UKCP response to the green paper on mental health provision for children and young people Background In December 2017, the Department of Health and Social Care and the Department for Education jointly launched a consultation on mental health provision for children and young people. The green paper focused on earlier intervention and prevention, especially in and linked to schools and colleges. The proposals included: creating a new mental health workforce of community-based mental health support teams every school and college will be encouraged to appoint a designated lead for mental health a new 4-week waiting time for NHS children and young people s mental health services to be piloted in some areas. Our response The response to the Green Paper was submitted using an online form. Below, are the questions asked and our responses. 1. Do you think these core proposals have the right balance of emphasis across a) schools and colleges and b) NHS specialist children and young people s mental health services? Share your thoughts on your choice (max 250) We welcome the focus on young people s mental health. These proposals represent progress, but cannot come soon enough. With 50% of adult mental health issues established by 14 and 75% by 24, it is in everyone s interest that future generations are more emotionally stable, more securely attached and free from anxiety and depression. They will make better parents and bring up children who are steadier, happier, more focused and able to contribute to the prosperity of the UK and to wider society. However, these proposals occur against a backdrop of substantial, long-standing underfunding, and withdrawal of social care support services. Failure to act early to prevent long-term chronic conditions, comes with huge costs in terms of the health service, criminal justice, alcohol dependency, UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 1
radicalisation, and unemployment. Our concerns are not about balance; even if the paper s ambitions are realised, the level of resources available both to schools and NHS services will only help a fraction of the young people who need support. While these proposals are a step forward, we really need a leap. There is an urgent need for good services in schools, supported by highly trained professionals in CAMHS services. The thin spread of psychotherapists in CAMHS remains woefully insufficient. Commitment to properly funding services, ensuring comprehensive data collection, and securing evenness of provision is desperately needed. Good services cost money, however the cost of failing to properly address childhood mental health issues is even higher. There is a highly trained workforce available to help with this. To support every school and college to train a Designated Senior Lead for Mental Health, we will provide a training fund. 2. What do you think is the best way to distribute the training fund to schools and colleges? Please rank in order of preference: Set amount of funding to be made available to each school, for them to buy relevant training with Funded training places made available locally for schools to book into Funding allocated to local authorities and multi-academy trusts to administer to schools Funding distributed through teaching school alliances. If you wish, please provide any further details on why you have ranked in this order of preference (max 250 words) In the preference list, we marked Funded training places made available locally for schools to book into. Despite the options listed above, we believe that additional money should be spent on psychotherapeutic practitioners who can both work with children and train school staff to recognise children s needs, thus integrating understanding across the whole organisation. One of the most significant findings about children s care is the need for consistency of approach, understanding and culture across an organisation, just as within a family. Above all, it will be necessary to integrate the therapeutic culture across each school. It is professional child psychotherapists and family therapists who understand and have experience of such psychodynamic and systemic realities and ways of working. With such therapeutic cultural UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 2
integration across the school, the government s investment is likely to be considerably more effective than otherwise the whole will be much more than the sum of the parts. The therapists could be sourced from the NHS or elsewhere. The key consideration should be the level of their training. It must be acknowledge that additional funding comes against a backdrop of substantial, long-standing underfunding, and withdrawal of social care support services. The level of extra investment proposed will only fill a small part of the gap. 3. Do you have any other ideas for how the training fund could be distributed to schools? (max 250 words) As above in question 2. 4. Do you know of any examples of areas we can learn from, where they already work in a similar way to the proposal for Mental Health Support Teams? Please give your answer below (max 250 words): Mental Health Support Teams could draw on the experiences and approaches of applied child psychotherapy and systemic family therapy. This includes some CAMHS services, such as Lewisham, Croydon and Bexley, which have previously run services in schools. It also includes the residential therapeutic community movement where whole-school, whole-family and whole-organisation integrated therapeutic approaches have been developed and used for over 50 years. Examples include Childhood First and The Mulberry Bush. These models have been used with great success in healing troubled children and enabling them to thrive and meet their potential. There are also many practitioners amongst the UKCP membership who have developed integrated and creative applied psychotherapeutic approaches within schools, for example Metaphors in Newham. UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 3
Different organisations could take the lead and receive funding to set up the Mental Health Support Teams. We would like to test different approaches. 5. Which organisations do you think we should test as leads on this? Please rank the following organisations in order of preference: Clinical Commissioning Groups Local Authorities Groups of schools Charities/NGOs Others 1. Charities/NGOs 2. Groups of schools 3. Others: new organisations formed by groups of UKCP or ACP Child Psychotherapists who have successful experience of developing working schools. 4. Clinical Commissioning Groups 5. Local Authorities Mental Health Support Teams will work and link with a range of other professionals and we would like to test different approaches. 6. From the list below, please identify the three most important 'links' to test in the way they would work with Mental Health Support Teams: Educational psychologists Local authority troubled families team Local authority children and young people s services Local authority special educational needs and disability (SEND) teams School nurses School-based counsellors Voluntary and community sector support services Youth offending teams Other Local authority children and young peoples services Local authority troubled families teams School based counsellors UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 4
Mental Health Support Teams and Designated Senior Leads for Mental Health in schools and colleges will work closely together, and we will test this working through the trailblazer phase. Trailblazer phase: A trailblazer phase is when we try out different approaches 7. Out of the following options how do you think we should measure the success of the trailblazer phase? Please pick your top three: Impact on children and young people s mental health Impact on quality of referrals to NHS Children and Young People Mental Health Services Impact on number of referrals to NHS Children and Young People Mental Health Services Quality of mental health support delivered in schools and colleges Amount of mental health support delivered in schools and colleges Effectiveness of interventions delivered by Mental Health Support Teams Children and young people s educational outcomes Mental health knowledge and understanding among staff in schools and colleges Young people s knowledge and understanding of mental health issues, support and self-care Numbers of children and young people getting the support they need Other Impact on children and young people s mental health Numbers of children and young people getting the support they need Quality of mental health support delivered in schools and colleges 8. Trailblazer phase: A trailblazer phase is when we try out different approaches When we select areas to be trailblazers for the Mental Health Support Teams, we want to make sure we cover a range of different local factors. What factors should we take into account when choosing trailblazer areas? Please rank the following in order of importance: Deprived areas Levels of health inequality Urban areas Rural areas Areas where children and young people in the same school/college come under different Clinical Commissioning Groups (CCGs) Other: Urban UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 5
Rural Deprived areas 9. How can we include the views of children and young people in the development of Mental Health Support Teams? Please provide your answer below (max 250 words) The views of children and young people could be included both at the development stage and the evaluation/refinement stage. At the outset, children could be asked about the factors that make it more or less likely that they would seek help, and in what settings they would feel comfortable receiving support these could be one factor feeding in to the initial service design. Once a service is running, the outcomes and views of children accessing services should be collected on a routine basis to feedback into service design along with the views of children in the wider school, to check, for instance, if they feel excluded by services, or are put off by them. This should be one part of a wider evaluation package, including assessments of need, access to services, and school-wide mental health and wellbeing outcomes. Piloting a waiting time standard 10. Waiting time standards are currently in place for early intervention for psychosis and for eating disorder services. Outside of this, are you aware of any examples of local areas that are reducing the amount of time to receive specialist NHS help for children and young people's mental health services? Can we learn from these to inform the waiting times pilots? Please give your example(s) below (max 250 words) This consultation does not ask about the factors that need to be considered when introducing this target, so we will write them here. In and of itself, the 28-day waiting time target is positive. It must be delivered with sufficient resource, and be monitored to ensure meeting the target does not lead to a deterioration in service provision to those most in need. Without adequate resource, CAMHS services may raise thresholds for access, or reduce quality of UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 6
service in terms of the number of sessions, or replace experienced staff with cheaper, less experienced staff. Furthermore, a lesson that can be learned from the adult IAPT programme is that services often class an assessment as a first appointment, and then leave a large gap prior to treatment. In IAPT the gap between first and second recorded appointments for 2015/16 was more than a month. Appropriate data collection must be put in place, monitoring access rates, access thresholds, number of sessions, mental health outcomes of all children and young people in contact with CAMHS including long term follow up. Above all the goal should be the nurturing of an integrated and integrating culture, and not on fragmented and fragmenting interventions, which arbitrary targets such as this can easily become. Schools and colleges 11. Schools publish policies on behaviour, safeguarding and special educational needs and disability. To what extent do you think this gives parents enough information on the mental health support that schools offer to children and young people? All of the information they need Most of the information they need Some of the information they need None of the information they need Don t know Please tell us more about why you think this (max 250 words) This very much depends on the school and its culture there are a very wide range of such policies in schools. Published policies can sometimes be meaningful and helpful, sometimes not. This initiative may help the development of better, more comprehensive policies. 12. How can schools and colleges measure the impact of what they do to support children and young people s mental wellbeing? Please give your answer below (max 250 words) The mental health and wellbeing of children and young people in schools should be routinely monitored UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 7
using quantitative and qualitative measures. The Mental Health Team within each school needs to be assessment-led, and therefore to have a clear assessment model, consistently applied, using a range of quantitative and qualitative measures, including standard clinical measurement tools. This means that the Mental Health Lead within schools needs to be a mental health professional we would argue an experienced professional child psychotherapist or systemic family therapist who is both capable of developing and deploying, or selecting and using, such a measurement framework and also designing the psychotherapeutic interventions that are needed to respond to the data gathered and analysed. There are many organisations and practitioners using such assessment frameworks to monitor and shape the success of their therapeutic interventions. Two we can recommend from amongst our members are those of Childhood First and Metaphors. Vulnerable groups 13. In the development of the Mental Health Support Teams, we will be considering how teams could work with children and young people who experience different vulnerabilities. How could the Support Teams provide better support to vulnerable groups of children and young people? Please give your answer below (max 250 words) Virtually no details are given in the green paper about who will staff the Mental Health Support Teams other than a statement about expanding training provision for a new mental health workforce. If the teams are to genuinely help children who are vulnerable, it is vital that they include properly trained and qualified staff. We suggest, at minimum, the inclusion of a UKCP qualified child psychotherapist or family therapist leading this team, with the skills and experience to deal with the full range of presentations they may face. Mental health and behavioural problems cannot always readily identified and addressed by nonqualified staff. Outward manifestations of behaviour can mask deeper causes and needs. It is critically important for the welfare of the child, and wider society, that an experienced and skilled psychotherapist is present. We emphasise that a qualified workforce of psychotherapists already exists, with minimal need for additional training. UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 8
We must also emphasise that good supervision is essential, together with CPD. Supervision, is the norm in the psychotherapeutic world. However, the concepts behind psychotherapeutic supervision could be extended to school staff as a means of supporting them in their work with children who have mental health needs, as well as in ensuring their own mental health. In order to ensure school leaders are held accountable, efforts to promote good mental health should be included in in OFSTED and other assessment frameworks. Support for children looked after or previously looked after 14. As we are rolling out the proposals, how can we test whether looked after children and previously looked after children can easily access the right support? Please give your answer below (max 250 words) This is possible provided the government collects the statistics in the correct way. If statistics are collected on the proportion of children who are looked after and previously looked after, and an estimate is possible on the proportion of those children who have diagnosable mental health issues it would then be possible to see whether those children are more or less likely to get help than other groups with equally severe mental health issues. If they are unrepresented (controlling for severity) then it would indicate that they were not able to access services. However, we suggest a more active approach to ensuring looked after children receive the help they need, which would be provided by the assessment-led approach we are recommending, which could be targeted in additional detail at all looked after and formerly looked after children, many of whom have high levels of need. We also recommend social workers are consulted on this question. Support for children in need 15. As we are rolling the proposals out, how can we test whether children in need who are not in the care system can access support? Please give your answer below (max 250 words) UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 9
Similar to the answer to Q14, it requires statistics on the numbers of children in need who are not in the care system, and the prevalence of mental health issues in this group. Access can then be compared to other groups with equal levels of severity. However, again, we suggest a more active approach to ensuring children in need who are not in the care system receive the help they need, which would be provided by the assessment-led approach we are recommending, which could be targeted in additional detail at all groups of children with potentially higher levels of need. This is an important point as many of these children can be hidden from view. Support for children and young people with special educational needs or disability 16. As we are rolling the proposals out, how can we test whether children and young people with special educational needs or disability are able to access support? Please give your answer below (max 250 words) As per answers to Q14 and 15 above. Providing evidence for an Impact Assessment A consultation stage Impact Assessment was published alongside the green paper. The following questions seek to gather further evidence to inform future versions of the Impact Assessment. We welcome references to any evidence, published or in development, or expert opinion on the topics set out above to help refine our final Impact Assessment. If you have not read the Impact Assessment or do not wish to respond to these questions then please skip to the next section. 17. Please provide any evidence you have on the proportion of children with diagnosable mental health disorders, who would benefit from support from the Mental Health Support Teams Please give your answer below At present, this is impossible to answer with any certainty. There are two big unknowns. Firstly, while it is noted in the impact assessment that 8,000 new staff will be employed in Mental Health Support Teams, which will support 325,000 children by 2027, it has not been specified what the UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 10
qualifications, training and capabilities of the staff will be. This makes a huge difference as to whether the individuals will actually benefit. If the teams include highly qualified staff, like Child Psychotherapists and Family Therapists, then the proportion of individuals who would benefit would likely be considerably higher than if the staff employed only had basic or intermediate levels of training. Secondly, in your impact assessment you assume that 325,000 children will be supported by Mental Health Support Teams (although, for the aforementioned reasons, it s questionable what support these teams will be able to provide). However, you have no current up-to-date denominator, as the last official statistics on the proportion of children and young people with mental health issues were collected in 2004. Without these statistics, it is impossible to calculate an accurate fraction. It is also true that a number of children can be hidden from view in terms of the need for short or long term support with mental health issues and would not necessarily be accessed, and may be hindered by broad assessments. Interventions such as Group-based interventions, eg psychodynamic; story groups; psychodrama can be diagnostic in uncovering needs previously masked by either acting out of withdrawn behaviours. See below answer to question 19. Pre diagnosable: Children and young people who have mild or low-level needs which do not constitute a diagnosable mental health condition but are at risk of developing one and would benefit from a form of support 18. Please provide any evidence you have on the proportion of children with pre-diagnosable mild to low-level mental health problems who would benefit from support from the Mental Health Support Teams. Please give your answer below See answer to questions 17 and 19. 19. Please provide any evidence you have of the impact of interventions for children with mild to moderate mental health needs, as could be delivered by the Mental Health Support Teams. We are interested both in evidence of impact on mental health and also on wider outcomes such as education, employment, physical health etc. Please give your answer below UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 11
The following are of proven success in current use: Group-based interventions, e.g. psychodynamic; story groups; psychodrama Experienced individual counselling and psychotherapy Family systemic therapeutic interventions For family therapy, key references include: Carr, Alan (2014). The evidence base for family therapy and systemic interventions for child focused problems, Journal of Family Therapy, 36(2): 107157. Retzlaff, R. et al (2013). The efficacy of systemic therapy for internalizing and other disorders of childhood and adolescence: A systematic review of 38 Randomized Trials. Family Process. 2013; 52(4): 619652. Von Sydow, K., et al (2013). The efficacy of systemic therapy for childhood and adolescent externalizing disorders: A systematic review of 47 RCTs. Family Process, 52:576618. It is worth noting that without effective assessment mild to moderate will include a wide range of needs including those on a developmental pathway to chronic and severe, for deep-seated reasons that will not be addressed, but may well be quickly uncovered and activated by the interventions of the mental health support team. Hence the classification of need cannot mean that lower-level therapeutic resources will be adequate. All mental health needs must be considered by experienced therapeutic professionals in order to evaluate and work effectively with the conscious and unconscious levels of need, if the work is to be of maximum cost effectiveness and usefulness to the child. This is an example of a time when a generic Mental Health Team may be less what is required than a specialised intervention though it would be important that these are able to work effectively alongside each other and with family systems professional within the setting of a school. 20. Please provide any evidence you have on the impact of Children and Young People Mental Health Services therapeutic treatments. Please give your answer below We have access to a wide range of such data via our members, and would need a more in-depth process to identify and target what would be most helpful to you. UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 12
21. Is there any other evidence that we should consider for future versions of the Impact Assessment? Please give your answer below The forthcoming new statistics on the prevalence of mental health issues among children and young people. It would also be important to take into account more holistic data, as children are rarely affected in isolation from other circumstance. UK Council for Psychotherapy (UKCP), America House, 2 America Square, London, EC3N 2LU 13