[Relevant Documents: Third Report from the Health Committee, Children’s and adolescents’ mental health services andCAMHS, HC 342, and the Government response, HC 1036]
Motion made, and Question proposed,
That, for the year ending with
(1) further resources, not exceeding £866,629,000 be authorised for use for current purposes as set out in HC 1019,
(2) the resources authorised for use for capital purposes be reduced by £635,000,000 as so set out, and
(3) the sum authorised for issue out of the Consolidated Fund be reduced by £679,772,000 as so set out.—(Mark Lancaster.)
It is a pleasure to open this debate on our report into child and adolescent mental health services. For the record, I am married to a full-time NHS adult forensic psychiatrist who is also the chair of the Westminster Parliamentary Liaison Committee for the Royal College of Psychiatrists. I thank the many organisations and individuals who have contributed to our report, my fellow Committee members and also the Clerk of our Committee, David Lloyd for his exemplary leadership and work over the course of this Parliament.
May I start by setting the scene? This report was launched in part because of the number of children and young people who were being admitted to hospitals many hundreds of miles from home when they were in mental health crisis and needing the highest level of support.
During the course of our inquiry, we identified serious and deeply ingrained problems with the commissioning and provision of child and adolescent mental health services, and we found that they ran throughout the whole system from prevention and early intervention services to in-patient services for the most vulnerable children and young people.
We welcomed the setting up by the Government of the Children and Young People’s Mental Health and Wellbeing Taskforce, and many of our recommendations were directed at that taskforce. I am sorry that it has not yet reported, but I understand that it is to report very shortly, and we look forward to seeing its recommendations. The taskforce knows that it is a matter not just of tweaking the CAMHS system but of fundamental change. I hope that it will clearly set out how that will be implemented. We have legislated for parity of esteem, we have written it into the NHS Mandate, but all that counts for nothing if it does not translate into better services for children and young people.
The key recommendation in our report is about the importance of prevention and early intervention. However, services cannot be planned without knowing the extent of the problem. It is a matter of great regret that the five-yearly prevalence survey was cancelled under the previous Government. That means that our data are 10 years out of date. I very much welcome the reinstatement of that survey. In his response, will the Minister give further details of the extent? I know that he has already announced that the funding has been identified, but many professionals are waiting to hear further detail about exactly what will be included. That would be very welcome.
While we wait for the prevalence data to appear—it would be nice to hear the expected time frame in which we will hear the results—we all acknowledge that there has been an alarming rise in the level of distress and need reported by all those who work in the field, including those in the voluntary sector, in teaching and in CAMHS. There are unprecedented levels of demand at a time when, unfortunately, 60% of local authorities that responded to a survey from YoungMinds report cuts or a freeze in their CAMHS budget. That is where the front line of prevention should be.
The compelling evidence that we heard throughout our report was that early intervention prevents children from presenting when they have become more unwell, so that is where we need to focus our resources. Clearly, the Government were right and everybody welcomes the investment in 50 extra beds in the areas of greatest need—some of which are in my area—but it costs around £25,000 a month for a child or young person to be treated in an in-patient setting. For every young person who is in one of those beds, we have to ask whether they would have needed to be admitted to hospital in the first place had those resources been properly directed to prevention services. We need double running. If we just keep investing in in-patient beds at the expense of prevention, we will fill those beds and there will be a demand for more.
I hope the Minister will recognise the need for double running so that we focus relentlessly on prevention and early intervention. As he will know, if we are looking at in-patients and admissions, the very last place that any young person should be at a time of mental health crisis is in a police cell. I pay tribute to all those who, over a number of years, have campaigned on that. The problem is not new. I am one of the few MPs—or perhaps not so few—who has been inside a police cell at night, because for many years I was a forensic medical examiner. It was always profoundly shocking to think that children as young as 12 or 13 across the west country were being taken into police cells under section 136 of the Mental Health Act 1983—an horrific experience.
It is sometimes an individual case that finally brings an unacceptable practice to an end. I pay tribute to Assistant Chief Constable Paul Netherton of Devon and Cornwall police for highlighting the awful case in Torbay of a child who was detained in a police cell, and I pay tribute to Chief Constable Shaun Sawyer because they have taken steps to bring the practice to an end. Although as a Committee we called for this to be a “never event” within the NHS, in effect the procedures that will be put in place will be equivalent. Finally, on this Government’s watch, we will see this unacceptable practice coming to an end. That is long overdue and very welcome.
In focusing on the need to keep that timely support for children and young people, I also hope that the taskforce will set out what can be done to address some of the perverse financial incentives in children and young people’s mental health services. For example, a child who is admitted to hospital no longer has to be funded by the clinical commissioning group—in other words, they are handed over to specialist commissioning— creating all sorts of inappropriate decision making in the system. It also means that children are more likely to be readmitted because there are no step-down services. Therefore, a focus on active intervention to try to prevent that admission and keep children at home is very important. I also look forward to hearing the taskforce’s recommendations on how that can be done consistently across the country, because another issue we raised was the extent of variation in practice.
I will now turn my attention to volunteers. If we are to retain a focus on the earliest intervention and prevention, we have to recognise the value of our volunteers. I would like to pay tribute to a number of volunteers in my constituency. I am a patron of Cool Recovery, a charity that provides mental health support to carers and those affected by mental health problemsacross south Devon. There are many such organisations working directly with young people. Representatives from Spiritulized, which supports young people in Kingsbridge, recently came to Parliament after being shortlisted for an award for the work it is doing in mental health first aid out in the community. In Brixham there is the Youth Genesis Trust and volunteers from The Edge. Work is also being done in schools. Representatives from South Devon college, which is based in my constituency, recently came to Parliament after it received an award for its work in student well-being and prevention of mental health problems.
Those organisations are reporting that both the demand for their services and the level of complexity have never been greater. Part of the reason for that, as the Minister will know, is the increasing waiting times for CAMHS. That means more young people are becoming much more unwell before being seen in the CAMHS setting. I hope that in his response he will be able to say exactly how we can balance that across the whole system. I very much welcome the investment in services for eating disorders and self-harm and early interventions in psychosis, and of course the Improving Access to Psychological Therapies programme. However, as he will know, fundamentally the issue comes down to funding. We will never achieve parity of esteem for mental health unless we address the funding inequality, with 6% of the mental health budget going to services for children and young people, and that budget itself is an inappropriately small slice of the overall funding pot for the NHS. How will we actually drive change in increasing funding?
I agree with everything my hon. Friend has said and very much welcome her Committee’s report. I agree on the need to address the funding issue. In particular, it is critical that we achieve what I call an equilibrium of rights to access between mental and physical health in order to address the awful problem on waiting times, and that must include children’s mental health services.
I thank the Minister for that intervention. It is very welcome that we now have waiting time targets as a right for people with mental health problems, alongside those for people with physical health problems, but the challenge is not so much about the budget for children and young people’s mental health services, but what we take that from, because there are no areas of slack in the mental health budget, as he will know. I think that the mental health budget overall must achieve some parity. Again, if we look at prevention and the really small amounts of money, in relative terms, that are required to keep excellent voluntary services running in our communities, we see that it would be the greatest waste and tragedy to lose those vital services in our communities for the want of what are really quite small sums. When children, young people and voluntary services came to give evidence to our inquiry, we heard time and again that what they need is stable, long-term funding. They do not require a great deal of money, but they are currently limping from one short-term budget to another. Another issue raised was that if funding is available, it often gets directed to a new start-up project, not towards a project in the same community that may have proven value.
The hon. Lady is no doubt aware that some of the small, really good charities will find that a bigger charity that is very good at filling in application forms will get the funding and then subcontract the work back to the small charity that was doing it before, having taken a cut of the funding as well.
I absolutely agree. The other problem is that sometimes those larger national charities may have no local presence or understanding.
We need greater flexibility so that commissioners within health and local authorities are able to provide stable, long-term funding and to set the priorities for these new pots of money. It is always easy to announce new projects, but we must allow funding to be directed at existing services that have a fantastic proven track record. The value for money that we get from these services is extraordinary, as is the value that young people place on them. Young people have told me—this applies particularly to a rural constituency such as mine—that it is no good having a CAMHS service in a neighbouring town if they cannot get to it because there is no transport. That is why voluntary services are so particularly valued.
I was going to discuss our comments on schools, but my hon. Friend Andrew Percy, as a former teacher, is far better placed to talk about that, so I will leave it to him to elaborate. I just want to touch on the new challenges that young people face with cyber-bullying, sexting, and image sharing. This is a 24-hour pressure; there is no safe haven for them in these circumstances. I welcome the fact that the taskforce will comment on not only the challenges but the opportunities that the internet may give us to assist young people.
My hon. Friend is making some important remarks, as has her Committee. Somebody who suffers from a condition such as depression or anxiety, and has already been taught coping techniques, often finds it helpful to have a mentor. Perhaps apps, mobile phones or the like could reinforce those coping techniques at times when life seems difficult. That is an important part of the picture.
I thank my hon. and learned Friend.
In using the internet, one of the challenges is how to know which of the sometimes thousands of resources that will pop up as a result of a search are valuable and to be trusted. It would be useful to have a mechanism for directing people to those that have the best evidence base behind them, and have been rated by young people as being the most helpful. While these kinds of resources may be welcomed by some people, they will not be the most appropriate for everybody. We need to have choice and a range of resources. That also applies to IAPT—improving access to psychological therapies. Cognitive behavioural therapy has an evidence base behind it, but it does not necessarily work for everybody. Those who do not find CBT helpful must have other avenues they can go down, including longer-term support where that is appropriate.
In closing, I draw the Minister’s attention to another area of early intervention—perhaps the earliest of all. Does he have any encouraging points to make on the provision of perinatal mental health services? I look forward to his response.
In the September recess each year, I organise a series of consultation meetings across my constituency. The one I enjoy most is that with young people. It is organised with a range of youth groups, such as Members of the Youth Parliament, and brings together a good number of young people aged from 18 to their early 20s. It is really sparky and lively, and they pull no punches in raising issues. When I ask them what are the top priorities that I, as their Member of Parliament, ought to take up on their behalf, it has been very striking just how high mental provision has come in the past couple of years. That would not have been the case when I was young.
The fact that young people themselves put such a high priority on mental health as an issue should send us a very clear warning signal. That does not only apply in Sheffield. Following ballots of tens of thousands of young people across the country, the Youth Parliament has made mental health one of its two priority campaigns this year. If it is so important for young people and they are pressing us on the issue, we should be deeply concerned.
In advance of today’s debate, I have been in contact with three of the groups I work with in Sheffield: CHILYPEP —the Children and Young People’s Empowerment Project; Young Healthwatch; and STAMP—Support, Think, Act, Motivate, Participate—which is a group of 14 to 25-year-olds who have come together with the specific objective of improving mental health support for other young people. They are concerned about the current state of provision, or what they would describe as the lack of provision, and they fear for the future and the impact of cuts on an already desperately inadequate service.
The groups have identified three key problems. The first is that reductions in funding are taking place at a time of increasing need. The second, which very much echoes the points made by the hon. Lady and the report, is about the lack of early intervention. The STAMP young people’s manifesto states:
“Act now, tomorrow could be too late!”
That indicates the severity of what we are talking about. The third is that young people are abandoned at 16.
On the issue of resources, budget cuts have been inflicted on local authorities, such as Coventry. Some of them have had to find about £3 million or £4 million, which is an extra burden. The Government hope that local authorities can somehow resolve that situation, and then they wonder why they have problems with young people.
My hon. Friend makes a very important point. Such a matter is close to my heart in Sheffield, where funding from central Government will halve over the lifetime of this Parliament. That is putting an enormous strain on all the related services and support for young people that can play a broader role in alleviating some of the difficulties. In Sheffield, we are very conscious that our position is in sharp contrast to that in wealthier parts of the country.
The first point is about cuts at a time of increasing need. We know that budget cuts to front-line services are difficult and can be devastating at any time, but cuts to child and adolescent mental health services are being made at a time of increasing need. From 2011-12 to 2013-14, Sheffield CAMHS saw a 36% increase in referrals, and a 57% increase in initial appointments. If we are serious about reducing stigma, talking openly about mental health problems—we have made enormous advances in doing that—and having parity of esteem, we should welcome those referrals. However, that demand comes against the background of what has effectively been a 4% budget cut, disguised as a requirement to drive efficiency savings. That has had severe consequences for the level of support that young people are receiving. There has been a stark increase in waiting times.
It is certainly true that councils are faced with really tough decisions, given the 40% cuts to local government budgets. My understanding is that within the overall mental health budget of £14 billion, only £0.8 billion goes on child and adolescent mental health services. That seems to be a disproportionately small sum of money, given the scale of the problem.
My hon. Friend makes a powerful point. It is a relatively small sum of money. Perhaps that indicates that a relatively small level of resource intervention could make a significant difference.
As I was saying, the consequence of the rising demand and falling resource in Sheffield is that some 18% of young people—almost one in five—wait over 13 weeks for treatment. The cuts not only impact on young people up to the age of 17, but have a knock-on effect on adult mental health services and on acute and emergency provision.
I am very grateful to my hon. Friend for that intervention. While on one level we have seen enormous progress in the openness with which we confront mental health issues and the willingness of people to come forward, we must be deeply conscious that there is still a wider problem of people who do not present. The absence of resource and the inability of the system to support people with needs when they do seek help sends out a powerful message, because young people are very well networked. Those who might be on the tipping point of coming forward to seek help will get the message from their friends, “What’s the point, because you have to wait so long?” That is an important point.
That brings me to the second point that young people raise with me, which is the importance of early intervention. Again, that was emphasised by the hon. Member for Totnes. In the words of STAMP:
“Act now, tomorrow could be too late!”
I want to share the harrowing words of one 18-year-old young woman who is involved in the STAMP project in Sheffield:
“Sometimes I think, do I have to kill myself to get help? I probably do. It happens all the time. People are desperate for help, the only way they can get it is if they are at harm, so people harm themselves or attempt suicide just to get put on another waiting list. It just shouldn't be like that.”
She is right; it clearly should not be like that. Nobody should have to reach crisis point before receiving the support and care that they need, and certainly not our young people.
At a time of increasing need, we need to look at how we can do more with less money. Early intervention is a way of doing that. The hon. Member for Totnes made that point powerfully.
I appreciate my hon. Friend’s speech very much. He has put a thought in my mind about a point that the hon. Member for Totnes also raised about early intervention. Given that the cuts to other local authority front-line services have been worse than decimated in places such as Stoke-on-Trent, those services that would have been early intervention-type services—and, indeed, pre-early intervention services—are just not there any more.
I thank my hon. Friend for making that powerful point. The situation in Stoke, Sheffield and Coventry underlines his point that there used to be a hinterland beyond the NHS of youth groups, activities and support networks, many of which were supported by local government funding in combination with funding that was often raised within communities. The withdrawal of that funding, as local authorities have increasingly had to focus on statutory services, has put many of those groups at a tipping point and left the support that is available very weak.
The third point that young people have made to me is about being abandoned at 16. Historically, CAMHS in Sheffield have worked with people up to the age of 16, leaving those beyond that age—before they turn 18 and become part of adult provision—to fall through a hole. Things looked a bit brighter for 16 and 17-year-olds when the clinical commissioning group committed just £300,000 a year to a service for them, although I am not sure why it did not include 18-year-olds as well. However, budgets are squeezed and it has since been announced that the funding will be cut by a third. That is another example of the budget pressures being experienced and it is happening within the NHS as opposed to local authorities, which we have discussed.
In effect, £200,000 allows the service to work with little more than 100 young people aged 16 to 17 in a given year. On funding relative to need, there are 12,627 young people aged 16 to 17 living in Sheffield and it is estimated that 10% of them have some sort of mental health challenge. That leaves more than 90% of those we could expect to need support with no service at all. We cannot keep talking about reducing stigma, eradicating stereotypes and parity of esteem between physical and mental health without funding services properly when people—especially young people—need that help. We have serious questions to answer on the challenges posed to us by the issues raised with me by young people in Sheffield and those raised by the Youth Parliament.
We know that, nationally, mental health problems account for 28% of morbidity, but only 13% of expenditure is committed to mental health. Where is the parity in that? I hope the Minister will address that when he responds to the debate. We need to put our money where our mouth is. I am pleased that Labour has committed to increasing the proportion of mental health spend on CAMHS, which is currently a tiny amount of 6% even though three quarters of adult mental illness begins before the age of 18.
I agree with the hon. Gentleman about the need to increase resource in children’s mental health services. Is the proposal he mentions designed to increase investment in mental health or to shift resource from adult mental health to children’s mental health?
I am sure my hon. Friend Luciana Berger on the Front Bench will come back to this issue. My understanding is that our proposal is both to increase the overall resource available in the NHS and to shift resource within the service towards supporting CAMHS.
We will also train NHS staff and teachers to spot problems sooner. We will expand talking therapies and work towards a 28-day waiting time standard for access to both adult and young people’s talking therapies. That is crucial, given what I have heard from young people. Moreover, as I said a moment ago, we will invest an additional £2.5 billion in the NHS to fund extra nurses, doctors and other health workers, to relieve pressure on the service. We owe it to our young people to respond to their calls and I am pleased to have had the opportunity to articulate some of their concerns.
Order. Let me give Members guidance about how long we have for this debate. The wind-ups will start at 6.30 pm, so I do not think it necessary to have a time limit as long as Members take about 10 minutes each, including interventions. If everyone takes 15 or 16 minutes, we will not fit every Member in. We do not need a time limit just yet, but if those speaking could aim for 10 to 12 minutes, including interventions, that would be helpful.
I want to make a few remarks about adolescents. If we had to be reincarnated, I doubt that anyone in this room would choose to be reincarnated as an adolescent. They are neither fish nor fowl; they are attached to one family but dominated by their peers. They are going through new states of mind and body, which are exciting and disturbing in equal measure. They are no longer a child but are not quite an adult. They are advancing in knowledge and understanding, but hormonally and emotionally confused. It is probably the most difficult stage of anybody’s life to negotiate, and I believe it is quite hard to be genuinely and consistently happy. In a society without clear norms and rites of passage, it is probably doubly difficult.
Should we therefore be surprised that adult mental illness is on the rise—the hon. Lady called it an alarming rise—or does that indicate that we are in a pathogenic, sick-making society? Are we simply getting better at diagnosis, or are we applying clinical language to describe the mood swings of adolescents, which are more normal that we like to believe?
I find the figure of one in 10 surprising, although there are undoubtedly some troubled youngsters out there who will not get back on track or lead a normal life without extensive help. There are those in the early stage of psychosis or in the grip of a debilitating neurosis, or the depressively suicidal—I know a fair deal about that. As hon. Members have said, it is crucial that good services exist for such people, and nobody would disagree that diagnosis should be early and treatment sensitive and effective. I applaud—as does everybody—the new commitment and resources, the drive for parity of esteem, people speaking out and so on.
However, I have one problem with the current enlightened mindset and what I call the myth of the normal. Probably no one here would claim to be in perfect physical health—at least not for long—and we generally cope with the ailments, aches and pains of ordinary life, seeking help only when something dramatic happens or our own immune system cannot cope. I do not see why that should not apply to our perspective and our take on mental health. It is not a black or white issue—it is not an either/or. The world does not divide into those who have mental health issues and those who do not; there are simply those whose lives have been disabled by their mental health issues, and others who, by and large, have coped.
Many years ago I used to teach adolescents about mental health in a Bootle comprehensive school, which was my own idea. I used to discuss the issue as a spectrum, and I hoped to encourage a degree of sensitivity. Children in the playground badly misuse mental health vocabulary. They call one another “psycho”, “mong”, “retard” and so on—the school yard can be an awfully cruel place. As part of our course we went to visit an old-fashioned mental hospital called Winwick in Rainhill. It was a large, relatively benign, caring and good institution of its kind—I had previously worked in a less good institution, Oakwood hospital in Maidstone. I basically wanted the children to understand what mental ill health was like, and for them to have a deeper sensitivity towards it. I vividly recall one episode in a corridor. An elderly and somewhat confused old lady approached the party. She was happy to see young faces reminiscent of her grandchildren. The boys—tough Bootle lads—backed away in fear. They did not know what to do or how they were expected to react. At that stage, I thought I had clearly failed to get something across. We are still failing to get quite a lot of things across. We have a myth of the normal and believe that the world divides into the sane and the insane, the normal and the well, and those with issues and those without.
That is still going strong. The House of Commons applauds with all the enthusiasm of a revivalist meeting when someone owns up to having mental illness, and we pat ourselves on the back for being enlightened. However, when a prominent Member of the House has a memory lapse on TV, which was a mental failing—he said it was an age thing—we scream like banshees, “Bill, Bill, Bill!” at Prime Minister’s questions. That is not a fine example of an atmosphere conducive to good mental health. It is worse than the school yard, but it will be repeated again at 12 noon tomorrow.
The terrifying thing about adolescent mental illness is that the individuals will never have had anything like it happen to them before. There is no frame of reference for what they are going through—it is all new. For them, as they grow up, a chasm opens up between those who can hack life and the small minority who cannot. The dread is that they are doomed to be in the latter category more or less for ever. That is the underlying and horrible fear. Successful peers will surround their failing selves. Their fear is that there will be future adults and future casualties, the copers and the failures.
Those young people buy, as do big chunks of society, into the myth of the normal—the belief that mental illness and frailty is not on a spectrum like physical illness, or something that touches everyone to some extent, but something abnormal, unusual, permanently blighting and for keeps. The truth is that mental illness is not that. Unless we get that across, we will make matters a whole lot worse.
It is a pleasure to follow John Pugh and his contribution to the debate. He made extremely good points.
I should like to refer to an experience I had some 12 or so years ago of running an organisation in Birmingham called Malachi Community Trust, which worked with young people with emotional, behavioural and mental health issues. More often than not, it also worked with their families, including parents and their wider families, to resolve their issues. We worked with qualified cognitive behavioural therapists and teachers—they were primary age children—in the school setting. It is interesting but deeply saddening that so many items in this extremely good report take me straight back to some of the conversations of 12 or 14 years ago.
I want to give a brief outline in the unfortunately few minutes that are available of what Malachi did—it is still going strong. It used musical theatre to engage with young people and as a tool to identify their issues. It enabled processes to be set up to work with those children and young people who had more profound mental health issues. Pertinently for today’s debate, it acted to stabilise the situation for children who were on waiting lists to see CAMHS staff. Back then, there were three, four and five-month waits, or longer. Malachi was not the only group that did that work, although it was and still is particularly good—I have fond memories of what it did. Malachi and other organisations were very good at that stabilisation. They were good at holding those young people in a place where they were not deteriorating while waiting for CAMHS workers. My fear then, and sadly now, is that an awful lot of children—some of our most vulnerable citizens—are waiting for CAMHS workers and their conditions are deteriorating, and their needs are getting worse and not better, because of the waiting lists.
One of the big issues we identified was family breakdown. Parental conflict and family breakdown is a very strong factor in mental ill health in children. A statistic suggests that one in four young people in Stoke-on-Trent are affected by family breakdown and divorce. That means that approximately 15,500 children in Stoke-on-Trent alone will be affected by parental breakdown and divorce. That does not immediately mean that those children will have a mental health issue, but it is a factor that makes them more vulnerable. To pick up on some of the comments made by the hon. Member for Southport, children need the skills and the ability to have resilience, so that if there are factors that might tip them into having mental ill health issues, they have the resilience to address them. Sadly, for all too many of our children there is not the ability to build that resilience.
My hon. Friend Paul Blomfield referred to local authorities. The ability to gain that resilience from services such as those offered by local authorities is not possible in Stoke-on-Trent, where local budgets have almost been wiped out for some children’s services. I seem to be constantly talking to people who used to work for the local authority in children’s services, but have now gone off to do other things because they can no longer be afforded. The main thrust of what I want to say is that more than 10 years ago there was a shortage of access to CAMHS. We do not seem to have gone anywhere with that. It seemed to get better, but it is now getting dramatically worse.
Healthwatch Stoke-on-Trent helpfully brought to my attention a list of issues that they are concerned about. When I say “they”, I mean children, young people and the adults supporting them. It makes deeply saddening reading. The first item on their list of what they want is a single point of access for real-time professional advice and guidance that can refer them to mental health services with the support they need when there is a crisis. This was again being talked about more than 10 years ago when I was attending meetings in what was still then, despite the fact it had been going for 10 years, a fledgling CAMHS. Nevertheless, even back then there was talk about having a single point of access. We have come full circle on the need for a single point of access.
Those children, young people and the adults supporting them talk about information, options and guidance to navigate the range of services and pathways available to them, and evidence-based interventions that are appropriate to them, with follow-up support as needed—the right service, first time. It is sad that here we are, so many years later, without that service—or, where a service has been developed, it has gone because of the cuts. The Government are now having to undertake a review to take us back to the probably better work being done in the period leading up to 2010.
These people want a greater use of technology and access to online support. Technology has come a long way in the past 10 years, and I welcome that good suggestion from the children and young people themselves. They would like more support from schools and direct interventions on school premises in the school day, such as counselling, peer mentors and quiet spaces. There are quiet spaces in some of the good schools that I am blessed to have in Stoke-on-Trent. For example, St Thomas More school has a specific arrangement and understanding that young people who feel that they need to go out and get their head together can use the space that has been made available. I am sure other schools do that as well, but that example was highlighted to me. Malachi was doing innovative work on support in schools 15 or 20 years ago. I made the point in an intervention on Dr Wollaston that when Malachi lost bids to big national charities, those charities would then subcontract back to Malachi, because they knew they had an in with the schools and could provide the service.
Going back to the list, those children and young people and the adults supporting them want clearer step up, step down work given that their mental health needs change and fluctuate, as well as more early support from non-mental health practitioners and their peers and/or older mentors. Their final point is that they do not want to be stigmatised when seeking and accessing help, which is so important. In addition to those things that the children and young people want, they have asked for clear referral routes and pathways through services, so that they get the intervention they need quickly, without being referred to multiple services—often waiting some time for an assessment—before finding that the service is not the right one for them anyway: having waited three or four months to get into the system, they then find that it is not what they needed and they have to start all over again.
The children and young people have also asked to be involved in planning their own care, to be part of setting their own outcomes and goals, to be consulted when changes are made to service provision and for their parents to be given support so that they can support them. The parents themselves, the carers, have asked for there to be clear access to services—that comes up time and again—and parenting support in the community that is easily accessible and non-stigmatising. Going back to my Malachi days, one of the hugely important things we did was to work with the parents, supporting and helping them, enabling them to take on a lot of the work of maintaining and helping their own children.
There are a few more items on the list, but I am conscious that I will rapidly run out of time if I am not careful, so I want to move on to a few of the risk factors. Again, they are not new, but things that we have come across too often, and it is important to raise these in the context of Stoke-on-Trent. In a report on this, the first factor listed among those that will have an impact on children and young people’s mental health is—this comes up time and time again—deprivation and poverty:
“The close association between mental disorder”— as it is termed—
“and economic disadvantage was clearly illustrated by income analysis in the Mental Health of Children and Young People in Great Britain in 2004 survey”, so this is not new evidence. That is a huge problem in places such as Stoke-on-Trent, where we still have such high levels of deprivation—indeed, they have been made worse recently.
I have mentioned parental conflict and breakdown, but there is also communication/speech and language delay. In Stoke-on-Trent there is a huge problem with language delay. Fantastic projects such as Stoke Speaks Out are addressing it, but if a child is having difficulty expressing their needs, how much more difficult will it be for that child—that young person—to be able to eloquently, or indeed adequately, put across what they want from the system that is trying to help them? Attainment in education is still an issue, despite the dramatic improvements that we saw in Stoke-on-Trent. Then there is housing and homelessness; and again, the poor standard of so much housing still in Stoke-on-Trent is a tragedy.
I want to make an observation about children in care and some of the organisations. The local authority in Stoke-on-Trent has seen a rise in the number of children in care in just a short period. From July 2010 to June 2013, there has been an increase of 38% in the number of children needing support in care in Stoke-on-Trent. That is a massive increase in the number of young people in the care system, which is a huge risk factor for mental ill health.
I close by observing a couple of things about Stoke-on-Trent. There is, as I have mentioned, Healthwatch Stoke-on-Trent and the good work it does. There are other organisations doing fantastic and excellent work, including Young Carers—part of North Staffs Carers Association. I have had the huge privilege on a number of occasions to meet the young people from Young Carers and hear about the amazing things that they—children—are called upon to do, quite often looking after their parents, and the huge impact that has on their mental health. Finally, there is another scheme, whose details I have unfortunately lost in the pile of papers in front of me. Home Start has been running in Stoke-on-Trent for about 30 years. Sadly, because the local authority is so strapped for cash and has had to cut its budget, after all that time and after helping thousands of families, Home Start is now closed. It is gone. It is another resource that is no longer there to help the people of Stoke-on-Trent.
That is the backdrop to the report by the hon. Member for Totnes and to what the Minister is doing with his investigation, both of which I welcome. It saddens me so much, however, that we seem to have gone nowhere in 10 years. Let us try to make sure that we do something about this in the coming months rather than in the years ahead.
In listening to Robert Flello, I recognised some important themes that were also evident in the speech of the Select Committee Chairman, my hon. Friend Dr Wollaston. Both touched on what we can do to help people with mental health problems through volunteering, mentoring and bringing services together so that we have a more substantial whole that will help to tackle the fragmentation between different services and make something more rational and more joined up.
I was a governor of a residential school for young people with emotional and behavioural difficulties in the 1980s—Shaftesbury House in Royston. It was an Inner London education authority school, which did extremely good work with some very troubled young people. At that time, however, there was a different understanding of mental health issues from what we saw a few years later in 2001 when I was my party’s spokesman on mental health. By that time, there was much greater recognition that deep-seated mental health problems start at ages much younger than adulthood. Previously, there was a feeling that some of these issues were emotional, behavioural and developmental, but they were not seen in their true context.
I thus slightly disagree with the hon. Member for Stoke-on-Trent South. I think our understanding of mental health issues and what they mean for children and adolescents has changed over the period that he spoke about—and certainly since 2001, we know far more about the onset of these illnesses and about how they should be treated. I agree with him, however, that we are seeing a great number of young people affected by these issues. John Pugh talked about the ups and downs of adolescence and whether there was such a thing as a normal period of adolescence.
I believe that issues such as family breakdown, drugs, social media, and domestic violence put considerable pressure on young people, and it gets to the point where some adolescents have a series of crises. They can be intermittent, but there is often a recognisable crisis for which help is needed. It is more than just highs and lows; it is something more serious. In those circumstances, the delays about which we have heard can be particularly acute.
Two young people contacted me recently to raise issues about how child and adolescent mental health is dealt with. They were both very unhappy with the current situation. I thank the Minister for meeting one of them—a young lady who has been through CAMHS —to talk through the issues. She was very appreciative of hearing about the taskforce that has been set up, and it does the Minister great credit that he was prepared to meet her and that he has accepted that there are problems in the system that need tackling. Delay is certainly one them. Another is the amount of help available, and particularly whether there are sufficient numbers of trained staff—psychiatrists, community psychiatric nurses, therapists and so forth. We have never had the numbers we need, and I hope the taskforce will consider that issue.
The Hertfordshire Partnership Foundation Trust has a youth panel that is deliberately aimed at revealing concerns. The young lady who came to see the Minister had been on that youth panel. She had suffered from anxiety, bulimia and depression; she had been bullied, but got no proper response from her school. She waited nine months for CAMHS, and had still not been given an appointment when she attempted suicide. Even after she had been in hospital, she had to wait for six weeks. She had only five sessions of therapy in 20 months at a time when she was experiencing serious crises. Another young lady who has been in touch with me was taken into an in-care unit, and it was three weeks before she saw a psychiatrist, although she too had experienced a bad crisis.
I cannot disagree with what the hon. and learned Gentleman is saying or the examples that he is giving, but does he accept the general point that one of the problems when it comes to planning effective interventions is the lack of current and accurate prevalence data that would enable the relevant agencies to plan and commission services that meet local requirements?
I agree. I am sorry that action to deal with that problem was cancelled some years ago, because such action is definitely needed.
I was talking about the young woman who was taken to an in-care unit. She said that the staff always seemed to be overworked, and she was given no opportunity to exercise. She felt that, although she had been placed in the unit, nothing was being done to address her condition. I think that a great deal needs to be done to improve child and adolescent mental health services.
“to allow rational and effective use of resources in this area, which incentivises early intervention.”
That is an extremely important point. On page 77, the Committee deals with education and GP services and makes another important point, namely that this is not just about specialist CAMHS, but about school-based counselling. It quotes Mick Cooper, professor of counselling psychology at the university of Roehampton, as saying:
“Due to its short waiting times, convenient location, and broad intake criteria, school-based counselling is perceived by many stakeholder groups as a highly accessible intervention. It is able to offer a wide range of young people professional therapeutic support in a direct and immediate way.”
I think it is time that we joined up those services, using schools as a platform. In my constituency, there is an initiative called the North Herts Emotional Health Support Service, which aims to make a start with that. It has estimated that one in 10 young people aged between five and 16 is likely to be affected by a
“clinically significant mental health problem” at some point, and has calculated on that basis that 18,000 school-aged children in north Hertfordshire are affected, including about 6,000 with emotional disorders. It has looked at the schools in question, and says:
“Evidence suggests that vulnerable children, young people and their families find it easier to access services” at a school. It has trained a team of mentors consisting of teaching assistants, teachers and volunteers, and has identified a
“bank of quality-assured local counsellors and…therapists” who can provide the sort of art and drama therapy that was described by the hon. Member for Stoke-on-Trent South. It has two local lead therapists whose job is to oversee the training and supervising of the mentors. It speaks of the importance of “offering consultancy and training” and “co-ordinating”, and hopes to engage a “part-time administrator”. It has made considerable progress with that model, and, although it will need to be evaluated, I think that we should do something similar.
The service is harnessing the good will of people who volunteer, and there are people who will do that—when I was a mental health spokesman, I met people who volunteered to work for Rethink and MIND—but it also uses the skills of professionals to train the individuals concerned, under supervision. It is giving us a lot of coverage and an ability to help young people relatively cheaply. That is a consideration in these times. I therefore suggest to the Minister that looking at such initiatives and those described on that page of the report is a possible way forward.
Many young people spend a lot of their time using social media of course—thumbs clicking at great speed. This is not necessarily a bad thing. People with anxiety or depression or another mental health condition could find online services that could help them and they could reinforce the coping techniques that they have been taught. I hope the taskforce will look at that. I think it might be fruitful.
I am grateful to be called to speak in this debate after Sir Oliver Heald, who has ministerial experience in this sphere. I do not, but I have some experience in other spheres of finding money for it and I know how difficult that can be. I therefore congratulate Dr Wollaston, Chair of the Select Committee, on her report. We in Coventry find it very timely, and we look forward in due course to the Minister’s taskforce and its report, leading, we hope, to what the hon. Lady very precisely referred to in terms of improvements to services—better services for children and adults on the ground, which is where it matters. She also said she found having to grapple with out-of-date figures—it is rather surprising that we should have them—frustrating. I therefore thought I would take part in the debate in order to bring up one or two up-to-date figures on a particular aspect of young persons’ and adolescents’ mental health that is becoming more and more prevalent, and disconcertingly and alarmingly so in Coventry: self-harm.
We have seen a terrible and frightening increase in self-harm over the past five years. The first figures we had were back in 2010 and the figures for 2014 have just come out. They show an alarming increase from 50 referrals in 2010 to over 300 in 2014. That is a terrifying rate of increase. It has been going pretty steadily at over 20% year in, year out, and, as my hon. Friend Robert Flello pointed out so tellingly, it points to the impact deprivation and poverty can have on children, as there is a fairly well-established causal link between pockets and areas of deprivation and poverty and the tendency among adolescents to self-harm and referrals.
Those referrals come on top of what we already know is a crisis in A and E. They are only exacerbating that, and leading to youngsters with terrible mental
health problems being turned away—doors closed in their face. It is a situation that in Coventry has led to a clear and recognisable crisis, and to an emergency meeting of the scrutiny board to examine exactly what the situation is, to report on it, and to see what measures can be taken to deal with it.
It is often all too easy to blame lack of resources and the Government, but, as the Chair of the Select Committee said, there clearly is a lack of resources. Towards the end of my brief remarks, I will discuss the fact that mental health services have always been the Cinderella services of the health service. I think that is fairly well accepted both outside and within the NHS. If we are to embark on yet another reorganisation and integration of health services as a whole, I hope that the underfunding and the lack of past attention that has affected and led to the present situation in mental health services will not be overlooked. It is not as though all the services can be integrated equally or proportionately, but if certain services are not to be further damaged, they will need to receive particular recognition and get preferential priority in the integration—I do not like the word “reorganisation”—which all the parties agree needs to be done carefully. This should not be rushed. We do not want another reorganisation forced on the health service. It should be done sensibly and gradually, and with sensitivity to the individual needs of the services that are being integrated.
Does my hon. Friend agree that the Caludon health centre at the University hospital Coventry does a very good job in very difficult circumstances? Yesterday, I met some young people from Coventry college who told me about the pressures that they were under. They are worried about exams and about whether they will be able to get a job after their exams, because the number of young people out of work in the west midlands is extremely high. Does my hon. Friend agree that we need to consider all the pressures that young people face these days?
Yes, I do indeed. The pressure in the education system to achieve results at any cost simply adds to the problem, as do the deprivation and poverty to which other Members have referred. All those factors have resulted in a situation in which incidents of self-harm are increasing at the rate of 20% a year. Referrals in Coventry are going up, and that constitutes a crisis, given that our accident and emergency services are already overcrowded and hard pressed.
Let me explain what that crisis means in regard to the number of weeks involved. Normally, effective substantive intervention would be expected within 18 weeks, but in Coventry the average wait for a substantive intervention has been 44 weeks. That is in a sector in which early intervention is clearly the most effective route to the successful management and eventual elimination of a mental health condition. That simply is not good enough, and I put that to the Minister for consideration by his taskforce.
We have asked the local council what can be done. As my hon. Friend Mr Cunningham has said, budgets have been heavily cut. According to current Government plans to reduce public expenditure to 1930s levels—from which I know the Minister of State, Department of Health, Norman Lamb has dissociated himself—Coventry would experience a further 50% cut over the next five years. There would be nothing left. Fortunately, however, that is unlikely to happen, as I am sure that there will be changes of one kind or another to those plans, or to those making the plans, in the very near future.
It is impossible for the councils to find more funds, because they are under tremendous pressure, but there has already been a £50 million cut in the budget for CAMHS. It has been cut from £766 million. I think that that relates to the £800 million figure quoted by my hon. Friend for Eastleigh—
The hon. Gentleman is making a powerful case, particularly on resourcing. Clearly, we would all like to see more resources going into adolescent mental health challenges, but does he share my view that if we get this right, with proper standards, proper implementation and early intervention, there could be a net saving to the Exchequer overall?
I absolutely agree with the hon. Gentleman. I think the whole House would agree with his intervention, which was short and to the point. As in so many situations, prevention is better than cure. It is also a lot cheaper. We all know that, and there is a case for it in this context, but it will require investment up front. That is where the Government do not get it, because they usually take a short-sighted view of these matters.
I wish to make two points in closing. First, if local councils do not have the resources at the moment, we cannot look to them to provide these services and so they are likely to get overlooked. Lastly, will the Minister confirm something about the leak—I am sure he will have read about this in the press—from his taskforce, which speaks of the perverse incentives that have arisen, particularly in relation to mental health, from the Government’s reorganisation? Have they exacerbated the problem? As a result, is the real cost of that reorganisation to the mental heath services not £50 million, but possibly a much higher figure?
In any event, we all know from our constituency experience that we have had losses. Last night, I saw in a television programme that we have lost hundreds of doctors and thousands of nurses, and the prospect in the next few years is an accelerating trend on both. So the Labour party’s commitment for 20,000 new nurses and 8,000 new doctors is a bold one, but it is manageable. It is also absolutely necessary if we are to deal with any of our current problems. That is the message I would like to leave the House with. We need early intervention; a commitment to increase the number of doctors and nurses; parity of treatment—and even ahead of that— in the integration of mental health services; and the restoration of the CAMHS budget as soon as possible.
It is a pleasure to take part in this debate as a member of the Committee, and I associate myself with the kind words of our excellent chairperson, my hon. Friend Dr Wollaston, about everyone who gave evidence, and about all the Clerks and House staff who supported the inquiry. It was one of the most important and far-reaching inquiries we have undertaken in the past few years, and I was proud to have been a part of it, because the issue is so important.
I wish to make a few general comments about this whole area and then to talk specifically about the role schools can play in mental health services for children and young people. I noted with interest the comments made by Robert Flello. The comments today have generally been quite consensual, although something I will say a little later about funding may be less consensual. He pointed out that 10 years ago we were having many of these same conversations, but things have really moved on in the past 10 years, not least in this area; we heard in our inquiry about the increase in demand. Although many of the pressures young people faced 10 years ago are similar, a whole host of other pressures on young people now did not exist then, particularly those of a cyber nature, be it those arising from Facebook, Twitter or online bullying. When I started teaching in 2002 people did not have a great deal of understanding or expectation of any of those things, but they have now become so widespread that we have had a massive increase in demand in this area.
In addition, the way in which mental health services and care are delivered has changed beyond recognition during that period, and some would argue that it has not always been for the better. As we know, between 1998 and 2010 the number of mental health beds reduced from 35,000 to 25,000, and we have seen a continuing shift away from in-patient treatment units. What came out of this inquiry, and what I have seen in my constituency in mental health service provision for both young people and adults, is that although that more traditional unit-based, hospital-based, bed-based system of treatment has changed, what has replaced it has not necessarily always filled users with confidence or has even been consistent across the country. As our report makes clear, there is a lot more we need to do.
As I have said, I wish to focus on what we heard from young people. It was great that our inquiry had a session with young service users, including some from Hull, near my area, who came down to tell us about how they have engaged with local voluntary, local authority and, of course, school services. In our inquiry, we heard that the support schools offer young people is very patchy across the country, changing even within cities or within counties. Some young people we heard from, and some of the other evidence we took, made it clear that some of the best support they had received had come from dedicated teachers who understood mental health issues, really wanted to engage with those young people on them and help them access services. Having a teacher who was engaged and who understood what to look for in mental health really helped young people. Some pupils had different experiences. They felt that teachers either lacked the skills or were too disinterested to deal with the problem. Very often that can be because teachers are scared of mental health issues. In some cases, therefore, pupils experiencing mental health problems did not receive the support that they needed.
I started teaching in 2002. When I think back to some of the young people we had to deal with, I can see that many of them probably had mental health issues. At the time though, those pupils were dismissed as being badly behaved or as having background problems. As a practitioner, I was sometimes guilty of not understanding the signs that were being presented to me. However, teachers cannot be blamed for that; they work in a pressured environment. The pressures around school standards seem to get more intense every year and with every Government initiative.
What we did hear in our evidence was that 61% to 85% of schools are providing access to school-based counselling. Although that is a wide variation, it is a positive thing. We heard that some schools engage really proactively with the local authority and the NHS in this area. Unfortunately, though, we also heard of others that do not engage so well. Some schools seem to think that mental health issues are for health services and social services, but not for schools. When we talk about integration in all areas of health care, this area is one in which we need it the most and, potentially, it could have the biggest impact. My hon. Friend the Member for Totnes talked about early intervention. When we fail in that regard, the consequences are picked up by other services. That means that we have increased referrals and more behavioural difficulties in our schools, which leads to more exclusions. Those exclusions have consequences not just for the management of the school but for that young person’s life chances.
What can we do in schools to make a real difference? Increased collaboration among the services is vital. Although we talk about integration and greater collaboration, we need someone at some point to take responsibility for that and to be held accountable when that collaboration does not work. As we heard in our evidence sessions, some schools are keen to take the lead in that regard, and others less so. Clearly, this is an area where we need greater clarity.
The curriculum was raised by a number of young people, particularly around personal, social, health and economic education. They said, “We learn everything in PSHE. We learn about sexual activity, financial matters, career advice and career choices, but what we do not learn about is mental health and well-being.” Ofsted found that 40% of PSHE provision required improvements nationally and that one third of young people say that they want to know more about how to deal with stress and how to access help for eating disorders. Some 38% said that they wanted education around bereavement, which surprised me.
We have seen some good things happen with the curriculum. We heard in our inquiry that the ICT curriculum now contains a section on cyber-bullying. Clearly, some improvements have been highlighted but an awful lot more still needs to be done. The focus should be on young people as much as it is on teacher training. In our evidence sessions, we heard from the Secretary of State about how a great deal of effort has gone into providing teachers with the tools to deal with mental health issues and to improve training, and that is really important.
When I did my postgraduate certificate in education, I do not remember receiving a great deal of education about mental health and young people’s emotional well-being. Clearly, that needs to change, but the focus should be not only on equipping teachers better, but on ensuring through the curriculum that young people are able to understand mental health issues. The stigma needs to be removed through both teacher training and the curriculum, and young people who have had experience of mental health issues should be involved in developing that curriculum.
I wanted to say a little more about youth services, but I do not have a great deal of time. We have heard a lot about council spending reductions and the impact that that can have. The truth is that whoever was in power, we would be in this position, with council budgets having been reduced. In my area, I am very pleased that North Lincolnshire council has made a concerted effort to reverse the cuts to youth services instituted by the previous administration of a different party, which cut the services by £194,000. Even in these tough times the council has been able to put in an extra £100,000 of funding and over the next three years will add to that a further £300,000.
Local authorities can do that if they have the necessary vision. In the case of North Lincolnshire, the driver for that is a very good portfolio holder in the cabinet who understands that we have to get it right early. That means that we need proper investment in positive activities for young people, because that allows savings elsewhere down the line. Despite all the difficulties that we have faced in local government funding, where there is leadership and vision, people who understand the value of these services can find the money to invest in them. With that, I will end as I am conscious of time and I know that one of my colleagues wishes to speak.
I congratulate Andrew Percy, with whom I serve on the Health Committee, and Dr Wollaston, who so ably chairs the Committee. Although this report is the third report of the 2014-15 Session, I think it was the first report produced under the hon. Lady’s chairmanship, so it is quite an historic document. It is an important piece of work on a subject that has been neglected.
As time is short, I shall try to stick to a particular structure. I thank the Royal College of Paediatrics and Child Health for providing a briefing and for asking us to highlight some of its concerns about variations in services and funding for transition services and mental health care provision for prevention and early intervention. A number of right hon. and hon. Members have referred to those issues. I also want to make a few points from the perspective of local government. As we have heard and as the hon. Member for Brigg and Goole observed, this is an area of joint responsibility where local government, given the correct support and resourcing, can make a significant difference.
On the scale of the problem, it is a shocking statistic that 50% of mental illness in adult life, excluding dementia, starts before the age of 15, and 75% of mental illness starts before the age of 18. Apart from the mental health manifestations, there are often increased physical health problems associated with the deterioration in mental health. Disturbingly, since 1980, as others have mentioned, there has been no decline in the number of deaths caused by self-harm, suicide or assault, with more than 1,000 10 to 18-year-olds dying this way every year in the United Kingdom. The problem is particularly prevalent among boys.
An hon. Member who spoke earlier talked about the value of prevention and early intervention and alluded to a cost-benefit analysis, and he was absolutely right. Quite apart from the fact that it is the right thing to do, if we look at it purely in terms of the opportunity cost, we see that mental health problems that start in childhood and adolescence result in increased costs of between £11,000 and £59,000 per child annually, according to figures provided by the Royal College of Paediatrics and Child Health. Those are huge additional costs. With upstream interventions of the kind other Members have argued for, early identification of mental health difficulties should be established as a core capacity of all health, social care and educational professionals who work with children and young people, because the benefits would be considerable.
Another issue that has been talked about, and which I feel I must mention, is the provision of an evidence base on which to plan interventions. Indeed, the chief medical officer highlighted the lack of accurate prevalence data in evidence to the Committee. I fully understand that the Minister is carrying the can and making the arguments, but that survey had not been carried out for quite a few years. Although it has now been commissioned, my understanding is that the data will not be available for use until 2017. If we are to have a scientific or empirical basis on which to plan commissioning and resources, either in early years or in whichever tier is thought appropriate, we need an up-to-date and relevant evidence base of data.
On the hon. Gentleman’s point about prevalence data, with which I agree, is not the real point that many of the contracts in mental health are block contracts, whereby a fixed amount of activity is purchased? If we do not know exactly what the prevalence really is, that is a bit of a shot in the dark.
I cannot disagree with that. I come from the perspective that we need to plan interventions on the basis of evidence, but how can we do that without current and relevant data on child and adolescent mental health? We certainly need that data. On the structure of the contracts, I am a firm believer in integration. There may well be issues with block contracts. The Health Committee received evidence from the south-west indicating that there are vast areas of the country where there is very little access to certain types of in-patient mental health provision, which is clearly unacceptable. One might have thought that a large block contract would make that less likely, but apparently that is not so. However, I am not an expert in commissioning; I am simply trying to identify the policy areas.
Having spent a number of years in local government, I have no doubt that local authorities wish to tackle some of the barriers that young people face in accessing
mental health services. It is a complicated area, and we need to enable local areas—Sir Oliver Heald just referred to larger block contracts—to commission better services, and perhaps that is better done on a more local level.
Does my hon. Friend realise that one of the problems with block contracts is that, because of their size, they freeze out small voluntary organisations that could deliver services on a local basis?
That is true. Some of the organisations that submitted evidence to the Health Committee and subsequently provided briefings made that point.
Another issue of concern is the complex commissioning landscape for CAMHS, which can result in poorly co-ordinated services and a lack of clarity about roles and responsibilities, leading to gaps in provision and poor transitions from child to adolescent and from adolescent to adult. The service is certainly underfunded. We often talk in this place about parity of esteem. As other Members have reported, CAMHS nationally is receiving about £1.8 billion of the £14 billion that is spent on mental health. Local authority-provided services, which are often having to bridge the gap, are facing huge financial challenges. My local authority, which I share with my hon. Friend Mr Jones, has had to cope with cuts of £250 million over the lifetime of this Parliament. That is forcing councils to make extremely difficult decisions about which services are funded.
I fully understand the point made by the hon. Member for Brigg and Goole, but I also fully understand the difficult decisions faced particularly by authorities in the north that seem to be suffering disproportionate cuts. Councils are embracing their new public health responsibilities—
I am certainly aware that some authorities are facing higher cuts than others. My area is one of relatively high deprivation, but we seem to be in a far worse position than some in the south that are more affluent and do not have the same kinds of pressures.
In rural areas, in particular, people face problems with travelling long distances, a lack of accessibility to specialist services, and long waits. One issue is the 12-week target for referral to CAMHS in cases where children and adolescents are referred out of their local areas. Transition between services varies from one area to another. In some areas it happens at 16, in some at 18, and in some at a point in between. These issues all need to be addressed.
Fundamentally, this issue comes down to funding. I welcome the establishment of the taskforce and the provision of £30 million over the next five years to improve services for young people with mental health problems. However, we must recognise that councils play a vital role in working with health services to target support and co-ordinate services, and they should play a key role in directing the funding.
I apologise for not arriving for the first part of the debate; sadly, I was detained elsewhere. I wanted to say a few words about this excellent report. I commend the Chair of the Health Committee and its other members for producing a very well-balanced report that does not appear to be partisan in any way but does point to some of the problems that still exist in our child and adolescent mental health services, and to some of the possible solutions, if any future Government were to adopt its recommendations. The other impressive thing about the report is that it does not apportion blame. It merely observes that there are challenges, without attributing blame on a partisan basis or to a particular group or individual. It can often be hard to implement the recommendations in these reports if it is felt that a finger is pointed at particular body.
Clearly, mental health challenges are widespread. As other Members have observed, they generally start when people are younger; it is unusual for a mental health challenge suddenly to appear out of the blue. That is why this report and looking at early intervention is very important if we want to tackle mental health services for citizens and mental health outcomes for our constituents. The mental health unit at Heatherwood hospital in my constituency has been transferred to Reading. It strikes me that that is very positive in many ways, because it enables more integrated services to be provided in a larger establishment, which has more resources and is better able to deal with the people who present themselves there.
I want to focus on a couple of positives that I very much welcome among the recommendations. One is the recommendation to develop, implement and monitor minimum standards. It seems to me that that is exactly what we do in every other area of health care. When I was shadow Minister for Science and Innovation, it was precisely what the Medicines and Healthcare Products Regulatory Agency and the then National Institute for Health and Clinical Excellence intended when it came to interventions requiring medical trials and proper evidence. Minimum standards are an absolute minimum, to put it that way, if we are absolutely serious about ensuring that care is consistent and does not fall below a well defined level in services and the way in which they are provided.
It is clear that the recommendations on intervention and recognition in schools and GP surgeries are already very well known among Members. In the 10 years that I have been here, I have heard debates in which such points have been highlighted. It is good to see a recognition in print that there needs to be more awareness in schools. I thank my hon. Friend Andrew Percy, who was a teacher for many years before he entered this place, for his words on this subject. Without the relevant guidance, it is quite tricky to differentiate between children who, just from their background or families, one thinks are just being tricky, and children who are presenting with a diagnosable and observable emotional or clinical mental health condition.
On in-patient care for people under section 136 of the Mental Health Act 1983, times have moved on. The days when the idea was that somebody in such a unit should feel that it was akin to a prison must be well behind us. I very much welcome much of the work already done in the NHS and elsewhere to make sure that although such units are secure and can protect the vulnerable young people housed in them, they are developed not just as a location in which to keep them safe, but as a place with the services—the cognitive behavioural therapy, the psychiatrists and the psychologists—required to reintegrate them into society.
Without criticising the report, I would have liked it to go a little further on online resources and the digital world. It seems to me that we often see Twitter, social media and technology as a huge danger with all sorts of negative consequences, and that we seldom see the positive applications that could be made in the online and digital world. I very much welcome the acknowledgment of the extra stresses and burdens that social media place on young people in particular. I also welcome the allusion to how, perhaps with more resources and more proactive health care providers and more proactive people with an interest in mental health conditions, technology could be made part of the answer. When somebody is being bullied on Twitter or social media, technology could be used to create a little pop-up saying, “Hey. This looks like bullying. Would you like to analyse how you’re feeling about that?”
There could be all sorts of excellent uses of digital technology to help people through a process, through a partial process of CBT or in identifying the problems they face, and online resources could be exceptionally helpful in that regard. A lot of the process is about acknowledgment and recognition and then of leading people on to the next step, but if they do not feel that fulfilling the criteria for having a mental health challenge will be an embarrassment or that stigma will be attached to them, such technology could guide and lead them to getting additional help. When the Government look at the report, perhaps they could look even further into using the online world and digital technology as part of the cure.
As a former shadow Minister, I would like to say that if we had a pill that cured 50% of people of any illness or mental health condition that they had after six weeks, we would say that it was a miracle cure. Certainly for less acute mental health conditions among adolescents, cognitive behavioural therapy is that wonder pill. We need to see more investment in, further roll-out of and quicker access to such services.
I thank the Chair of the Health Committee, Dr Wollaston, and the other members of her Committee for their thorough and valuable report, and for giving us the opportunity to debate this important issue.
When we discuss complex commissioning and funding arrangements, as we are today, we must not lose sight of the people at the heart of the matter. I remind the House that we are talking about some of the most vulnerable children and young people, who are often scared and in states of high distress and trauma. They and their families deserve the very best care and support that our NHS can offer. However, as the Health Committee found, for too long they have been overlooked.
I think that anyone who has read the report would agree that it is damning in parts. It concludes:
“There are serious and deeply ingrained problems with the commissioning and provision of Children’s and adolescents’ mental health services. These run through the whole system from prevention and early intervention through to inpatient services for the most vulnerable young people.”
We have heard that Members from all parts of the House share the concerns that are expressed in the report. It was valuable and helpful to hear not only from members of the Committee, but from other Members who have experience from their constituencies and from before they came to the House.
Many Members in this debate and in previous debates in the House have raised horrifying and tragic cases involving their constituents. Most Members know all too well the pressure that too many parts of CAMHS are increasingly under. Sadly, the reports of children facing long waits for treatment, being sent hundreds of miles for a bed or not getting any help at all are too common. In my capacity as shadow Minister for public health with responsibility for mental health, I have received too many messages from young people across the country that paint a picture of services that are under immense pressure and of waits that pass the three month and six month marks. Indeed, we heard from my hon. Friend Mr Robinson about constituents who have waited 44 weeks.
The Minister is open about the scale of the challenge and acknowledges that there is much to do. The Government accepted in their response to the report that the mental health and well-being support that is offered to children and young people, as well as to their families and carers, often falls short. The Government accept that there is a need to improve the system. Today’s debate has been a much needed contribution to the parliamentary and public understanding of the challenges that the system is facing. It has been an opportunity for the House to hold the Government to account on their response and on the action that they must now take to get to grips with these challenges.
The shortage of beds, which the Select Committee highlighted, is of great concern to many Members. The Government response refers to NHS England’s commitment to commission 50 more beds. We understand that NHS England has opened the majority of those beds. I hope that in his response the Minister will confirm when the remaining few will open. Does he consider the additional 50 beds to be sufficient, in the light of the pressures that CAMHS is facing?
The system clearly is not working in some parts of the country. Members on both sides of the House will have been shocked to read in The Observer a few weeks ago that commissioners from NHS England sent out an e-mail on a Friday night to warn that there would be a national shortage of in-patient beds for children over the weekend and that it was likely that children would need to be placed on adult wards. Almost a year ago, the chief executive of YoungMinds said that the increase in the number of children placed on adult wards was entirely predictable following cuts to mental health services. I hope the Minister will say what more he can do to assess and reassess the situation.
Ensuring that we have enough beds to prevent children from having to travel hundreds of miles from home for treatment or to avoid being detained in police cells is, of course, critical, and Members have addressed that issue. However, as the Committee points out,
“commissioning extra inpatient capacity alone will not be enough to alleviate the current problems being experienced” in relation to in-patient services.
I appreciate that some of the issues are long-standing historical challenges, but it is certainly fair to say that this Government’s reorganisation has exacerbated those challenges. The Committee’s report states:
“Despite the move to national commissioning over a year ago…NHS England has yet to ‘take control’ of the inpatient commissioning process, with poor planning, lack of co-ordination, and inadequate communication with local providers and commissioners.”
NHS England itself has acknowledged weaknesses in commissioning as a reason for bed pressures and patients being inappropriately admitted to specialised units. The Committee highlighted the concerns that professionals have been raising for more than a year about the new split in commissioning between tier 4 services, which are the in-patient beds commissioned nationally by NHS England, and lower tier services, which are commissioned by clinical commissioning groups. It does not take a genius to work out that that arrangement results in the perverse incentive for CCGs to refer children to tier 4 in-patient services, because they do not have to pay for them, rather than treat them in the community, where they have to fund the places. We know that treatment in the community can be so much better for many of those young people’s outcomes and their long-term recovery, but the current situation is exacerbating many issues and problems.
The Minister himself has said that current fragmented commissioning arrangements make “no sense” and are “dysfunctional”. It would be helpful to hear from him what more the Government plan to do to address the situation. In their response to the Committee, the Government said that their taskforce would look at determining a way in which commissioning can be sufficiently integrated. Given that we had to read about the taskforce conclusions on the pages of The Times a couple of weeks ago, perhaps the Minister will do us the courtesy of updating the House on what action the Government will take.
The Government have also announced that NHS England has funded eight pilots looking into collaborative joint commissioning arrangements for children and young people’s mental health, so it would be really helpful to have an update on the progress of those pilots.
The commissioning confusion caused by the NHS reorganisation would be a challenge in itself, but, combined with the cuts to local authority CAMHS and early intervention services, it is having a devastating impact. There has been £50 million-worth of cuts to CAMHS since 2010. There have also been cuts to local authority CAMHS and to early intervention in psychosis services, a reduction in social workers and a decimation of the early intervention grant in many parts of the country, which is putting pressure on in-patient services, particularly in areas with higher levels of deprivation.
I listened to the speech by Andrew Percy, but Liverpool’s budget has been cut by 56%. The idea that Liverpool city council is not interested in youth services could not be further from the truth, but the reality is that applying the funds available to it to youth services is incredibly challenging.
According to research by YoungMinds, two thirds of councils in England have reduced their CAMHS budget since 2010. When the charity asked NHS trusts and councils about other mental health spending targeted at children and young people, such as youth counselling or specific services for schools, it found that more than half of them had cut their budgets, some by as much as 30%. It is therefore unsurprising that the Committee reported that poor provision of lower tier services has likely been a key factor in the increase in the number of children and young people requiring admission to in-patient services.
In their response the Government refer to extra funding for early intervention in psychosis services and crisis care, but will that not merely take us back to where we were before these cuts? What proportion of the new funding that the Minister has announced will be directed towards services for under 18s? I am particularly interested in the work of the Government’s taskforce on ways to incentivise investment in early intervention—again, it would be helpful to have an update on that. Will the Minister match the Opposition’s ambition to increase the proportion of the mental health budget that is spent on children over time—again, that point has been raised by hon. Members on both sides of the House?
Schools are an obvious place for prevention work to take place, and I was interested to hear the intervention from Sir Oliver Heald about the experience of schools in his area. The Committee found that in too many schools counselling services are unavailable, even though they can provide lower level preventive intervention that can stop problems from subsequently becoming more serious. Again, will the Minister update the House on his work with colleagues in the Department for Education to improve that situation? Will he meet the Opposition’s commitment to produce a strategy to help local authorities with their local NHS and schools to work together, to ensure that all children can access school-based counselling or therapy if they need it? Does he agree that in future all teachers should have training in child mental health so that they are equipped to identify, support and refer children with mental health problems?
A few other issues were raised in the debate, although I am conscious that we want to hear from the Minister and I have just three minutes to respond. The work force were mentioned, as was ensuring that all GPs are trained in mental health. The Opposition have committed to ensuring that training for all professional staff in the NHS includes mental health. Does the Minister support that ambition? Data were mentioned by Members on both sides of the House, and up-to-date data and information are critical to provide safe and effective services that meet the needs of children, young people, their families and carers.
I share the Committee’s concern that the most recent data from the Office for National Statistics on children and young people’s mental health are now 10 years old, and the Minister said that CAMHS has been operating in a fog without that information. I welcome the commitment to a new national prevalence survey of child and adolescent mental health data, and that that is a priority. Again, it would be helpful to have an update on that. Can the Minister set out the time frame for work that will take place before February 2016 when we understand that that data set will start?
In conclusion, as we have heard, significant questions remain. Much of the Government’s response to the Committee’s report has referred to the work of the CAMHS taskforce, which the Minister has established and is yet formally to publish its report, even though elements of it have been leaked to the press. It would be helpful for the Minister to update the House on when the taskforce report will be published in full, and to say whether he intends to follow it with tangible action—I appreciate that there will be recommendations, but it would be helpful to know what the Government intend to do.
Children and young people are struggling with mental illness, and in some cases their illness is becoming so severe that they are turning up in A and E—just this week a response to a parliamentary question showed that young people are turning up in A and E with mental illness not just once but two, three, four or five times. They often wake up in hospital beds too many miles from their families and friends, and are simply not receiving any help at all. We are having this debate on their behalf, and I hope the Minister will tell the House what action he will be taking to put that situation right.
We must get to a point where a child can feel that it is as safe to talk about their mental health as about their physical health, and where all children feel that they can tell someone about their anxiety as easily as they can speak about their headache or a stomach bug. Crucially, when they do that they must get the help they need, when and where they need it. I look forward to the Minister’s response.
The debate has been undertaken in a rational way—we have not had the hurling of abuse from one side to the other. My hon. Friend Adam Afriyie said that the report is objective and that it analyses problems and seeks to come up with solutions. The debate has been conducted in that way, which I welcome.
I am grateful to the Health Committee for its work, and for the inspired leadership of my hon. Friend Dr Wollaston, who speaks with great authority on the subject. She is a force for good in this place. I thank her for her leadership.
My hon. Friend said that the report was triggered by the awful practice of youngsters being shunted around the country in the middle of a crisis. The situation with adults is just as bad. That practice should not happen other than where there is a specialist need and a specialist service that cannot, with the best will in the world, be provided in every locality. We have sought to analyse the causes of out-of-area placements. We see enormous variation around the country. Many areas do not do it, but where it does happen, we believe that simple steps could be taken to stop it. In my view, they must be taken.
I agree. It is intolerable. One can only imagine the impact on the family having to travel such long distances. My hon. Friend and I had that discussion in Brecon with the family concerned. It is shocking that that practice continues. It must be a priority.
My hon. Friend the Member for Totnes said that the importance of early intervention is a central theme of the report. There is great scope for much more to be done on public mental health. It was revealed recently that a tiny proportion of public health budgets in localities is spent on public mental health, and yet we know—there is loads of evidence—that, if we invest in public mental health, we can achieve a significant return on it. I welcome the report.
Paul Blomfield talked about what young people had told him. It was great that they were given a voice directly in this place. I welcome his comments. In a very thoughtful speech, as always, my hon. Friend John Pugh talked about a continuum. Many of us are susceptible to poor mental health in certain circumstances. That makes the point about the importance of schools, which other hon. Members mentioned, in building resilience and keeping youngsters stronger so that they can cope with all the challenges they inevitably face these days.
Robert Flello talked about Malachi, an organisation he was involved with, and about the triggers that can cause mental ill health among youngsters. Family breakdown is one, but bereavement can have a significant impact, as can bullying at school, which another hon. Member mentioned.
I am conscious that I need to get through quite a lot in the time available to me.
I thank my hon. and learned Friend Sir Oliver Heald for his kind comments. He was absolutely right about the potential for online access. The hon. Member for Windsor made a similar point. There is enormous potential. One platform is called Kooth. Good evidence is developing about the impact that online access can have. Given that so many youngsters with poor mental health get no support at all, we can do a lot to increase access, not as a replacement for other services, but as a complement. He, too, talked about the importance of the role of schools.
I worked in Parliament as a junior researcher in 1980, for a Labour MP. I shared an office with the secretary of Mr Robinson. He is still here 35 years later. He is clearly the great survivor. He referred to the most appalling wait of 44 weeks in Coventry, which is totally unacceptable. I do not know what is going wrong in that locality, but that is not matched in many other places. There may be particular problems that need to be faced. In a way, that makes the case I have been making throughout my time as Minister that the same access and waiting time standards for physical health should exist for mental health. That is the big discrimination against mental health, and it has existed for a very long time.
I totally agree. When I embarked on the mission to introduce waiting time standards in mental health, I was very clear throughout that they must apply equally in children’s services, as in any other service. One of the first two standards we are introducing from April this year is a two-week standard to start treatment for early intervention in psychosis, where there is a wealth of evidence that quick intervention can lead to good results.
My hon. Friend Andrew Percy talked about the absolute importance of youngsters learning about mental health at school. It ought to be part of the curriculum, and we would benefit a lot if that was the case. He also made the important point that although lots of areas of the country have seen really ridiculous disinvestment in mental health and children’s mental health, other enlightened areas have not done that. There is no necessity for it to happen; it depends on what the local priorities are. In his area they have done the right thing and made the necessary investment.
Grahame M. Morris talked about the horror of suicide. The husband of my hon. Friend the Member for Totnes is a psychiatrist in Devon. He has been a brilliant advocate of the case for a zero-suicide ambition. Every organisation within the NHS ought to be setting the same ambition that has been set in Devon.
The Government have prioritised improving mental health as part of our commitment to achieving parity of esteem, or, as I would prefer to call it, equality. I have been frank that the current system for supporting children and young people’s mental health is simply not good enough, but let us be clear that this is not a new problem. Previous reviews into CAMHS have identified similar issues to those that the Committee highlights, such as a lack of beds, complex commissioning and referral arrangements, poor practice around transition from children to adult services, and instances of children being treated far from home or on adult wards. These issues are deep-seated and hard to resolve. Lord Crisp was recently quoted in the Health Service Journal, when asked about parity of esteem:
“If something has developed over 40 or 50 years you don’t solve it in five minutes.”
I know a youngster who in the past decade was horribly let down by mental health services at that time. This is not something that has just emerged over the course of this Parliament. I fully recognise that too many areas of the country have disinvested in young people’s mental health. I firmly believe that the situation can and must improve. The Government have taken steps to do this.
It is worth saying that, as I have done this job, I have seen some really impressive services. There is a brilliant NHS team in Accrington providing the best possible service to young people. I visited South London and Maudsley, where there is a fantastic eating disorder service based on the quickest intervention, with specialist support for youngsters very quickly reducing massively in-patient admissions. That is the sort of service we need to see across the country. There is a brilliant in-patient facility in Colchester, where there is a great school in the mental health service so that youngsters do not lose out on their education while they are receiving support. There are some brilliant third sector organisations. MAC-UK is a wonderful organisation, which takes therapy out on to the streets to support youngsters who get involved in gangs, rather than expecting youngsters in those circumstances to visit traditional services. MAP—the Mancroft Advice Project—in Norwich is a brilliant service supporting youngsters in a non-stigmatising way.
Since 2010, we have raised the profile of children and young people’s mental health to unprecedented levels. We have produced the mental health and suicide prevention strategies, set out the top 25 priorities to help to achieve parity of esteem in the “Closing the gap” document last year, and we have worked, through Time to Change, to reduce the stigma attached to mental health issues. The 2014-15 mandate to NHS England sets it a clear objective to deliver equality and parity of esteem, and in 2014 we published our five-year vision for mental health. At its heart was a radical change: an ambition to set access and waiting time standards for mental health—just as they exist for physical health—including children and young people’s mental health, for all services by 2020. That is a landmark step in rebalancing our health and care system and achieving equality.
It is good to hear that the Government are setting those targets. Will the Minister have a look at the situation in Coventry and explain to me why that has happened? Can he also confirm that the targets he has set will be achievable, despite the £50 million cut that has been made?
I am very happy to look at Coventry if the hon. Gentleman wants to send me a note about that.
I make the case that there needs to be more investment in mental health, and my party has argued for £500 million of additional investment a year in mental health in the next Parliament. Investing £54 million for the children and young people’s IAPT—improving access to psychological therapies—programme has started to transform existing services, and it now covers 68% of the nought to 19-year-old population, which exceeds the original target of 60% by 2015. NHS England continues to plan for nationwide roll-out, as set out in the mandate, which should be achieved by 2018.
As part of the autumn statement, the Deputy Prime Minister and I announced £150 million of investment over the next five years to deal with eating disorders. This will help to ensure that any young person can get the help they need, no matter where they live, and will allow the development of waiting time standards for eating disorders from 2016. This is a condition that can kill, so it is so important that we get early access. We have invested £3 million in MindEd, a digital resource to help people who work with young people and children. It is an online platform designed to give them the help that they need in the work that they do.
The prevalence survey is being undertaken—we have secured the money for it—and we plan for it to be ready by 2017. The aim is for it to cover children and young people from two years to 19 years, which is a wider range than in the original survey. That should be widely welcomed.
As for the taskforce, although there has been much progress, the Government have been open about the scale of the challenge and acknowledged that there is still much to do. As the Committee is aware, I set up the taskforce last summer. It is chaired jointly by the Department and NHS England and brings together a whole load of experts from outside Whitehall and listens to the voice of young people as well. This is a massive opportunity fundamentally to modernise the way that children and young people’s health services operate, embracing the role of the voluntary sector and the potential for online support for youngsters, and sorting out this ridiculous, fragmented commissioning. The problem has been there for a long time, but things need to be made much simpler, so that we can have coherent services that are easily understandable for children and their families. If we can grasp this opportunity, we can make a massive difference for young people.
Let me say a word about crisis care. In a way, this is the area where the gap between physical and mental health is greatest. The Torbay case that my hon. Friend the Member for Totnes mentioned was a shock to the system, although we have already seen considerable reductions in the number of young people going into police stations. We are on course to see a reduction of about 30% this year, but it needs to be much greater than that. In my view, we need to legislate to end the practice completely. It is surely completely unacceptable that young people under the age of 18 end up in police cells rather than in a hospital. That practice simply has to come to an end.
I applaud everyone who has participated in this debate on a really important subject. I think we have an opportunity massively to improve things.