School and Public Health Nurses Association : What can we do to develop a mental health system that works for children?

I have worked in School Nursing Service for over 30 years, currently leading a Healthy Child Programme 0-19 and working for the School and Public Health Nurses Association (SAPHNA). As a specialist public health nurse (qualified school nurse) I have always had an interest in child and family mental health and during my career developed my knowledge and skills in this area working in lead roles to develop emotional health and wellbeing services locally and leading the Targeted Mental Health in Schools programmes regionally. In this ‘Think Piece’ I reflect on progress and aspirations to improve mental health services for children and young people, the progress that has been made and the challenges that remain.

The progress made

There has been a raft of policy and strategies intended to improve provision and access to services for children and young people to respond to growing need to support their mental health needs. This includes Future in Mind (2015), the Five Year Forward View for Mental Health (2016), the Transforming Children and Young People’s Mental Health provision: green paper (2018), and the NHS Long Term Plan (2019). Within these policies there has been a significant focus on providing support through the education system and expanding children and young people’s mental health services. The Mental Health Support Teams programme being one such strategy. This has three core aims to:

• Provide direct 1-1 support to children and young people with mild-moderate problems,

• provide whole school support,  

• give advice and liaise with external services.

The programme has been welcomed by schools and has increased workforce capacity and ability to offer support to some children and young people. In 2023, the programme reaches approximately 28 per cent of schools and colleges in England. However, the evaluation has highlighted challenges including lack of capacity to fulfil core aims, with most time spent on 1-1 direct work at the expense of time spent on prevention and promotion.

The Challenges that remain

Policy has focused on improving services however children and young people’s mental and emotional wellbeing continues to be a significant public health priority. In my NHS role, I have witnessed first-hand the increasing need for emotional health and wellbeing support for children and young people. As interim professional officer for SAPHNA, school nurses tell me that the number of children and young people presenting to services has risen, increasingly so since COVID, and onward referral to specialist mental health services remains challenging. Emotional health and wellbeing is a top reason that young people contact school nursing services, seeking support about relationships & family issues, anxiety or panic attacks and depression or low mood. School nurses are well placed to support and improve outcomes for children and young people by providing mental health promotion, prevention and early intervention approaches. It is recognised that their unique position supports them to build trusting and enduring professional relationships with children and young people enabling them to become confident and healthy adults. Whilst the crucial role that school nurses can play is recognised, the Public Health Grant has seen significant cuts to these very services, capacity reduced and ability to deliver compromised.  

An independent review of mental health policy and strategy successes and challenges purported that whilst growth of the workforce has happened there remains challenges accessing support for mental health, coverage of provision is inconsistent and experiences of services are not consistently good. The report also highlighted a lack of progress made to integrate mental health support across the system meaning children in vulnerable groups face particular challenges in accessing support.  Significantly, the review highlighted missed opportunities to significantly ease pressure on the system by increasing the availability of preventative and early intervention support. 

What needs to be done?

There is clearly still much work to be done. I am not going to focus on specialist services, that is not to say that further progress is not needed in this area. My background is public health nursing, and this is where I place my challenge. 

We need to do more to shift the balance towards prevention, promotion and early intervention. There needs to be improvement in cross government working which emphasises the importance of promotion and prevention. Local systems need to work together to identify needs, develop robust pathways and commission services that meet those needs. Statutory partners including health, education, social care together with the voluntary sector need to understand and respond to the needs of children and young people, investing in prevention and early intervention alongside specialist provision and developing integrated pathways. 

The public health workforce is  integral to this. I have hope that the tide is turning and the commitment to prevention, promotion and early intervention will be prioritised. Professor Jamie Waterall, Deputy Chief Nurse Office (CNO) for Health Improvement & Disparities announced the imminent CNO Strategy which will focus on improving the public’s health and wellbeing and tackling health inequalities. He spoke of his hope to see an establishment of a clear workforce plan for the specialist public health workforce who will be able to “shape, lead and deliver on policies to improve the nation's health”.

Future in Mind (2015) highlighted the need to build resilience, promote good mental health, promote prevention, and provide early identification to reduce the burden of mental and physical ill health over the whole life course, reduce the cost of future interventions, and reduce health inequalities. It referenced the contribution that school nurses make to achieving these aims through their crucial role in leading the delivery of the Healthy Child Programme 0-19. School nurses, the only health professional providing universal health provision to school aged children, are well placed to support resilience and wellbeing. They have a unique, pivotal role working between education settings, wider health services, home and the community, they are well placed to lead the public health response to improving the mental health of children and young people. In order for them to fulfil their role and improve outcomes for children and young people there needs to be a commitment to restoring the Public Health grant and investment in the workforce, the NHS Workforce Plan makes a start towards this goal.

Mental health support in education needs to expand beyond the current mental health support teams (MHST) programme which is due to finish in 2023, and to reach all schools and colleges. However, the learning from the evaluations needs to trigger a re-think. Evaluation evidences that the important component of prevention and promotion is not being achieved and capacity has been focused on 1-1 direct work. We have a school nurse workforce, specialist public health nurses (SCPHNs) trained in child health, health promotion, public health and education who must be part of the mental health support in education, leading the public health response to improve children and young people’s health and wellbeing working alongside mental health professionals. 

In the wider community, children’s services, school nursing, education and voluntary sector must continue to work together to develop Early Help provision and ensure the Family Hub agenda expands across 0-19 years, and, together, develop a comprehensive mental health offer to children, young people and their families.