Part 2: Lib Dem Peers call for improved mental health services for young people

Yesterday we reported on the debate in the House of Lords on mental health services for children and young people secured by Earl Russell.

We thought you might like to read the other Lib Dem contributions to the debate. First up, Richard Allan who talked, among other things, about the effect of bullying on mental health:

My Lords, I am grateful to my noble friend Lord Russell for securing this debate. Like many others, I am impressed by how quickly he has brought value to the work of this House and by the combination of passion and reasoned argument that he brought to today’s debate.

I congratulate the noble and learned Baroness, Lady Hale, on her maiden speech. I had not realised that she is from Yorkshire but, based on the comments of the noble Baroness, Lady Hollins, I can say, as a Sheffielder, that we are now on a Yorkshire hat trick as a group of three speakers. In my household, it is not often that we talk about the law as a cool and attractive profession, but the activities of the noble and learned Baroness in her previous role triggered such comments. Based on her contribution today, I am sure that, in future, she will provide examples of how our words here can be both impactful and entertaining. I hope that she does not let her natural diffidence get the better of her too often.

Turning to the subject of the debate, I start with a question: what do we call a family with experience of child mental health issues? The answer is “a normal family”. That has been reflected in the debate, as well as in my noble friend’s contribution as he related his own experience, but I suspect that every person sitting here today has their own direct personal experience of a young person suffering from mental health issues during their childhood, whether through their children, their nieces and nephews, their grandchildren or those children’s cousins. This understanding is necessary not to trivialise the matter—quite the opposite. If we normalise it, we may get to a position where we understand that child mental health issues need to be treated as seriously as other child health conditions, with an infrastructure and an understanding that, as my noble friend said, it is unacceptable to ignore them or somehow treat them as less serious.

The tools that we need to help people are common to all kinds of healthcare. First, we need early and accurate identification of problems. Secondly, we need good availability of the right treatment options; that is the case whether it is a physical issue or a mental health one. There are also four settings that need to work for young people in order to achieve these goals of the identification and treatment of the issues with which they present. The first is families themselves; the noble Baroness, Lady Hollins, referred to the importance of family as the primary setting. The second is the educational institutions in which children find themselves; the third is primary healthcare; and then there are the acute services to which children may need to turn. I will not go into the issues around family support in any depth today other than to flag the fact that families and the care they provide must be recognised and supported. There is an important objective for government in supporting families who provide care for somebody, whether they have a physical condition or a mental health one; that care provides enormous value to the individual but also to society. There are questions around the extent to which, today, government provides the support that those families need.

I turn to educational settings. These are generally schools for younger children but we should not forget the significant role of universities and colleges. That is important because we are talking today about children and young people; to me, that extends through into those university years. It is another period of transition. For many of the young people who reach the age of 18 or 19 and transition to university, that is when the crisis hits. Again, universities have a critical role to play in this.

Major shifts are needed to improve staff training. Staff across all these different kinds of establishment need to be trained in such a way that they can help identify problems, because problems may first present themselves in an interaction between a young person and a professional in an institution. We also need to make sure that counsellors are available when they represent an appropriate form of treatment; they are frequently the first line. The Minister has made commitments around both those aspects previously—the training of all staff in educational establishments where that may be useful in identifying problems; and the provision of counselling services to the right degree so that, when issues have presented themselves, that first line of treatment is available—so I hope that he will be able to demonstrate progress.

I am interested to understand from the Minister how budgets will operate in this space given that it sits between different government departments. The young person does not care that one thing sits with DHSC and another sits with DfE, or whatever acronyms we are using now; they care about whether treatment is available. I hope that the Minister can indicate how we will ensure that budgets follow need rather than being stuck in departmental silos.

I want to touch on bullying, which can be both a cause and an exacerbating factor for somebody with mental health issues: it can trigger the mental health issue but, sadly, the start of bullying can also sometimes be the response of young people to someone in their school who has a mental health issue. It then compounds the crisis that a young person is suffering. The challenge is to have an effective response because these issues are often labour intensive, requiring engagement—often over a long period—with the children and families involved.

As noble Lords may be aware, I have professional experience of the online component of this as I spent many years working at a large online platform. It seems obvious that the nature of bullying has changed with ubiquitous connectivity. However, sometimes, there is also the risk of us seeing the solutions as entirely within the domain of technology. People report bullying to a platform, which can result in the removal of the content and sometimes the closure of the bullying account, but it rarely solves the underlying problem.

In some cases, the bullying is entirely within an online community, but much more typically the online activity is an extension of something that is happening offline in the real world. The intervention that resolves the problem is one that brings young people, parents and others together to discuss the offline and online activity. I understand the challenges for school staff in resourcing this, but some option will have to be found or we will simply be playing whack-a-mole on the online platforms, knocking down individual instances while the young person’s mental health continues to deteriorate because the bullying is moving from place to place and never being addressed at its root causes.

Some of the best work that I have seen on this involves civil society organisations working with schools. I cite one young person, Alex Holmes, an individual who experienced online bullying in large part because of a racial dimension. He came to me when I worked at an online platform to try to turn his experience into something positive. He went on to work for the Diana Award and he now works for the BBC Children in Need foundation. I saw the work that he did, and that similar organisations do, complementing the work that is being done in schools, running effective anti-bullying programmes and getting the kind of intervention that we need to deal with those root causes. I hope that the Minister will agree that this kind of approach, bringing together schools, platforms, online platforms, which do have their responsibilities, and also civil society organisations with anti-bullying expertise, is a smart way to reduce the risk of bullying affecting young people’s mental health.

The other natural choice for people who are seeking help is to look to primary care, particularly their GP. The response is likely to vary considerably, as not all general practices have the skills to offer specialist mental health support. This is not to criticise or blame GPs but is a simple recognition of the limitation in capacities in most practices and that the support needed may go beyond that which the GP contract was designed to deliver. GPs are bound within a particular framework. This may result in the GP referring someone to a mental health service, but it is worth asking whether more could be done in the primary care setting itself. This might be better for the patient, it might involve shorter waiting times and, from the Minister’s point of view, it may well be more cost effective, which the department would see as a positive take.

Recently, I met with a group of mental health nurses working in primary care at the Royal College of Nursing who made a very strong case for developing their profession. At the moment, there are not mental health nurses in all practices, but some of the best practices do have them. This could happen on a group basis—for example, where a primary care network contracts together to ensure that there is a mental health nurse available so that, whichever GP you go to, you get the benefit of that mental health nurse; it does not necessarily require every practice to have one. The noble Baroness, Lady Hollins, referred to the need for public health support. Understanding the pattern of need and ensuring that you resource appropriately is critical and something that public health professionals really can help with. This could also be delivered through specialist centres. We propose that there should be youth mental health drop-in centres. This is something that we need to ask young people about. It may be that they would prefer a different setting from the general practice setting if they want to talk about something as sensitive as this. In either case, the critical thing is that there is some trained professional available to that individual if they present within the primary care system. Today, we must recognise that support is very patchy.

The acute sector will be necessary for some young people as other interventions have proved insufficient. I think that we will come back to one aspect of this in our next debate, but I have some questions for the Government now. The first is whether there is sufficient investment in community-based treatment for people with serious mental health that allows them not to be moved into in-patient settings except where this is strictly necessary. Some of the stories that are reported to us suggest that people are being taken to an in-patient setting not because that is the best treatment option but simply because their complex needs cannot be treated in a community setting due to resources, not due to the fact there is no treatment available. It is a shame if we are moving people to in-patient settings where it is not necessary. I would be interested in the Minister’s view on whether the test is being met or whether too many young people are still being treated as in-patients only because of that lack of appropriate out-patient support.

Secondly, and somewhat related, there is the question of where young people go when they need a place in a hospital. It is usually beneficial for all patients, but especially for young people, to be near to their home area, for the family visits and support and, crucially, because of their reintegration into the community on discharge. Being taken far away and then moved back is clearly more disruptive, particularly if you are going through a process of phased discharge from an institution, when it is much more helpful to be in your home community normally. There are exceptions, but typically we would want to see that. I am keen to understand the Minister’s views on out-of-area placements and how these can be minimised where they are not helpful from a treatment point of view.

Once again, I thank my noble friend Lord Russell for securing this debate, and I congratulate the noble and learned Baroness, Lady Hale, on her maiden speech. I close with a ready reckoner reminding the Minister of the issues which I hope that he can address in his response. Are the Government committed to building a culture where we treat mental health on a par with other forms of childhood illness? How are the Government ensuring that educational institutions can provide the support that their students need, especially around anti-bullying where that is a significant component in mental health problems? What is the department doing to provide more specialist support in primary care settings, whether that is by GPs or dedicated centres? What is the NHS doing to minimise the need for in-patient treatment where there are out-patient alternatives available but it is simply a question of resourcing? Finally, what are the Government doing to ensure that placements are not out-of-area where in-patient treatment is unavoidable?

Mike Storey looked at mental health provision in schools:

My Lords, I want to look at mental health in the context of schools. Before I do, I congratulate the noble Baroness, Lady Hale, on her maiden speech. She is wearing a butterfly brooch, as opposed to a spider, and I feel more relaxed seeing that. I also congratulate my noble friend Lord Russell on his speech. I thought it was very honest, and perhaps brave of him, to reference his own family and his daughter in an open Chamber.

I will give two brief examples before I turn to children. Four years ago, as part of Learn with the Lords, I went to speak to some secondary pupils at a school in Cheshire. The school was on a large council estate. I went into the school and the head sort of pushed me off with one of her teachers, and so I went in and spoke to the pupils. When I came out, the head asked me if I would like a cup of tea, and I said yes. I got into her office and she just burst into tears. I did not see it coming and I did not know what to do. She just stood there crying, so I naturally gave her a cuddle. She pulled herself together and said, “I’m really sorry about that. I have just had a letter from Ofsted telling me that we are a failed school, and I don’t know how to tell my staff. My staff are so hard-working. This is a very difficult circumstance for the school and I just don’t know what to do.”. We talked it through, and that made it clear to me that when we talk about mental health in schools, we should think about the teaching and non-teaching staff as well.

Interestingly, a friend of mine is head teacher of a three-form entry primary school of more than 500 pupils in a very deprived part of Liverpool. I asked—I will call him by his first name—Andrew how he is coping in his community. He said, “Well, I see my job not as a head teacher but as a social worker, quite honestly”. I turned to the subject of mental health and how he supports the pupils in that school. He said that from his school budget, he is able to spend £10,000 on one person to support the probably hundreds of pupils in his school who need mental health support. He said that the problem is that professionals are in high demand and other schools will pay more to poach them. He said, “I am lucky to get somebody to stay with me for a year”. That is a major problem. If we are to support pupils, children and staff in schools, we will need to be sure that professionals are available to do that and that they will not suddenly leave, leaving disappointed pupils and a case load of other children for somebody else to deal with.

My noble friend Lord Allan mentioned the second problem we face in education. There are literally—this is no exaggeration—hundreds of thousands of children missing from our school registers. They are missing because they were at home during Covid, they came back to school and they could not cope. They went back to their parents, mainly in deprived communities, and said, “Mum, dad, I don’t want to go to school. I can’t cope”. “Oh, stay at home. We will have home education”, they were told. As we know, home education is not registered. After a brief period, those children increasingly do no home education at all.

Imagine the strain that puts on the parent and the mental problems it will create for those children in the future. We can see that in the published figures and the increasing numbers of children who are permanently excluded from school. We have hundreds of thousands of children missing from our school registers, and there are even children who have been put on education healthcare plans who are permanently excluded from school, so we cannot implement those plans. That does not seem in the best interests of our pupils’ education.

Why has the number of children with mental health problems in school increased? Perhaps we have always had children with mental health problems in our schools but have never recognised or realised it. Perhaps we thought, “This is a disruptive child” or “This is a child with behavioural problems”. Thankfully, that is not the case now.

We know why there has been such a dramatic increase: Covid was one reason. I was also interested in my noble friend Lord Allan’s comments on social media, but the pressures of it—of having to respond, and the potential bullying—all create mental anguish and problems.

Our school system does not help. We are the most tested country in the world. We subject our children and young people to more tests than any other country does. Imagine the pressure that puts on young children. Imagine the pressures of Ofsted: I mentioned the example of the head teacher I met, and we know the tragic circumstances of the head teacher who took her own life as the result of an Ofsted inspection. All those pressures are happening at schools, with the high grades that schools require their pupils to achieve. What happened to the enjoyment of school? What happened to discovery and fun in school? It is all focused on a results outcome.

We name and shame. We put banners outside schools saying, “We are a good school”. In schools that do not have that banner, do parents and children feel a sort of anguish as a result? Our education system is not conducive to people’s well-being.

As has been said, we need to ensure that teachers are properly trained. As I have said on so many occasions, I do not think that Teach First, which takes a graduate, gives them a few weeks’ intensive training and then puts them in a school with a mentor, is the best possible way to train a teacher. It took me three years and when I started teaching, I was still learning. There needs to be an understanding of child development, for example, and of how to identify special educational needs. Part of that training should also include an understanding and recognition of mental health problems.

Finally, we need to support parents. We also need parents to understand what they can do to support their children. They need to bring routine to their children’s lives, to talk to their children, to ask how they are doing, to encourage them and be able to speak to them.

Mental health is a very serious issue in education and schooling. If we think that we can just put in a few million pounds here and make a promise there, it will not go away. We need dedicated, well-trained professionals in our schools who know what they are doing and how to support those pupils.

Finally, Claire Tyler spoke about the postcode lottery of provision across the country and the sheer scale of the numbers of children suffering. In one horrifying anecdote, she said that CAMHS were refusing referrals until a child had made two viable attempts on their life.

My Lords, it is always a great pleasure to follow on from the wise words of the noble Lord, Lord Laming. I congratulate my noble friend Lord Russell on securing and introducing this debate in such a moving and comprehensive way. It is such an important issue and is very dear to my heart. I also congratulate the noble and learned Baroness, Lady Hale, on her excellent and highly entertaining maiden speech. I was a bit perplexed when I saw that it was her maiden speech, but now I understand. I also thank the many charities and others in the sector who have sent me excellent briefings.

It has been an excellent and very well-informed debate. I will pick up on some of the main themes covered. Quite rightly, we have heard a lot about the state of children’s mental health in this country, and many of the statistics are indeed bleak. To summarise a complex picture, an increasing number of young people are experiencing mental health problems for a wide range of reasons, which have been highlighted compellingly today. Yet far too many are unable to access the help that they desperately need, either through school or NHS services.

Without doubt, young people’s mental health services are struggling to meet demand. As a result, thresholds for treatment are very high, with many young people turned away because they are “not well enough”. Those who do get accepted into CAMHS are often left waiting many months, if not years, for treatment, during which time their mental health often deteriorates.

I will say a few more things about demand for, and access to, services. Mental health providers are concerned that they are seeing an increase in both the severity and complexity of the mental health needs of children and young people—exacerbated by both Covid and the cost of living crisis, which we have heard about today. The NHS Confederation estimates that demand has increased by 89% and that mental health services are treating double the number of children and young people with eating disorders who need urgent care than before the pandemic—which we just heard about. That is the equivalent of six children in a class of 30. The number of referrals to CAMHS reached a record number in May of this year and the number of urgent referrals of children to crisis teams has also reached a record high. Particularly worryingly, suicide rates among young females have been steadily increasing.

Looking ahead, it is pretty daunting. It has been estimated that 1.5 million children and teenagers will need new or additional support for their mental health over the next three to five years. That is going to take a very different approach. The unpalatable fact is that only around a third of children with a probable mental health problem are, at the moment, able to access treatment. I think that shows how far away from parity of esteem with physical health we really are.

I am particularly concerned about the huge regional inequalities and the lottery of what support is available depending on where you live. My noble friend Earl Russell referred to an FoI investigation by the journalist Justine Smith, published in the House magazine in April. It revealed a postcode lottery in child mental health care, with some desperate young people waiting up to four years for help. Results from the 58 trusts and boards that responded to the request showed that the position in England was considerably worse than in Scotland and particularly Wales. Almost three-quarters of the English trusts said that they currently had at least one young person who had been waiting at least a year, and two-fifths had someone waiting at least two years. Funding ranged from £35 per child under the former Doncaster clinical commissioning group—0.5% of its total budget—to £135 per child in Salford, or 2.2% of its budget. That is a huge difference. I think variations of this scale are simply unacceptable. This data needs to be tracked and published regularly to throw a spotlight on what is going on locally.

On funding, years of underfunding and neglect of children’s mental health services have taken their toll, as we have heard loud and clear. They have been subject to what I call the “double Cinderella syndrome”, or indeed the “double-8 syndrome”—by which I mean that only 8% of mental health services spending was spent on children and young people’s mental health in 2021-22, and in 2022-23 just over 8% of the NHS budget was spent on mental health generally. To meet increasing demand, it has been estimated that funding for mental health services would have to rise to as much as £27 billion by 2033-34. That is the backdrop against which the very welcome but, frankly, relatively modest increases in government funding since 2017 should be viewed.

The NHS Long Term Plan, published in January 2019, included a welcome commitment that funding for children and young people’s mental health services should grow faster than both overall NHS funding and total mental health spending. But it has become harder to track whether this has happened in the switch from CCGs to integrated care boards, and with the changes to how the mental health investment standard and the dashboard operate. So could the Minister say when the NHS mental health dashboard is next due to be updated and whether, and by how much, the commitment in the NHS Long Term Plan has been met? If he does not have those figures to hand, could he please write to me.Toggle showing location ofColumn 851

A point not covered so far in our debate relates to the fact that mental health is now part of a new major conditions strategy, rather than having its own stand-alone strategy. I know that many consider that a regressive step. This occurred following the cancellation of the previous long-term mental health and well-being plan that had been proposed by the Government. With the new major conditions strategy focusing on a range of conditions such as cancer, heart disease, musculoskeletal disorders, dementia and respiratory diseases, there is a clear risk that it will focus mainly on middle-aged and older people and that the mental health of infants, children and young people will be neglected.

So, what is needed? A lot of it has been covered in today’s debate and I support others who have been calling for a comprehensive cross-government strategy, looking at all aspects of mental health support. There are a number of things that need to be included.

I will start with prevention; any good strategy should start with prevention. The Royal College of Psychiatrists has recently published a report calling on the Government to prioritise the mental health of babies and children. It set out evidence showing that intervening very early on may help stop conditions arising or worsening, and prevent babies and young children developing mental health problems in later life. This might include support for mothers in pregnancy, working with parents to promote attachment to their children and recommending parenting programmes in the early stages—many of the things that the noble Baroness, Lady Hollins, talked about. I very much hope that family hubs will develop such services so that they are available wherever people live. Could the Minister say whether this is the case? I fully endorse the calls today for the family to be supported as the primary source of emotional support and well-being.

I turn next to early intervention services. Again, we have heard today how crucial early intervention is to stop problems escalating. In other words, the earlier a young person can get support for their mental health, the more effective it is likely to be. That is why I have been a strong backer of the early drop-in support hubs for 11 to 25 year-olds. They are on a self-referral basis, which I think is exactly what is needed, and are embedded in the community. They have been championed by YoungMinds and many others. I very much welcome the £5 million announced by the Government last month for 10 existing hubs and I strongly support the call for a national network of hubs to support young people who do not meet the threshold for CAMHS support.

I move on to schools, which have an absolutely vital role to play, as my noble friend Lord Storey set out so eloquently. I have always supported the creation of mental health support teams in schools. I was struck by research evidence earlier this year from Barnardo’s, which delivers 12 such teams. The research found that the teams are effective at supporting children and young people with mild to moderate mental health problems. They improve their outcomes and, critically, are cost effective; they say that they save the Government £1.90 for every £1 invested. But, as we all know, the problem has been the frankly glacial rollout of this programme.

The high demand and long waiting lists for CAMHS that I talked about earlier place real pressure on these mental health support teams, which were not really set up to deal with the more severe issues. The Barnardo’s research identified a gap in the current model to address the needs of children with moderate or more complex needs, children with special educational needs and younger children. It recommended that the rollout should include school counsellors to fill this gap. I support this recommendation and am delighted that next Monday I will be introducing my Private Member’s Bill, which is designed to ensure that every school has access to a qualified mental health professional or school counsellor—a key Lib Dem policy, as we heard earlier. I hope that this will provide a much-needed boost to ensure that all schools are able to provide their pupils with the mental health support they need.

I turn briefly to CAMHS services. As the Children’s Commissioner pointed out in her annual report, the stark reality is that too many children still face high access thresholds, rejected referrals and long waiting times. Children’s mental health was looked at by the Lords Select Committee examining the implementation of the Children and Families Act 2014, which I had the honour to chair. We were shocked by the results of a survey we commissioned, which showed that in many places CAMHS had reached crisis point. I vividly remember one mother, who told us:

“Having had a seven-year-old son who was so dysregulated he was trying to throw himself out of windows and grabbing knives, there was no support for him (or us). The GP, after two failed CAMHS referrals as he ‘didn’t meet the threshold’ told us, if we could at all afford it, even if it means borrowing money, to find support privately. That CAMHS will not accept a child unless they have made two viable attempts on their own life”.

I join my noble friend Lord Russell in asking the Minister what plans the Government have to implement the four-week clinical access standards for children and young people’s community health services, which have already been piloted? What have those pilots found? Will a fully funded plan be introduced to reach those standards?

In-patient care is another key area of concern that has come up today. It is estimated that some 3,500 children under the age of 18 are admitted to mental health in-patient facilities. As my noble friend Lord Allan said, despite the commitment to eliminate out-of-area placements, too often children are still being admitted to places far from home without a clear understanding of their rights and subject to restrictive interventions and inappropriate care. The right reverend Prelate the Bishop of St Albans made that point compellingly.

The transition to adult mental health services is just not working for too many young people. The NHS long-term plan set out an ambition to move to a nought to 25 model for young people. I supported that, but it is not clear what progress has been made towards it. Is the Minister able to say more about this? There is significant variation across the country in the age at which young people are expected to move to adult services. This transition is often abrupt and based on a person’s age rather than their readiness. Differences in threshold also mean that young people getting support from CAMHS may not meet the threshold for support for adult services, so yet again they fall through gaps.

I finish with a number of questions for the Minister. I ask him to write to me if he is unable to answer them now. What plans do the Government have to expand access to mental health support teams to children and young people across all schools and colleges in the country as quickly as possible? How do the Government intend to tackle the major regional inequalities in spending and wait times for CAMHS? Given the Government’s regrettable decision to roll back on previous plans to publish a stand-alone 10-year mental health plan, can the Minister say how the Government will ensure that the inclusion of mental health in the forthcoming major conditions strategy will properly tackle the huge challenges in children and young people’s mental health? Given the recent funding for the 10 innovative early support hubs, can the Minister clarify when this programme will report, what the evaluation will entail, and whether Ministers will commit to a rollout if findings are favourable? Given the postponement, yet again, of the long overdue reforms to the Mental Health Act, what immediate action are the Government taking to improve the plight of under-18s admitted to in-patient care units to ensure they and their families are aware of their rights and receiving appropriate care?

Today’s debate has shown that there is a lot of consensus on what we need to do. I hope the policymakers will listen to us so that we can make real progress.

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2 Comments

  • Steve Trevethan 9th Dec '23 - 12:22pm

    Might it be that the around 25% plus of our children and young people who are permanently underfed/hungry/starving affects emotional and mental health?

    Might this be made more harmful when our hungry children and young people cannot avoid seeing multiple pictures of well fed royal children dressed in expensive clothes?

  • Steve Trevethan 10th Dec '23 - 8:13am

    Thank you for another important article!

    Might it be that emotional and mental health are much affected to controlled by our personal relationships with our world, our perceptions of it, our relationship with our inner selves and our feelings about them?

    Might all relationships be somewhere on a continuum between the symbiotic and the parasitic?

    Might the relationship between our recent and current government and the economically vulnerable, not least the not rich young, be too far towards the parasitic pole?

    Might this affect personal relationships with the world and relationships within individuals?

    Might this form of material and emotional oppression of the not rich contribute to an avoidable increase in emotional and mental well-being problems?

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