicable more generally but the following key points should be noted.

The 18-25 cohort, which receives little attention in the Green Paper, are quick to access new

services. Need is as great among 11-17 year olds, but these young people may be slower to react

to the establishment of new services. Parental need is also substantial and if it is available they

will seek it out. Professionals also want help and support and if it is available will seek it out. Over

the first year footfall increased by 500%.

PAUSE does not provide all the kinds of support outlined in the Green Paper. Whilst group work

is available, CBT is not routinely offered at the hub and is accessed in other parts of the Forward

Thinking Birmingham consortium. PAUSE’s main role is to offer advice and signposting for a

significant number of children, young people, parents and professionals. When designing the role

of the designated mental health lead and the MHSTs the Departments will need to carefully think

about how this information and advice need will be met within the system or risk undermining the

MHSTs ability to deliver interventions because they are constantly firefighting the information and

advice needs of the local population. These should not be underestimated.

Also of note are the presenting needs of young people at PAUSE. The most common issue at

presentation is anxiety followed by depression or low mood, then anger, stress and family

difficulties.41 The MHST and designated leads in schools will need to be well prepared to deal

with these kinds of issues effectively.

Forward Thinking Birmingham has done much to widen access to CAMHS in the city. Expanding

access does however place strain on other services in the system and we can provide more

insight into this on request. The team at PAUSE have also had to do significant outreach work to

ensure that PAUSE is accessed by all of Birmingham’s communities and we recommend

embedding outreach work into all the trailblazers.

Our Recommendations:

The MHSTs should be designed to manage a significant increase in referrals over at least

the first year of operation.

Trailblazers must put in place significant resource to respond to the advice and signposting

functions that will be required in order to make the pilot successful. This should include

information for parents and professionals in addition to children and young people.

MHSTs and designated school leads should have good understanding of, and be able to

offer quality interventions to young people with, anxiety, depression and low mood, anger

issues, stress and family dysfunction.

Widening access in schools will have a consequence for other NHS CAMHS services. The

Departments should explore this with any available data and build significant tolerances into

their model in terms of financing and caseload modelling. We can provide insight into our

own experiences if helpful.

Trailblazers should have a proactive outreach model to all local communities to ensure all

children can access the new services.

7. Recommendations

Headline recommendations

childrenssociety.org.uk March 2018 17

The Departments should publish a full costing of the plans, informed by the new prevalence

survey and provide ring-fenced finance until the Comprehensive Spending Review (CSR). At

the CSR they should make an ambitious spending ask that covers the whole programme and

provides further funding for NHS CAMHS in addition to the £1.4 billion already committed in

2015. The ring-fence should be flexible so that money can be spent in schools, colleges,

universities, the community and the NHS, but it must ensure that the money goes directly to

children and young people’s mental health services.

The Departments should require trailblazers to be led by a partnership of the local authority

and the relevant CCGs. Testing a single, democratic and accountable model in multiple places

will allow the Departments to understand how to provide a robust statutory framework for

national rollout. The statutory duty all local authorities have to the welfare of children and

young people mean they must play a role.

Alongside formal monitoring and evaluation the trailblazers, after 18 months of operation,

should be subject to a Joint Targeted Area Inspection (JTAI) by Ofsted, the CQC, HMIC, and

HMIP so that the observations and expertise of the inspectorates can be utilised in roll-out.

Mental Health Support Teams

All trailblazers should be led jointly by the local authority and relevant CCGs.

Schools should not play a leading role in the commissioning and management of the

trailblazers.

The voluntary sector should be properly included with the trailblazers. Both a partnership and

commissioned model should be tested and compared.

Joint working arrangements with professionals largely outside the schools context should be

prioritised over joint working with professionals already heavily based in schools.

The trailblazers should test different information sharing methods between partners to ensure

that treatment notes, safeguarding information, and public health data can be easily shared.

The trailblazers should measure the impact on children’s mental health but this should be

done through measuring the impact of individual interventions so their effectiveness can be

gauged. This must include take-up, drop-out, and missed appointment rates, so that future

areas can understand which interventions young people themselves most valued.

The trailblazers should also measure the number of NHS CAMHS referrals and other relevant

NHS performance data so that future areas to adopt the model can understand the pressures

the new system is likely to place on the NHS.

The most vulnerable children should be the central consideration of where to place the

trailblazers. The departments must prioritise areas of deprivation and areas of high income

and health inequalities.

The trailblazers should test co-design, and more traditional participation techniques within

both their design and delivery phases.

Waiting Time Standards

The forthcoming Mental Health Bill should introduce maximum waiting time standards for an

initial assessment across CAMHS. These standards should at least match the six-week

standard currently expected for a diagnosis in physical health services.42

To support trailblazers the Green Paper response must outline the financial support available

to the trailblazers to implement the waiting time standards in way that is safe and prevents

perverse incentives.

childrenssociety.org.uk March 2018 18

The waiting time pilots should be rigorously evaluated – numbers of referrals, outcomes,

waiting times, thresholds, user experience and unintended consequences should all be

measured or explored with staff and patients.

All young people within local mental health services, whether NHS, community or schools

based should be offered access to an independent advocacy service to help ensure that they

get the support they need. The Department of Health and NHS England need to strengthen national guidance on Did Not

Attend cases across children and young people’s health services and on what follow up needs

to be undertaken by services. The Department of Health should implement and publicise a suite of interventions to expand,

improve and retain the children’s mental health workforce. Support for students, tax breaks,

continuing professional development, publicity campaigns and fast-track routes from other

professions, or for graduates, should all be considered.

Designated Mental Health Lead in Schools

The designated mental health lead in schools should be made statutory at the next

legislative opportunity and the Department for Education should publish statutory guidance

on the position. This should include a clear statement that the safeguarding lead role and

mental health lead role cannot be assigned to the same teacher.

The course for the Designated Mental Health lead should be comprehensive. A continuing

professional development framework should be provided and a higher-level qualification.

The course, in full, or shortened form, should be made available to professionals across the

children’s work force.

In their response to the Green Paper consultation the Government should clarify how the

Green Paper relates to the Blueprint for Counselling in schools43 and commit to a national

strategy to provide a counsellor in every secondary school and college in England.

In order to ensure children and young people can access in-school counselling the

government should use primary legislation to provide a legal entitlement for children and

young people to access counselling in schools and colleges. This entitlement must be

matched with sufficient funding for services.

The Department of Education should explore mechanisms to support schools in embedding

a whole school approach to well-being and mental health. This should include use of the

current Public Health England guidance,44 a best practice document, conferences, learning

materials and other departmental advice if required.

We recommend the whole school approach has a specific focus on gender, disability,

learning difficulties and children in low income families.

The Ofsted Inspections Framework for schools must include well-being and mental health.

Vulnerable Young People

There is a need for national advice to provide clarity around the roles and responsibilities of

health, social care and immigration services in providing integrated mental health support to

young people they work with.

All local areas must work towards developing integrated referral pathways to mental health

care for vulnerable young people that include clear routes into an out of children’s social

care and other local partners.

childrenssociety.org.uk March 2018 19

One or two trailblazers should have an explicit focus on provision for the most vulnerable.

They should seek to embed a range of current national initiatives alongside existing best

practice and embed this alongside, or as part of the MHSTs.

In the trailblazers focused on vulnerability, the number of vulnerable young people accessing

services must be recorded to understand reach, outcomes, and multiple disadvantage.

Impact Assessment

The MHSTs should be designed to manage a significant increase in referrals over at least

the first year of operation.

Trailblazers must put in place significant resource to respond to the advice and signposting

functions that will be required in order to make the pilot successful. This should include

information for parents and professionals in addition to children and young people.

MHSTs and designated school leads should have good understanding of, and be able to

offer quality interventions to young people with, anxiety, depression and low mood, anger

issues, stress and family dysfunction.

Widening access in schools will have a consequence for other NHS CAMHS services. The

Departments should explore this with any available data and build significant tolerances into

their model in terms of financing and caseload modelling. We can provide insight into our

own experiences if helpful.

Trailblazers should have a proactive outreach model to all local communities to ensure all

children can access the new services.

If you require more information or have any questions please contact Richard Crellin, Policy and Research Manager, Mental Health and Well-being on 0207 841 4557 or

richard.crellin@childrenssociety.org.uk

References

1 https://youngminds.org.uk/about-us/media-centre/press-releases/children-s-mental-health-funding-not-going-where-it-should-be/ [Last accessed 27th February 2018] 2 http://www.waspi.org/home [Last accessed 27th February 2018] 3 https://www.local.gov.uk/invitation-apply-lga-peer-learning-programme-improving-childrens-and-young-peoples-mental-health [Last accessed 27th February 2018] 4 The Children’s Society (2016) Poor Mental Health. https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/poor-mental-health-the-links-between-child-poverty-and-mental Page 10 [Last accessed 27th February 2018] 5 Centre for Longitudinal Studies (2015) Counting the true cost of childhood psychological problems in adult life. http://www.cls.ioe.ac.uk/news.spx?itemid=3223&itemTitle=Counting+the+true+cost+of+childhood+psychological+problems+in+adult+life&sitesectionid=27&sitesectiontitle=News [Last accessed 27th February 2018] 6 For examples of The Children’s Society’s local wellbeing work in Elmbridge, Nottingham and Portsmouth please use the following links respectively: https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/the-2016-report-well-on-childrens-well-being-elmbridge and https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/the-2016-report-on-childrens-well-being-nottingham-city and https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/publications-library/portsmouth-survey-children-and-young-peop [Last accessed 27th February 2018] 7 The Children’s Society (2017) Stick with us: Tackling missed appointments in children’s mental health services. https://www.childrenssociety.org.uk/sites/default/files/stick_with_us_tackling_missed_appointments_in_children_s_mental_health_services.pdf [Last accessed 27th February 2018] 8 Ibid. 9 Children and Young People’s Mental Health Taskforce (2015) Future in Mind. https://www.gov.uk/government/publications/improving-mental-health-services-for-young-people [Last accessed 27th February 2018] 10 The Children’s Society (2017) Stick with us: Tackling missed appointments in children’s mental health services. https://www.childrenssociety.org.uk/sites/default/files/stick_with_us_tackling_missed_appointments_in_children_s_mental_health_services.pdf [Last accessed 27th February 2018] 11 Ibid 12 Ibid 13 Ibid 14 The Mental Health Taskforce. 2016. The five year forward view for mental health. https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf [Last accessed 27th February 2018] 15 Cooper, M. (2009). Counselling in UK secondary schools: A comprehensive review of audit and evaluation studies. Counselling and Psychotherapy Research, 9(3), pp. 137–150

childrenssociety.org.uk March 2018 20

16 Pybis, J., Hill, A., Cooper, M. & Cromarty, K. (2012). A comparative analysis of the attitudes of key stakeholder groups to the Welsh Government’s school-based counselling strategy. British Journal of Guidance & Counselling, 40(5), pp. 485–498 17 Banerjee, R., Weare, K. & Farr, W. (2014), Working with ‘Social and Emotional Aspects of Learning’ (SEAL): associations with schools ethos, pupil social experiences, attendance, and attainment. British Educational Research Journal, 40(4), pp. 718–742 18 https://www.local.gov.uk/about/news/lga-calls-compulsory-independent-mental-health-counselling-roll-out-all-secondary [Last accessed 27th February 2018] 19 Department for Education (2017) Supporting Mental Health in Schools and Colleges https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/634725/Supporting_Mental-Health_synthesis_report.pdf [Last accessed 27th February 2018] 20 The Children’s Society and BACP (2017) Supporting children’s wellbeing and mental health in a school environment https://www.childrenssociety.org.uk/sites/default/files/westminster-hall-debate_mental-health-and-wellbeing-support-in-schools-.pdf [Last accessed 27th February 2018] 21 BCAP (2015) Schools counselling for all. https://www.bacp.co.uk/docs/pdf/14839_sbc_for_all_england.pdf [Last accessed 27th February 2018] 22 The Children’s Society. (2017) Good Childhood Report, 2017. https://www.childrenssociety.org.uk/sites/default/files/the-good-childhood-report-2017_full-report_0.pdf Page 17 [Last accessed 27th February 2018] 23 Our work on Poverty Proofing came out of the work of our Children’s Commission on Poverty who took evidence from a range of organisations, particularly in the North East, working to poverty proof the schools day. Since the Commission we have worked with a number of schools on this issue. For more information: https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/the-childrens-commission-on-poverty [Last accessed 27th February 2018] 24 https://www.churchofengland.org/more/education-and-schools/church-schools-and-academies/siams-school-inspections [Last accessed 27th February 2018] 25 Department for Education (2016) Counselling in schools: a blueprint for the future. https://www.gov.uk/government/publications/counselling-in-schools [Last accessed 27th February 2018] 26 Public Health England and the Children and Young People’s Mental Health Coalition (2015) Promoting children and young people’s emotional health and wellbeing: a whole school and college approach. https://www.gov.uk/government/publications/promoting-children-and-young-peoples-emotional-health-and-wellbeing [Last accessed 27th February 2018] 27 Kessler, R. (2010) ‘Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys’ British Journal of Psychiatry 197(5): 378–385. 28 The Children’s Society (2015) Access Denied. https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/access-denied-a-teenagers-pathway-through-the-mental-health [Last accessed 27th February 2018] 29 Ibid. 30 https://www.scie.org.uk/children/care/mental-health/about-the-project/expert-working-group [Last accessed 27th February 2018] 31 https://www.gov.uk/government/publications/lenehan-review-into-care-of-children-with-learning-disabilities [Last accessed 27th February 2018] 32 https://www.cypnow.co.uk/cyp/news/2002811/mental-health-checks-for-children-entering-care-set-for-trial [Last accessed 27th February 2018] 33 https://www.gov.uk/government/consultations/national-lgbt-survey [Last accessed 27th February 2018] 34 https://www.england.nhs.uk/commissioning/health-just/children-and-young-people/ [Last accessed 27th February 2018] 35 The Children’s Society. (2017) Good Childhood Report, 2017. https://www.childrenssociety.org.uk/sites/default/files/the-good-childhood-report-2017_full-report_0.pdf Page 50 [Last accessed 27th February 2018] 36 https://www.forwardthinkingbirmingham.org.uk/services/13-pause [Last accessed 27th February 2018] 37 https://www.forwardthinkingbirmingham.org.uk/ [Last accessed 27th February 2018] 38 The Children’s Society (2017) The Pause service: Sharing successes to date. The Children’s Society: London. Available on request – please use the contact details on this response. 39 Ibid 40 Ibid 41 The Children’s Society (2017) The Pause service: Sharing successes to date. The Children’s Society: London. Available on request – please use the contact details on this response. 42 The Mental Health Taskforce. 2016. The five year forward view for mental health. https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf [Last accessed 27th February 2018] 43 Department for Education (2016) Counselling in schools: a blueprint for the future. https://www.gov.uk/government/publications/counselling-in-schools [Last accessed 27th February 2018] 44 Public Health England and the Children and Young People’s Mental Health Coalition (2015) Promoting children and young people’s emotional health and wellbeing: a whole school and college approach. https://www.gov.uk/government/publications/promoting-children-and-young-peoples-emotional-health-and-wellbeing [Last accessed 27th February 2018]