Defragmenting the children and young people’s mental health system
In recent times, the issue of children and young people’s (CYP) mental health has been increasingly reported in the news. This has significantly raised the profile of what has historically been an overlooked topic, however we shouldn’t become complacent about the challenges we face in creating an integrated system that provides the full range of mental health support.
The recently published Research in Practice Strategic Briefing on Defragmenting child and adolescent mental health services (CAMHS) argues that commissioners, whether from Clinical Commissioning Groups (CCGs) or local authorities have a key role in transforming the whole children and young people’s mental health system. This blog highlights some of the key issues from the briefing, such as the importance of joint commissioning, prevention and integration and highlights some of the good practice that is already being commissioned across the country.
The 2017 NHS statistics on prevalence of mental health difficulties in children and young people revealed that:
- 12.8% of CYP aged 5-19 years have a diagnosable mental disorder.
- Prevalence increased with age, with 5.5% of 2-5-year olds, compared to 16.9% 16-19-year-olds having a mental disorder.
- Only 25.2% of CYP with a mental disorder had accessed mental health services, compared to 48.5% who had asked their teacher for support.
- Unfortunately, about 24% of 5-19-year olds with a mental disorder are not accessing any support.
- One in five CYP with a disorder reported waiting more than six months to access mental health services.
Whilst there are proposals for improving services in the NHS Long Term Plan, the current approach is not universally meeting demand, and we need to do things differently if we are to help our children stay mentally healthy. CYP mental health requires a system wide approach, and so this work falls to education, social services, public health, youth justice as well as the NHS. It also needs to involve CYP themselves and their families.
Integration and joint commissioning
The policy framework for children and young people’s mental health has, for many years, highlighted the need for an integrated approach. There are good reasons for this. It reduces the chances of duplication in terms of commissioning and provision of services; potential for sharing budgets and risk, and it helps planning around the needs of the child rather than around services.
Whilst it is good practice to have a joint approach, implementing it is not without challenge as CCGs and local authorities have their own duties and priorities. Manchester, for example, has made great progress towards integration, particularly in adult services. Although a recent article by the Chief Officer for Greater Manchester Health and Social Care Partnership, Jon Rouse explained that integrated commissioning for CYP on their patch is less developed than systems for adults.
Prevention is key
50% of people with lifetime mental illness experienced symptoms by age 14, and 75% experienced symptoms by age 24 (Public Health England, 2016). These figures highlight that commissioning effective, upstream interventions are key if we are to reduce the number of people needing specialist mental health services further down the line. The problem is it can take a big leap of faith for many commissioners to invest in something that they may not see the benefits of for many years, or that may benefit another agency. Having a joined-up approach with a shared vision and a joint or aligned budget can help everyone.
A shared vision for children and young people
A shared vision and commitment from leaders in CCGs, local authorities and other partners is a good place to start. This is important because it sets the tone and the higher-level outcomes and objectives that the county or borough want to see. Below is Hertfordshire’s positive vision for children and young people. It includes good mental health and wellbeing, but it is part of a broader focus on a child’s needs.
Models for children and young people’s mental health services
Many areas are now implementing the i-Thrive model and our briefing advocates the commissioning of this approach. It is important because it focuses on need rather than on structures or interventions. The framework conceptualises need in five categories as displayed in the diagram below. It includes a focus on maintaining wellbeing through community-based promotion and prevention strategies, as well as on addressing specific mental health concerns. The NHS Long Term Plan advocates extending i-Thrive to cover those up to the age of 25. If that approach is fully implemented, it would be a seismic shift for CYP mental health.
The CYP mental health sector have talked about the importance of integration for a long-time, but despite some levers that help, such as being able to pool budgets, it has largely remained an ambition rather than a reality.
However, the increased prioritisation of children's and young people's mental health and the proposals for integrated care systems in the NHS Long Term Plan, should if implemented, result in a sustainable and truly integrated system.
About the author
Paula Lavis is Member Network and Policy Manager for NHS Clinical Commissioners. Paula worked with NHS clinical commisioners to produce the recent Research in Practice Strategic Briefing Defragmenting CAMHS - commissioning the children and young people’s mental health system. The briefing provides a more detailed account of the information discussed in this blog.
Public Health England (2016) The mental health of children and young people in England. London: Public Health England. Available online: https://bit.ly/2rqSanJ
Department of Health (2012) Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing. London: Department of Health. Available online: https://bit.ly/2Kr7RTn
Wolpert M, Harris R, Hodges S, Fuggle P, James R, Wiener A and Munk S (2019) THRIVE Framework for system change. London: CAMHS Press. Available online: https://www.annafreud.org/media/9242/thrive-framework-for-system-change-2019.pdf
Wolpert M, Harris R, Hodges S, Fuggle P, James R, Wiener A, McKenna C, Law D, York A, Jones M, Fonagy P, Fleming I and Munk S (2016) THRIVE elaborated 2nd edition. CAMHS Press. Available online: https://www.annafreud.org/media/4817/thrive-elaborated-2nd-edition.pdf
Youth Sport Trust (2018) Mentally healthy schools pilot report. Manchester: Youth Sport Trust. Available online: https://bit.ly/2WHw8KS