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Health and Social Care Committee and Education Committee

Volume 640: debated on Thursday 10 May 2018

Select Committee statement

Mr Deputy Speaker, thank you for allowing me to address the House on behalf of the Health and Social Care Committee and the Education Committee. I am addressing the Select Committees’ report on the Government’s Green Paper on transforming children and young people’s mental health provision, which was published yesterday.

If I tell the House that the subtitle of our report is “failing a generation”, hon. Members will get a sense of our shared disappointment at the scope and scale of the Government’s Green Paper. We welcome the Green Paper but have serious concerns that it lacks ambition, as well as concerns about the very specific measures that it contains. It represents a huge missed opportunity. Every right hon. and hon. Member across the House will know that our mental health services are under enormous strain. There is growing demand that local services are often unable to meet. This is especially apparent when it comes to child and adolescent mental health services, or CAMHS. Our Committees reflect on the fact that half of all mental health conditions occur by the age of 14, and three quarters by the age of 24.

Around one in 10 children are living with some form of diagnosable mental health condition, but this figure stems from a prevalence study that was conducted back in 2004, and the results of a repeated study are not due until autumn this year. We heard from Jonathan Marron, the director general of community care at the Department of Health and Social Care, in an evidence session who said that this figure is not expected to go down. This represents hundreds of thousands of children and adolescents who will be affected by mental ill health, but for whom life should be filled with hope, opportunity and promise.

If ever there was a case for early intervention and, crucially, for preventive measures, it is children’s mental health. The earlier we diagnose and treat a child’s mental health condition when it appears, the better it is for the patient, their family and the NHS. If we leave it until there is a crisis, it is so much worse for those concerned, and costs the NHS and our country far more. So we might have hoped for a raft of preventive measures, tackling the root causes of mental ill health to keep our young people well. Instead, as we report, the Green Paper

“fails to consider how to prevent child and adolescent mental ill health in the first place.”

This is a terrible omission, for if we can tackle the causes of mental ill health in children, we can prevent a lifetime of mental ill health in adults.

There is a significant evidence base for the importance of the first 1,001 days of a child’s life in their development and wellbeing. The Green Paper itself indicated how early years brain development is a key factor for a child’s future and their mental and physical health. We know that there are key factors that are more likely to give rise to child mental health problems, such as parental mental health problems—especially perinatal mental health—and adverse childhood experiences. They were referenced in the Green Paper, but only in passing. If the Government really want to effect change, they need to adopt a preventive approach and do much more work to address the needs of key vulnerable groups at risk of adverse childhood experiences, and very young children as well.

What about the scale of the Green Paper? We report that it lacks ambition. The majority of children will not benefit from the Government’s proposals to roll out “trailblazer” pilot schemes to tackle waiting time targets. These schemes will only affect between a fifth and a quarter of the country, and will not come into effect until 2022-23. That means that between three quarters and four fifths of children who need the extra support will simply not get it. We predict that hundreds of thousands of young people will be left without the proper care that they need, even if the Government’s strategy is a success on its own terms. We express concerns that funding is not guaranteed post-2021 and is dependent on an unspecified level of success. This strategy strikes us as being utterly devoid of ambition, negligent of the true level of need and storing up trouble for the future.

Then there is the question of tackling health inequalities. We heard from many witnesses—in both oral and written evidence—about the correlation between social disadvantage and mental health. The Centre for Mental Health told us that

“the Green Paper makes little recognition of the wide inequalities in children’s mental health. At age 11 children from the poorest 20% of households are four times more likely to have a serious mental health difficulty as those in the wealthiest 20%”.

We asked how the Government’s mental health strategy was integrated in the Government’s other plans to contend with the issue of social mobility, but the Minister for School Standards told us that the two were not linked. Our Committees felt that this was a disappointing response and a massive missed opportunity.

We highlighted the need for services to be tailored for specific vulnerable groups—for example, looked-after children and children in care. The Green Paper’s current proposals will not deliver the support needed for these groups and will miss out others entirely, including children in the criminal justice system, young people who are not in education or training, excluded children and young people who are in further education or undertaking apprenticeships.

Further disappointment was visited upon us when we investigated the degree to which the Green Paper embodied joined-up government. Mental health services for children and adolescents is the archetypal area of policy that needs co-ordination across a range of agencies and Departments—from schools to the criminal justice system, and from the NHS to our youth services and social care. We were very disappointed that there was no reference at all to social workers in the Green Paper. We got no sense whatever that this Green Paper intends to break down the barriers, explode the silos and provide person-centred services. Our report states that

“there must be effective coordination with other initiatives from across Government when building a new strategy.”

Beyond these strategic concerns and issues, our Committees had a number of concerns about specific areas of the Green Paper, and I hope that the House will not mind if I outline some of these.

We looked at the factors affecting children’s mental health, and the fierce system of high-stakes exams was highlighted both by the young people we heard from and educational professionals as a cause of mental ill health. We heard that very much while taking evidence. We reasserted the recommendation of our predecessor Committees that personal, social and health and economic education should be compulsory in all maintained and academy schools to educate young people about wellbeing and to give them a language to discuss their concerns and a space to build resilience.

We were especially concerned about the transition from child to adult mental health services at the age of 18, which was described to us as a “cliff edge”. We recommend that the Government commit to a full assessment of the current transition arrangements between child and adult mental health services. Our Committees looked at the mental health workforce and heard how stretched it already is. We recommend that Health Education England sets out how it will address concerns about the impact of the Green Paper’s proposals on the entire CAMHS workforce, including psychiatrist roles and community services, in its upcoming workforce strategy, which is due to be published in July.

We were concerned by the lack of detail about the training provided for designated senior leads for mental health in schools and the fact that the roles will be voluntary and unfunded. We recommend that the Government should set out an assessment of the feasibility of providing an additional responsibility payment for teachers who take on the designated senior lead role in schools. Further, we recommend that the Government develop contingency plans to ensure that the role could be delivered by qualified professionals. In those plans, they should also consider whether this should actually be the first course of action, rather than a contingency plan.

Overall, we were concerned that the health and education workforce may not have the capacity or capability to meet the extra demands of the proposals in the Green Paper. We recommend that the Government set out and publish plans to ensure that the existing workforce are not overburdened by the demands of the Green Paper. We were specifically concerned that the implementation of the four-week waiting time target for CAMHS referrals could have unintended consequences by making the threshold for accessing services even higher, and we recommend that adequate resource is made available to ensure that this does not happen.

We heard from witnesses that what is needed is a “seismic shift” in the approach to mental health for our young people. We need a system built around prevention, early intervention and personalisation. We need adequate resources and joined-up government to do everything possible to keep our children well and deliver a world- class service. On the evidence of the Green Paper, the Government’s strategy will deliver no more than a minor tremor, not the seismic shift that we want to see. This is a missed opportunity.

I thank the hon. Lady for presenting the report on behalf of the two Committees, where it was a pleasure to join her as a member. Notwithstanding the concerns that have rightly been highlighted, I very much view the report as a piece of work to influence the Government’s future policy making. Noting paragraph 36 on the damaging effects of social media on young people, what work does she think it might be necessary to undertake on this in future?

That was indeed a key part of our report. We had a mixed bag of evidence on social media. We heard from young people and from representatives of the Children’s and Young People’s Mental Health Coalition about this very specific issue. They told us about the opportunities for social media to provide peer support for young people, but also about the many challenges within social media. We said in our recommendation that we look forward to the forthcoming report from the chief medical officer on the impact of technology on children’s health. That will be very important for us to consider in future plans.

The Science and Technology Committee is also conducting an inquiry, and its report will be key. We look forward to the outcome of the work by the working group on social media and digital sector companies that is being conducted in a partnership between the Department of Health and Social Care and the Department for Digital, Culture, Media and Sport. All those pieces of work are incredibly important. As I said, we recommended that teaching on social media should be included in the compulsory PSHE curriculum that we want to be introduced in all schools. That will equip the next generation with the tools to contend with navigating the technological landscape.

I congratulate the two Committees on a very good piece of work, even though it makes very unhappy reading. My hon. Friend referred to the correlation between social disadvantage and mental health. Will she say a little more about how the Government’s Green Paper links to other Government initiatives such as the social mobility agenda?

I touched on that point in my introductory remarks. A report on social mobility entitled “Unlocking Talent, Fulfilling Potential” that was released by the Department for Education just 10 days after the release of the Green Paper on children’s mental health contained just one passing reference to the Green Paper. We asked the Minister about this and were very disappointed that he saw no connection or correlation between the two strategies. Ultimately, from the evidence we heard, this is a massive social justice issue for young people from the most disadvantaged and vulnerable backgrounds. We hope that the two strategies will now be joined up, because that has not been done so far.

I congratulate the hon. Lady on her statement and the two Committees on their report. These joint Committee reports are a really good idea. Paragraph 50 says:

“We recommend that the Government commit to a full assessment of the current transition arrangements between child and adult mental health services.”

I particularly welcome that, because it seems to me and my constituents in Kettering that too many young people are falling through the gaps at 18 and not receiving the services they need as they enter adulthood.

That is a critical issue that was raised on a number of occasions. A cliff edge exists between the services that young people receive until 18 and what happens when they then try to access adult services. The services are very different. In one part of the country, where services go up to 25, this is working very successfully. That was a recommendation in “Future in mind”, a report published back in 2014. We were firmly of the opinion that the Government should actively address this situation and see it amended across the country.

I congratulate the hon. Lady on her statement and the Committees on this excellent report, which I endorse. Does she agree—she touched on this issue—that the absence of a real focus on early years before children get to school, and the absence of any real, in-depth understanding of the impact of adverse experiences of trauma, abuse or neglect in early years, is a gaping hole? Does she agree that the Government need to go back to the drawing board to extend the scope of the Green Paper to really focus on this issue, to gain a better understanding of it?

I thank the right hon. Gentleman for his important contribution. One of our key recommendations was that the Government should publish the evidence review alongside the response to the report. They limited the scope of the Green Paper too early by restricting the terms of that evidence review. In fact, we heard in evidence that evolved during our inquiry that under-fives are completely absent from the Government’s plans, yet that is a time in a child’s life that determines their life chances and life outcomes. Clearly, this is very much a gaping hole that needs to be addressed.

I congratulate my hon. Friend on her introduction of this excellent report. Desperate parents in my constituency report waiting months, sometimes over a year, for their children to receive assessments or to see mental health professionals. Her comments on workforce issues are therefore particularly welcome. One issue is the very high level of staff sickness due to stress. What comments has she to offer the House on how the wellbeing of staff should be part of the Government’s strategy?

I thank my hon. Friend for her important contribution. The chapter on the workforce was a key part of the report. The wellbeing of both the mental health workforce and the workforce in our schools and education sector should be addressed adequately. That is not happening at the moment. We heard in evidence that the mental health workforce, particularly for children, has the greatest vacancy rates. No doubt that is one of the reasons there is such a high absence rate due to sickness. We hope that Health Education England will heed our recommendation on the need to address an area that is massively wanting.

Prenatal exposure to alcohol causes permanent brain damage and is one of the contributory factors in mental ill health among children—and indeed into adult life as well. In a recent study, as many as 40% of women said that they may have drunk alcohol during pregnancy. May I, through my hon. Friend, urge the Government to carry out a prevalence study on exactly how many children are damaged in this way? There is also a need for much greater awareness. The chief medical officer’s advice is that those who are planning a pregnancy or are pregnant should not drink alcohol, but that advice is not widely known. May I, through my hon. Friend, urge the Government to make sure that far more is done to raise awareness of the damage done by this condition?

I thank my hon. Friend for his comments. No doubt the Government were listening to the very important points he has made. We did not address this in our report, but clearly issues around perinatal mental health and support for expectant mums are very important, including in the area that he mentions.

The report refers to the Government’s proposal for a four-week time limit for access to mental health services for children. My hon. Friend will know that access has been a huge issue. She talked about unintended consequences. What was the Committee’s view on what needs to be done to avoid those?

Officials in the Department of Health and Social Care told us that they expect that there will be some unintended consequences in seeking to achieve the four-week waiting time target if there are not adequate resources to make sure that the staff are in place to meet these young people’s needs. We know from the evidence we heard that right across the country there are already massive waiting times. In my own area, for example, 460 young people are waiting 24 weeks just for an assessment, let alone treatment. Unless we know that there will be more counsellors, psychiatrists and psycho- therapists to support these young people, there is no way that the Government will be able to introduce a four-week waiting time standard without raising thresholds for young people to access those services. That is a key recommendation of our report that we want the Government to address.

I, too, thank my hon. Friend for her statement and the work of the Committees in producing this really important report. Paragraph 81 goes to the heart of the matter:

“The Government should consider in its plans whether the role being delivered by qualified professionals rather than teachers should be its first course of action rather than the contingency plan.”

Does she agree that, owing to the scale, seriousness and severity of mental health challenges in young people, the Government should build a service based around school but available out of school and staffed by mental health professionals?

I thank my hon. Friend for her comments. A key concern we heard from education professionals in written evidence was how those designated mental health leads will be able to do their job. It was not clear from the evidence we heard from the Minister for School Standards that adequate resources will be in place to equip those teachers with the skills they need to do that role. That is why we recommend that there should be a specific payment and that it should be a senior role. That is also why we recommend that mental health professionals should not be a contingency; the first port of call should be those professionals in mental health, who have a fuller and wider training to be able to fulfil that role, rather than relying on teachers, who already have a massive burden.

I welcome this very valuable report, and in particular paragraphs 31 and 32 on building resilience against exam pressure and the effect on mental health of the narrowing of the curriculum. However, rather than building resilience against something that is likely to be causing part of the problem, did the Select Committee ever consider suggesting an independent root-and-branch reform of the assessment system, and in particular key stage 1 and 2 SATS, which we hear are a large cause of this problem up and down the country?

I thank the hon. Lady for her comments. Some people are keen to paint this issue as being just to do with social media, which is why I sought to address in my remarks the fact that, in the view of many who sit on the Committees, the No. 1 concern is the academic system. That is why one of our recommendations says that:

“the Government should gather independent evidence concerning the impact of exam pressure on young people’s mental health”.

We want to see that right through the entire education system, including the stages she mentioned.

We also need to look at the narrowing of the curriculum. We heard from young people about the pressures they felt that that put on them, which was exacerbating their mental health issues. We would like to see that addressed. We were disappointed with the response from the Minister for School Standards, who said that there was no connection or correlation between the two. We heard clear evidence that it has a very negative impact on too many young children in this country.

I thank my hon. Friend for making such a compelling case on behalf of the two Select Committees. This is a very important report. One problem with the slowness of assessment and treatment is that cases often end up in the courts, which costs a fortune and means that things play out in a spirit of confrontation between parents and the authorities. That cannot be any good for the children. Does she agree that we ought to do something about that?

I thank my hon. Friend for his comments. We are clear that too many children are ending up in crisis and needing support. It might ultimately end up in the courts, but they are definitely in crisis. That is not good for them, their families, the NHS or society. I do not like to talk about this in financial terms, but it comes at a massive cost to society. For all those reasons, we should be doing everything possible to prevent mental ill health in our young people in the first place. If we cannot prevent it—we cannot prevent everything—we should at least intervene earlier, for financial reasons but also for the social and moral reason that it is important to give every child in this country the best chance in life.

Several Members have mentioned the need for interventions for the under-fives. My hon. Friend visited the Bangor mindfulness centre in north Wales with me a couple of years ago. A curriculum for three to seven-year-olds is being developed in north Wales. What role does she think mindfulness can play in infant, junior, secondary and tertiary education?

I thank my hon. Friend for his comments. I have had the opportunity to see at first hand the benefits of mindfulness, particularly in education. I look forward to seeing the results of the curriculum being developed for three to seven-year-olds. We did not specifically address that in our inquiry and report, but it could be contained within the PSHE curriculum that we would like to see introduced in all schools, both primary and secondary, and could particularly target the under-fives. The Government should look closely at that.

Is my hon. Friend aware that young people are self-medicating due to stress, because they cannot get access to the mental health services that they need? Does she think that that is worthy of note in the report?

I thank my hon. Friend for his comments. While we did not talk about that explicitly in our report, we were able to have an informal discussion with young people from across the country, including young people being cared for by Place2Be, a mental health organisation that supports young people in schools. Young people said they were turning to illegal medication or prescription medication that they were getting through illegal means to make themselves feel better. That is clearly an issue for our young people. I know that my hon. Friend has raised that in the House, and I hope the Government will look specifically at it.

I would like to thank members of both Select Committees for this very forthright report. I was pleased to be part of the inquiry, and I would particularly like to thank the hon. Lady for bringing the report to the House. It is one of the most important reports for the next generation.

I want to raise two particular points. The first relates to workforce planning. As chair of the all-party parliamentary group on psychology and as a psychologist, I was very concerned by the evidence that educational psychology training places are being reduced and clinical psychology training places are currently inadequate, despite the fact that the Government’s delivery of the strategy relies very much on supervision from those key professionals. Secondly, we need to be targeting complex groups where more than one difficulty is present, such as the many children with autistic spectrum disorder who also suffer mental health problems comorbidly. Much more must be done on access to autism diagnosis alongside treatment and early intervention for mental health issues.

I thank the hon. Lady for her important contribution, which emphasised the need to focus on the workforce that the Government are expecting to deliver their Green Paper plans. We know that Health Education England is due to publish in July this year its workforce strategy, and I sincerely hope that it has listened to the points we heard in the Committee and those that she just made about the massive gap that exists in terms of psychologists and child psychiatrists in the community. That is a critical issue.

On the hon. Lady’s point about comorbidities, there is a gaping hole in the Government’s Green Paper on the children who are the most vulnerable and need the most support. There are references to children from the most vulnerable backgrounds, but nothing in practice about how that might be addressed. I hope that, in the Government’s response, they will reflect on our recommendations and seek to bring forward proposals that target children who most need support.

I congratulate my hon. Friend on the way she has introduced the report and the Select Committees on producing it. She will know that YoungMinds and NHS Providers have expressed concerns about the fact that increasingly high eligibility thresholds for child and adolescent mental health services mean that the mental ill health of children and young people escalates to crisis point before a referral. That was reinforced by the Care Quality Commission’s thematic review, which recently reported that GPs were telling children to pretend to be more ill than they were, to ensure they got treatment. There is much for the Government to respond to in the report, but will she join me in calling on them to investigate that urgently?

I thank my hon. Friend for her important contribution. On the thresholds over which children have to jump to access services in the first place, I get emails almost every week from young people or their parents or carers, sharing their experiences of how long it has taken them to get access to services, if they have even been able to get through the door at all. Young people are having to attempt to take their lives before they see a clinical professional. That is not acceptable, and the Government need to address it now if they are going to successfully implement their plans.

One of our recommendations was that within the mental health investment standard introduced by the Government to ensure that clinical commissioning groups apportion a certain amount of funds to mental health, there should be a specific ring fence for children and young people’s mental health. We know from the investigations and research that has been done that at the moment, too many clinical commissioning groups are diverting money away from young people’s mental health to other parts of the NHS. It is under enormous strain, but that money needs to be protected.