Analysis

Transforming mental health services for children and young people: the latest government green paper

Ahead of Mental Health Nurses' Day, RCN forum chair Ed Freshwater and professional lead Catherine Gamble urge mental health nurses to articulate what they do

Ahead of Mental Health Nurses' Day, RCN forum chair Ed Freshwater and professional lead Catherine Gamble urge mental health nurses to articulate what they do

It is difficult to hide from the statistics that highlight how many children and young people are experiencing poor mental health.


Picture: iStock

According to new data, one in eight 5-19 year olds in England had at least one mental health disorder when they were assessed in 2017 (NHS Digital 2018).

In an attempt to prevent these statistics from getting worse, NHS England and the government are trying to transform services for children and young people.

£300 million

Amount the government is investing in the transformation of children and young people’s mental health services

Green paper

Following consultation, the Department of Health and Social Care and the Department for Education have published Consultation on Transforming Children and Young People’s Mental Health Provision: A Green Paper and Next Steps.

The overall plan is to support young people with mental health conditions so they have less of an impact on their adult lives.

With an investment of more than £300 million, the government has established three core areas of work:

  • Having a trained and designated mental health lead in every school by 2025.
  • Funding new mental health support teams.
  • Piloting a maximum four-week waiting time target for access to child and adolescent mental health services (CAMHS).

It is expected that by 2022-23 between one fifth and one quarter of the country will be covered by pilot areas.

However, Barnardo’s chief executive Javed Khan is concerned that, because the trial will reach only certain areas of the country, it ‘reinforces existing geographical inequalities in access to support’.

The green paper does not specify who the mental health leads will be, but having such a strong focus on schools could be considered a step in the right direction.

RCN professional lead for children and young people’s nursing Fiona Smith is aware that ‘many head teachers say they would appreciate an increase in school nursing resources that enable them to prevent mental health and emotional well-being issues’.

Focus on schools

The paper states that the leads ‘should not be a mental health professional’. RCN mental health forum chair Ed Freshwater is not convinced by this proposal and says it would be better to make use of the already established, highly skilled workforce.


Ed Freshwater: 'Nurses need to
elbow their way in'

‘CAMHS could benefit from having an appropriately trained mental health professional undertake this role as a full-time task; a mental health nurse would do this brilliantly,’ Mr Freshwater says.

The new school-based mental health leads will not be allowed to diagnose mental health conditions. Instead they will outline mental health strategies for the school. The people who take on these roles should know enough about local mental health services to be able to refer children when appropriate.

Unused expertise

RCN mental health professional lead Catherine Gamble is concerned about the new role being ‘developed without actually tapping into expertise that is already out there’.

But Ms Gamble is also concerned that the paper does not refer to providing any service outside of normal office hours and at weekends. ‘When are parents supposed to be able to come and participate? Mental health nurses are particularly used to working out of hours,’ she says.

The government also wants to implement mental health support teams, in or near schools and colleges. These will comprise junior and senior staff and will be supervised by qualified members of CAMHS. Recruitment has already begun and training is expected to begin early in 2019.

One in eight

5-19 year olds had at least one mental health disorder when assessed in 2017

Source: NHS Digital 2018

Overstretched services

Mr Khan takes issue with this format because of the extra demands it will make on already overstretched services. He says: ‘Supervision of new staff is vital, but we are concerned that this may take CAMHS staff away from their clinical work with children; the government needs to ensure that the funding can cover this.’

The purpose of these teams will be to deliver interventions to children and young people with mild-to-moderate mental health issues and direct more serious cases to specialist NHS services. But with resources for these services already constrained Ms Gamble asks why CAMHS staff are not commissioned directly by schools.

Four-week target

The paper’s final core proposal is to trial a maximum four-week waiting time target for children and young people to access to CAMHS staff.

Given that children and young people can wait months to be seen by a CAMHS team, is a four-week target a realistic possibility?


Catherine Gamble: 'We should use
existing expertise'

‘What is the point of introducing a waiting time limit if there are no staff to achieve it, no services available and nowhere to deliver interventions?’ says Mr Freshwater.

Both he and Ms Gamble point out that a four-week waiting time target is only one piece of the jigsaw; the big issue is treatment, they say.

They want to know what happens after the assessment stage and how children and young people will be helped. And Mr Freshwater warns: ‘A smart administrator will find a way around the four-week target without actually having to do anything therapeutic.’

According to the paper, the government wants records to be kept on how quickly people access services, how quickly they start treatment and what outcomes are achieved.

Rise in reported conditions

A recent study found a significant increase in reported mental health conditions among young people. People aged between 16 and 24 in England were ten times more likely to report a long-standing mental health condition in 2014 than in 1995 (Pitchforth et al 2018). In light of the study findings, there is a question about whether the government proposals go far enough and whether there will be the capacity to tackle mental health issues in young people.

Mr Freshwater fears that the plans amount to too little too late.

‘Services are overwhelmed, and the only realistic solution is to improve recruitment and retention with a long-term fully-funded strategy that politicians are banned from tinkering with. It needs to be a new kind of service with co-production, where nurses and service users work out care plans together, and nursing care being the two most essential foundations,’ he says.

However, Ms Gamble thinks that part of the answer could lie in another report in 2018, the Mental Health Policy Commission: Investing in a Resilient Generation.

Bringing nurses to the table

‘It’s got a strategic framework for mental health in the 21st century. They have new ideas about positive peer and community relationships and education and employment programmes that are mental-health friendly,’ she explains.

Yet nursing is only briefly mentioned in either report.

‘Whenever these things are produced, you look at who is contributing,’ says Ms Gamble. ‘Mental health nurses know how to convert things from fiction into reality; we are really good at it. What concerns me is that we are not at the table to make that difference.’

Despite nurses only being mentioned once in the government paper in the form of school nurses, Ms Gamble is keen to point out that some school nurses are mental health nurses. She says that the new roles being developed undermine the good work that is already going on in some areas across the country.

Supporting recovery

16-24 year olds

were ten times more likely to report a long-standing mental health condition in 2014 than in 1995

Source: Pitchforth et al 2018

So, what can mental health nurses take from the government paper?

For Ms Gamble, it is that the government is interested in mental health and ‘they want to support recovery’.

However, both she and Mr Freshwater want mental health nurses to do more to articulate who they are and what they do, for example though Mental Health Nurses' Day on 21 February, and play a bigger part in such changes.

‘The only way forward for mental health nursing is for us to regroup, establish our identity, prove our efficacy and elbow our way into meetings,’ Mr Freshwater says.

Early intervention

Ms Gamble, Mr Freshwater and Ms Smith all agree that the government’s plan to put early interventions in place leads to a greater chance of people having fewer mental health conditions in adult life.

But Mr Freshwater thinks that, as is often the case, the outcome will be determined by the funding available: ‘Where services are constantly fighting for restricted resources, you will always see us going from one crisis to another.’

Leading by example

Lucille Ellis-Jones, team coordinator, clinical nurse specialist and mental health nurse, child and adolescent early intervention mental health schools-based service, Merton, London

‘We are a team of clinical specialists with a variety of professional backgrounds including mental health nursing and art and systemic psychotherapy.

‘We are commissioned by primary and secondary schools in Merton to provide specialist mental health consultation for parents, education staff and other professionals as well as assessment and evidence-based therapeutic interventions for children and young people and their families.

‘Interventions include those that focus on behaviour management and individual and group therapies for families and carers.

‘We also provide support to education staff to improve outcomes for children presenting with emotional and behavioural difficulties.

‘Clinical interventions are holistic and driven by the outcome of the assessment. To assess the outcomes, we use the Strengths and Difficulties Questionnaire, Revised Children’s Anxiety and Depression Scale, as well as Conners Questionnaire and Social Communication Questionnaire when appropriate.  

‘In terms of nursing, we provide a good understanding of the interplay between physiological and psychological issues while promoting health generally, within the team as well as directly to schools. 

‘I believe we are in a privileged role as we can offer a service in an environment that promotes collaboration and reduces anxiety and stigma.’


References

  • NHS Digital (2018) Mental Health of Children and Young People in England.
  • Pitchforth J, Fahy K, Ford T et al (2018) Mental health and well-being trends among children and young people in the UK, 1995-2014: analysis of repeated cross-sectional national health surveys. doi: 10.1017/S0033291718001757

Further reading

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