(9 years, 9 months ago)
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The Earl of Listowel
To ask Her Majesty’s Government what plans they have to improve mental health services for infants, children and young people, for care leavers, and for adults with care experience.
The Earl of Listowel (CB)
My Lords, I am delighted to have this opportunity to discuss the mental health needs of children and young people in care.
I am grateful to the people I have worked with—the young people who are in care and leaving care who have shared their experiences with the parliamentary group; the clinicians, academics and practitioners who have made time to talk to me; and all those who have equipped me to speak to noble Lords today. I am grateful, too, for the lessons I have learnt from MPs who have chaired the parliamentary group for young people in care or who have campaigned in the area. They include former MP Hilton Dawson, Timothy Loughton MP, Edward Timpson MP, Craig Whittaker MP, Ann Coffey MP and the late lamented former MP Paul Goggins.
I have learnt that a cornerstone for mental health is to be able to make and keep relationships, and that family breakdown can destroy or impair that ability. Much of our job in repairing the mental health of abused or neglected children is to provide them with an opportunity of at least one enduring, consistent and benign relationship. Ten years ago, the charity Voice consulted young people on a blueprint for the care system. The children told us that they wanted one adult who would consistently follow them through their experience of care. They called him the Big Friendly Giant, after a character by Roald Dahl.
I hope that many of your Lordships present may attend future meetings of the all-party parliamentary group for children and young people in care. I know that it would mean a lot for the 60 or so young people who visit us each couple of months to see your Lordships there. There you will hear how young people have valued their relationships with foster carers, social workers and teachers. You will also hear children speaking of having more than 20 placements of fostering or more than five different social workers in a year and a half. From the care-experienced adults, you may hear from successful broadcasters who still see their social worker for tea today, or family men who now visit their children’s home to celebrate the manager’s birthday.
I am always pleased to hear the Minister say that he recognises the importance of an infant’s attachment to his mother. When key relationships fail, young people need to find someone else to be that reliable parental figure. A clinical psychologist, Sylvia Duncan, recently described the process of trauma in a seminar for the Institute of Recovery from Childhood Trauma. Many of us experienced trauma as a child—the loss of someone we love, a serious illness, even perhaps sexual harm. In the context of a loving family, where the trauma is not repeated, where one has not been betrayed by someone one trusts, where one can speak immediately about the trauma, recovery may be quick and leave no scars. Where the harm has been undertaken by one who one trusts, where that harm is repeated over years, where there is no one to discuss the harm with, serious trauma of the kind most young people entering care have experienced results.
Therefore, the finding of the Office for National Statistics survey of the mental health of looked-after children from 2003 should not have been a surprise. Mental disorders in children among the general population stand at 10%, half of which are conduct disorders. In the care population overall, 45% have a mental disorder and 37% of those are conduct disorders. In residential care, 72% have mental disorders and 60% of those are conduct disorders.
What does this mean for the experience of those working in children’s homes and foster care, and for adoptive parents? I will try to describe it. One may be caring for a strong, tall and beefy 15 year-old boy. Yet, for weeks or months, he may behave like an infant. He may not be prepared to leave his bed, may never show any gratitude for help given, may never clean up in the kitchen, and may not wash himself or cut his fingernails. Over time he may move towards his chronological age. Then one may be faced with rages from nowhere, with the fear that he may throw himself under a train when he next leaves the house, or that he may attack oneself or another child. One may be worried that he could set fire to the building.
Should the child be a girl, one may be worried about her sexual exploitation by men—although that might also be a concern for a boy. All this may leave one feeling bitterly resentful against the child; after all, he is 15 years of age. How can any trauma justify such selfish behaviour? One might say: “Next time he misbehaves, I will call the police, exclude him from the home, shout at him and see how he likes it, give him a slap in the mouth, the little wretch”.
This is where clinical group supervision is so important. Residential workers and foster carers need a space where they can vent the frustration, anger, fear and despair they feel about the children they work with. They need a clinician who can remind them that the child has regressed to an earlier stage of development, remind them how lonely and bereft that child is, and remind them that the most important thing that they can do for that child is to be reliable and tolerant, and continue to care. Without such support, carers are likely to burn out, quit, emotionally withdraw, or possibly even—we know this happens—attack the child. The most important thing for the recovery of that child is that there is nothing he can do to break the relationship with his carer.
It is therefore vital that the Minister is involved in ensuring that staff in children’s homes receive regular supervision or consultation from an appropriate mental health practitioner. I am very disappointed that in neither the guidance nor the new quality standards does there seem to be a stipulation on this. The psychiatrists who gave evidence to the noble Lord, Lord Warner, for his report on children’s homes in the mid-1990s advised that such an ongoing relationship with a mental health professional was the norm on the continent. Yet I am advised that this multidisciplinary approach may be applied in only about half our homes, even today. Does the Minister agree that such supervision or consultation is necessary? If so, what means will he use to see that it is implemented uniformly? I suggest that some of the payment for this—perhaps 50%—should come from the Department of Health.
A great deal of good work has been undertaken by this Government on reforming residential care. Serious consideration has been given to staff qualifications and staff are now better qualified. I commend the education Minister Edward Timpson MP, his predecessor Timothy Loughton and their officials on what has been achieved in a very difficult financial climate. However, I would urge whoever is responsible in the next Government to push further on qualifications as soon as possible.
If one of your Lordships’ children was deeply troubled and you were seriously troubled about their health and whether they would self-harm, would you wish to put them in the care of staff required to have only one A-level qualification? Would it satisfy you that the managers of these homes are required to have only a foundation degree—one year of higher education? The contrast with the continent is stark. There the status and qualification of staff is higher, yet they care for less challenging children.
Professor Berridge’s research on staff training is oft quoted by those who prefer the status quo. Yet in his recent blog for the NSPCC he emphasises the challenges of residential care, particularly in the light of the Rotherham experience, and the need by the next Government to raise the professional status of these people by raising the required qualifications.
Much of what I have said applies equally to foster care and adoption. While their children might be less trouble if they are with them 24/7, excellent social work support for foster carers and adoptive parents is vital, and I am grateful for the Government’s additional funding to support work with fosterers and adopters; and to my noble and learned friend Lady Butler-Sloss for her committee’s work in achieving this. Much training is offered to foster carers; consultation to groups of foster carers is rarer, but should be the bread and butter of specialist looked-after CAMHS. Access to individual therapies, including child psychotherapy, is important. I much look forward to the report of the taskforce that the Government have set up, due in March; I hope that it might refer to these therapies.
The last meeting of the parliamentary group discussed access to CAMHS for young people who are care leavers. We heard from one young woman who faced long delays in beginning therapy, and met her therapist once and only once because she was about to turn 18. A group of about 50 young people from all parts of England voted on the move from a 15 to a 25 year-old CAMHS service. All but one supported it. The Tavistock and Portman NHS Trust currently provides such a service to all young people. How is the Minister addressing the transition from child to adult mental health service for care leavers?
Finally, the Royal College of Psychiatrists points out that we can prevent so many children being taken into care each year by investing in parenting programmes. Does the Minister recognise the value of such programmes in keeping children out of care? So much good work has been undertaken by this and the previous Government on the education of looked-after children. I very much hope that in future, Governments will give as much attention to the mental health of looked-after children as to their education. I look forward to the Minister’s reply and to the contributions of your Lordships.
Baroness Stedman-Scott (Con)
My Lords, I thank the noble Earl, Lord Listowel, for securing this debate; I am especially pleased that he has specifically referred to young people with experience of being in the care system. I declare an interest in that I am the chief executive of Tomorrow’s People and a fellow of the Centre for Social Justice.
I want to start by saying more generally that broken relationships lie at the heart of so many people’s mental health difficulties. Research suggests family breakdown and early separation are risk factors for the onset of severe mental illness, including psychosis, in populations where there is a greater prevalence of these factors. Moreover, even in seemingly intact families, inadequate and neglectful parenting often contributes greatly to various emotional and behavioural problems, such as panic disorders, ADHD, post-traumatic stress disorder and reactive attachment disorder. With around two-thirds of children coming into care having done so due to abuse or neglect, looked-after children have often been at the sharpest end of these adversities. Unsurprisingly, the emotional and behavioural health of half of looked-after children is borderline or a cause for concern.
What is perhaps even more troubling is that, according to a recent survey carried out by the Centre for Social Justice for its report Finding their Feet, half of care leavers still found coping with mental health problems “difficult” or “very difficult” at the point of exiting the care system. Things also seem to worsen during early adulthood: one study found that self-reported mental health problems doubled in the 12 to 15 months after leaving care and three-quarters struggled with loneliness. Social isolation is a well known risk factor for mental illness, including depression. This points to something seriously wrong with transitions from care. The Centre for Social Justice concluded that the care system very often fails to help young people build the relationships they need; the social isolation that often ensues can serve to compound the trauma of difficult early life experiences.
This need not be the case. For instance, much more could be done to ensure that children do not lose touch with siblings in care, which often means that a potentially valuable, lifelong relationship is lost; they lose what little bit of family they had. A shocking 71% of looked-after children with a sibling in care are separated from a brother or sister. Social workers say that they feel their training does not adequately prepare them for deciding when to place siblings together in care, but also that their options are narrowed by a lack of available foster placements for sibling groups.
Ensuring that broader networks of support are built up and maintained as young people are in the process of leaving care is vital. I particularly point to the recommendation of the Centre for Social Justice, supported by the British Association of Adoption and Fostering, to introduce the practice developed in the USA of “family finding and engagement”. In this model, professionals seek at least 40 individuals with some kind of connection to a young person. Casting the net so wide means there are almost always some reliable adults—perhaps a great aunt, or a former teacher or youth worker—able to make unconditional commitments to support children in care into the future.
The model that we have adopted of giving young people a coach in school to make sure that they do not leave school without a job or a training place could easily be adapted for young people in care. Having a coach—somebody personal to them helping them make the journey from care and the transition to adulthood—would really help young people. Moving into their lives in years 8 and 9, the coaches could help them become work-ready and able to fulfil their potential by instilling them with confidence, self-belief and self-discipline. Some 89% of children in care in the Orange County Family Finding Project made lifelong connections; both President Bush and President Obama ordered this approach to be a nationwide requirement. Let us do the same.
Baroness Warwick of Undercliffe (Lab)
My Lords, I thank the noble Earl, Lord Listowel, for introducing this timely debate, and for his sustained interest in some of our most vulnerable children and young people. As we await the findings and recommendations of the Child and Adolescent Mental Health Services taskforce, I welcome this opportunity to consider the disturbing statistics that have prompted its work.
We know that childhood and the teenage years are where patterns are set for the future. A child with good mental health is more likely to develop healthy relationships, to do well at school, and to become an adult with good mental health, able to take on adult responsibilities and fulfil their potential. Yet the pressures of today’s society can be overwhelming. Family breakdown, violence in many communities and the fear of crime can be a real source of distress for young people. Social media and social networking keep up a constant pressure to have the right lifestyle, the right friends or the right possessions. Inequalities in childhood also have a bearing on mental health: young people in the poorest households are three times more likely to have poor mental health than those in wealthier homes.
It is nevertheless a shock to hear that 45% of children in care are suffering from a diagnosable mental health disorder, and that these particularly vulnerable children also have a greatly increased risk of “conduct disorders”, the most common childhood psychiatric disorders. Yet the stigma around mental health means that young people often do not get the right help: disruptive, difficult, withdrawn and disturbed children need to be supported, not ignored or punished. My aim in speaking today is therefore quite simple. Will the Minister reassure us that the CAMHS taskforce will have teeth and that its recommendations for improving access to services more responsive to children’s and young people’s needs—particularly to those for care leavers and those in local authority care—will be given real, urgent consideration?
The importance of early intervention in relation to vulnerable children is something I have spoken about before. The task force’s most urgent priority must be to focus on how to bring about a shift in resources to invest in early intervention, so that no child or young person has to wait two years to be seen, by which time the situation is so dire that they need intensive support. The recent announcement of £8.5 million for schemes to provide families with mental health support and early intervention services is therefore welcome, but we need to know how local authorities, schools, GPs, the NHS and clinical commissioning groups are going to be enabled to work together to target the right, cost-effective actions.
The noble Earl, Lord Listowel, referred to parenting programmes. The College of Psychiatrists says that up to 60% of the cost of these programmes is recovered within two years, and all costs recovered within about five years. Given that the lifetime cost to society per child with a severe behaviour disorder is about £260,000, that is pretty effective. Will the Minister tell us what the Government are doing to ensure that a cross-departmental strategy is in place to improve the provision and accessibility of parenting programmes? I ask the question in the knowledge that two-thirds of local authorities in England have been shown to have reduced their CAMHS budget since 2010. The stark reality is that funding has been cut by both local authorities and clinical commissioning groups, with the catastrophic effects that we have heard outlined today already.
I was shocked last week to learn that during 2013-14 there were 17,000 visits to hospital emergency departments by young people in mental health crisis. That is almost double the figure for 2010-11. How can the Minister ensure that effective children’s mental health services are not compromised by cuts to local government?
We need to be able to provide support to children, young people and their families when they start to struggle. Only then will we avoid the costly and intense suffering that entrenched mental illness can cause.
Baroness Tyler of Enfield (LD)
My Lords, in a rapidly changing world, children and young people face a wide range of risk factors for mental health problems, both now and later in life. It is salutary to note that in an average classroom, 10 children will have witnessed their parents separate, eight will have experienced physical violence, sexual abuse or neglect, and seven will have been bullied.
Those in the particularly vulnerable group, children in care, are typically in care precisely because they have experienced neglect or abuse, and these traumatic experiences can affect them for the rest of their lives. The recent Barnardo’s report, The Costs of Not Caring, showed that children in care are five times more likely to develop childhood mental health problems and, shockingly, are five times more likely to commit suicide later in life.
Despite the widespread concern about the current state of mental health services for children and young people, it is important to acknowledge what the Government have done to improve things, including investing £54 million into the children and young people’s IAPT programme and the recent announcement by the Deputy Prime Minister that £150 million will be invested over the next five years to improve treatment for eating disorders. It is welcome, of course, but nothing like enough.
We are all aware of the impact of budget cuts on CAMHS services. As a consequence, children have too often been transferred far from home or placed in adult wards that are ill equipped to take care of them. Services provided by the voluntary sector have picked up some of the slack, but there is often a lack of awareness about these services and they may be ill equipped to deal with serious mental health problems.
In reality, the help that is available can be hard to find. A 2013 YoungMinds study found that one in three young people does not know where to turn for mental health support; and, as the National Children’s Bureau pointed out, only a quarter of five to 15 year- olds with anxiety or diagnosable depression are in contact with CAMHS. By the time young people do get support it can be too late. More than 80% of parents said that children and young people were at crisis point before they managed to get support.
What is to be done? I greatly look forward to the findings and recommendations of the Government’s Children and Young People’s Mental Health and Wellbeing Taskforce. What is on my wish list? First is far more joined-up commissioning for CAMHS, with young people’s voice at the heart of service design. Secondly, counselling in schools can provide an alternative and valuable route for young people to get therapeutic help. Schools in Wales and Northern Ireland are already required to provide counselling. In my view, children in England should have the same opportunity. Can the Minister say what practical steps the Government are taking to ensure that all children have access to school counselling?
Thirdly, as already stated, children in care are not only more likely to experience mental health problems in childhood, they are also more likely to experience the sorts of problems—emotional instability, substance abuse, self-harm—that lead to worse outcomes later in life. That is why I think that CAMHS, IAPT and school counselling should explicitly prioritise the needs of children in care as part of the corporate parenting role that government plays.
When we think about children’s mental health we should think not only about the 10% who already have a diagnosable condition. Relatively minor problems in childhood often snowball and develop into fully fledged mental health disorders in adulthood. There are good examples of effective early intervention, such as specialist support to help parents develop a healthy connection with their young babies, and parenting programmes, as we have already heard.
I believe that schools should have a responsibility to prepare children not only for exams but for the difficulties they may face in later life. That is why I would like to see PSHE programmes to address issues such as bullying, drugs and alcohol, and mental health being compulsory for all primary and secondary schools.
Finally, preventive mental health support should be offered to all children in care and care leavers so that they can access the support they need to overcome past trauma and achieve stability later in life. I thank the noble Earl, Lord Listowel, for having secured this debate.
The Lord Bishop of St Albans
My Lords, the terrible reality of the effects of mental health could not have been more powerfully illustrated than by the story reported in the press last week of 18 year-old Edward Mallen. He was not one of “those unfortunates”—he had 12 A* GCSEs and was predicted to achieve three A* A-levels; he had got grade 8 piano and a place at Girton to read geography—but he rapidly descended, over quite a short time, into depression and died under a train. Not only is it an affront to think of that young life, with all its potential and opportunities, suddenly being lost with his death, but the scars will stay with all the members of his family for the rest of their lives.
Recently published ONS figures show a worrying rise in the number of suicides in the UK, particularly among men. There were 6,233 suicides of over-15 year-olds registered in 2013, 252 more than in 2012, with the male suicide rate three times that for women. In the UK, suicide is the main cause of death of young people under the age of 35—more than 1,600 every year. Hundreds more attempt suicide and thousands more self-harm.
Much more needs to be done, perhaps drawing on research such as that provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. In last year’s annual report, it identified various key points at which there was much greater risk. For example, the first three months after a patient’s discharge remain a time of particularly high suicide risk, especially in the first two weeks. Between 2002 and 2012 there were 3,225 suicides in the UK by mental health patients in the post-discharge period, 18% of all suicides. The report also pointed to suicide by patients receiving care under crisis resolution or home treatment teams. Such people are much more likely to commit suicide than those in in-patient care. It also pointed to living alone as a common antecedent of suicide by patients receiving care under crisis resolution and home treatment teams.
I welcome the Government’s initiatives in the area of suicide prevention. Indeed, I applaud the Government’s ambition to achieve zero suicides through the NHS adopting the approach pioneered by the Henry Ford Medical Group in Detroit. The dramatic improvements in Detroit will give hope that those who feel such desperation and so little hope in our society can also be reached. They point to the need for rapid and thorough expert assessment of patients who are having suicidal thoughts; for improvement in the care of those who present with self-harm injuries at A&E units; for better education for the families of people deemed to be at risk; and for improvement of data collection on patients to get a better understanding of how and where patients are most at risk of suicide and then to target resources at them.
The charity PAPYRUS has highlighted the need to ensure that children, young people and vulnerable adults receive due attention under this new strategy. It is imperative that the provision of resources is sustainable and adequate to facilitate a wider understanding of people with mental health problems as well as to enable the necessary preventive training and aftercare. I therefore applaud the good work that is going on, not least in organisations such as the Samaritans and the churches. I also ask the Minister whether the Government will respond to the campaign by Mind to guarantee referrals to talking strategies, which have clear benefits for those who receive them, within 28 days.
Baroness Uddin (Non-Afl)
My Lords, the commitment to ensuring equity between mental and physical health services is in disarray. The NHS has undoubtedly hit mental health provision hardest, according to a BBC report, with as many as 1,700 beds being cut and patients having to travel huge distances to access care, putting patients and families through significant distress and displacement. Despite the promise of guarantees of parity in funding, the overall proportion of funding going to mental health has been falling, compounding the long-standing underfunding of mental health services which is so costly to human lives and our society at large.
The impact of these cuts on children and adolescents has often been lost in the furore about mental health. I thank the noble Earl, Lord Listowel, for highlighting this issue, not only through this debate but also through his involvement in Young Minds, which has campaigned so effectively to highlight cuts and freezes to mental health services across most local authorities.
Only yesterday, I and colleagues in this and the other place, heard Sally Burke describe her family’s plight when her daughter Maisie, now aged 13, went into crisis. Suicidal and distressed at the age of 12, Maisie had to be taken by the police—because no GP was available to tend to her—and was eventually hospitalised in Stafford, 130 miles from her home in Hull. Sally Burke has had to fight tooth and nail for her daughter to get appropriate care, including getting her MP, Alan Johnson, to intervene with Norman Lamb and the health commissioner in order to get Maisie moved closer to home. However, she still remained 60 miles away in Sheffield due to the removal of mental health beds for children in Hull.
One of the many distressing features of Maisie Shaw’s case is that she was only aged 13, after being hospitalised, when she was diagnosed with autism. As a high-functioning autistic child, at no point had the health or education practitioners she had come into contact with pushed her towards a diagnosis. Instead, Sally Burke says that she was made to feel responsible for Maisie’s irregular behaviour as a small child. She has had to develop huge resilience to withstand battle after battle with atomised public services. She describes the experience as fundamentally “cruel”. This is one example among many that has come to our attention, particularly from carers struggling to manage their loved ones with mental health and autism as an added dimension.
The figures are stark. NHS England reports that as many as 70% of children and young people with autism have at least one mental health disorder. Some 40% have two or more mental health disorders. The Minister will acknowledge that the condition of autism is associated with significant mental health needs. At present, however, specialist child and adolescent mental health services—CAMHS—for autism are few and far between. As NHS England has acknowledged,
“there is a scarcity of professionals with the necessary levels of expertise to provide this highly specialist service across the country”.
Professionals working within CAMHS say that children are not adequately supported while waiting for psychological therapies and that support for parents and carers is negligible.
Can the Minister assure the House that, to address these challenges, the Government will address autism specifically in their work on mental health, for example through the task force on children and young people’s mental health and via the mental health system board and the ministerial advisory group? Given the complexity of autism, will he agree that this group requires specialised attention?
Lord Addington (LD)
My Lords, this is one of those debates where we find ourselves addressing the ground very close to the subject we are covering tonight, because we have been there before.
The primary thread through this is the fact that those who have stressful lives are going to experience a slightly higher occurrence of mental health problems. The noble Baroness, Lady Uddin, and I have taken part in several debates where we talked about people with disabilities and how they are going to have a slightly higher occurrence of mental health problems because their lives are more stressful. Every time that occurs, we are going to find more mental health problems. The problem is the fact that we have not, until very recently, acknowledged that this is what is going on. We have a historical problem which we are now starting to address. I do not know if we are coming up with more solutions with this Government, but at least we are acknowledging the problem and taking the first step.
Will the Minister give us some assurances about where we are improving training in recognising this problem? We have identified the fact that where people are under greater stress, anxiety and depression are going to be more common. What are we doing to make sure that those who are dealing with this recognise the underlying problems and intervene early? Every time we delay dealing with these problems, behaviour gets entrenched and educational problems become more pronounced.
The problem with the education system is that children and young people are on a conveyor belt. If they slip at any stage, they have to run very fast to catch up. Mental health will account for some of that slippage. When mental health issues occur with a special educational need, a situation is created where the child is under even more stress and dropping out is only the short-term survival mechanism. What are we doing to address this?
The noble Earl, Lord Listowel, addressed the point that care workers are undertrained to recognise this problem. They do not know what is going on. I think the Government have recognised that GPs do not have enough training to spot the problem early enough to push clients towards services. It may be the case that, as in many of these things, if you are going to have a problem, choose your parents well, and they will battle through for you. But, without that backing, children do not get that thrust to intervention and we end up with this point of crisis intervention and it tends to be papering over the cracks. Will my noble friend give the House some idea about the general strategy of making sure that there is greater awareness of the importance of early intervention? Without that we will carry on papering over cracks.
Lord Ramsbotham (CB)
My Lords, I begin by congratulating my noble friend Lord Listowel on securing this important debate and once again demonstrating to this House his intense and continuous focus on improving all kinds of services for children and young people.
A number of noble Lords have already mentioned the very welcome development by the National Health Service of the Children and Young People’s Mental Health and Wellbeing Taskforce. I want to build my contribution on a meeting held with the children’s group which is currently considering the mental health of children and young people. I was very struck by the fact that members of the group said that one of the problems they were finding as they were going round the country was a complete lack of co-ordination between what was going on in various ministries. They illustrated this by demonstrating to us that they were conducting eight pilots.
One of the pilots listed was a bid from the Black Country to,
“map and analyse commissioning of CAMHS … and other health funded out of area placements, with the aim of preventing the large numbers of children from the Black Country being placed ‘out of area’. … It will include commissioning urgent care … to include the focus upon delivering a Black Country wide solution to children and young people requiring admission to a place of safety (under Section 136 of the Mental Health Act.”
I thought that at the same time that the Ministry of Justice is developing this appalling idea of building the biggest children’s prison in the western world—called the secure college—which will contain a cohort of these very children from the Black Country, for whom the Black Country services are seeking to find a place of safety. To me, that is an absolute illustration of the lack of co-ordination which is inhibiting the development of satisfactory mental health services for this particular cohort.
I happen to chair three all-party interest groups at the moment: one on speech, language and communication difficulties; one on criminal justice, drugs and alcohol; and the Criminal Justice and Acquired Brain Injury Interest Group. I have had meetings with all three to discuss the agenda that they would like to put to the next Government and to ask them what problems were inhibiting them in achieving what they want to achieve. We have had a fascinating agenda. We are drawing it up with some care. Interestingly, time and again—and this very afternoon with the speech and language people—I was told that at a meeting NICE was not prepared to accept educational research in respect of improving the lot of people with SLCN.
I know the Minister understands this—he is someone whom the whole House respects greatly for the way he looks at things. Will the Government follow this line of looking and seeing how cross-government working can improve the services for this group because, sure enough, out in the field are all the people who want to do the work and are being inhibited in one way or another in a preventable way?
Lord Bradley (Lab)
My Lords, I, too, congratulate the noble Earl, Lord Listowel, on securing this very important and timely debate on mental health services, particularly for children in care. As we have heard, it has produced many important speeches. I believe that we are at a time when mental health has never been higher on the political and, more importantly, the public agenda. As such, we must all seize the moment. In my brief contribution, I want to remind the House of some key facts that are behind the barriers that may be stopping improvement in mental health services for children, care leavers and, in particular, adolescents.
As we know, mental health problems affect 23% of the population at any one time, and the economic and social cost of mental ill health was estimated in 2009-10 to be £105 billion. As has been pointed out, that is the entire annual National Health Service budget. Furthermore, three-quarters of people with depression receive no treatment at all. That includes children, and 10% of five to 15 year-olds have a mental health problem. This is especially true of children in the care system, who have a poorer level of physical and mental health than their peers and whose long-term outcomes remain worse. Two-thirds of looked-after children have at least one physical health complaint and nearly half have a mental health disorder.
Although the ambition for parity of esteem between mental and physical health is clearly welcome—nothing could be more important in this ambition than children in care—there are concerns that there are major problems in actually achieving it. For example, a recent survey by the Royal College of Nursing revealed that there are now 3,300 fewer posts in mental health nursing and 1,500 fewer beds than in 2010. These problems were further exposed by the Health Select Committee in October 2014, in its report on child and adolescent mental health services. 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”.
That is not surprising given that we know that only 6% of the mental health budget is spent on children and young people in the mental health system and, as has been pointed out, this has been exacerbated by recent cuts in CAMHS services.
Against this backdrop, what needs to be done to improve mental health services, particularly for children in care? First, we need to ensure that there is an adequate number and proper geographical distribution of in-patient beds for all age groups, but particularly for children, when they are required. This should resolve the problem of children being taken hundreds of miles away from home or ending up in adult psychiatric beds, which is totally unacceptable, as the whole House will agree. I know the task force is undertaking this work, and I would be grateful if the Minister could advise us what progress has been made on this issue.
We heard from the noble Lord, Lord Ramsbotham, about the use of police cells and the inaccessibility of proper places of safety. Linked to that, we must ensure that the liaison and diversion programme is completed by 2017. We heard about the expansion of therapy, particularly the IAPT programme, and therapy services for children, which I support, but we must look in particular at transitional arrangements and the ages at which people have access, in a timely way, to those programmes. It is crucial that we recognise the value of early intervention and the dramatic effect on people’s lives, particularly for young people and their families, if that intervention does not take place.
We need a real focus on schools, with all staff, especially teachers, having some level of training in mental health so that they can identity possible issues and passport children to specialist services. We need to look at the Mentally Healthy Society report that was published today, which recognises the need within schools to have a named CAMHS worker for proper link and access. It also recommends training health workers—we have heard a lot about training today—on mental health issues, because, again, they can be crucial in early intervention.
I recently visited a liaison project in Sunderland and met with parents of children who had a mental health problem. The scheme is excellent and the parents are wonderful, but they need tailored, timely and continuous support. Parenting programmes, which are supported by the Royal College of Psychiatrists, need to be expanded and must be funded and developed. Finally, we need a clear strategic commissioning framework to ensure that all relevant agencies—health, criminal justice and others, as well as local authorities, particularly for children in care—work effectively together so that we do far better for all children who have mental health problems.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank the noble Earl, Lord Listowel, for securing this important debate and for speaking to his Question so powerfully and with such authority.
Improving the mental health of children and young people is a key priority for the Government. It is part of our commitments to achieving parity of esteem between mental and physical health and to improving the lives of children and young people. Since 2010, we have raised the profile of mental health to unprecedented levels. We have produced the mental health and suicide prevention strategies and worked, through Time to Change, to reduce the stigma attached to mental health issues.
Although there has been much progress, the Government have been open about the scale of the challenge and acknowledge that there is still much to do. This includes action to improve outcomes for looked- after children and care leavers. Around 68,000 children are looked after by a local authority. For nearly two-thirds of these, the primary reason for being looked after is abuse or neglect. Although looked-after children have many of the same health risks and problems as their peers, they tend to have poorer outcomes. Almost half have a diagnosable mental health disorder and two-thirds have special educational needs. I can reassure my noble friend Lady Tyler, in particular, that it is the responsibility of the local authority, as corporate parent, to assess each looked-after child’s needs and draw up a care plan that sets out the services which will be provided to meet those needs. It must make arrangements to ensure that the child has his or her health needs fully assessed, and a health plan developed and reviewed.
At the end of last year, we consulted on revised statutory guidance on promoting the health and well-being of looked-after children. In that guidance, which will be published in its final form shortly, we emphasise the need for parity of esteem between mental and physical health. My noble friend Lady Stedman-Scott spoke about the social isolation felt by those leaving care. The guidance stresses the importance of ensuring continuing support for those leaving care, and that suitable transition arrangements are in place so that the young person’s health needs continue to be met.
That leads me to the concern expressed by the noble Earl about the problems that can arise during transition from children’s to adults’ services, a point touched on by the noble Lord, Lord Bradley. Indeed, ending the unacceptable cliff edge that some young people—not just those in or leaving care—face of support being lost as they reach the age of 18 is a key priority for action. I am delighted that NHS England has now published new service specifications for child and adolescent mental health that give guidance to local commissioners on how to improve transition practice. The Children and Young People’s Mental Health and Wellbeing Taskforce, to which I shall return in a moment, is also considering how to deliver more seamless transition built around the needs of young people. Our statutory guidance on promoting the health and well-being of looked-after children stresses the importance of ensuring continuing support for those leaving care and that suitable transition arrangements are in place, so that the young person’s health needs continue to be met.
The noble Earl asked how specialist mental health services for looked-after children, including psychotherapy, can be protected and, indeed, expanded. Rather than mandating mental health services targeted at specific groups such as care leavers, our aim is to ensure that everyone has timely access to evidence-based services when they need them. That is why—as mentioned by the right reverend Prelate—we have invested £54 million over the last five years in the Children and Young People’s Improving Access to Psychological Therapies Programme. This has transformed children’s mental health services throughout the country through the use of evidence-based therapies alongside session-by-session outcome monitoring, so that both therapist and patient know how well therapy is working toward a goal. We are strengthening the statutory guidance to make it clear that service commissioners must make sure that services provide targeted and dedicated mental health support to looked-after children, according to need. How they do that is for local determination, but it could include a dedicated team or seconding a CAMHS professional into a looked-after children multi-agency team.
The Government are clear that lack of investment in children and young people’s mental health services is not acceptable. Last November, we provided £7 million of additional funding to NHS England, allowing more in-patient tier 4 CAMHS beds to open. So far 53 new beds have been commissioned, taking the total to over 1,400 beds, more than ever before. We are well aware that there is variation across the country in investment in services provided by local authorities, schools and clinical commissioning groups. The noble Baroness, Lady Uddin, and other noble Lords have mentioned funding. We have legislated for mental health to get its fair share of local funding and this year’s NHS planning guidance is clear that spending on mental health services must increase. It is not enough simply to provide more and more beds. In order to ensure that improvements are sustainable, we need to focus on preventing issues arising, or taking action before hospital treatment is required. The task force is considering how best we strike this balance.
In addition, I can tell my noble friend Lord Addington that we have produced MindEd, which is an online platform designed to give those who work with children and young people every day the skills and knowledge to recognise the earliest signs of mental health problems. Health Education England is working with the Royal College of General Practitioners and others to improve training on CAMHS and the task force is also looking at the capacity and capability of the workforce. The Department of Health is commissioning a new prevalence survey of child and adolescent mental health, giving us something that we have needed for years: an accurate picture of mental ill health in youth.
I shall now try to cover as many points as I can that have been raised in the debate. I will of course write to noble Lords whose questions I have not been able to address in the time available. The noble Earl spoke very eloquently about the need for proper supervision of staff. All staff working in a children’s home should receive supervision of their practice from an appropriately qualified and experienced professional. In the majority of homes the supervisor will have experience or qualifications in the mental health field. The national minimum standards for fostering services expect them to ensure that foster carers receive the support and supervision they need. Programmes such as Multidimensional Treatment Foster Care can provide support, both to the child and to its foster carers. We expect to lay before Parliament next week new quality standards regulations for children’s homes in England, to come into force on 1 April. The regulations will require all staff in a home to receive practice-related supervision by a person with appropriate experience.
The noble Earl also referred to the qualifications of managers and staff. The Department for Education introduced new mandatory qualifications for children’s home managers and staff from this January. These include requirements to be able to support the well-being and resilience of children and young people.
The noble Baroness, Lady Warwick, referred to the reported drop in investment in CAMHS. As she knows, we have taken difficult economic decisions to protect the NHS budget and there have been no central government funding cuts to children and young people’s mental health services. We have been clear that a lack of investment in mental health services for children and young people is not acceptable, as I have said, and the child and adolescent mental health task force was commissioned to identify how to improve the quality of and access to children and young people’s mental health services.
My noble friend Lady Tyler asked what practical steps the Government are taking to ensure access to school counselling. The Department for Education is producing new guidance on good school counselling. We anticipate that this will be published in March. She also asked what we are doing to promote PSHE in schools. The Department for Education has funded the PSHE Association to produce new guidance for schools on teaching about mental health.
The right reverend Prelate the Bishop of St Albans spoke very powerfully about young people who self-harm and who commit suicide. Indeed, in January this year we issued a call to every part of the NHS to commit to a zero suicide ambition. In addition, the Government announced £150 million over the next five years to improve services for eating disorders and self-harm. He will know, I am sure, that preventing suicide in children and young people is a central part of the cross-government suicide prevention strategy published in 2012. That is backed by £1.5 billion of funding for research on suicide and self-harm.
As regards Mind’s call for talking therapies to be available within 28 days, the five-year plan for mental health sets out the ambition to have new waiting time standards across all mental health services by 2020. The Department of Health and NHS England are working to do this, and I think that introducing those waiting time standards is a landmark for mental health services that we have not seen hitherto.
The noble Baroness, Lady Uddin, spoke about the need for CAMHS for autistic children in particular. The new statutory framework for children and young people with special educational needs and disability is designed to greatly improve integrated working across health, education and social care, to deliver improved outcomes for the child and their family. CCGs and local authorities have joint arrangements for assessing, planning and commissioning services for children and young people with special educational needs.
The noble Lord, Lord Ramsbotham, asked how best we should address the lack of co-ordination across CAMHS. On 11 December last year, eight pilot projects were announced that will look to accelerate new collaborative commissioning approaches for children and young people’s mental health. These new pilots will be in various parts of the country—I will not read them out—and have each been awarded up to £75,000 to develop their plans. They have until April to get their new approaches up and running.
Time prevents me from covering the questions posed by the noble Lord, Lord Bradley, in particular. I undertake to write to him and other noble Lords, as I said. But I would just like to touch on the subject of parenting, which the noble Earl, Lord Listowel, mentioned, as did the noble Baroness, Lady Warwick, and the noble Lord, Lord Bradley. The CYP IAPT programme includes a focus on parenting for three to 10 year-olds with conduct disorder. It currently works with services covering 68% of the population and the ambition is for nationwide coverage in 2018.
The task force is a crucial element of our plans. It brings together experts from across health, social care and education to look at how to improve the way children and young people’s mental health services are organised. It has a particular focus on the needs of the most vulnerable children and young people, including looked-after children. We will publish the Government’s report of the task force’s findings shortly. I hope that noble Lords will be reassured that there is much going on in this area. The Government are very focused on the subjects that we have heard about this evening. I very much hope that the progress we have seen over recent years will be continued under the next Government.