Schools (Mental Health Professionals) Bill, 18 December 2023

• The LGA welcomes the introduction of the Schools (Mental Health Professionals) Bill. The Bill will make it a requirement for schools and academies to provide an education mental health practitioner or school counsellor.
• School-based counselling needs to be available and fully funded by the Government in all state funded secondary schools and academies to help support rising numbers of children and young people reporting mental health issues.
• We need to ensure that children and young people can also access high-quality mental health support outside of school. Many children and young people face challenges accessing support for their mental health. Patchy implementation of policies has also fuelled a postcode lottery in provision meaning that children and young people do not get a consistent offer of support.
• At the same time, there is also much positive practice and councils and their partners are exploring innovative ways to support children’s mental health. Examples include Durham County Council, Portsmouth and Solihull Metropolitan Borough Council.
• Research commissioned by the LGA found that whilst there have been a raft of successive policies and strategies to improve mental health outcomes for children, there has been a missed opportunity to significantly ease pressure on the system by increasing the availability of preventative and early intervention support. Early intervention has been highlighted as a central aspect in many of these policies, however, this focus has not translated through to action with the system leaning towards prioritising specialist and complex treatments rather than early intervention and prevention.
• A rise in mental health problems in children and young people in recent years, exacerbated by COVID-19, has placed additional pressures on services and has hindered progress in reaching access targets. Targets set to improve the quality of care within inpatient settings, and to reduce their use in the long term, not been met.
• While some attempts have been made to integrate mental health support across the system, there has been an overall lack of progress in effectively integrating services within children’s social care and the special education needs (SEN) and disabilities system of support.
• Efforts have also been hampered by wider funding constraints, such as real term reductions in the Public Health Grant, which has significantly limited the work of local authorities in this area.
• The Health and Social Care Select Committee has highlighted that while many of the ambitions laid out by the Government to date have been a step in the right direction, they were not ambitious enough in creating the scale of change that is needed. As a result, the policies implemented to date have not had sufficient impact in ensuring children and young people get the mental health support they need.

Since 2004, research suggests that there has been a sharp rise in mental ill-health among children and young people in England.

• Data from the 2004 children and young people’s mental health prevalence study found that one in ten children and young people aged 5 to 16 experienced a mental health difficulty.
• Data from NHS Digital in 2017 suggested there was a marginal increase to one in nine among 7- to 16-year-olds.
• However, by 2022 we observed a significant rise within the same age group reporting a common mental health problem.

Evidence suggests that some groups of children and young people are disproportionately impacted by mental health problems largely driven by a complex interplay of social and environmental determinants of poor mental health. This includes the following:

• Looked-after children and care leavers experience a higher rate of mental disorders than the general population – 45 per cent, rising to 72 per cent for those in residential care compared to 10 per cent in the general population.
• People who identify as LGBT+ have higher rates of common mental health problems and lower wellbeing than heterosexual people. A 2018 report by Stonewall found that just over half (52 per cent) experienced depression in the last year.
• Black boys and young men report lower levels of diagnosable mental health difficulties at the age of 11 years than white or mixed heritage boys. But, while sample sizes are generally small, national data suggests that from early adulthood Black men are 11 times as likely as white young men to present with major psychiatric conditions; three times more likely to present with suicidal risk; and 1.5 times more likely to present with post-traumatic stress disorder (PTSD).
• Refugees and asylum seekers are more likely to experience poor mental health (including depression, PTSD, and other anxiety disorders) than the general population.
• Children and young people with learning disabilities are more than four times more likely to develop a mental health problem than average. This means that 14 per cent or one in seven of all children and young people with mental health difficulties in the UK will also have a learning disability.
• Autistic children and young people are more likely than the general population to experience a range of mental health problems including hyperactivity disorders, anxiety, and depressive disorders.

The following are some of the key risk factors that contribute to poor mental health:

• Poverty: Children from low-income families are four times more likely to experience mental health problems by the age of 11 than children from higher-income families. Housing insecurity and homelessness are also risk factors.
• Parental mental health: According to the Children’s Commissioner for England, around a third (32 per cent) of children aged 0 to 15 live in a household where an adult has moderate or severe symptoms of mental ill-health. While most parents with mental health problems are responsive and sensitive parents, this remains a consistent risk factor for diagnosable mental health problems in children.
• Children who have experienced adversity and trauma: Children who experience maltreatment, violence, abuse, bullying, loss or bereavement are much more likely to experience mental health problems in later life. An estimated one in three adult mental health conditions is thought to be associated with adverse experiences in childhood.
• Caring responsibilities: Around one in three young carers are estimated to experience a mental health problem. The estimated total number of young carers in the UK is around 800,000.
• Bullying: Data by NHS Digital suggests that young people with a mental health condition are nearly twice as likely to be bullied, and more than twice as likely to be cyberbullied.

Emerging evidence also suggests that there are other key risk factors for young people’s mental health which are contemporary concerns for many practitioners and researchers. These include factors such as:

• Racism and discrimination. Everyday experiences of racism can undermine self-belief and self-confidence.
• Poor housing can lead to psychological distress, respiratory problems and impact on development.
• The climate crisis. A survey of over 10,000 young people across the world highlighted that 45 per cent of respondents felt their feelings about climate change negatively affected their daily life and functioning.

The LGA has long called for the roll out of counsellors in all state secondary schools across England to provide support to young people. This should be alongside support seen through the expansion of mental health support teams (MHSTs) in schools.

It is essential that a range of professionals can support children and young people’s mental health needs. Whilst the MHSTs are an essential part of the support landscape, an interim evaluation has shown that there are some young people that they do not support, those with moderate or complex needs. Exploring other ways to support these young people, such as through counsellors is important.

Councils also have a crucial role in supporting schools, coordinating across local communities and working alongside health to ensure children and young people have access to services that work for them. Despite a changed relationship with schools, local authorities should be seen as a part of the jigsaw in the delivery of this support.

Councils have a range of responsibilities in relation to children and young people’s mental health. They also have a key leadership and delivery role in promoting good mental health and wellbeing in local communities. For example, through system-wide local leadership on health and wellbeing boards, integrated care partnerships and place-based care and support systems. Councils also have statutory duties and powers for children and young people, those in care and under the Mental Health Act. Having a strong partnership with schools is also essential, providing a strategic oversight role in co-ordinating different partners (mental health specialists but also youth groups and the voluntary sector) to support schools, children and young people, as well as using their expertise to facilitate conversations locally and bringing schools nurses, educational psychologists and others together.

The reduction of budgets for early intervention and prevention services, the stress on public health budgets, despite some small increases in the past year, and pressures on other services such as green space, housing and communities has impacted the ability of councils to create happy, healthy environments that support children and young people’s mental health.

Many councils have high quality services for children and young people’s mental health, including:

• Cheshire West and Chester: the Youth Federation’s Holistic Mental Health Support service
• Durham County Council: the Rollercoaster project supporting parents and carers of children and young people with emotional and mental health problems.
• Portsmouth: a needs-led city for children and young people.
• Salford: place-based centres with easy access for young people and their families.
• Solihull Metropolitan Borough Council: an integrated approach for children’s mental health, supporting families and carers as well as young people.

But these are under pressure with rising demand and workforce pressures. Some children and young people will also require a clinical intervention. Often, the system considers what the medical response is to children and young people rather than the social factors that may be contributing to their mental health needs. This means the system sometimes does not have the right response to children and young people with mental health needs and looks to clinical treatments rather than holistic support.

We are also seeing the impact of the cost-of-living on young people which can impact mental health. There is also some emerging evidence that social media pressures are growing for young people, particularly with regard to accessing harmful content. School can be both a protective factor and a cause for poor mental health, particularly when considering stressful periods such as exams.

The current system is constructed to incentivise behaviours that prioritise specialist and complex treatments at the expense of earlier intervention and prevention. There remains inadequate data collected on the outcomes of children and young people with health and commissioned services measured against access to specialist treatments. Strong and robust partnerships can be part of the jigsaw that improves local systems to deliver support for children and young people.

Local health services have gone through significant change over the past decade with a move from smaller footprints through Clinical Commissioning Groups to now larger bodies, Integrated Care Systems, working through integrated care boards and integrated care partnerships. Although this means local arrangements can be complex with the possibility that different services are available to children living in slightly different post codes, the move to a new model provides an opportunity for children’s mental health to move up the priority agenda. Furthermore, the LGA maintains that local decision making is key. Local areas know their communities best, what services are available and what the needs of children and young people are.

Research commissioned by the LGA has shown that although there have been some positive ambitions in government policies over the past ten years, there is a lack of national direction and the ambitions haven’t been sufficient to keep pace with the mental health needs of children and young people. Positive steps included the vision set out in Future in Mind and the subsequent expansion of services, the Transforming Children and Young People’s Provision green paper and its focus on support in schools and the NHS Long Term Plan with greater commitment for funding for children and young people’s mental health services. It is crucial that the Government maintains a strong focus on children and young people’s physical and mental health. With the change from a mental health action plan to the major conditions strategy, we remain concerned that without an explicit strategy on children’s health, mental health needs will be overlooked. Many of the conditions in the major conditions strategy are primarily, though not exclusively, experienced by adults so there is a substantial risk that children’s physical and mental health may not receive the prominence it deserves.

The LGA would like a series of changes made to improve children and young people’s mental health and wellbeing and the system that supports them. This includes expanding mental health support teams in schools to full country coverage, investing in youth services and other forms of early intervention and prevention support, introducing counsellors in all state secondary schools (for example, local authority maintained, academies and free schools), building early support hubs in each local community, developing the specialist mental health workforce and supporting all staff to recognise that mental health is ‘everyone’s business’.

Partnership approaches

• The whole system needs to work together to support children and young people’s mental health, no one partner can do it alone which means fragmentation of the system needs to be reduced. There are positive steps forward with the Integrated Care Systems, however, further focus on children and young people needs to be part of these discussions as well as joined up funding to ensure that the right support and treatment is in place. A series of examples showing good practice within local systems is shown in the LGA report ‘Building resilience: how local partnerships are supporting children and young people’s mental health and emotional wellbeing’. Local partners should come together to tackle the social determinants of children and young people’s mental health, including poverty and inequality, and consider the role of other local departments including housing, transport, sport and leisure services.

Early intervention and prevention

• The Government needs to reverse the reductions to the public health grant and ensure local authorities have the resources they need to commission innovative and effective services. This will also support school nurses and other professionals in schools.
• The Government should increase the provision of early intervention support in the community through a national roll out of early support hubs in every local area so that all children and young people have early support for their mental health.
• The Government should gather clear data on early intervention services including availability of these services in local areas, access, and spend, in order to have a clear picture of the landscape and to monitor progress made in developing and implementing services of this kind.
• The Government should increase investment in youth services to ensure youth services are able to continue and expand to be available for all young people. The key strategic and coordinating role of local authorities should be recognised for them to be able to implement their statutory duty through the recently amended statutory guidance.
• To help address the inequalities that emerge in the early years, local authorities should work with their partners to develop a dedicated mental health offer for families around early years which draws on support offered through parenting programmes, health visiting, perinatal mental health services, and family hubs.
• The Government should ensure full roll out of Family Hubs across all local authority areas.
• The Government should seek to increase the number of health visitors, school nurses and other vital public health teams to support children having the best start to life.
• Mental health support teams in schools need to have sustainable investment and be expanded to all state secondary schools.
• Counsellors should be in all state secondary schools.

NHS Children and Young People’s Mental Health Services

• Alongside supporting the whole children and young people’s workforce to be able to talk to children and young people about mental health, specific focus needs to be taken to build the workforce. Significant progress has been made in expanding the children and young people’s mental health workforce, however growth in the workforce still continues to be the biggest risk to the expansion of services as do increasing vacancies. Vital parts of the workforce continue to experience cuts in the face of funding shortages, and issues remain with retention of the workforce. The NHS Long Term Plan committed to developing a comprehensive offer for 0 to 25 year olds. However, there is limited understanding of the work that has taken place to introduce this offer and young people still continue to experience challenging transitions between children’s mental health services and adults mental health services. This particularly impacts care leavers, who may be left with decreased access to mental health support at the very time they may be leaving care placements, going through significant life changes and living independently. 
   
• There are well documented challenges facing inpatient mental health provision for children and young people. A concerted review of how to improve these services needs to be considered with a view of the whole journey of the child. Although the proposals made in the stable homes, built on love Government proposal to improving the social care system go some way to supporting children and young people in the community, without significant investment this will not go far enough. All partners need to be around the table to support children and young people with the most acute needs.

Support for vulnerable children and those with special educational needs and disabilities

• The Government should use the SEND improvement plan to recognise the interconnection between special educational needs, emotional needs and mental health which is welcomed. However, the current proposals do not go far enough in tackling the rising demand of mental health need, nor sufficiently focus on the particular needs of children with special educational needs. In particular, roll out of mental health support teams in schools to all of the country is required as is investment in community mental health support for children who cannot access school-based mental health provision.
• All local authorities and health partners, in partnership with other key agencies, should establish a dedicated pathway to mental health support services for children in care and care leavers and for neurodivergent young people.
• Provide support for the most vulnerable children and those with the most complex needs. Multiple pressures are being presented to the system at once. Increasing numbers of children are being subject to Deprivation of Liberty Orders (DOLs), councils and health partners are seeing more children presenting with emotional wellbeing and mental health needs but without a diagnosable mental health condition and there are increasing pressures on identifying the right support of provision for these children and young people, including placements for children in care. This requires holistic working between different partners to ensure that children get the right support, a review of the way to support children with emotional needs that are not deemed to have a mental health diagnosis.
• Children in the justice system need to receive better mental health support, with health partners working alongside others to co-commission appropriate services for children who have emotional and behavioural needs which affect their mental health both in custody and in the community.

Data collection

• For children and young people, understanding a clear picture of access to mental health services is challenging with no definitive national dataset which covers referrals, access to support and outcomes for mental health at different levels of need. The data which is regularly collected nationally typically only relates to CAMHS or very specialist admissions, with no visibility afforded to the significant activity in supporting children and young people with lower levels of need.

Archie Ratcliffe, Public Affairs and Campaigns Advisor

Email: [email protected]