CYP mental health: Is it acceptable?

Source: NHE Sept/Oct 2018

Dr Phil Moore, deputy chair (clinical) at NHS Kingston CCG and chair of NHS Clinical Commissioners’ Mental Health Commissioners Network, makes the case for a long-term commitment to children and young people’s (CYP’s) mental health.

The real question is, is it acceptable?

Is it acceptable that mental health problems in CYP are increasing? It is often reported, but we need to pause and remind ourselves that one in 10 CYP have a clinically significant mental disorder. This must be a major concern; one example being that indicators suggest the number of teenage girls being admitted to hospital due to self-harming has nearly doubled in the past 10 years. Add to that the increased likelihood of a suicide attempt in those who have self-harmed and we need to pay attention. We need to do things differently and prioritise prevention and early intervention to reduce the number needing specialist mental health services.

Is it acceptable that we do not have recent data on prevalence? We think of the increase in CYP’s mental health problems as a modern phenomenon driven by social media, but such problems have been on the rise since the 1970s at least. However, the best national prevalence data we have is 14 years old, predating social media (as we know it), the deepest recession since World War II, and the longest period of austerity in living memory.  We expect that when the next national CYP mental health prevalence survey is published this autumn, more young people than ever will display signs of a mental disorder.

Is it acceptable that only a small proportion of CYP with a mental health problem receive help? Consider that only about a quarter of CYP with a diagnosable mental disorder are accessing specialist NHS mental health services (the target is to move to 33% through the five-year plan), and many more will have emerging problems that haven’t yet met the clinical threshold of a mental disorder – this is just the tip of the iceberg. As the prevalence of mental health problems has increased, the problems regarding the CYP’s mental health system have largely stayed the same, despite efforts to improve over the years. The seminal report ‘Together We Stand,’ published back in 1995, outlined failings in the CYP’s mental health system that still continue in 2018. The difficulty in supporting young people to transition to adult mental health services has been highlighted regularly in reviews of CAMHS for at least the last 30 years. Something is not working. The NHS’s 10-year plan is the perfect opportunity to lay the groundwork and do things differently. 

Is it acceptable that we do not intervene in childhood when we know this makes a difference to adult mental health? Mental health problems experienced during childhood cause considerable distress and, if not properly addressed, often continue into adulthood where they frequently become chronic. For example, evidence suggests that intervening in primary school children with behavioural problems can reduce mental health problems in later life by 30%. About 50% of adult mental health problems are present by age 15 and 75% by age 24. As a GP, I see the consequences of this every day, both in terms of the impact on the person (having mental health problems as a child increases the risk of doing badly at school, being in contact with the justice system, having poor physical health, unemployment, and can shorten life expectancy) but also in terms of the cost to the NHS.

Is it acceptable that insufficient resources are being ploughed into CYP mental health? It is vital that the CYP’s mental health system is properly resourced, financially and in terms of workforce. This includes not only the services we provide in the NHS, but also support from local authorities and schools, who have all seen sizeable cuts to their budgets.

In the past, NHS Clinical Commissioners, the independent membership organisation for CCGs, has called for ringfencing of transformation funding to ensure that this money is spent appropriately in these financially challenging times. And yet, even with this investment, it is estimated that only a third of young people with mental disorders will be able to access the specialist services they need. This is an improvement, but we need to look again and ensure that the funding for mental health is being used to commission services that improve outcomes.

Is it acceptable that much of our focus is on highly specialised services? Currently, specialist NHS mental health services tend to be quite small, and any capacity increases are often insufficient to cope with increased demand. This results in changes to referral thresholds and longer waiting times.

We are already moving away from the tiered model of delivering CYP’s mental health services and towards innovative and disruptive community-based models of care that focus on the needs of the child or young person and emphasise prevention and early intervention. One such model is i-Thrive, which has been tipped as the next generation of mental health models and a potential replacement for the current system. It focuses on the needs of CYP and has prevention and early intervention at its core. I-Thrive is currently being piloted in 10 accelerator sites across the country; an evaluation of the pilot is due to be published this December.

Is it acceptable that the commissioning of CYP services is fragmented? As a mental health commissioner, I live with this fragmentation. It does not work, and it can no longer be solely the NHS’s responsibility. Poverty, violence and abuse, disjointed family lives, as well as pressures to do well at school and uncertainties about their futures can all affect children’s mental health. These problems are not easy to fix and will require long-term commitments from many different organisations. The development of integrated care systems is bringing together different agencies within health and social care more broadly, and we look forward to seeing how CYP’s mental health services develop in these areas. We need both the appetite and the legal framework to join up the whole system, cutting across social care, public health, the NHS, education, the voluntary sector and the justice system, whilst considering the full range of services that support children and young people’s mental health. 

We need a long-term commitment. Whilst there is still a long way to go, progress has, of course, been made and many areas are delivering outstanding services in difficult circumstances. For instance, CYP’s Improving Access to Psychological Therapies has been rolled out across the country. This should be celebrated, but there is still a lot of work to be done.

Nonetheless, years of underinvestment and lack of focus will not be corrected quickly. Despite the five-year funding settlement, budgets will continue to be tight, so we need to ensure we are providing services that are cost-effective and meet the needs of children, young people and their families.

We know that the system often doesn’t work as well as it could. So rather than continuing with a broken model and having the same conversations in 10 years’ time, we need to do things differently. Long-term change needs a long-term commitment that is backed up with sufficient funding to turn these services around so that we can do the best we can for our children and young people.

Children and young people are our future. And they are our present. It is time to agree the current state of CYP mental health services is not acceptable and accelerate change.


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