Children and young people’s mental health: An independent review into policy success and challenges over the last decade

First launched in 2009, the Healthy Child programme is an evidence-informed, universal programme for children aged 0-19 and provides the bedrock for health improvement, public health and supporting families (UK Health Security Agency, 2021). The programme aims to bring together health, education and other key partners to deliver an effective programme for prevention and support. It is led by health visitors and school nurses, who work in partnership with a range of professionals to support children and families. 

To support the delivery of the programme, high impact areas have been identified where health visitors and school nurses have the highest impact on the health and wellbeing of children, families and communities. Supporting resilience and wellbeing of children and young people has been identified as a high impact area for school nurses.  

A commitment has been made over the next few years to ensure the programme is current both in terms of evidence and context. As part of the modernisation, OHID committed to extending the programme to include pre-conceptual care and to extend from 19 to 24 years of age for those children with a statutory requirement (Public Health England, 2021). This includes those in the care system and with additional health needs or a disability.

First launched in 2017 in response to the Five Year Forward View for Mental Health, the Prevention Concordat for Better Mental Health aims to facilitate local and national action around preventing mental health problems and promoting good mental health. The Concordat promotes evidence-based planning and commissioning to reduce health inequalities and is intended to provide a focus for cross-sector action to increase the adoption of public mental health approaches across a range of partners including local authorities, ICSs, social care, the voluntary and community sector (VCS), educational settings and employers (Office for Health Improvement and Disparities, 2023).

In 2019, the Department of Health and Social Care (DHSC) and OHID launched a new campaign called Every Mind Matters. The campaign seeks to empower people to look after their own mental health and is supported by an online platform with free resources and tools people can use (Department of Health and Social Care & Office of Health Disparities and Improvement, 2021). Following its successful launch, DHSC developed further content and material aimed at parents, carers and trusted adults to help them support the wellbeing of their children and young people. The Mental Health Policy Research Unit has been commissioned to lead an evaluation of the programme. Findings from the evaluation showed there were small improvements in knowledge of management of stress, depression, and anxiety, help seeking self-efficacy, stigma related to mental health problems and mental health vigilance (Hahn et al., 2022).

Analysis by the Health Foundation shows that the Public Health Grant has been cut by 26 per cent on a real terms per person basis since 2015/16 (Finch, 2023). The 2021 Spending Review committed to maintain the Public Health Grant in real terms until 2024/25; however, higher than expected inflation means it was lower in real terms in 2022/23 and it is now expected to remain broadly constant in real terms by 2024/25 (ibid).

There have been concerns that cuts to the Public Health Grant could lead to essential services for children and young people, such as school nurses, being cut. Further analysis estimates that spending by local authorities on children’s services for those aged 5-19 has seen a 20 per cent reduction and services for children aged 0-5 has seen a 19 per cent reduction since 2015/16. (ibid). Cuts to the Grant have also been found to be greater in more deprived areas. For example, in Blackpool, ranked as the most deprived upper tier local authority in England, the per person cut to allocations is the largest at £33 per person, compared to £10 per person in Surrey.

Children and young people’s public health nurses, including health visitors and school nurses, have a key role in delivering the Healthy Child Programme. School nurses in particular have been identified as the single biggest workforce trained and skilled to deliver public health interventions for schools (Local Government Association, 2022). However, there have been concerns about the decline in the number of school nurses, with the Royal College of Nursing reporting a loss of 30 per cent in the school nursing workforce between 2010-18 (SAPHNA, 2021). These services have also experienced considerable cuts as a result of reductions in the Public Health Grant. Some local authorities, as part of managing pressures on their budgets, have sought reductions in the cost of contracts to deliver these services, which has resulted in fewer school nurses being commissioned (ibid).

Despite its crucial role in identifying needs at an early stage, health visiting is also an area that has seen reductions in its workforce. In 2011, the Government launched the Health Visitor Implementation Plan to deliver on its commitment to increase the number of health visitors by 4,200 by 2015 and to create a transformed health visiting service providing improved outcomes for children and families (Department of Health, 2011). The Health Visitor Implementation Plan was in place between 2011-15 to support these aims and set out the full range of services that families will be able to expect from health visitors. 

However, evidence shows there has been a steady decline in the number of health visitors since 2015. Data published on the health visiting workforce in 2023 shows that health visiting numbers have decreased by almost 40 per cent since 2015 (Institute of Health Visiting, 2023). What is more, the number of health visitors is now well below the figures which triggered the Health Visitor Implementation Plan in 2011. In January 2023 there were 6,893 full time equivalent (FTE) health visitors, compared to 7,849 FTE in 2011 (ibid). It has been highlighted that a reduction in health visitors within a local area increases the risk of families falling under the radar (First 1001 Days Movement, 2022).

Local systems:

• ICBs and ICPs should work with local partners, including local authorities, 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.
• Local authorities should develop a Joint Strategic Needs Assessment on children and young people’s mental health and wellbeing, in order to better understand and respond to children and young people’s mental health and wellbeing needs.

National government:

• The Office for Health Improvement and Disparities should develop a framework for addressing the social determinants of health and should produce local guidance to support the implementation of this. 
• The Government should restore the Public Health Grant to pre-2015 levels and above. This should be accompanied by the development of a Prevention Transformation in order to ensure a specific focus on preventative support. 
• 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.

Whilst early intervention has been an ambition of many strategies and policies, there has been no specific workstream to ensure early intervention support has been effectively implemented across local areas and progress within this area has been lacking.

A lack of clear policy direction at a national level has subsequently translated into confusion at a local level as to which agencies should be providing early intervention services. Responsibility for the provision of early intervention services is shared between the NHS, schools, local authorities and the voluntary sector. Yet, there is a significant lack of accountability and transparency across health partners and local authorities as to who is responsible for ensuring this provision is available for all young people. In the Health and Social Care Select Committee’s 2014 report on children’s mental health, commissioners of CYPMHS giving evidence described the difficulties they faced in prioritising early intervention services when services of this kind are not considered as core business, particularly in times of financial constraints (Health Select Committee, 2014).  What is more, General Practitioners (GPs) are a frontline service for young people struggling with their mental health and are often the first port of call for advice and support. However, evidence highlights that, in the face of overstretched specialist services, GPs often do not know where to signpost to for further support leaving some to hold cases themselves (YoungMinds & The Children’s Society, 2021). Despite the crucial role that GPs play in children and young people’s mental health, they have been overlooked in policy development in this area.

Accountability arrangements are further confused by a lack of a dedicated funding stream for local areas to provide services of this kind. Whilst there is a better understanding of how much is spent on specialist services, very little national data is collected on what is spent on early intervention services. In their 2019 report on early access to mental health support, the Office of the Children’s Commissioner estimated that around £226 million was spent on low-level mental health services in the financial year 2018/19 (Children’s Commissioner, 2019). It was found that the split between spending on these services between local authorities and the NHS was fairly equal, with around half of this funding coming from NHS sources and half from local authorities. About three-fifths of local authority spending is through children’s services and two-fifths through public health (ibid). However, overall spending on early support per child has fallen in real terms in around three-fifths of local areas (ibid).

Following reductions in funding being provided to local authorities, many have had to make challenging decisions to reduce their early intervention spend. The Children’s Commissioners’ report noted that local authority spending in this area has fallen in real terms in a number of areas, likely driven by the reductions in children’s services and public health budgets (ibid). A Pro Bono Economics report also found that local authority spending on early intervention support services (including mental health) declined by 48 per cent between 2010/11 and 2019/20, whilst expenditure on late interventions has increased by 34 per cent (Williams & Franklin, 2021). As a result, the proportion of children’s services budgets now being spent on preventative early interventions has declined from more than a third of total expenditure in 2010/11 to less than a fifth in 2019/20 (Williams, et al. 2021). Significant variations have also been found in spending across regions. In the financial year 2018/19, local authority spend per child was highest in London where it was £17.88 per child, and lowest in the East of England at £5.32 per child (Children’s Commissioner, 2019).

In addition to this, the most deprived local authorities have experienced the most significant declines in early intervention spending. Early intervention spending in the most deprived Local Authorities has decreased from £290 per young person in 2010/11 to £118 per young person in 2019/20 – a 59 per cent reduction (Williams & Franklin, 2021). Findings from a review of the children’s mental health system by the National Audit Office demonstrated a need to rebalance current and future investment from late intervention, crisis, and urgent care to early intervention provision in local communities (National Audit Office, 2018).

Local authorities:

Local authorities should develop a local offer, in partnership with Integrated Care Systems, for infant, children and young people’s mental health, which outlines the support available for children’s mental health in the local area. This should be aligned with the SEND local offer where appropriate.

National government:

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 Nest, Southwark: The Nest is an open-access, mental health support service for young people based in Peckham, delivered by Groundwork London on behalf of Southwark council. The Nest provides support at the point of need, without requiring a professional referral, and offers early intervention and prevention for emotional issues and low-level mental health concerns such as worries, anxieties and stress.

42^nd Street, Manchester: 42nd Street is an early support hub that works with young people aged 13-25 years across Greater Manchester who present with mental health problems. Their activities include counselling and psychotherapy; 1-1 mental health support; group work; a youth leadership programme; mental health promotion work; and youth work activities.

In 2011, the No Health without Mental Health strategy intended to show the commitment to the Government’s aim of achieving parity of esteem and set out six shared objectives to improve mental health and wellbeing (Department of Health and Social Care, 2011). The strategy recognised the importance of early intervention, particularly for vulnerable children and young people, and committed to expanding provision for children and young people.

The Closing the Gap: Priorities for Essential Change in Mental Health Strategy followed in 2014 and set out the short-term actions and changes needed to support the long-term vision set out in No Health Without Mental Health’ (Department of Health, 2014). This identified 25 aspects of mental health care and support where action was required, and included ambitions to increase access to mental health services, to better integrate physical and mental care, and to act early to prevent mental health problems from occurring. For the first time, this strategy introduced waiting time targets for mental health services.

In 2014, the Department of Health and NHS England established the Children and Young People’s Mental Health and Wellbeing Taskforce, bringing together experts on children and young people’s mental health to explore how to improve the way children’s mental health services were organised, commissioned and provided, and how to make it easier for young people to access help and support. The Taskforce reported on their findings in the Future in Mind strategy, which set out ambitions for improving mental health care for children and young people over the next five years (2015-2020). 

Future in Mind established a clear national ambition to make it easier for children and young people to access high quality mental health care when they need it (Department of Health & NHS England, 2015). It described an integrated whole system approach, setting out an expectation for the NHS, public health, the VCS, local authorities, education, and youth justice sectors to work together to achieve its aims. Future in Mind focused on five key themes: promoting resilience, prevention and early intervention, improving access to effective support - a system without tiers, care for the most vulnerable, accountability and transparency and developing the workforce (ibid). To support the delivery of Future in Mind, the Government made £1.25 billion available to be spent over the five year period. 

In order to incentivise local leadership and ownership, the strategy introduced Local Transformation Plans for children and young people’s mental health and wellbeing. Clinical Commissioning Groups were expected to work with local partners to develop local plans to transform the local offer to improve children and young people’s mental health and wellbeing, aligning with overarching principles and ambitions set out in Future in Mind. The plans were intended to cover the full spectrum of service provision and address the needs of children and young people aged 0 to 25.

The Five Year Forward View for Mental Health was published in 2016 and built on the recommendations set out in Future in Mind. It set out 58 recommendations for the Government and NHS England to implement by 2020, including targets for children and young people such as:

• At least 70,000 children and young people each year will receive evidence-based treatment - representing an increase in access to NHS-funded community services to meet the needs of at least 35 per cent of those with diagnosable mental health conditions. 
• By 2020/21, evidence-based community eating disorder services for children and young people will be in place in all areas, ensuring that 95 per cent of children in need receive treatment within one week for urgent cases and within four weeks for routine cases.
• CCGs to commission 24/7 crisis resolution and liaison mental health services which are appropriate for children and young people (NHS England, 2016).

In 2019, NHS England published their long-term plan, which set out their priorities for healthcare over the next 10 years. The Long Term Plan reinforced the importance of preventative action, early intervention, and of ensuring prompt access to help for children and young people. At the centre of this was the commitment that funding for children and young people’s mental health services will grow faster than both overall NHS funding and total mental health spending (NHS England, 2019). In total, the plan committed at least £2.3 billion a year for mental health services by 2023/24.

The plan pledged to continue expanding access to NHS funded mental health services, so that by 2023/24 at least an additional 345,000 children and young people aged 0-25 would be able to access support (ibid). The National Audit Office estimates that this equates to around two-fifths of young people aged 0-17 with a diagnosable need accessing services (National Audit Office, 2023). The plan also reaffirmed commitments to improving access to crisis services for children and young people, to embedding mental health support in schools, and to boosting investment in children and young people’s eating disorder services (NHS England, 2019). In addition, the Plan committed to developing a new approach to young adult mental health services for young people aged 18-25 (ibid). This includes creating a comprehensive offer for 0-25 year olds, which will deliver an integrated approach across health, social care, education and the voluntary sector. This builds on the commitment set out in the Transforming Children and Young People’s Mental Health Provision Green Paper, which stated it would set up partnerships to look at the needs of 16-25 year olds (Department of Health and Social Care & Department for Education, 2018).

Finally, the Plan set out commitments to expand and embed social prescribing and community-based approaches across the NHS. This includes introducing social prescribing link workers into primary care networks so that every person in England can access a social prescribing service through their GP practice, starting with 1,000 new social prescribing link workers in place by 2020/21, and a goal that at least 900,000 people will be referred to social prescribing by 2023/24.

To tackle long waits for care, the Transforming Children and Young People’s Mental Health Provision Green Paper committed to piloting a four week waiting time standard for access to specialist services. The pilots began in 2019 and sites were initially asked to focus on reporting the initiatives they were using to tackle long waiting times, and what could be measured to support a clinically meaningful response to children and young people in need of mental healthcare (NHS England, n.d. a). They ran until the end of 2020/21. 

Following the pilots, NHS England published their Mental Health Clinically Led Review of Standards which set out recommendations on new mental health standards. For children and young people presenting to non-urgent, community-based mental health services, it was proposed that they should start to receive help within four weeks from request to service (NHS England, 2021). A public consultation on these standards was also published. Further information is yet to be published on implementation of these standards as well as the results from the initial pilots. Since 2015, access and waiting time standards have been in place for children and young people’s eating disorder services. The standard requires services to ensure that, by 2020/21, 95 per cent of children and young people in need begin treatment within one week for urgent cases and four weeks for non-urgent cases.

The Stepping Forward Strategy was published in 2017 and set out the workforce development required to deliver the Five Year Forward View Commitments. The strategy set an aim to increase the children and young people’s mental health workforce by 4,500 full time equivalent staff by 2020-21, against a baseline of 11,300 full staff (National Audit Office, 2018). Building on this, the NHS Long-Term Plan further noted that to deliver its commitments, the workforce would need to increase by more than 27,000 people, across a range of specialist roles, to continue improving access to services and outcomes for children and young people (Health Education England, 2021).

In 2022, the Government committed to developing a ten-year plan for mental health in which children and young people would form an integral part (Department of Health and Social Care, 2023). This plan was to cover all aspects of the mental health system from prevention and early intervention to crisis care. The Government has recently announced that this plan will now be rolled into a new Major Conditions Strategy which will cover mental health alongside other major conditions such as cancer and dementia (Barclay, 2023). The strategy is expected to be published in summer 2023.

The cross-government suicide prevention strategy was first published in 2012 and set out two overall objectives: to reduce the suicide rate in England and to better support those bereaved or affected by suicide (Department of Health and Social Care, 2012). The strategy states that children and young people have ‘an important place’ in the strategy and highlights the role that schools, social care, the youth justice system and charities have in contributing to suicide prevention among children and young people (ibid).

The strategy stated that by April 2013, suicide prevention would become an integral part of local authorities’ new responsibilities for leading on local public health and health improvement (Balogun & Garratt, 2022). Guidance for local authorities on developing multi-agency suicide prevention plans was published in 2014. The guidance states that local areas should aim to tackle all seven areas of action identified in national strategy, as well as priorities for action based on local data. It was reported that by 2016, 95 per cent of local authorities had local suicide prevention plans in place or in development (Health Select Committee, 2017). Following the announcement of the Major Conditions Strategy, the Government has committed to taking forward a separate Suicide Prevention Strategy. No further detail has yet been announced on what the strategy will cover or when it is due to be published.

Whilst some progress has been made in improving access, many children and young people still face high access thresholds for support and rejected referrals, followed by long waits if they do get accepted into services. As a result, many children and young people do not get the timely mental health support they need. A report by the Children’s Commissioner for England finds that of the 1.4 million children estimated to have a mental health problem, less than half (48 per cent) received at least one contact with CYPMHS in 2021/22 (Children’s Commissioner, 2023).

The Covid-19 pandemic has also created additional pressures, and there are concerns that existing NHS service capacity and infrastructure may not be able to cope with growing mental health needs. Findings from the Children’s Commissioner show that the percentage of children who had their mental health referrals closed without accessing treatment has increased for the first time since 2017-18. In 2021/22, 32 per cent (equivalent to 238,000 children in England) of those referred to mental health services did not receive treatment (Children’s Commissioner, 2023). Whilst welcome efforts have been made to introduce a waiting time standard for specialist services for children and young people, the progress made on implementing this is unclear, and the Government has not set out how it will support trusts to achieve this target. What is more, whilst the 95 per cent target for eating disorder services has been described as the right one, this target has never been met by NHS (National Audit Office, 2023). Performance was improving before the pandemic but deteriorated during it, in the face of particularly large increases in referrals and activity (ibid).

In the meantime, estimates show that waiting times for NHS CYPMHS have increased by two-thirds in two years in England, meaning that children are waiting on average 21 weeks for a first appointment (Smith, 2023). High thresholds for support and long waiting times can leave many children without the support they need and can increase the risk of them reaching crisis point. A survey of almost 14,000 young people aged under 25 by YoungMinds found that more than one in four young people (26 per cent) who responded to the survey said they had tried to take their own life as a result of having to wait for mental health support (YoungMinds, 2022). Additionally, more than half of those (58 per cent) who took part in the survey said their mental health got worse while they were waiting for support (ibid).

The commitments pledged by the Government have been criticised for not being ambitious enough in improving access. For example, an independent Expert Panel of the Health and Social Care Select Committee evaluated progress against targets set out in the Five Year Forward View for Mental Health and found that whilst progress against the target to expand access to an additional 70,000 children and young people has been good, the target was not ambitious enough to start with (Health and Social Care Select Committee, 2021a). It is positive to see progress made in attempting to meet targets, yet there is still not sufficient support to meet demand and a treatment gap remains for children and young people.

A report by the Health and Social Care Committee on children and young people’s mental health further noted that even after ambitions for access and waiting times are met, far too many children and young people will be unable to access the care they need (Health and Social Care Select Committee, 2021b). The Committee concluded that the combination of unmet need prior to the pandemic and additional needs created by the pandemic means that the scale and speed of improvements planned are not enough and that services are at risk of going backwards (ibid).

Future in Mind recognised the challenges that certain groups of children and young people face in accessing specialist services and set out commitments to dismantle the barriers to access and improve care for the most vulnerable (Department of Health & NHS England, 2015). Whilst this was a welcome commitment, the National Audit Office commented in its 2018 report on children’s mental health services that the Government did not set out explicit objectives to achieve this making it particularly challenging to track progress (National Audit Office, 2018).

In its 2018 review of NHS CYPMHS, the Care Quality Commission (CQC) also found that in many areas, services were not responsive to the needs of different groups of children and young people: these included children with autism spectrum disorder or attention hyperactivity disorder, LGBTQ+ young people, and those from racialised communities (Care Quality Commission, 2018). A further review conducted by the Education Policy Institute found that local commissioners and providers of mental health support services often fail to engage with the most vulnerable children and young people, resulting in patchy provision at a local level (Crenna-Jennings & Hutchinson, 2020). The research also highlighted how children with complex, less well-understood difficulties that do not fit clearly into diagnostic boxes are at risk of not being able to access NHS specialist support through NHS CYPMHS (ibid).

A 2016 Education Committee inquiry into the mental health and wellbeing of looked-after children found that provision for this group is poor in many parts of the country. The emotional needs of many children in care were not being properly identified which contributed to delays in accessing much needed support (Education Select Committee, 2016). The inquiry also revealed that there was too often a lack of coordination between health, education and social services locally which left children in care at risk of falling through the cracks of services. The committee further noted that gaps in data relating to this group was a challenge and that too often their views were overlooked during care planning processes (ibid).

There have been concerns that the Government has not specified what achieving full parity of esteem would mean in practice, making it challenging to say how far improvement programmes achieve this goal and what more is needed (National Audit Office, 2023). Whilst some positive steps have been made, many children and young people still struggle to access mental health services or face long waits for treatment. 

Challenges have also been identified with accountability arrangements in ensuring that strategies and plans have been implemented and delivered on. For example, the National Audit Office found that no cross-government accountability arrangements were put in place to ensure Future in Mind was delivered as intended, and national oversight of local transformation plans was found to be weak (National Audit Office, 2018). In addition, while some progress has been made in recent years, there remain ongoing challenges relating to data on need, access and outcomes. The challenges include issues around data gaps as well as quality. This hinders our understanding of the programme’s effectiveness.

Similar concerns have been raised in relation to the Suicide Prevention Strategy (2012). An inquiry by the Health Select Committee on suicide prevention in 2017 reported concerns with the implementation of the strategy, stating that there has been a failure to translate the suicide prevention strategy into actual improvements, and implementation has been highly variable and subject to insufficient oversight (Health Select Committee, 2017).

What is more, current children and young people’s mental health policy sits between various government departments and executive agencies including Department of Health and Social Care, Department of Education, and NHS England. There is no cross-governmental group to oversee the joined-up delivery of these programmes and therefore opportunities to strengthen the offer to children and their families may be overlooked.

Mental health care for children and young people has been underfunded for many years. Prior to the NHS Long Term Plan, for example, the National Audit Office stated that the Government had not set out or costed what must be done to realise aspirations set out in the Five Year Forward View for Mental Health and Future in Mind (National Audit Office, 2018).The National Audit Office further highlighted that NHS England cannot be confident that the additional £1.4 billion for Future in Mind was spent as intended because NHS England did not have accountability arrangements to ensure CCGs increased spending was in line with intentions (ibid).

The NHS Long Term Plan sought to address this disparity by investing in children and young people’s mental health services at a rate faster than both overall NHS funding and total mental health spending. Positively, since 2018-19, the share of mental health services funding going to children and young people’s services has increased (National Audit Office, 2023). But it is unclear if this means that spend is increasing at a faster rate than overall NHS and total mental health spending. The Mental Health Investment Standard also seeks to increase the level of investment in mental health services in England, including children and young people’s services. The Standard ensures that local health commissioners increase investment in mental health services at a higher percentage than their overall rise in allocation from NHS England each year.

Large variations in local expenditure on children and young people’s mental health services still exist. Spend per child in the population varies from as low as £34 to a high of £141 (Children’s Commissioner, 2023). Analysis completed by Centre for Mental Health shows a correlation between spend and outcomes: those CCGs with the best outcomes typically spend more than average per person and those with the worst outcomes usually spend less than average (O’Shea & McHayle, 2021). Postcode lotteries – where spending is dependent on location – therefore result in differential outcomes.

Positively, progress has been made in growing the children and young people’s mental health workforce. The National Audit Office found a high growth in workforce numbers for children and young people’s mental health services (including non-NHS staff): these grew by 70 per cent between 2016 and 2021, higher than the estimated requirement of 55 per cent (National Audit Office, 2023). However, the workforce continues to be the largest barrier to increasing access to mental health provision for children and young people (Health and Social Care Select Committee, 2021a). For example, evidence from the Royal College of Psychiatrists shows that, while Health Education England estimated children and young people’s mental health services would need to recruit an extra 100 consultant psychiatrists by March 2021 in order to expand access, the actual number of psychiatrists has decreased in this time (ibid).

National government:

• The Government should develop a comprehensive, cross-government strategy on mental health and wellbeing. This should be supported by a clear, implementation framework and a cross-government oversight group should be established to oversee implementation.
• To address the shortfalls in workforce, the Government should commit to developing an integrated workforce strategy for children and young people’s mental health.
• The Government should improve the quality and availability of data on children and young people’s mental health, including data on outcomes.

NHS England:

• NHS England must deliver on its commitment to establish a comprehensive mental health pathway for children and young people aged 0-25, which should include the increased provision of parent infant specialist teams.
• NHS England should carry out a review of the progress made to date on implementing the NHS Long Term Plan and set out a successor plan to cover the following five years, 2024-29.

Future in Mind emphasised the need for improved care for children and young people in crisis, so they are treated in the right place, at the right time and as close to home as possible (Department of Health & NHS England, 2015). The plan set out commitments to ensure that no young person under the age of 18 is detained in a police cell as a place of safety, and to implement clear evidence-based pathways for community-based care to avoid unnecessary admissions to inpatient care (ibid).

The Five Year Forward View for Mental Health further committed that, by 2020/21, inpatient stays for children and young people would only take place where clinically appropriate, would have the minimum possible length of stay, and would be as close to home as possible to avoid inappropriate out of area placements – while inappropriate use of beds in paediatric and adult wards would be eliminated (NHS England, 2016). It also set out plans for a New Care Model for Tier 4 CYPMHS and some adult inpatient services. Budgets were delegated to local systems with lead providers taking responsibility. An aim of this programme, which was expanded in the NHS Long Term Plan into the renamed ‘provider collaboratives’, was to end the perverse incentive for local systems to shift costs to NHS England following NHSE becoming the commissioner of Tier 4 care (O’Shea, 2020b).

The Mental Health Act 1983 provides a legal framework to authorise the detention for assessment and compulsory treatment of people who have a mental health disorder and are considered a risk of harm to themselves or others and applies to all children and young people under the age of 18. The Government committed to modernising the Act, following the Independent Review of the Mental Health Act in 2018, which found that the Act does not work as well as it should for patients (Department of Health and Social Care, 2021a).

The Independent Review proposed a range of changes, which were widely accepted by the Government in their Reforming the Mental Health Act White Paper (Department of Health and Social Care, 2021a). This included proposals to strengthen the rights of patients to have a greater say in their care and treatment, including children and young people aged under 18. The Government’s reforms also aim to reduce the disproportionate use of the Act against racialised communities and proposes to change the definition of a mental disorder so no one with learning disabilities and autism will be detained solely because they have learning disabilities or autism (ibid). A draft Mental Health Bill has been published, which has undergone pre-legislative scrutiny. It is currently unclear when a Mental Health Bill will enter Parliament.

The rapid review into data on mental health inpatient settings was launched in February 2023 in response to reports of abuse taking place in inpatient settings. The purpose of the review is to produce recommendations to improve the way data and information is used in relation to patient safety in mental health inpatient care settings and pathways (Department of Health and Social Care, 2023b). The review is due to publish its final report and recommendations in May 2023.

Whilst targets set within Future in Mind and the Five Year Forward View for Mental Health around ending the use of inappropriate placements are a step in the right direction, far too many children continue to be admitted to inpatient units far from home, without adequate understanding of their rights, and subject to restrictive interventions and inappropriate care (Health and Social Care Select Committee, 2021a). NHS data shows that for the past three years over 1,000 children a year have been placed ‘out of area’, most of whom were detained under the Mental Health Act (CYPMHC, 2021).

There is also a lack of research about children’s experiences of being detained under the Mental Health Act. Where we do have insight, we know children and young people’s experiences of inpatient care are not consistently good. Recent insights gathered by the Children’s Commissioner for England show how children and young people can find inpatient settings frightening places to be, separated from their friends and families, and often seeing and experiencing high levels of restraint (Children’s Commissioner, 2023).

What is more, around one-third of children in mental health wards are there informally. In their 2020 report Who are they? Where are they? The Children’s Commissioner for England explored what life was like for children admitted informally and how their experiences differed to those admitted under the Mental Health Act (Children’s Commissioner, 2020). The report identified a risk that children admitted informally can end up de-facto detained without all the safeguards that children formally detained have – such as the right to have an Independent Mental Health Advocate, to be provided with information about their rights, and to have complaints investigated by the CQC (ibid).

Evidence suggests that young people from racialised communities are less likely to access support from community services but are more likely to be detained under the Mental Health Act. An article by The Independent highlighted that Black and mixed-race children accounted for 36 per cent of young people detained in acute mental health services despite making up 11 per cent of the population (based on unpublished data from NHS Benchmarking) (Centre for Mental Health, 2022). Conversely, young Black people make up just 5 per cent of those accessing community-based child and adolescent mental health services (ibid). What is more, findings from the Children’s Commissioner showed that Black children are less likely to be admitted informally than their white peers – around one in 10 of these children are admitted informally compared to just over one in three white children – but are more likely to be held in secure wards or Psychiatric Intensive Care Units (Children’s Commissioner, 2020).

A key aim of the reforms to the Mental Health Act is to reduce the disproportionate number of individuals from racialised communities subject to compulsory detention and treatment. Whilst this aim is welcome, concerns have been expressed that action to address racial inequalities has been lost in the proposed reforms.

Following the Independent Review of the Mental Health Act, NHS England has established the Patient and Carer Race Equality Framework (PCREF). This framework is intended to support services to provide culturally appropriate care and to help mental health trusts work with those from racialised communities in order to address racial disparities in care. This forms part of wider work being undertaken by NHSE to implement their Advancing Mental Health Equalities Strategy (published in 2020) which seeks to take steps to address inequalities in access to mental health care.

There are significant gaps in available data on children in mental health hospitals, and the data that does exist can often be incomplete and difficult to access. It is only since January 2016 that figures showing the number of children aged under 18 admitted to hospital under the Mental Health Act have been published, and there is still no published data on the total number of children admitted to Tier 4 units as informal patients. As a result, it can be difficult to monitor progress on commitments made and whether children’s rights are being upheld within these settings.

Another group of children who currently fall between the gaps in data are children for whom it is deemed that a mental health admission would not be appropriate, but for whom no children’s home that can provide the necessary high level of both security and therapeutic intervention can be found (Children’s Commissioner, 2023). These children end up being deprived of their liberty under the inherent jurisdiction of the High Court. This is used when no existing piece of legislation allows for a child to be deprived of liberty, but it is judged necessary to keep them safe.

There is no official data on how many of these children there are, where they are living, or how long they are there for (Children’s Commissioner, 2023). However, there is evidence to suggest that the numbers of children and young people in this position are rising. In 2020/21, 579 applications were made under the inherent jurisdiction in England – a 462% increase from 2017/18 (Roe, 2022). Information about the number of children deprived of their liberty under the mental Capacity Act is also not regularly published (ibid).

• The Government should bring forward the Mental Health Bill to reform the Mental Health Act 1983 at the earliest opportunity.
• The Mental Health Bill should strengthen the requirement for under 16s not to be placed in adult wards. The duty to notify the local authority when a child or young person is placed in an adult ward or out of area, or if an admission lasts more than 28 days, should also be set out in primary legislation.
• The Government should ensure that national data is regularly collected and published on children and young people as mental health inpatients, including information on experiences of care. This should include a detailed breakdown of the number of detained and informal patients. Information about the number of children deprived of their liberty in different settings and via different legislative routes should also be collected and published by different government bodies.
• Following the Rapid Review of Inpatient Care, the Government should set out an action plan on improving care and patient experience within inpatient settings. This should include actions to reduce the use of inappropriate placements for children and young people.

In order to support improved relationships between schools and specialist services, Future in Mind recommended the establishment of a named point of contact within specialist NHS CYPMHS and a named lead within each school, who would be responsible for mental health and for developing closer relationships with NHS CYPMHS (Department of Health & NHS England, 2015). The report also recommended the development of a joint training programme for named school leads and NHS CYPMHS.

In response, NHS England and the Department for Education jointly launched the Mental Health Services and Schools Link pilots. The pilot funded a total of 22 local areas, incorporating 27 CCGs and 255 schools, to establish named lead contacts within NHS CYPMHS and schools (Day et al., 2017) Led by local authorities and CCGs, the overall aim of the pilots was to test the extent to which joint professional working between schools and NHS CYPMHS can improve local knowledge and identification of mental health issues and improve the quality and timeliness of referrals to specialist services. The 2018 government response to the consultation on the Transforming Children and Young People’s Mental Health Provision Green Paper further committed to rolling out the Link programme nationally, with national roll out commencing in 2019 delivered by the Anna Freud Centre (NHS England, n.d. d).

An independent evaluation of both the pilots and the national roll out found that the programme had considerable success in strengthening communication and joint working arrangements between schools and NHS CYPMHS (Day et al., 2017). In particular, improvements were noted in communication between schools and NHS CYPMHS, the understanding of referral routes to specialist mental health services, and knowledge and awareness of mental health issues affecting children and young people among school lead contacts. In May 2021, the Link Programme was relaunched as an offer of free, bespoke facilitation for local strategic leaders, to be delivered completely online. This intended to encourage local stakeholders to come together at a strategic level to identify and work towards joint working priorities and goals that will lead to improvements in partnership working on mental health and wellbeing. The programme concluded in March 2022 (NHS England, n.d. d).

A whole school approach involves the universal and continuous promotion of good mental health across all parts of the school including the curriculum, the school leadership and staff-student relationships (Health and Social Care Select Committee, 2021a). The Department for Education has identified a whole school approach as an important tool in promoting good mental health in children and young people (HM Government, 2021).

In 2015, Public Health England issued guidance for schools and colleges describing the eight principles of a whole school or college approach to promoting mental health and wellbeing – the guidance was updated in 2021. A whole school and college approach has since been the foundation for the Government’s work on improving mental health support in education settings. However, whilst education settings are encouraged to implement such an approach, it is not a mandatory requirement for schools or colleges and therefore not resourced by the Department. 

The Transforming Children and Young People’s Mental Health Provision: A Green Paper was published in 2018 and set out a vision for a whole school and college approach to mental health and wellbeing through increasing the availability of early intervention and prevention support in schools and colleges (Department of Health and Social Care & Department for Education, 2018). The Green Paper set out three key proposals:

• To incentivise and support all schools and colleges to identify and train a Designated Senior Lead for mental health 
• To fund new Mental Health Support Teams (MHSTs), which will be supervised by NHS children and young people’s mental health staff
• To pilot a four week waiting time for access to specialist NHS children and young people’s mental health services. 

The Government made £3 million of funding available to implement these proposals. The Green Paper stated that these proposals would only be rolled out to at least a fifth to a quarter of the country by the end of 2022/23, and that precise rollout would be determined by future funding.

The delivery of MHSTs in education settings is led by NHS England, with support from the Department for Education. MHSTs support the mental health needs of children and young people in primary, secondary and further education (ages five to 18) and use an evidence-based approach to provide early intervention on some mental health and emotional wellbeing issues, such as mild to moderate anxiety (Department for Education, 2022a). MHSTs have three core functions:

• To deliver evidence-based interventions for mild to moderate mental health issues
• Support the senior mental health lead (where established) in each school or college to introduce or develop their whole school or college approach to mental health and wellbeing
• Give timely advice to school and college staff, and liaise with external specialist services, to help children and young people to get the right support and stay in education. 

The Green Paper set out that MHSTs will reach a fifth to a quarter of the country by the end of 2022/23 (Department of Health and Social Care & Department for Education, 2018). The establishment of MHSTs began in 2018 and the number of teams has increased each year. In response to the Covid-19 pandemic, the Government invested an additional £79 million to boost mental health support for children and young people, including increasing the number of MHSTs in schools and colleges (Department of Health and Social Care, 2021b).

In May 2021 the Government announced £9.5 million in grants for schools and colleges to access training to train a senior mental health lead on implementing an effective whole school or college approach to mental health and wellbeing in their setting (Department for Education, 2022). The ambition was for around a third of all state schools and colleges to benefit in 2021/22 as part of its commitment to offer this training to all state schools and colleges by 2025. To support implementation, the Department for Education offered a grant of £1,200 for eligible state funded schools and colleges in England.

Following the Green Paper, the Government announced its intention to ensure that children and young people are taught good physical and mental health as part of the school curriculum (Department for Education, 2018). The Children and Social Work Act 2017 made Relationships Education compulsory for all pupils receiving primary education and Relationships and Sex Education (RSE) compulsory for all pupils receiving secondary education. Health Education was also made mandatory for all schools. In 2019, statutory guidance was issued to schools on the RSHE curriculum and since 2020 this has become a required part of the curriculum. The Department for Education has since announced that it will conduct a review of how the RSHE curriculum is taught in schools, with a consultation expected later this year (BBC, 2023). 

In 2019, Ofsted updated their School Inspection Framework to include a new judgement area on personal development. As part of this judgement area, inspectors will explore the broader development of pupils, including how schools support pupils to develop confidence and resilience so that they can keep mentally healthy.

he Wellbeing for Education Return programme ran from August 2020 to March 2021. It made £8 million available to local authorities in England. The funds were intended to support schools and colleges to address immediate mental health and wellbeing challenges during the pandemic. The programme provided free expert training, and support and resources for school and college staff. This was followed by the Wellbeing for Education Recovery programme, which was launched in May 2021. £7 million was provided to local authorities to support schools and colleges in recovery from the pandemic. 

Education settings have welcomed the additional mental health support provided through the Green Paper provisions and in response to the Covid-19 pandemic, and evaluations have found some positive impacts. In relation to the Wellbeing for Education Return and Recovery programmes, surveys of local authorities found that the funding provided for the programmes had a positive impact in a number of areas. These included: enabling education staff to increase their knowledge and awareness of mental health evidence; support and advice; and improving joint working and local collaboration (Department for Education, 2022).

The early evaluation of the MHST programme also found that positive outcomes were reported by education settings (Ellins et al., 2023). This included staff feeling more confident talking to children about mental health problems, being able to access advice about mental health problems more easily, and having quicker access to support. Improvements in children and young people’s understanding of mental health and wellbeing was widely reported, as were strengthened relationships between education settings, mental health services and other local partners (ibid).

However, the evaluation highlighted how some groups of children and young people continue to fall through the gaps in support. Challenges with defining what was in scope of the ‘mild to moderate’ remit of MHSTs were identified, and as a result concerns were expressed about children and young people falling through the gaps between MHSTs’ remit and the criteria for specialist support (ibid). Onward referrals to specialist services were also noted as a major challenge within the evaluation, with capacity constraints and long waiting times for specialist mental health services being a recurring theme. It was noted that pressure on services following the Covid-19 pandemic was widening the gap between the support offered by MHSTs and meeting the criteria for specialist services.

It has been identified that some groups of children and young people are underserved by MHSTs including children and young people with special educational needs or neurodiversity, those from racialised communities and some religious backgrounds, and children with challenging family or social circumstances (Ellins et al., 2023). The evaluation of MHSTs noted that there were concerns relating to the reach and effectiveness of MHSTs. These issues were attributed to gaps in the initial training programmes for Education Mental Health Practitioners (EMHPs) and the limitations of the type of interventions that EMHPs had been trained to deliver, which were felt to be poorly suited to some groups of children and young people (ibid).

Provisions such as MHSTs and the new senior lead role have been seen to be welcome additional resources to school and colleges. The Government also ensured implementation continued during the pandemic and put in place additional support for schools and colleges through the Wellbeing for Education Return and Recovery programmes.

Positively, the current roll out of MHSTs in schools and colleges surpassed the coverage target set out in the Green Paper a year earlier than planned. By 2021/22, 2.4 million pupils had access to an MHST, equating to 26 per cent of all pupils and learners in England (Department for Education, 2022a). By 2022/23, the Department for Education estimates that that overall coverage will have increased to 36 per cent of all pupils and learners (ibid).

Yet, there have been significant concerns about the implementation and ambition of the Green Paper proposals and the speed at which all areas of the country will have access to this additional support. Findings from Barnardo’s suggest that the current timetable for the roll out of MHSTs leaves around 6.5 million children without access in the medium term, further exacerbating inequality in access to support (Barnardo’s, 2022). Funding for MHSTs beyond 2023/24 is yet to be decided, meaning there is no guarantee on how much further, or how quickly, MHSTs will be expanded (Department of Health and Social Care written answer, 2021). This risks leaving huge numbers of children and young people without this additional support, further fuelling the postcode lottery that already exists for children and young people’s mental health services. 

It has been noted by the Department for Education that local authorities have an important role to play in promoting the take up of senior mental health lead training as part of the local mental health and wellbeing promotion and support offer to schools and colleges (Department for Education, 2022a). Take up of this training across local authorities is variable. Data shows that in five local authorities (3 per cent) fewer than 20 per cent of state-funded schools had completed their applications for the senior mental health lead training grant by March 2022 (ibid). In more than half of local authorities (56 per cent) between 20 per cent and 40 per cent of their state-funded schools had applied for the senior mental health lead training grant (ibid).

It is important to highlight, however, that where schools are part of multi-academy trusts (39% of primary schools and 80 per cent of secondary schools are academies or free schools), this can make it challenging for local authorities to influence take up of this training, due to academies being outside local authorities’ jurisdiction.

As part of the proposals set out in the Green Paper, a grant of £1,200 is available to school and colleges to train a senior mental health lead. However, this is a one-off training opportunity, meaning if the trained staff member leaves the school then this funding cannot be accessed again. Concerns have been highlighted in relation to the retention of Education Mental Health Practitioners (EMHPs) within MHSTs. The evaluation of the MHST programme identified various reasons for poor retention, including the role being seen as a stepping stone to other careers, lack of opportunities for career development, high workloads, and frustrations about the limitations of the role (Ellins et al., 2023). 

• The Department for Education should develop a fully resourced, national implementation programme to support every school, college and university to adopt a whole education approach to mental health and wellbeing.
• The Department for Education and the Department of Health and Social Care should commit to and fund the full national roll out of Mental Health Support Teams across all schools and colleges in England.

• Compass Buzz, North Yorkshire: The Compass Buzz project, which covered 396 schools across North Yorkshire, aimed to improve the resilience and emotional wellbeing of school-aged children and young people by supporting education settings to implement and embed whole school approaches to mental health and wellbeing.
• HeadStart, Hull: HeadStart in Hull is one of six HeadStart programmes being run across England, funded until 2022, by The National Lottery Community Fund. It aimed to explore and test new ways to improve the mental health and wellbeing of young people aged 10 to 16 and prevent serious mental health issues from developing. As part of the programme, policy and practice officers worked with schools to implement a whole school approach across all 97 schools in the Hull local authority area.

The Children and Families Act 2014 introduced wide-ranging reforms to change the way children with SEND are supported, including new duties on local authorities for how services and support are delivered. The reforms aimed: to identify children’s needs earlier; for families to be more involved in decision-making; for education, health and social care services to be better integrated; and for support to remain in place up to the age of 25 where appropriate (National Audit Office, 2019). Under the reforms, local authorities have a statutory responsibility to ensure that individual children, young people and their families receive the support they need.

The reforms also introduced EHCPs (replacing Statements of SEN) and duties on local statutory partners to work together to design and deliver a more coordinated system of support for children, young people and their families. Alongside, key principles were designed to support the participation of children, young people and families in decision making. The SEND Code of Practice was published in 2015 to provide statutory guidance for organisations working with children and young people with special educational needs and disabilities (Department for Education & Department of Health and Social Care 2015).

In 2019, the Department for Education commissioned the SEND Review to understand the challenges faced by children and young people with special educational needs and disabilities, and those educated in alternative provision. The review aimed to improve the services available to families who need support, equip staff in schools and colleges to respond effectively to their needs, and to end the postcode lottery in support.

In March 2022, the findings from this review were published in the SEND Review Green Paper, which set out a series of proposals to reform the SEND system of support (Department for Education, 2022b). These include:

• Establishing a new national SEND and alternative system setting nationally consistent standards for how needs are identified and met
• Creating new local SEND partnerships to bring together education, health and care partners with local government to produce a local inclusion plan setting out how each area will meet the national standards
• Improving oversight and transparency through the publication of new inclusion dashboards to make roles and responsibilities of all partners within the system clearer 
• Introducing a standardised and digitised EHCP process and template.

In response to the Green Paper, the Government published its SEND and Alternative Provision Improvement Plan in March 2023. The Plan sets out a series of proposals to improve the accessibility and availability of SEND provision from the ages of 0-25. 

The Oliver McGowan training aims to ensure that staff working in health and social care are better able to understand the needs of autistic people and people with a learning disability in order to provide safe, compassionate and informed care (Health Education England, 2022). The Department for Health and Social Care invested £1.4 million to develop and test the training (ibid).

Following an evaluation of the trials between 2020 and 2022, the Health and Care Act 2022 introduced a requirement that regulated service providers should ensure their staff receive training on learning disability and autism which is appropriate to the person’s role (Health Education England, 2022). To support Integrated Care Boards to proceed with the delivery of training, Health Education England created an e-learning platform in 2022, and a code of practice for mandatory training will be developed, which is anticipated to be published in 2023 (ibid).

Findings from inspections carried out by Ofsted and the CQC on the effectiveness of support for pupils with special educational needs and disabilities found that many local areas are not supporting them as effectively as they should be. Under the SEND area inspection framework, inspectors look for evidence of: how children and young people needs are identified; how their needs are assessed and met; and how they are supported onto the next stage of education, employment, and wider preparation for adulthood (Ofsted, 2021). As of March 2021, in around half (51 per cent) of areas, inspectors had significant concerns about how effectively the local area was meeting its duties or securing better outcomes for children and young people who have special educational needs and disabilities (ibid).

In 2022, Ofsted and CQC consulted on a new approach to the way they inspect local area partnerships. Under the new area SEND framework, inspections will now place a strong emphasis on the impact that local area partnerships are having on the experiences of children and young people with SEND (Ofsted, 2022).

Attempts to attain SEND support have been found to negatively impact the mental health of children and young people. In the Education Committee’s 2019 inquiry on special educational needs and disabilities, many submissions highlighted the effects of the EHCP process on the mental health of children and young people with SEND, with key issues being raised including anxiety, suicidal thoughts, depression, and self-harm (Education Select Committee, 2019b). The inquiry also raised concerns regarding access to NHS CYPMHS, and how many children and young people were being left without support for their mental health (ibid).

What is more, services that offer assessments for neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) have been found to have the longest wait times amongst all NHS CYPMH services (Smith, 2023). And, without a diagnosis, many children may not be able to receive the additional support they need.

Evidence suggests that the reforms to the SEND system set out in Children’s Act 2014 have failed to achieve the goal of improving provision for children with special educational needs and disabilities. A 2019 inquiry by the Education Select Committee on the 2014 reforms concluded that the reforms had set up a new system of support for SEND, but that children and young people were being badly let down by a system that was insufficiently funded and poorly implemented (Long & Danechi, 2022).

The Committee also found: issues with a lack of joint working between responsible bodies, meaning that even significant funding increases might make little difference to children and young people with SEND; an adversarial, hard-to-navigate system, with parents needing to fight for support they are entitled to, often through repeated visits to Tribunal; an absence of responsibility for driving change and accountability for failure; and a lack of involvement of children and young people in decisions about the support they receive. 

To respond to these challenges, the Government announced a review of the SEND system and have since announced a SEND Improvement Plan. However, many of the reforms set out in the Improvement Plan are long-term, meaning that there won’t be any immediate change to the SEND system of support and no legislative changes are forthcoming. 

In relation to funding, a National Audit Office review of support for pupils with special educational needs and disabilities in England estimates that school funding has not kept pace with the rise in the number of pupils with SEND, and that local authorities are increasingly overspending their budgets for supporting pupils with high needs (National Audit Office, 2019). In 2017-18, the net overspend across all local authorities was £282 million; this compared to a net underspend of £63 million in 2017-18. The review concludes that the likely financial consequences of the 2014 Act was not fully assessed by the Government and that current overspending is making the system unsustainable. It was also estimated that local authorities would face a funding shortfall in excess of £1 billion by 2021 due to there not being enough funding to provide for the scale of demand (Education Select Committee, 2019a).

Whilst the SEND Improvement Plan does set out an approach to workforce planning, there are concerns regarding the capacity of the specialist workforce. This includes the insufficient number of specialists being trained to meet demand, a reduction in the number of specialists in the workforce, and an increase in demand for support. It has been highlighted that ambitions laid out in the SEND Review and Improvement Plan will not be achieved without a clear workforce plan to ensure there are sufficient specialist professionals (Royal College of Speech and Language Therapists, 2022).

• Local authorities should work with Integrated Care Systems and schools to develop a more coordinated approach to care for children and young people who have special educational needs and disabilities and who need mental health support.
• The Government should use the SEND Improvement Plan to strengthen the availability of specialist support services and to address gaps in the specialist workforce.

National government:

• Local leaders should identify opportunities for young people with special educational needs and disabilities and their families to shape local strategy and co-design services.

When a young person enters the care of a local authority, an initial assessment should take place of their physical, emotional and mental health needs as set out in the Care Planning, Placement and Case Review (England) Regulations 2010. To assess emotional wellbeing needs, local authorities are required to use the Strengths and Difficulties Questionnaire (SDQ). However, the effectiveness of such assessments in identifying mental health needs has been questioned. In a 2016 report, the Education Select Committee identified that a significant number of local areas fail to identify mental health issues when children enter care (Education Select Committee, 2016). They found assessments of children’s mental health are inconsistent and too often fail to identify those in need of specialist care.

In response, the Government committed to pilot a new approach to mental health assessments for children in care in nine local authority areas over two years (with delivery running from July 2019 to March 2021) to develop and test changes to the assessment system for children on entry into care (Department for Education, 2021). All pilots received grant funding until September 2020.

The Government’s manifesto committed to review the children’s social care system to make sure children and young people get the support they need. The Independent Review of Children’s Social Care was launched in March 2021, and the findings and recommendations were published in May 2022.

The Review highlighted mental health as one of the top issues brought to the attention of the Review and put forward a series of recommendations to increase the support available to children in care and care leavers. The Review identified that alongside greater investment in mental health services, further work is needed to upskill professionals in mental health in order to aid better identification of need (MacAlister, 2022). The Review also emphasised the role of new Integrated Care Boards in developing and publishing plans for improving the physical and mental health of children in care and care leavers, with the relevant Director of Children’s Services (DCS) taking responsibility for signing off the section on care leavers’ mental health (ibid). 

In response to the Independent Review, in February 2023, the Government published their plans to reform the children’s social care system in their Stable Homes, Built on Love strategy. The strategy recognises the importance of rebalancing the children’s social care system away from late intervention to more effective help for families at an earlier stage (Department for Education, 2023). This strategy is currently undergoing a public consultation.

A key ambition of the strategy is to decrease the mental health and physical health disparities faced by children in care and care leavers. The strategy references the importance of the NHS Long Term Plan commitments in increasing investment and expanding access to specialist services (ibid). In addition to this, the strategy commits to building social workers’ and other practitioners’ understanding and skills to respond to children’s mental health needs, and states it will work with health partners to drive high expectations and service delivery for physical and mental health support.

What is more, the strategy references the role of health, particularly in the commissioning of services to meet the health needs of children in care and care leavers. This will include working with NHS England and DHSC to ensure all Integrated Care Boards, Integrated Care Partnerships, Health and Wellbeing Boards and local authorities better support the planning and commissioning of services to meet the assessed physical and mental health needs of children in care and care leavers in their area (ibid).

Previous research has raised questions around mental health provision for children with social care related needs or family issues. The Education Policy Institute (EPI) undertook research to determine what provision was in place for children in need, children under protection orders and children in care with mental health needs (Crenna-Jennings & Hutchinson, 2020). They found that specific mental health services for looked-after children exist in over half of the areas in the country, yet there are significant inconsistencies in provision. What is more, EPI raised concerns that fragmented commissioning arrangements across agencies would result in children not receiving the specific support they need or falling through the gaps (ibid).

The Independent Review identified further challenges with children in care accessing timely mental health support (MacAlister, 2022). The Review found that whilst fast tracking arrangements to NHS CYPMHS were up and running in most areas for those with higher levels of need, children with lower levels of need often had to wait long periods before receiving an assessment or treatment. The Review further highlighted a number of barriers hindering the delivery of effective mental health care for children in care, including: therapeutic input cannot be provided where there isn’t a stable placement, the transient circumstances of many children in care may mean they lose contact with services whilst waiting to be seen, and children do not always receive the ongoing support and care they need once discharged from the service (ibid).

Whilst the NHS Long-Term Plan and other strategies aim to improve access to services, the Independent Review concluded that these changes are not enough to meet the mental health needs of children in care and care leavers (ibid).

It is not possible to analyse the progress of the most recent government strategy for the children’s social care system, Stable Homes Built on Love, as it is currently undergoing a public consultation. It is welcome to see the emphasis within the strategy on improving mental health outcomes for children in care and care leavers, but the strategy still remains light on detail on how this will be achieved in practice and how access to mental health support will be improved for these groups. Many of the pledges relating to mental health are reliant on existing NHS plans to expand support, rather than placing additional expectations on NHS England to provide specific support for children and young people in care and care leavers.

It is also unclear what the next steps are for the looked-after children pilot assessments and how they will fit into the Government’s future plans around social care. An evaluation of the programme found that the pilots succeeded in helping develop a new child centred approach to the mental health assessments of children entering care and in care, and applying it to a range of circumstances, yet concluded further evidence is needed to demonstrate effectiveness of the new approach to assessments (Brown et al., 2021).

Local systems:

• Local areas should ensure that mental health representatives are involved in local multi-agency safeguarding arrangements.
• 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.
• Health partners and local authorities should jointly commission and establish integrated therapeutic teams to be based in children’s services, offering early help and intervention for children and young people who come into contact with children’s social care.

National government:

• The Department for Education should publish the findings from the mental health assessments pilot for looked-after children and how this work will be taken forward within the Stable Homes, Built on Love strategy.

The Troubled Families Programme started in 2012 and has since been relaunched as the Supporting Families programme. The programme aims to provide targeted interventions for families with complex interconnected problems including unemployment, poor school attendance, mental and physical health problems, involvement in crime and antisocial behaviour, domestic abuse, and children in need of help and protection (Department for Levelling Up, Housing and Communities, 2023). The programme also focuses on driving system change so that every local area has joined up, efficient local services which are able to identify families in need and provide support at the right time. Central to the programme is the commitment to create multi-agency local partnerships in every area with mature local and national data systems (Department for Education & Department for Levelling Up, Housing and Communities, 2022).

The Autumn Budget and Spending Review 2021 announced an increase in funding for the programme, so that by 2024/25 total planned investment across the following three years would be nearly £700 million (Foster, 2023). The funding will enable the programme to continue to deliver until March 2025, and is aimed at helping 300,000 families facing multiple interconnected issues access effective whole-family support and improve their life outcomes.

The Best Start for Life: A Vision for the 1,001 Critical Days was published in March 2021, following the Early Years Healthy Development Review, which was commissioned by the Prime Minister and chaired by Rt Hon Dame Andrea Leadsom. The report highlighted that the services offered to families between conception and age two are often disjointed, making it hard for those who need help to navigate the support available to them (HM Government, 2022). The report committed to six action areas: 

• A coherent joined up Start for Life offer available to all families.
• Family hubs as a place for families to access start for life services.
• Designing digital, virtual and telephone offers of support, including a digital child health record.
• Developing the workforce to meet the needs of families.
• Improving data, evaluation, outcomes and proportionate inspection.
• Ensuring local and national accountability.

To support delivery of these action areas, the Autumn Budget in 2021 committed over £300 million to fund a new three year Family Hubs and Start for Life Programme. This programme will fund new or transformed family hubs and a range of Start for Life services in 75 local authorities in England. In addition, 14 local authorities have been appointed as trailblazers for the programme, who will lead in delivering the programme and who will share their learning (HM Government, n.d.).

As part of this commitment, the Government funded the establishment of a new National Centre for Family Hubs in May 2021 to champion family hubs and share best practice, and a further £12 million was announced to establish a Transformation Fund to support 12 local authorities to open a family hub by March 2024. Guidance has also been published to all local authorities on providing a universal Start for Life offer.

Family hubs are central to this vision. Family hubs aim to provide families with a single access point to integrated family support services for early help with social, emotional, physical and financial needs. Hubs deliver these services from conception through until children reach the age of 19 or, for young people with special educational needs and disabilities, 25.

Specialised parent-infant relationship teams are multi-disciplinary teams with expertise in supporting and strengthening the relationship between babies and their parents. Only 27 parent-infant teams are currently in operation in England, and there is very little mental health provision in place for children aged two and under (Parent-Infant Foundation, 2019). To further support children in the early years, £100 million of funding was committed in 2022 to be shared among eligible areas to roll out bespoke parent-infant relationship support and perinatal support (Department for Education, Department for Levelling Up, Housing and Communities & Department for Health and Social Care, 2022).

The Government has implemented a range of programmes to provide improved support for families. For example, since 2015, over 470,000 families have received direct support through the Supporting Families Programme (Department for Education & Department for Levelling Up, Housing and Communities, 2022). An impact study which tracked the outcomes achieved by families supported by the programme between 2015 and 2018 highlighted its role in preventing high-cost statutory intervention (Ministry of Housing, Communities and Local Government, 2021). In particular, the study found that the programme reduced the number of children entering care (a 32 per cent decrease between 2015-18) and the number of young people receiving custodial sentences (38 per cent decrease). Improvements have also been identified in multi-agency working, and how information is used and shared in local areas. Local authorities and other agencies have been credited for their leadership in delivering the programme, and the flexibility has enabled local authorities to invest strategically and adapt the programme based on local needs (Ministry of Housing, Communities and Local Government, 2021).

However, it has been noted that whilst some local areas have achieved positive outcomes for the families they work with, progress in other areas is variable, and more work is needed to achieve positive outcomes consistently across all local areas. Where outcomes were not being achieved, it was found this was due to a lack of progress in developing local partnerships and data sharing arrangements (ibid). The Early Intervention Foundation has stated that the programme could have an even greater impact if there was central investment in training and professional development for key workers and there was a commitment to evaluating, piloting and trialling new interventions with families with the most complex needs (Early Intervention Foundation, 2021).

The Best Start for Life and Family Hubs Programme also sets out a vision for developing improved, joined-up support for families. It is estimated that 930,000 babies aged nought to two will have the opportunity to benefit from new family hubs by 2025 (HM Government, n.d.). To date, around half of upper tier local authorities have received funding to implement the programme. For those areas who have not received additional funding, they will be supported with implementation via national guidance and support. It is challenging to know how far this guidance will go in supporting and encouraging implementation, particularly where funding is already a challenge. As a result, Family Hubs are not yet universally distributed throughout England and no further information has been published on when all areas of the country will receive funding. Whilst some local authorities still do commission children’s centres, they do not receive additional funding to do so.

What is more, there is still a lack of evidence about the impact of the programme. An evaluation of Sure Start, the predecessor programme to Family Hubs, highlighted the positive health impacts of bringing together a range of support for families under one roof (Cattanet al., 2021). The evaluation conducted by the Institute for Fiscal Studies found that Sure Start’s effects on child health last well beyond the end of the programme itself, with some of the biggest impacts only felt in adolescence, nearly a decade after children have ‘aged out’ of eligibility (ibid). The evaluation also noted far fewer hospitalisations for mental health reasons in early adolescence.

The £300 million committed as part of the Autumn 2021 spending review will help to develop new services for families through the Family Hubs and Start for Life Programme. However, it is not a comprehensive funding pledge and funding in other areas, such as the Public Health Grant which has also been used to fund family and early years services such as health visiting, has seen significant real term cuts. The First 1,001 Days Movement’s A Decade of Disinvestment report highlights, for example, that annual public health expenditure on services for nought to five year olds dropped by 20 per cent between 2016/17 and 2019/20 (First 1001 Days Movement, 2021).

Local authorities:

• 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. 

National government:

• The Department for Education should ensure full roll out of Family Hubs across all local authority areas.

The Five Year Forward View for Mental Health recommended the development of a complete health and justice pathway to deliver integrated health and justice interventions (NHS England, 2016). Following the publication of this strategy, the Health and Justice Specialised Workstream was established by NHSE Health and Justice in order to focus on the needs of vulnerable children and young people whose needs cannot be met in conventional services as a result of their complex circumstances. This workstream not only seeks to improve support for young people in the children and young people’s secure estate, but also those who are at risk of entering it. Alongside this, the workstream also focuses on the needs of those who have transitioned out of the secure estate and back into the community.

NHS England has identified that this workstream has three discrete projects (NHS England, n.d.):

1. Establishing specialist child and adolescent mental health services for high risk young people with complex needs (also known as Forensic CAMHS or F:CAMHS). This includes providing improved and clearer pathways for young people with complex needs between specialist services, secure inpatient units and for those leaving custody or secure welfare care.
2. The Framework for Integrated Care project (SECURE STAIRS). The framework aims to transform the culture and practices in the secure estate to be trauma informed and to ensure that staff have the right skills and support to care for children appropriately. Collaborative Commissioning Network project.
3. The project supports NHS England and Justice commissioners to work together with local partners to coordinate commissioning activities more effectively.

The NHS Long Term Plan also committed to investing in additional support for the most vulnerable children and young people in, or at risk of being in, contact with the youth justice system (NHS England, 2019). The plan proposed the development of a high harm, high risk, high vulnerability trauma informed service that will provide consultation, advice, assessment, treatment and transition into integrated services. No further detail has been published on what this will look like.

Liaison and diversion services are commissioned by NHS England and NHS Improvement and are designed to support people as early as possible who come into contact with the criminal and youth justice system. The purpose of these services is to reduce re-offending rates for children and young people and divert them away from the criminal justice system and associated poor health outcomes (National Institute for Health and Care Research, 2021). Following screening and assessment, individuals are given access to services such as mental health support. The roll out of NHS England commissioned Liaison and Diversion services achieved 100 per cent coverage across England in March 2020 (ibid)

Liaison and diversion services aim to intervene early and provide appropriate support to children and young people, diverting them away from the criminal justice system. A 2012 evaluation of Youth Justice Liaison and Diversion services found significant reductions in overall need amongst children and young people, including levels of depression and levels of self-harm, and a significant association between improvements in these aspects and the amount of liaison and diversion contact (HM Inspectorate of Probation, n.d.).

The most recent data from the Ministry of Justice shows that in 2018/19, 12,685 children and young people were seen by Liaison and Diversion services (Justice Committee, 2020). Of these, 5,616 children and young people were identified as having a mental health problem; however, only 951 referrals for mental health support were made, equating to just 17 per cent of those identified (ibid).

A report by the Commission on Young Lives on mental health support for vulnerable groups noted that the mental health needs of those at risk of offending are not being recognised and met by existing services. It has been identified that gaining access to NHS CYPMHS for children in contact with the justice system is an ongoing challenge, and high thresholds for support mean children can only be seen when they are in crisis, despite initially presenting with multiple needs (HM Inspectorate of Probation, n.d.).

An evaluation of the forensic CAMHS model (F:CAMHS) for those children and young people with complex and high risk presentations found that input from F:CAMHS results in an improvement in the mental health and wellbeing and the overall health and quality of life of the children and young people it is commissioned to support. The evaluation concludes that F:CAMHS supports the development of a system of integrated care for children with multiple and complex needs and highlights the importance of sustaining and scaling up Community F:CAMHS as a service (Anna Freud Centre, 2021).

Some welcome progress has been made in implementing the projects that form the Health and Specialised Commissioning Workstreams. Thirteen Community Forensic Child and Adolescent Mental Health Services (F:CAMHS) are in place covering all of England. However, evaluations of both Community Forensic CAMHS and SECURE STAIRS by the Anna Freud Centre highlight how further work is needed to sustain and embed these models to ensure integrated care for those with multiple and complex needs.

The Framework for Integrated Care (SECURE STAIRS) is intended to improve the quality of care and outcomes for children and young people in the children and young people secure estate. It aims to do this through culture change promoting consistent, trauma informed, formulation-driven, evidence-based care, delivered within a whole-systems approach by well trained and supported staff (Anna Freud Centre, 2022). A further evaluation of this model by the Anna Freud Centre found that whilst changes in cultures and practices were widely adopted, the framework was not yet fully embedded in some settings (Anna Freud Centre, 2022). In particular, implementation was found to be more challenging in young offender institutions and the secure training centre compared to the secure children’s homes.

The Collaborative Commissioning Networks commenced in 2016 in order to support a collaborative approach to the commissioning of services locally that ensure the full clinical pathway consideration for children and young people transitioning into and out of NHSE and NHSI Health and Justice commissioned services, including the secure estate and liaison and diversion services (NHS England & NHS Improvement, 2021). By 2021, 104 initiatives had been implemented locally as part of this project, with many being noted as being successful in closing the gaps in clinical pathways (ibid). For example, East Lancashire put in place training for the Lancashire Youth Offending Team (YOT) Health Practitioners to enable specialist clinical and safeguarding supervision for YOT staff and to implement trauma informed ways of working, and in Bristol a CAMHS practitioner was placed in the YOT to ensure improved mental health assessments (ibid).  

Local systems:

• Local authorities and health partners should work together to implement trauma informed approaches to working with young people at risk of contact with the youth justice system.

NHS England:

• NHS England should work to ensure the SECURE STAIRS framework is fully implemented across all settings in the secure estate.

• Project Future, Haringey: Project Future is a co-produced holistic wellbeing and mental health service that is community based and works with young people aged 16-25 and families who have experience in the criminal justice system. The team consists of Clinical Psychologists, specialist youth workers, education/employment specialists and local young people employed as community consultants who work together to provide interventions and support.
• MAC-UK ‘Integrate approach: This approach, developed by MAC-UK, seeks to wrap holistic and responsive support around excluded young people. INTEGRATE projects have mental health and wellbeing support built in by supporting a psychologically informed environment and a ‘Streetherapy’ approach. INTEGRATE teams are led by mental health professionals and are made up of workers with lived experience and other professional staff, such as youth workers, all of whom are trained in mental health.

The government-backed National Citizen Service (NCS) programme was launched in 2011 to provide young people between the ages of 15 and 17 with the opportunity to develop new skills, meet new people and make a difference in their communities. It involves a residential experience and community project work. In 2017, the then Prime Minister Theresa May announced a package of measures to boost young people’s mental health through the NCS programme (Prime Minister’s Office, 10 Downing Street, 2017). This included the development of a mental health awareness course for young participants of the programme, mental health training for more than 10,000 NCS staff, and the establishment of a network of young NCS graduates to champion mental health awareness (ibid).

In 2021, the Treasury and Department for Digital, Culture, Media, and Sport (DCMS) launched a review of programmes to support youth services. The review sought to strengthen the youth policy agenda and inform funding decisions relating to the Youth Investment Fund and the NCS programme. It also sought to respond to ambitions set out in the Levelling Up White Paper.

DCMS engaged with over 6,000 young people across the country and over 170 youth sector organisations and academics. In response to the engagement exercise, the Government established a new ‘Youth Guarantee’ package backed by £560 million: to ensure the roll out of youth spaces and services, which will result in over 45,000 extra youth activities per year over the next decade; fund a reformed NCS programme for the next three years; eliminate current non-military Uniformed Groups’ waiting lists for teenagers across the country; and provide £4 million to the #iwill fund to expand youth volunteering opportunities (Department for Culture, Media and Sport, 2022).

Launched in 2022 after delays caused by the pandemic, the Youth Investment Fund aims to create, expand and improve youth facilities and their services in local areas, in order to drive positive outcomes for young people, including improved health and wellbeing, and skills for work, employability and life. The fund is now in its second round of funding.



In March 2023, the Prime Minister Rishi Sunak restated that an additional 43 youth centres are to benefit from the next £90 million investment from the Youth Investment Fund, distributed by the DCMS (Prime Minister’s Office, 10 Downing Street, 2023). It is intended that the investment will result in 45,000 more young people a year having access to regular and out-of-school activities.

Over the last decade, youth services across the country have been hard hit by financial cuts and pressures. According to a recent report by the YMCA, local authority spending on youth services totalled £379 million in 2020/21 (YMCA, 2022). This represents a £1.1 billion cut in youth services funding over the past ten years in England, with real-terms expenditure down 74 per cent from 2010/11’s £1.48 billion spend. Whilst additional investment has been provided through the Youth Investment Fund, it is not sufficient in compensating for what has been lost from local authority budgets and the impact on youth services.

The report also highlighted regional disparities in spending with spend per head in Inner London totalling £72 compared to £46 in outer London. Funding pressures have limited the availability of high quality provision and support for young people, including for their mental health (YMCA, 2022). What is more, it has been noted that for every £16 cut on local authority services, £1 is youth work (ibid). At a national level, DCMS is responsible for some £350 million annual funding for youth work and out of school activities. However, a disconnect has been identified between coordination of current government funding for out of school activities and for specialist and targeted youth services, where the legal responsibilities are largely held by the Department for Education and within local authorities (Tiley, 2021).

A survey of youth workers carried out as part of a study on the role of trusted adults in children’s mental health found that 87 per cent of adults who work with under-25s in the community frequently support them with their mental health but feel under-equipped to spot the warning signs of distress. Many youth workers reported challenges navigating the children and young people’s mental health system, including signposting, and referring young people to specialist services. Only 54 per cent of youth workers agreed or strongly agreed that they felt well supported by mental health specialists.

An All Party Parliamentary Group report on youth work has further highlighted that 4,500 youth workers have been displaced in recent years, and there is a shortfall of volunteers which has been exacerbated by the Covid-19 pandemic, resulting in long waiting lists for activities and support (Tiley, 2021).

• 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 Government should provide dedicated funding for local areas to integrate youth services into their overall package of mental health support for children and young people. This funding should cover initiatives including co-locating youth services and mental health services, clinical supervision for professionals supporting young people in the community, developing reciprocal referral pathways, and involving young people in designing services.

• The Brandon Centre, Camden and Islington: The Brandon Centre provides the Outreach services for the Wellbeing of Adolescents (OnWArd), which provides a multi-professional service for young people aged 13-18 years in Camden and Islington. The service offers holistic reviews of the young person’s physical and mental health within the context of their needs and wider lives.
• The Well Centre, Lambeth: The Well Centre is a youth health hub for 11-20 year olds based in Lambeth, South London. The centre provides access to a GP, a CAMHS senior mental health practitioner and Health and Wellbeing Practitioners (HWP). Young people are able to go to the Well Centre about any health concerns that they have, including physical, mental and sexual health. They have a good working relationship with NHS CYPMHS, who not only provide the senior NHS CYPMHS practitioner embedded in the Well Centre but also a monthly meeting with a NHS CYPMHS consultant to discuss more complex cases, thereby managing to retain many within the Well Centre and reduce the need for onward referral to NHS CYPMHS.

• Ongoing health reforms: The implementation of ICSs marks the biggest shift in the health landscape towards integrated working, and welcome provisions have been put in place to ensure that the needs of children and young people are considered and represented within these new structures. As ICSs become embedded, there is a real opportunity for local areas to create more collaborative approaches to planning, commissioning and delivering mental health services for children and young people.
  
   
• Policy development: The voluntary and community sector (VCS) plays a crucial role in the mental health system, and we have seen a growth in the sector in organisational interest and work in children’s mental health and wellbeing, particularly following the Covid-19 pandemic. There is an opportunity to utilise the power of the VCS within local areas in order to provide an improved and integrated offer of mental health support for children and young people. Awareness of mental health has also increased in recent years following high profile campaigns such as Time to Change. A general election is due to take place in 2024 or early 2025. This will result in a new government with a five year term, providing a significant amount of time and opportunities to implement new policies.
  
   
• Growing voluntary and community sector interest: There has been positive growth in the children and young people’s mental health workforce, particularly through the introduction of new roles such as Education Mental Health Practitioners and Children’s Wellbeing Practitioners. This needs to be sustained and built upon to ensure continued growth in the workforce.
  
   
• General election:  At a national level, the development of new strategies provides the opportunity to secure commitments around children and young people’s mental health. We see that there are three upcoming opportunities within this Parliament.  First, a new Major Conditions Strategy is due to be published, which will focus on the prevention of major conditions such as mental health issues, alongside other conditions such as cancer and dementia. This strategy will replace the promised ten-year mental health plan. Whilst details and timings of the strategy are still unclear, there is an opportunity to ensure that a commitment to children and young people’s mental health is included as part of the Government’s main health strategy.  Second, the Government has also committed to delivering a new Suicide Prevention Strategy. Whilst details of this strategy are yet to be released, we believe this will provide another key opportunity.  Third, the reforms to the Mental Health Act should help to improve the care and treatment of children and young people in mental health hospitals. We are currently waiting for a Mental Health Bill to enter Parliament, but we believe the Bill should be used as a mechanism to improve support and strengthen safeguards for children and young people admitted to inpatient care.

• De-prioritisation of mental health: Whilst the Major Conditions Strategy marks a route to influence, there are also concerns that the incorporation of the ten-year mental health plan into this strategy signals a de-prioritisation by the Government of mental health. The future roll out and funding of initiatives such as Mental Health Support Teams and the next steps to the NHS Long Term Plan also remain uncertain. As we approach a general election and a new government, there is a risk that work on children and young people’s is deprioritised in order to focus on other areas of policy.
  
   
• Funding: Whilst we recognise that investment has been made in children and young people’s mental health support to date, services are still significantly under-resourced. Different parts of the mental health system are also funded by different government departments meaning it is challenging to get a full picture of how much money is actually spent on the mental health system as a whole. With no funding forthcoming for children and young people’s mental health and cuts being made to budgets within local areas, it is challenging to see how effective change can be successfully implemented. 
  
   
• Fragmented commissioning and delivery landscape: Fragmentation in policy at a national level has resulted in challenges in delivering effective care and treatment in local areas that best supports children and young people. Responsibility for commissioning services to support children’s mental health is split between local authorities and the NHS. Whilst it is still early days in the development of the new health and care system, it is currently unclear how children and young people’s mental health provision will be prioritised across ICS footprints and what this means for the commissioning and delivery of mental health services.
  
   
• Rising mental health needs: Over recent years there has been an increase in children and young people experiencing mental health problems, and it is likely that the Covid-19 pandemic has exacerbated need. The pandemic also heightened inequalities experienced by children and young people, such as educational inequalities, growing levels of poverty, the impact on employment and income, and children living in unsafe households. The current cost of living crisis risks widening these inequalities even further. We are already seeing increased pressure being placed on children and young people’s mental health services as a result of rising need, and services are subsequently struggling to respond to this. With the risk of mental health need increasing even further, there are questions about whether the mental health system has the capacity to respond effectively.
  
   
• Workforce: Workforce expansion and development continues to be the biggest risk in efforts to expand and transform children and young people’s mental health services. Burnout and stress are also major concerns, and there are challenges with recruiting and retaining staff. Without the workforce in place, it will be challenging to deliver the scale of change that is required.