This independent article from Paula Lavis, policy manager for NHS Confederation is part of the LGA children and young people's mental health think piece series. The piece explores how can we support children with the most acute needs.
Children and young people’s mental health services were under pressure well before the pandemic, but the significant increase in demand for support during that time has exacerbated the challenges. To meet this need and improve access, services need to be transformed and properly integrated, bringing the NHS closer together with local authorities and wider public services.
What is the current challenge and what impact does this have on children, young people and families?
Around one in five children and young people has a probable mental disorder – a rate that is increasing in some age groups. To put this into context around one in 10 people aged 17 to 19 had a probable mental disorder in 2017, compared to one in four in 2022. There are particular concerns about girls and young women’s mental health, as we have seen an increase in the number seeking help for eating disorders and self harm. The number of young women taking their own life has also been increasing.
Demand for mental health support was expected to have increased during the pandemic by 10 million, including 1.5 million children and young people. There were 43,268 referrals to children and young people’s mental health services in July 2020, rising to 73,874 by July 2022 and dropping back to 68,002 in April 2023.
In particular, demand for eating disorders in community eating disorder services went through the roof during the pandemic. The number of young people completing an urgent pathway for eating disorders increased by 141 per cent between quarter four in 2019/20 and quarter one in 2021/22.
As this demand for children and young people’s mental health services has increased, so too have waiting times. In 2022, the average waiting time from referral to first appointment in community children and young people’s mental health was about 8 weeks and the average waiting time from referral to second appointment was about 13.5 weeks.
More challenging is the increase in the acuity and complexity of the needs of these young people, who are more likely to be admitted to hospital and need to stay there for longer. This is clearly undesirable for the young people involved – 1,141 under 18s were in hospital for 90 days or more in 2021-22-, this is also more expensive for services too. The average cost of one admission would support almost 100 young people in the community for a year.
Mental health problems in childhood often continue into adulthood, so providing effective care at the earliest opportunity is crucial and helping children and young people to stay mentally healthy as adults.
What needs to change?
While some of the steps to improving early intervention are already underway, the challenge is significant: to ensure that services are fully and sustainably funded, that they are coproduced with children and young people, and that there are sufficient people with the right skills in place to provide care in facilities that are fit for purpose.
A recently published joint report by the NHS Confederation and the Centre for Mental Health, ‘No Wrong Door’, - sets out a vision for mental health services in 10 years’ time, and the steps it will take to get there. Prevention and early intervention are at the top of the list. This is essential if we are to reduce demand for specialist mental health services. We can’t just keep investing in acute mental health services once people reach crisis point.
This will mean a significant change. There has been a drive to reduce the reliance on inpatient beds and provide more intensive community-based support, which research shows produce good outcomes for children and young people.
While some children and young people will need a bed, this should be for as short a time as possible with step up and step-down plans in place and community-based support is in place post discharge. It is important too that beds are safe, high quality and age and developmentally appropriate, considering the impact on the child or young person, especially if they are being placed out of area where it may be difficult for family and friends to visit, and they will be disconnected from their support network. Services also need to make reasonable adjustments for children and young people with disabilities, such as ensuring that services for autistic young people ("It's Not Rocket Science" report from the National Development Team for Inclusion) are sensory friendly and not overwhelming at a time that is already potentially overwhelming. There are existing examples of good practice to learn from, such as The Hope service in Surrey, which is a multiagency service, and Alder Hey, which has created a sensory friendly environment for children and young people.
System working can help take the integrated approach needed for planning and delivering these services across the NHS, local authority, education and other agencies to ensure that children and young people can access the right care at the right time in a way that works for them. Utilising the voluntary sector, and other new roles such as peer support workers, and social prescribers will also help increase capacity and improve access to mental health support.
The NHS Long Term Plan made welcome commitments, some of which still need to be fulfilled, such as every young person aged 0 to 25 being able to access specialist mental health support when needed rolling out the Mental Health Support Teams to every school, ensuring early access hubs are available everywhere, and making children and young people’s mental health practitioners and other relevant support available in primary care or community settings.
The shift to a 0-25 approach in particular should help address the need for mental health support for babies and preschool children – essential to getting children off to a good start in life - and improve the transition to adult mental health services with fewer people able to fall through gaps in service provision.
At the centre of all of these changes is the need to make services more children and young people-centric. The Thrive model, already being used in over 70 areas of England, is a needs-led, person-centred approach replacing what used to be referred to as the tiered model with a conceptualisation of a whole system approach.
Finally, if we are to meet intense capacity challenges, then digital services should be part of the solution. These services are anonymous, encouraging some groups who do not want to or are not ready to engage in face-to-face mental health support.
How do we get there?
The establishment of integrated care systems and provider collaboratives means there is a real opportunity to bring agencies together and work across a system or place with people with lived experience, to address the many challenges they face.
All trusts providing acute and/or mental health services are now required to be part of one or more provider collaborative. These are partnership arrangements involving at least two trusts working at scale across multiple places to reduce unwarranted variation and inequality in health outcomes, access to services and experience. This is an area where mental health is ahead of the game, with six pilots across England to improve outcomes for young people in inpatient mental health services.
An economic evaluation of these pilots found that by investing in local services, each of the sites has achieved reductions in overall spending at the same time as a significant expansion of community-based care, with comprehensive offers of 24-hour availability of highly skilled teams and innovative models of support. South London Mental Health and Community Partnership was one of these pilots and saw a 32 per cent reduction in its use of children and young people’s mental health beds.
Crucially, we can’t deliver change and meet greater demand unless we have the staff in place to deliver services. Although there has been a 46 per cent increase in the children and young people’s mental health workforce between 2019 and 2022 we are starting from a low base and we currently still have a 17 per cent vacancy rate.
Meeting the increased demand for children and young people’s mental health is undoubtedly an enormous challenge. We are already seeing providers, systems and partners stepping up to meet it, while national policy is in place to drive forward improvements. Given the scale of the challenge and the impact across the system, we will need to see children and young people’s mental health support becoming a real priority both nationally and at a system level if we are to ensure that all children and young people have seamless access to high quality mental health services when they first need them, that meet their needs and reduces the demand for inpatient provision.
