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).