Dear Prime Minister,
Your time in office is coming to an end. I realise that the frustrations of the last three years have been huge, and that many of your political hopes have been casualties of the Brexit impasse. With all that’s gone on, it’s good to know that you haven’t given up on other issues. It’s even better to hear that one place you still hope to have an impact is on the mental wellbeing of children. I’ve been reading the Government’s Green Paper on transforming young people’s mental health and I have a few thoughts I want to share. This isn’t a straightforward subject and I’d really like what you do to have lasting benefits.
Before getting to the tricky bits, I do want to first say thank you. It’s a relief to finally get some money aimed at supporting young people. The green paper does seem to be taking the results of its consultation seriously. And, credit where credit is due, it’s refreshing to have an acknowledgement that mental health provision in this area is far short of where it needs to be. Having worked in child and adolescent mental health services (CAMHS) for 20 years, I have seen the current situation develop slowly but inexorably and through different governments. A huge rise in referrals has never been balanced out by an equal rise in funding. With scant resources services often end focusing on the most complex young people. This complexity means that throughput is reduced and staff either leave or go off sick as their caseloads become more risky and difficult. Space for new referrals is inevitably reduced.
To address this bottleneck the Green Paper is largely focused on early intervention. The reasoning goes that if we solve problems at an early stage, we will reduce the number of people who get to crisis. This is an admirable aim, but the evidence on early intervention reducing problems later on is rather thin. This is the case whether it’s reducing emotional distress or increasing resilience. It’s actually more likely that early intervention risks increased demand for CAMHS by directing more and more children towards specialist pathways. Your critics have been quick to point out that the resources to meet such an increase in referrals are just not there.
Of course picking up unmet need can be a very good thing and may help stimulate more investment in CAMHS longer term. However, offering mental health screening in places such as schools means also more of life is seen through the lens of diagnostic categories. Our childhoods and teens can be tough: difficulties with friendships, anxieties about schoolwork, the pains of loneliness and confusions about where we fit in all go with the territory. While children who genuinely need more in-depth intervention may be identified by teachers, it is worth asking if the struggles of an “ordinary” childhood are always best seen as depression or anxiety? Perhaps they might sometimes better be addressed with kind and supportive adults giving good pastoral care than by deciding that children are sick?
When you’ve been around in this area though you begin to realise that initiatives such as prevention are not so new. Many of the problems I’ve described, and a good many others, have been encountered in the past. I know time is short but there is a chance to make a difference and, I hope, to avoid some of the pitfalls. With that in mind here is my advice to you, Prime Minister. I hope it goes well. Well enough to be a lasting legacy.
Build on what has gone before and don’t re-invent the wheel. Previous governments have spent millions on early intervention initiatives. They may be great at reducing stigma, but are often not used by the families that really need them. The TaMHS (targeted mental health in schools initiative) brought in by Labour had many similar aims to yours. After a brief evaluation, and once the money ran out, many of the projects were dropped. Learn from past successes and just as much from past failures.
Have clear targets for improvement and ways of measuring your desired outcomes. Although it is tempting to allow services to develop their own initiatives to address local need, this makes for messy data and uncertainty about what has worked. The trial of TaMHS showed an improvement in behaviour for children in primary schools, but not in secondary schools. Also there was no improvement in emotional problems in either setting. Such results can be hard to make sense of. It’s centrally important that you know what you are hoping to achieve for your money. So have clear targets, measures for those and, crucially, keep the money coming in long enough to give those interventions a chance to work.
Don’t let prejudices come before evidence. We think we all know what has caused the surge in mental health problems in adolescents don’t we? It’s all that social media stuff they do. Well actually no, the evidence is far from clear on that front. We all have our views about what is causing the rise in children’s mental health problems but only unprejudiced research can give us an accurate picture. Think about what’s really driving increased referrals (you have loads of data at your fingertips) and address those factors.
Engage vulnerable families. One very welcome part of the green paper is the value placed on perinatal mental health services. This recognition of the bond between carer and infant is important and (especially welcome) is based on good quality evidence. In light of this it’s good to read that the new school mental health teams are to include support workers trained with families and parents. However, the people who are most likely to need help are the ones who won’t be coming to parents’ evenings. They will have their own problems, and those are likely to include poor relationships with their own education. We know what makes vulnerable children, it is vulnerable parents. Don’t neglect them.
Make sure your policies across departments make sense. There is no point in increasing funding for child and adolescent mental health services if, at the same time, you’re introducing policies that might increase stress. Think holistically. Where do children play? How do they learn? Where do their families get support? Which third sector organisations support children and families? Use your research and lack of prejudice to target your money wisely. Don’t just go for easy headlines. One benefit of walking away is that you don’t need to worry about them any more.
For readers interested in finding out more about this topic here are some suggestions:
If you haven’t got time to read the whole of the green paper, here is the quick read version:
Read here for a realistic account of a day in Specialist CAMHS.
If you like numbers, read here the Children’s Commissioner’s own report of the inequality in funding for young people’s mental health.
Trish Joscelyne is a Clinical Psychologist specialising in children and young people’s mental health.