The Mental Health and Wellbeing Plan is an important opportunity to recognise local government’s leadership role in improving the mental health and wellbeing of our communities.
- The plan is an important opportunity to recognise local government’s leadership role in improving the mental health and wellbeing of our communities, ensuring that local, regional, and national NHS partners, the voluntary and community enterprise sector (VCSE) and employers work together with local communities to improve mental health and wellbeing.
- We need a system wide focus on early intervention and prevention. Intervening early to prevent mental health problems developing, or to treat and support children’s, parents and families before problems progress is essential.
- We need increased investment in local government to reflect the statutory and wider role that councils play in supporting good mental health in the community. We are calling for sustainable funding for local government statutory and non-statutory mental health services to put them on an equal footing with NHS clinical mental health services.
- A clear workforce strategy for both the adults and children’s workforce is required. This should look at recruitment and retention of Approved Mental Health Professionals, increasing the workforce in the key pressure areas and in early intervention and prevention spaces and at developing an appropriate training plan for workforce to make sure that mental health is everyone’s business.
- 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.
- There are clear links between poor mental health and health inequalities. The Government should use the mental health plan to make a commitment to reducing the life expectancy gap for people with a mental illness and addressing other inequalities in mental health with a particular focus on reducing the racial inequalities that persist.
- For children and young people, there needs to be effective interventions in and out of schools to ensure they can get the support they need in the places that suit them best.
- To address the crisis in mental health and emotional wellbeing for our children and young people, we need to build on the progress made so far and develop a systematic approach which prioritises and funds early intervention and brings together a partnership approach, with clear accountability across local partners.
- Supporting the whole family network is essential as both a protective factor for poor mental health and to improve the recovery of children and young people. A whole household approach to young people’s mental health recognises the important roles that parents, carers or siblings can play in supporting young people’s mental health.
- The LGA wish to remain involved in the development of the plan and are happy to contribute on an ongoing basis.
How can we all promote positive mental wellbeing?
Councils have a key leadership role and formal mental health responsibilities
Councils have a key leadership role in promoting positive mental health in their local communities and providing information, care, and support across the life course. Promoting good mental wellbeing and preventing poor mental health helps individuals and communities stay healthy, live meaningful lives, and potentially avoid the need for long term or inpatient care.
The Social Care Covid-19 Task Force Mental Health and Wellbeing Advisory Group recently highlighted the role of adult social care in meeting the needs of people with mental health challenges and keeping them safe. It recognised that through their adult social care functions, councils are the primary local commissioners and funders of VCSE mental health and wellbeing services. Councils as leaders of place, also have a key role in ensuring effective partnership with housing, leisure, learning, community safety and the police in supporting people with mental health needs.
The expertise of the mental health social care professionals employed by councils, and the VCSE, adds distinctive value to that of colleagues in the NHS and elsewhere. Councils hold levers that can transform the lives of adults and children with mental health difficulties. The everyday work of care assessment and planning means that, with sufficient resources, councils are in an unparalleled position to prevent mental health problems, intervene at an early stage and give people the rounded support that is their right.
Mental health is interwoven with other agendas – including housing, public health, social care, employment, social inclusion, economic development, and safety. Councils are uniquely placed to connect all parts of the system. With an ability to bridge between voluntary and community sector and health service partners, councils can, if resourced and with sufficient staffing, trigger a sea-change in the effectiveness of collaboration between different agencies. This can dramatically change how care and support feels from a service user’s point of view.
Local government has a key leadership and delivery role in promoting good mental health and wellbeing in local communities. Roles and responsibilities include:
- system-wide local leadership through health and wellbeing boards, integrated partnerships and place-based care and support systems
- public health responsibilities to promote mental wellbeing and prevent poor mental health throughout the life course. Public health also addresses lifestyle issues related to mental health such as obesity, smoking and drug use and has a key leadership role in suicide prevention
- statutory duties and powers related to adult social care and mental health for children and young people and for adults under the Mental Health Act
- the overview and scrutiny of mental health provision
- councils have a critical role to play in reducing inequalities and enhancing inclusion and cohesion within their communities
- provision of wider council services that promote wellbeing such as housing and housing support, libraries, green spaces and commissioned voluntary and community services
- councils also provide or commission information and advice on local services that can offer mental health support. Many of these services are culturally specific, such as advocacy
- councils have responsibilities to their own employee’s health and wellbeing.
Many councils have identified promoting mentally healthy communities as a key strategic priority and are taking forward innovative partnership work. The LGA with the Centre for Mental Health published ‘Our Place’which has several impressive examples of local strategic leadership and creative approaches to addressing mental health.
Mental health inequalities
Councils have a critical role to play in reducing mental health inequalities and enhancing inclusion and cohesion within their communities.
There are clear links between poor mental health and health and racial inequalities. Children from low-income families are four times more likely than those from the wealthiest households to have a serious mental health difficulty by the time they leave primary school. Unemployment and poverty are strongly associated with poorer mental health and a higher risk of death from suicide. And rates of mental health problems can be higher for some black and ethnic minority groups than for white people.
Councils are key to identifying and addressing the intersectionality between health inequalities, protected characteristics, socioeconomic deprivation and poor mental health, however, resources limit the work that councils can do. The Centre for Mental Health in its Commission for Equality in Mental Health recommended that councils need an urgent funding boost to coordinate action to pursue mental health equality. We need recurrent long-term funding in councils so that children’s, adults and public health services can meet existing, new and unmet demands to combat mental health problems.
The pandemic has meant that existing inequalities have been exacerbated during the last two years, which has led to an increase in mental health needs. People already living with mental health conditions have reported losing both informal networks and essential services during the lockdowns, and there is evidence that deaths from COVID-19 have been three times higher than average for people with schizophrenia.
Children and young people
The LGA is calling for a cross Whitehall strategy that puts the needs of children and young people at its centre. This will support the wider system to work collaboratively towards clear roles with identified outputs and outcomes, including drawing together the direction from this mental health plan.
The Government should ensure that practitioners, parents, carers and the wider public continue to de-stigmatise mental health through campaigns and open conversations. This requires effective training and workforce development to ensure these conversations are managed well.
Children’s emotional wellbeing and mental health needs should not be medicalised except when necessary. Children should be supported to understand that there are fluctuations in emotional wellbeing, and this is normal. Therefore, supportive relationships with non-medical professionals are key to ensuring that children and young people have somewhere to go and a trusted adult to speak with. This could include a youth worker or third sector partner as an intervention by a medical professional should not be seen as the only way to tackle poor mental health. These services however need to be prioritised and invested in. Youth services have lost 70 per cent of funding since 2010/11 and recent investment through the Youth Investment Fund has not been sufficient to combat this. Children and young people should also be supported to recognise that their mental ill health can be a long-term condition, that they can live and thrive with, and that an effective approach is to have relapse plans in place and an ability to recognise triggers.
Compulsory personal, social and health and economic (PSHE) education is a step in the right direction in ensuring these conversations and topics are raised in a supportive and sensitive manner. However, many schools have not yet been able to fully implement an effective curriculum, and this means young people are missing out on crucial knowledge. We recognise the importance of delivering PSHE in the most effective way and our recommendations from 2019 remain useful in the current context.
How can we all prevent the onset of mental ill-health?
Mental ill health is one of the most prevalent forms of illnesswith one in six people experiencing diagnosable symptoms at any time, at a cost of over £119 billion in England alone.
To achieve better mental health for everyone, we need a system wide focus on early intervention and prevention. It is essential that the plan recognises the lead role of councils in promoting good mental health and there is a shift in focus away from the medical model towards prevention and appropriate mental health support in the community. We should also support individuals to recognise that everyone has a responsibility to help themselves and help others with their emotional wellbeing and mental health, and that with supportive social connections, we can move to a place where poor emotional wellbeing and mental health is reduced.
To address the inequality for people with a mental health illness the Government should use the plan to make a commitment to reducing the life expectancy gap for people with a mental illness. Inequalities, inequities, and disparities are the result of economic and social factors that put some people and communities at a dramatically higher risk of poor mental health. This means they are amenable to action.
The plan is a great opportunity for the Government to tackle the causes of inequalities that contribute to a large proportion of the cost of mental ill health. Mental health problems are frequently associated with a range of other factors including poverty, poor housing, homelessness, disability and long-term illness and experience of violence or abuse. Groups who have higher levels of mental health problems include refugees and asylum seekers, veterans, the lesbian, gay, bisexual and transgender community (LGBT), looked after children, and some Asian, black and ethnic minority groups. People with these characteristics were already at higher risk of some adverse mental health outcomes before March 2020; the pandemic has exacerbated these health inequalities.
The impact of coronavirus (COVID-19) and the social and economic consequences of the pandemic have meant that tackling mental health at a population level has never been more important. COVID-19 has been recognised as a public mental health emergency that exacerbates existing mental health inequalities.
The role of public mental health, including suicide prevention, should be considered as part of understanding and responding to the impact of ill-health and promoting wellness. Key principles underpinning successful public mental health responses include:
- Whole-system approach – no single agency can be left to address this by themselves; it needs input from all sectors including education, voluntary, statutory, employer and faith - as well as local neighbourhood action.
- Life-course and whole family/household approach – an evidence-based understanding of local need and interventions that target the whole population, populations at higher risk and people who need additional support. Recognising that mental ill-health affects the whole family or household, beyond any individual who receives support.
- Build on existing arrangements – for example, mental health programmes for young people, multi-agency suicide prevention partnerships and bereavement networks.
- Tackling inequalities - the determinants of mental health interact with inequalities including communities of geography, ethnicity and gender in ways that put some people at a far higher risk of poor mental health than others.
- Good communication and strong system links - both to professionals and to the public. Particularly aimed at reassurance and building resilience.
- It’s important to highlight positive examples of communities coming together and supporting each other. An example of this is the Prevention Concordat for Better Mental Health, a shared commitment to work collaboratively, through local and national action, to prevent mental health problems and promote good mental health. The LGA and many councils have signed the concordat.
Children and young people
Currently, the system does not support an early intervention approach. There is a lack of data about children and young people accessing lower-level mental health support, or the outcomes they achieve. The responsibilities for providing and overseeing earlier intervention in mental health are unclear. An understanding of what good looks like in terms of universal provision for mental health has not been defined and the system is incentivised to strive for targets that relate to access to specialist support and not long-term outcomes.
Wider community-based services will support children and young people’s mental health and support them to build resilience, for example, youth services. Access to sport and other non-academic experiences will also support children and young people to be engaged members of their community, improving involvement in education and bolstering their resilience. This includes the importance of play and outdoor leisure activities.
Councils have a clear role in providing strategic oversight and co-ordination of different partners to support schools, children and young people, as well as using their expertise to facilitate conversations locally and bring schools nurses, educational psychologists and other professionals who support and use an early intervention approach. However, councils have to make extremely difficult decisions about how to allocate increasingly scarce resources, and youth services have seen their funding reduced as councils are forced to prioritise urgent help for children at immediate risk of harm. This has had a particularly strong impact on the availability of open access, universal services, with provision increasingly targeted at those in greatest need.
Best start in life
Good mental health starts in the early years and a good early environment can be a protective factor for mental health, providing the opportunity for children to grow and develop well. Infant mental health is crucial to the long-term development of good mental, physical and emotional health, and wellbeing throughout the whole life course. However, sometimes the early years of a child’s life are challenging; they may experience poverty, parental conflict or another adverse childhood experience. This can lead to a different developmental path and poor mental health outcomes in later life.
We were pleased with the Government announcement to focus on the early years through the Best start in life and have welcomed the alignment with the Family Hubs programme with its focus on perinatal mental health services. It is clear however that the pandemic has not only exacerbated existing inequalities but also impacted children who were not able to access early years provision which has therefore affected their development. We are still anticipating the long-term impact of this disruption and its impact on children and their future development. To combat this, we need to ensure that early years practitioners have the skills they need to support children and access to wrap around specialist support when needed such as education psychologists and therapeutic support.
Ensuring that all women receive access to the right type of care during the perinatal period is needed to reduce the impact of maternal mental health problems for the mother and family during pregnancy and beyond. However, to ensure that children and their families have the support they need to thrive, we need to invest in preventative services that support children in the earliest stages, such as health visitors and early years practitioners.
Health visiting service
The health visiting service plays a crucial role in giving children the best start in life. Many councils have embraced the opportunity to make a difference in this key development stage since the transfer of responsibility of the Healthy Child Programme in 2015. Health visitors lead on the delivery of the Government’s Healthy Child Programme for children aged 0 to five, working alongside other health and social care colleagues, including family nurse partnership teams, nursery nurses and other specialist health professionals. However, we know that many areas are struggling to recruit Health Visitors, with the number of Health Visitors falling by around a third over the last five years. Current projections estimate that there is a shortfall of 5,000 health visitors in England. We are therefore calling for a properly resourced, integrated workforce plan that underpins the current refresh of the Healthy Child Programme. A workforce strategy should recognise the benefits of having a diverse range of health visiting, school nursing, children’s centre and other early years staff in children’s and health services. This needs to be an integrated strategy between councils, health, education and third sector partners, putting the child’s journey at the centre.
The local authority public health grant allocation was £1 billion less on a real term per capita basis in 2021/22 compared to 2015/16. To develop ‘excellence’ in the early years, the Government will need to reverse the reductions to the public health grant and ensure councils have the resources they need to commission innovative and effective services. We believe this will ensure councils are able to provide a consistent service which leads to better outcomes for children and families.
How can we all intervene earlier when people need support with their mental health?
We need to recognise and build upon the benefits of the connectivity between the NHS, local government, and other partners in preventing health prevention deterioration and promoting recovery, such as integrated NHS/local government community mental health teams.
A focus on community integration will strengthen links between NHS services and other council services and help to embed a ‘whole person’ approach that seeks to address the often-multiple factors that affect mental wellbeing. Councils deliver or commission services that help people in vulnerable circumstances and at crisis points, such as social care, supported housing, public health, domestic abuse, homelessness support, substance and alcohol abuse and money advice, as well as services such as libraries, parks and leisure centres that help to improve people’s general mental wellbeing.
Social determinants of poor mental health
The plan needs to have a strong evidence-based approach to addressing the social determinants of poor mental health, including poverty, employment and skills, substance use and domestic violence.
There is a strong link between poverty and poor mental health with higher rates of poverty and disadvantage increasing the risk of poor mental health but also being a consequence of poor mental health. For a child growing up in poverty, this can contribute to adverse childhood experiences and can have a long-term impact on their mental health and wellbeing. Poverty can be a significant risk factor for mental illnesses like schizophrenia, anxiety and addiction.
Poverty can also act as a barrier to accessing mental health services. This can be due to accessing services during times that work for families or due to the need to follow up or chase support. Furthermore, the stigma of living in poverty can be a deterrent to asking for help.
Alongside this there is a growing awareness of the relationship between health and prosperity, with differences in health helping to explain productivity gaps between places. The recent Levelling Up White Paper stresses the link between people’s health, education, skills and employment prospects and focuses on policies to ensure everyone, wherever they live, can lead healthy and productive lives. The mental health and wellbeing plan should offer support for more local place-based solutions to employment.
Where local government has more flexibility to work hand in hand with employers and providers from the outset, there are positive outcomes. The LGA Work Local approach shows that enabling local government to coordinate partners and employment and skills provision across a place could each year unlock talent and result in a 15 per cent increase in the number of people improving their skills or finding work. This will improve the health and wellbeing of local communities while reducing costs to the public purse.
Poor health is one of the greatest barriers to finding and retaining a satisfying and rewarding job and wider involvement in society. Conversely, having high-quality employment and being socially connected are key factors in a person’s health and wellbeing. Councils have developed many innovative interventions over recent years in these areas. Such interventions help their citizens to acquire the skills and opportunities to find work that suits them, overcome barriers to work and engagement in society, and become more healthy, active and resilient.
It is important that the plan recognises the link between substance misuse and mental health. For adults undergoing treatment, 59 per cent said they had a mental health treatment need. Over half of new starters in all substance groups needed mental health treatment .
Additionally, the plan needs to address the impact of domestic violence on victims' mental health which is profound and obvious. Women experiencing domestic abuse are more likely to experience a mental health problem, while women with mental health problems are more likely to be domestically abused, with 30-60 per cent of women with a mental health problem having experienced domestic violence. Domestic violence is associated with depression, anxiety, PTSD and substance abuse in the general population. Exposure to domestic violence has a significant impact on children's mental health. Studies have found strong links with poorer educational outcomes and higher levels of mental health problems.
Housing, homelessness, and mental health
There are well recorded links between mental health, housing, and homelessness. Councils have a range of statutory duties related to housing and homelessness, and in turn, provide housing support for those experiencing mental illness. The quality of the home can also have an impact on mental wellness, and councils have a role to play through their housing, health and safety regulations and their planning duties, in terms of issues such as space requirements and noise abatement.
The 2016 Mental Health Taskforce report notes that: ‘Stable housing is a factor contributing to someone being able to maintain good mental health and important … for their recovery if they have developed a mental health problem. Common mental health problems are over twice as high among people who are homeless compared with the general population, and psychosis is up to 15 times as high. Children living in poor housing have increased chances of experiencing stress, anxiety and depression’.
There are many examples of council good practice in relation to mental health and homelessness, for example Camden has designated homeless pathway workers co-located with mental health and offender services to assist single people threatened with homelessness on institutional discharge.
Children and young people
It is crucial we focus on prevention and intervention at an early stage, particularly for children and young people. By doing this we will help prevent poor mental health blighting peoples’ lives and improve the well-being of our communities. The role of children’s centres, perinatal services and early years settings in supporting parents and professionals to understand young children’s emotional development and implement proven strategies for promoting ongoing good mental health are all integral. As is working with schools to embed positive ways of promoting mental health within the curriculum. Normalising periods of emotional difficulty for children and young people, maximising the opportunities for engaging in positive activities and attending to the link between physical and mental health all formed important elements in promoting good mental health.
To address the crisis in mental health and emotional wellbeing for our children and young people, we need to build on the progress made so far and develop a systematic approach which prioritises and funds early intervention and brings together a partnership approach, with clear accountability across local partners.
Children’s mental health is everyone’s business and this needs to be reflected in the capability of the workforce, and the support that surrounds practitioners. There needs to be training put in place and advice and support so that staff working in schools, colleges, nurseries, youth services and frontline health roles are equipped with the skills and techniques to begin to have supportive conversations about mental health with children and young people. Local areas have told us about the importance of reducing professional anxiety around children’s mental health, providing practical examples of what professionals could do within the course of their day-to-day work, and knowing what to look for which might indicate that more specialist help is needed. Furthermore, it is important that children and young people can access and be supported by a workforce that is reflective of the diverse experiences, ethnicities and needs that young people are. This would be supported by a commitment to a culturally competent workforce.
2017 Green paper ambitions
Current government interventions are focusing significantly on the role of schools in supporting children and young people. We recognise the importance of supporting children where they are seen most frequently and welcomed the intentions set out in the 2017 Green Paper ‘Transforming children and young people’s mental health provision’ although the timeframe and scale of the intention will not solve the challenge that schools are seeing in their day to day to support children and young people. The delivery of these ambitions has been too slow. Designated Senior Lead Training in schools has only recently rolled out and Mental Health Support Teams in Schools are directed to only reach 35 per cent of the country by the current proposal. Furthermore, the Green Paper did not set out a whole system response to mental health. We hope that this plan will go some way towards filling these gaps.
Support in schools and colleges
There is more that can be done to provide support for and through schools and colleges for children and young people to access mental health support such as through school-based counselling.
This not only covers support in schools, but also that schools themselves should be welcoming environments and not exacerbate existing mental health conditions. Supporting children and their families to ensure good attendance at school involves partnership working, including input from health. Timely support from the health sector, including medical and therapeutic interventions for example, is vital in allowing children with physical and mental health needs to attend school.
Councils were instrumental in supporting all schools throughout the pandemic, including working to support vulnerable pupils and interpreting guidance to help ensure learning has continued as safely and effectively as possible for all children and young people.
The Department for Education’s £1.4 billion Education Recovery Fund announced on 2 June was welcomed, but we are concerned that it does not go far enough. The Education Policy Institute (EPI) recommends that £13.5 billion is needed to tackle lost learning caused by the pandemic. While the Government’s focus on academic recovery is understandable, a broader approach is needed that includes measures to support children and young people’s socialisation, communication and mental health and well-being and this continues to be the case.
It is vital that vulnerable children, who have been disproportionately impacted by the pandemic, are the focus of this programme of work. In their role as leaders of local education systems, councils can bring together partners, join up local efforts to promote education recovery.
The role of school nurses is also integral to ensure there is the right support available. Commissioned by Local Authority Public Health Teams, school nurses lead the delivery of the Healthy Child Programme 5-19, which sets out good practice guidance for prevention and early intervention, including resilience and emotional wellbeing.
School nurses are registered nurses with an additional post registration qualification in Public Health Nursing, many with additional skills, experience, and qualifications in young people’s mental health. This makes school nurses well placed to provide health promotion, prevention and early intervention to improve young people’s emotional health and mental wellbeing.
School nurses are trusted and valued by children and young people, have the flexibility to work with them in school and community settings, and provide holistic assessments of needs. They take strengths-based approaches and work in partnership with children and their parents to encourage behaviour change which encourages positive health outcomes. An example is Walsall’s school nursing service which started running dedicated emotional and mental health support groups more than 10 years ago and is targeted at those struggling with anxiety, low self-esteem and confidence issues.
Schools also need to be inclusive and welcoming environments that promote good emotional wellbeing among children and young people. This includes challenging bullying in schools which can have a long-term negative impact on young people’s mental health. At the same time, children with mental health problems are more likely to be bullied. A robust PSHE programme can reduce the stigma of mental health and can also teach children to treat each other well and be resilient to the challenges presented at school. Schools can develop a whole school approach to prevent bullying and support an inclusive mental health environment.
Wrap around support for schools is essential. For example, the presence of drug and alcohol workers in schools. Drug and alcohol can either exacerbate mental health symptoms, cause poor mental health or young people may find they use drug and alcohol to deal with the symptoms of their mental health. Therefore, it is essential to ensure that schools have the resources they can draw on to support children and young people when they are coping with drug and alcohol use.
It is vital that the Government’s education reforms prioritise addressing the wider factors that impact children’s educational outcomes. We will only begin to tackle the widening disadvantage gap in education with holistic support that tackles rising levels of financial hardship and poor mental health. We look forward to working with Government to ensure recent papers, such as the draft Schools Bill and the Special Educational Needs and Disabilities Green paper makes use of councils’ expertise and delivers the best outcomes for all children and young people.
We also welcome the focus in the recent Independent Review of Children’s Social Care on family help and the importance of supporting children and their families as early as possible. We urge the Government to implement the review’s recommendation to invest in early help to make sure that children, young people and their families get the support they need to thrive, including mental health support and help with the factors that can lead to people struggling with their mental health.
Support in the community
Many children and young people will not feel comfortable accessing support through schools and provision in their communities or online is essential. The LGA is calling for the roll out of Early support hubs. This approach is already working well in some local areas, for example, the Hive in Camden. Online support already provides some support for children and young people, as shown with Kooth in Portsmouth. However, we know that some young people did not feel supported through the pandemic and the move to digital services as they are either unable to access computers, or they did not have a private space to go to have a discussion. Not one service fits all young people and there needs to be a range of holistic support in place for children and young people.
Children and young people also need to have access to support for other experiences that may impact their mental health. Specific and dedicated support for children and young people is often underdeveloped, such as in the domestic abuse space, and there are known challenges in accessing Child and Adolescent Mental Health Services (CAMHS) which are required to support children in their recovery.
Whole household approach
Supporting the whole family network is essential as both a protective factor for poor mental health and to improve the recovery of children and young people. A whole household approach to young people’s mental health recognises the important roles that parents, carers or siblings can play in supporting young people’s mental health. This can take place through a range of ways including systemwide redesign of CAMHS with a focus on community support, transition to adulthood, and involvement of parents, parenting programmes and tailored support for parents whose children have mental health problems. This includes support aimed at foster carers and adoptive parents. Flexible, non-judgemental holistic support for young people, tailored to work around family needs and circumstances. In addition, family mediation for young people at risk of homelessness.
It is important to listen to children and young people when developing services and councils have a range of good practices in place, ensuring that young people’s voice is heard in the development of services.
Evidence-based parenting programmes are estimated to generate savings in public expenditure of nearly £3 for every pound spent over seven years, with the value of savings increasing significantly longer term. They will also lead to better outcomes for children and families.
An estimated 200,000 children in England live with alcohol-dependent parents. In an average secondary school in England 40 pupils will be living with a parent with a drug or alcohol problem. About one in six Child in Need assessments carried out by councils last year record parental alcohol problems. Problem parental alcohol or drug use were each recorded in over a third (36 per cent) of serious case reviews where a child died or was seriously harmed.
In 2018, the government's programme to support children of alcohol dependent parents recognised that there is more to be learnt about how systems and services can better identify and support children and families as well as to expand the capacity to do so. The Department of Health and Social Care and Department for Work and Pensions invested £6 million over two years in a range of projects across councils and the voluntary sector. This included £4.5 million across nine areas through an innovation fund, which areas used to explore a range of ideas for changing their systems and services to better meet the needs of their local communities.
While some councils will be able to provide more support for children living in households with an alcohol-dependent parent, the Government should provide sufficient funding to enable councils to provide all children with the support they need. We have therefore been calling for the restoration of the £1.7 billion early intervention funding. The Early Intervention Grant has been reduced by the Government by almost two-thirds – down from £2.8 billion in 2010/11 to £1.1 billion in 2018/19. As a result, many children’s services departments have been forced to cut back the universal and early help services – such as children’s centres and family support services – that can help tackle and prevent emerging problems before they reach crisis point. The LGA estimates that councils in England face a funding gap of more than £5 billion by 2024 to maintain children’s services at current levels.
Transition points are key for children and young people. This includes from early years to school, primary school to secondary school and within services as well, including from CAMHS to adult mental health services, or into community support. It is a positive step forward that the NHS Long Term Plan looks at ways of supporting young people up to the age of 25 particularly as young adulthood can be a particularly vulnerable time for young people who experience mental illness for the first time. However, still too many young people report feeling lost when they reach 18 and face uncertainty around their care. Ensuring a robust early intervention system alongside an integrated approach between local partners has been shown to improve the experience of young people during transition points.
Colleges also have a key role in supporting young people, particularly facilitating some of those challenging transition points, and should be included in all education-based policies.
Support for vulnerable children
Poor mental health also impacts some children and young people disproportionately, and some young people are less likely to be able to access support. For example, children and young people with a learning disability are three times more likely than average to have a mental health problem, however, only just over a quarter of children who experience both a learning disability and a mental health problem have had any contact with mental health services. More than four in five trans young people have self-harmed and more than two in five trans young people have attempted to take their own life, but often trans young people find it more difficult to access support. Children from the poorest 20 per cent of households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20 per cent. Children and young people from ethnic minority backgrounds are more likely to access support from informal support routes, such as youth workers, than access clinical services, in part, it is believed, due to the stigma in accessing mental health services but comprehensive ethnicity data about access to services is not available.
We are particularly concerned about the growing difficulties in accessing the right help and support for children and young people with the most complex and overlapping needs, finding themselves on the edge of the criminal justice or care systems and/or the brink of hospitalisation. There were 77,390 children who had been assessed as having a mental health need by councils on 31 March 2021, an increase of 25 per cent on the 61,830 seen two years earlier.
How can we improve the quality and effectiveness of treatment for mental health conditions?
To support this plan, long term investment needs to be prioritised. Although there are areas where improved joint-working or different ways of working may be effective, at the core of developing a system that provides good quality and effective for treatment of mental health conditions is sufficient investment and an approach where a person’s social and psychological wellbeing is considered. We are calling for sustainable funding for local government statutory and non-statutory mental health services to put them on an equal footing with NHS clinical mental health services.
The LGA led Care and Health Improvement Programme recently commissioned The Centre for Mental Health to undertake a short project to support case for the development of a sector led improvement programme for adult mental health services. This paper is unpublished but identified ensuring the consideration of social and psychological wellbeing as part of mainstream assessment and care planning and strengthening collaboration in the commissioning and provision of mental health support.
Councils' children's and adults’ mental health services and commissioned voluntary sector service are largely funded from the council social care budget. Local government needs sufficient and sustainable public health and social care funding to enable councils and their partners to harness all their services and assets to help the whole population to be mentally healthy, prevent escalation to more costly clinical services and work with health colleagues to support people of all ages while they are mentally unwell and to support their recovery.
Investment and development of the workforce is also key. The recent data shows gaps in the workforce with high vacancy rates, the slow growth of certain sections of the workforce and particular challenges in inpatient beds. This needs a concerted effort to challenge. It is essential that it is not just the NHS workforce that is focused on but all partners and practitioners that have a role in supporting children and young people’s mental health, from teachers to GPs and youth workers.
Research by the National Audit Office found that spending on preventative children’s services fell from 41 per cent of children’s services budgets in 2010/11 to just 25 per cent in 2017/18. This has been driven by the dual impact of significant cuts to council budgets over the last decade and increasing demand for child protection services.
Rising demand for services means that despite budgets for children’s social care rising by more than half a billion pounds in 2019/20 from the previous year, and more than £1.1 billion between 2017/18 and 2019/20, more than eight in 10 councils were still forced to overspend to ensure children were protected.
Councils have proved how critical they are in providing services during COVID-19, working closely with schools and other partners to provide support to children and young people, but have had to divert all their early intervention spending into more acute services due to overstretched budgets this is part of the reason as to why in recent Health Education England figures reflect a fall in the proportion of mental health staff employed by councils.
The council mental health services and public health responsibilities need parity of funding with NHS mental health services, so that councils can help the whole population to be mentally healthy, prevent the escalation to clinical services and work with health colleagues to support people of all ages who are mentally unwell.
There will be additional needs to support councils to develop the capacity and capability of mental health community service providers. Many of these are commissioned by councils and all are operating in an increasingly fragile market. Council commissioning services may also have additional burdens and require resourcing. It is important that the additional costs are identified and resourced.
The Spending Review announced £500 million of funding for mental health to address waiting times, expand support, and invest in the workforce. And the Government’s Mental Health Recovery Plan announced some additional spending for councils. However, research has predicted a rise in demand following the pandemic, which will impact upon councils.
In 2019/20 net expenditure on mental health support for adults, according to the LGA analysis of the General Fund Revenue account represented seven per cent of total net expenditure on adult social care.
A significant proportion of this funding is spent on section 117 aftercare for adults who have been subject to the Mental Health Act. The independent review of the Mental Health Act identified concerns about the funding and provision of health and social care support for people who have been subject to the Act. The plan and the reform of the Mental Health Act need to clarify Section 117 responsibilities.
Councils currently receive £3.4 billion through the Public Health grant and some of that is spent on public mental health services. The grant has been cut in real terms by over £1 billion since 2015/16. According to the grant returns, councils spent £80 million last year and since 2016/17, the amount councils spent has almost doubled. We need a clear long-term plan on the future which recognises the public health challenges we face as a country, addresses the current and future pressures on the public health workforce and recognises the interconnectedness with other parts of the health and care system.
COVID-19 put adult social care firmly in the public, political and media spotlight. The crisis highlighted the essential value of social care to the wider public and this interest needs to be harnessed in the debate about the future of care and support.
Years of significant underfunding, coupled with rising demand and costs for care and support, have combined to push adult social care services to breaking point. Over the past decade, adult social care costs increased by £8.5 billion while total funding (including the Better Care Fund) only increased by £2.4 billion. This left councils with a funding gap of £6.1 billion. Of this, £4.1 billion was managed through savings to the service, and £2 billion was managed through funding diverted from other services by cutting them faster than otherwise would have been the case.
Whilst the LGA are supportive of the introduction of a cap on care costs and other reforms announced as part of the Government’s ‘Build Back Better’ plan for health and social care, we have previously raised our concerns about the adequacy of the announced £5.4 billion to fund these reforms through the new Health and Social Care Levy. The Spending Review and Autumn Budget did nothing to allay those concerns and we are troubled that only £200 million is available in 2022/23 to support reform implementation, particularly if that includes the commitment to move towards councils paying a fair rate of care.
Without proper long-term investment it is likely that councils will continue to struggle to meet their statutory duties under the Mental Health Act and the Care Act, with real consequences for people. More people who draw on social care, including people with mental health needs, will be unable to live an equal life. More people will live with unmet care needs; unpaid carers will experience further deterioration of their mental, physical and emotional wellbeing, the mental health workforce will remain under strain and providers’ financial viability will be tested to the extreme, with more likely to exit the market or hand back their contracts with councils.
Children and young people
The mental health system requires a clear, long-term strategy which is why we welcome the development of this plan. It is important to note however that the system is complex, with a range of different partners involved in supporting children, young people and adults which all have their own priorities and plans (such as the NHS Long Term Plan). This plan also needs to have the voice of the service user central to its development.
Support for the workforce
For all services the impact of increasing pressures on staff needs to be considered, particularly those that do not have routine clinical supervision. Schools are being expected to support more children with lower-level mental health needs and the needs and wellbeing of the teachers and practitioners involved in this need to be considered. A clear workforce strategy for the children’s workforce is required, not just within NHS services. This should look both at increasing the workforce in the key pressure areas and in early intervention and prevention spaces and at developing an appropriate training plan for workforce to make sure that mental health is everyone’s business.
At the centre of the system needs to be the child, young person and their family as demonstrated through the Thrive framework ensuring a person-centred approach. The child’s voice shouldn’t just be central for service development, but also in their support plan.
Too often children and young people report appointments during school hours, in locations that they must travel some distance to and in places where they do not feel comfortable. Services need to be delivered where children already are and where they will feel comfortable. Considering where children and young people will want to access services needs to be a central component of mental health service development.
Some young people may experience poor mental health more than others, for example, those with additional needs or vulnerabilities if they are or have been in care, or if they are unaccompanied asylum-seeking children. Particular care needs to be given to these groups. The NHS must commit to improving capacity within children’s mental health services – both at a Child and Adolescent Mental Health threshold and below this – to ensure that young people are able to get the support they need, when they need it.
There needs to be a greater focus on multi agency teams, for example, health and social care, which are well integrated and supported by robust data sharing agreements that enable information about the child to be brought together so they can get the best support necessary.
There is a role for primary care, such as GPs, to provide support to children, young people and their families. They can provide crucial advice to families and undertake the right referrals to ensure that families are able to get the support they need whilst being a trusted relationship for the family during a difficult time. However, GPs often report finding it challenging to navigate the system, are left with nowhere to go when there are long waiting lists for specialist support and their understand and support can vary across the country. This shows the need for greater clarity in the system, alongside more resources being invested into mental health support. GPs are also a crucial partner in social prescribing of non-medical interventions for mental health support.
Improved data focussing on the experience of service users
The LGA led Care and Health Improvement Programme recently commissioned the Centre for Mental Health to undertake a short project to support case for the development of a sector led improvement programme for adult mental health services. The final project report is currently unpublished, but it identified that when it comes to adult mental health that councils and partners do not currently have a means of assessing the quality of their support which puts how service users feel at its heart. Given that mental health is necessarily about how people feel, this gap raises serious questions about the validity of existing assessment measures.
Combining a set of benchmarks for ‘what good feels like’ with ‘what good looks like’ would give councils and partners a holistic and robust means to assess the quality of services. A particular strength of this approach is to highlight inequalities and the structural disadvantages faced by racialised and marginalised communities and what may help to address this.
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.
How can we support people living with mental health conditions to live well?
The LGA supports measures that remove the barriers to greater collaboration between NHS organisations and between the NHS and local government to improve mental health care in the community. We welcome the commitment to ensure flexibility for systems to develop their own Integrated Care Partnerships (ICPs). ICPs need to give serious consideration to how they can best serve people’s mental health needs in their area and will need to be mindful of what is and could be best delivered at place level and how to build on this. Through joint strategic needs assessments and intelligence from public health and the NHS, councils and their partners can target investment in a way which meets local needs and supports the shift to prevention. For example, dependent on data, some areas may focus on reducing suicide, some on tackling bullying in young people and some on men’s mental health.
A model that can inform local approaches is the Community Mental Health Framework (CMHF) which describes how the NHS Long-Term Plan’s vision for place-based community mental health can be realised, and how community mental health services will be supported to redesign and reorganise to move towards a new place-based, multidisciplinary service across health and social care aligned with primary care networks.
The framework will enable a place-based integrated service, with available interventions to include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management, and support for self-harm and co-occurring drug or alcohol-use disorders.
The CMHF pilots have shown that greater collaboration benefits individual mental health care. An example is Somerset County Council which has worked in partnership with Somerset NHS Foundation Trust, Somerset Clinical Commissioning Group, organisations from the local VCSE sector and crucially, experts by experience. They have pooled their local strengths to support whole communities by addressing the social, therapeutic, and wider determinants of mental illness.
Children and young People
Effective social prescribing could be used to better effect to support children and young people with mental health conditions. Often a therapeutic or medical, response is not always required to respond to a young person’s mental health needs, and these could be met with support in the community. A social prescribing approach requires strong links with education, employment and training and the voluntary sector that can ensure a child or young person has social connections, resilience and aspirations alongside any mental health needs.
The whole system needs to work together to meet these aspirations, 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.
Support for children with specific needs is essential particularly given the increase in children with eating disorders following the pandemic. However, we also need to recognise that young people may have comorbid needs. For example, they may have an eating disorder, but also another need such as autism and they need to be supported holistically and not passed from one pathway to another. Too often we see children in siloes and do not constructively build support around them and their needs.
How can we all improve support for people in crisis?
The LGA supports the reform of the Mental Health Act and submitted a detailed response to the consultation. Supporting people in crisis is not solely about inpatient care under the Mental Health Act, it also means providing personalised support in the community, this could be community-based crisis support services, such as crisis cafes or advocacy services. To develop a broader range of appropriate specialised mental health support in the community will require additional funding for councils and councils. The plan needs to reflect the operational needs and resource pressures on local government, and partners, who will need to be resourced to support effective implementation. For many years mental health services at all levels have been reduced despite rising demand.
Achieving a reduction in detentions is not solely about legislative change. There also needs to be alternative treatments and services available commissioned by councils in the community, as well as NHS services. There needs to be a system-wide shift in policy and resources away from medicalisation and treating mental ill health, to early intervention, prevention, and support for recovery through integrated community-based services.
The success of the new act will require the NHS and councils working in partnership. More needs to be done to fully embed mental health into integrated care teams, primary care, urgent and emergency care pathways. The recent Health and Social Care White Paper provides a base on which to build a more collaborative culture.
Commissioning of mental health services should reflect local needs and knowledge, the process should not be overly prescribed by central government. It is important that any crisis Improvement programme makes links with the mental health role of councils, not just the NHS.
The new plan should outline on how it will interact with other legislation such as the new Mental Health Act, the Care Act, the Human Rights Act, the Mental Capacity Act, the Equality Act, and the Children Act 2004 and the new Health and Care Bill, the Autism Strategy, the Schools Bill, the Special Educational Needs and Alternative Provision Green Paper and the Liberty Protection Safeguards.
The plan will need to address the pressures on the mental health workforce employed by councils. A current and future pressure on community mental health services is recruitment and retention of Approved Mental Health Professionals (AMHPs) are largely employed by councils and it is recommended that local areas have a minimum number of AMHPs. The AMHP role is under a great deal of pressure both in terms of recruitment and retention of numbers of staff and ongoing pressures upon the role – especially bed issues, workload, and complexity of cases. They often feel exposed to violence and aggression, expending large amounts of emotional labour coordinating complex and risky situations supporting service users and their families while they wait for other professionals to mobilise support and resources – such as providing beds or ambulance conveyance. In some areas, it is becoming increasingly hard to provide the statutory service prescribed by the Mental Health Act. This may lead to delays for assessments, an inability to find an appropriate bed for someone detained under the act or a lack of community alternatives.
In a recent Care Quality Commission briefing on the rise in the use of the Mental Health Act, they found that between 2005/06 and 2015/16, uses of the act have increased by 40 per cent to 63,622 sections per year. Most of these sections, plus the 58,920 short-term holding powers, will have needed the involvement of an AMHP at some stage in the process. AMHPs also act as Best Interest Assessors locally for the Deprivation of Liberty Safeguards (now Liberty Protection Safeguards), a duty that has increased significantly since 2014.
Suicide prevention is a public health priority for local government and every council has a suicide prevention plan in place. Councils are already working closely with schools, railway operators, businesses, hospitals and the police to prevent suicide and help those affected by it.
The Samaritans found in their evaluation of local authorities’ suicide prevention plans that there is a clear commitment to collaborative working at local level, made possible by strong leadership from Public Health teams and other local agencies, and there are a wide range of actions being delivered.
This work is taking place in the context of cuts to local public health budgets and cuts to provision fundamental to good suicide prevention, such as substance misuse services, and wider community services. There is an ever stretching of thin resources. Their report shows that councils and multi-agency groups are working hard with what they have, to try and reduce the rates of suicide and self-harm in their communities. Multi-agency partnership working is crucial in this context. Many of the resources required to effect change do not sit within local public health budgets and much of the activity taking place is delivered by other actors, including health services and the voluntary sector.
Children and young people
Swift and timely access to the right support is essential when a young person is in crisis, which is why 24/7 mental health crisis support is so valuable. There should also be a range of local support for children that can prevent them reaching crisis point, such as crisis centres or ‘Havens’. The staff who can provide the support at crisis points need to be well skilled and equipped to cope with the scenarios presented to them as well as manage any risk.
Training practitioners to know the right interventions is key in supporting children who may be in crisis. This should enable them to manage risk, and recognise when a crisis is presented, or when the situation can be best managed by the team that knows the child and young person best. As a child or young person is coming out of a crisis, they should be supported by a trusted adult, for example, a youth worker who can provide long term support to that child or young person. This can prevent a return to crisis situations.
Hospitals also need to ensure children are effectively and safely discharged into the community where there is a good support package in place that ensures home treatment or outreach where required. Practitioners who are involved in the child’s care need to be informed of crisis situations, for example, the hospital informing the school if the young person has been in hospital or another crisis setting.
Data and insight can be integral in informing local areas, commissioners and public health teams in understanding if there are patterns of behaviours from children in crisis. This can inform intervention responses, for example, if there are patterns around self-harm in a particular area or suicide attempts.
Children in crisis may present in a range of different environments and all partners need to be able to support them. A reduction in health provided acute care beds has resulted in increased pressure on other parts of the system, such as the council. As set out in the LGA response to the Care Review we believe it missed an opportunity to clearly set out the role of health in supporting children in crisis, particularly children in care. We would have also liked to see consideration of the role of health in supporting placements for children with complex or challenging needs. Reductions in inpatient mental health beds are putting additional pressure on children’s social care (as acknowledged later by the report) and helping to drive the use of unregulated placements as councils struggle to find suitable homes for these young people. Health can and should play a key role in delivering appropriate homes for children in care and we urge government to consider this carefully in its response to the review.
There is an opportunity to look innovatively at what can be done to support children in care within a joined-up system, particularly reflecting on the opportunities presented by integrated care. This could include a replication of the no wrong door model which can ensure that wherever a child presents in crisis, they are able to access the right support.