About the authors Emily Frith is CentreForum's Director of Mental Health and Rehabilitation. Prior to this she was Special Adviser to the Deputy Prime Minister Nick Clegg, with responsibility for Health and Welfare policy from 2013 to 2015. During this time she coordinated on behalf of the Deputy Prime Minister the campaign to improve mental health services. Emily has also worked for the Prison Reform Trust on support for people with mental health problems in the criminal justice system, and the Driver Youth Trust on support for children with special educational needs. From 2005 to 2009, she was External Affairs Manager for Turning Point, the social care organisation which provides services for people with a substance misuse problem, a mental health problem or a learning disability. Acknowledgements CentreForum would like to thank our Commissioners for their advice and expertise and the following people and organisations who have helped with the research for this report: NHS England, NHS Benchmarking, Geraldine Strathdee, Peter Hindley, Royal College of Psychiatrists, Steve Mallen of the MindED Trust, Paula Lavis, Children and Young People’s Mental Health Coalition, Professor Sue Bailey, Academy of Medical Royal Colleges, Sam Royston and Kadra Abdinasir from the Children’s Society and Catherine Roche, Place2Be. The author would like to thank David Laws and Natalie Perera for their editorial advice and Anthony Rowlands, Jo Hutchinson, Becky Johnes, Russell Eagling and Imogen Longhurst for their support on final drafting. About CentreForum is an independent think tank which develops evidence-based research to influence both national debate and policy making. Published April 2016 CentreForum This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. For more information visit creativecommons.org Contents Foreword: Rt. Hon. Norman Lamb MP 4 Executive summary 5 Introduction 7 Prevalence 8 A growing problem? 10 Risk factors 12 Impact 14 The treatment gap 15 1: Funding 15 2: Funding more effective treatments 17 3: Treatment in non-specialist settings 18 4: Access to specialist treatment 18 5: Long waiting times 21 6. Crisis and inpatient care 23 7. Quality of treatment 26 8. Transition 27 Recent policy developments 28 1: Future in Mind 28 2: Progress since Future in Mind 29 3: Education policy 30 Conclusion 31 3 Foreword By Rt. Hon. Norman Lamb MP In my time as Minister for Mental Health I was appalled by the institutional bias against mental health within our NHS. This has existed for decades and is intrinsically linked to the stigma and discrimination faced by people with mental health problems. Child and adolescent mental health services are often described as the ‘Cinderella of the Cinderella service’, receiving less than 1% of NHS funding. I was determined to change this, so launched Future in Mind in March 2015, a plan to transform services around the country. This was accompanied by £1.25bn investment over five years to increase access to the right treatment, in the right place, at the right time. I was delighted that CentreForum invited me to chair this Commission to understand and explore progress since the publication of Future in Mind. This, our first report, charts where we are now, and describes the scale of the transformation process that is needed to achieve the vision set out in that document. It tells a story of children and young people who are denied timely access to the treatment they need or who are treated in the wrong place. This is not about blaming services, or those who commission them. It is a highly complex problem which has existed for decades. Those who work in services are all too aware of the lack of equality for mental health care. Transforming services will take time and sustained commitment. This Commission seeks to understand the problem as it exists across the country so that we can work together to find a lasting solution. 4 Executive summary One in 10 young people have a mental health problem. That’s the equivalent of three in every classroom1. This means there are around 720,000 children and young people aged between 5 and 16 experiencing a mental health problem in England2. CentreForum analysis suggests that there has also been a significant rise in children’s mental health problems over the last five years. In the context of this rising prevalence, Centre Forum’s new research for this report reveals serious concerns over access to treatment: : CentreForum research has revealed that child and adolescent mental health services (CAMHS) are, on average, turning away nearly a quarter (23 per cent) of children referred to them for treatment by concerned parents, GPs, teachers and others. This was often because their condition was not considered serious enough, or not considered suitable for specialist mental health treatment. : CentreForum’s new analysis of providers’ eligibility criteria indicates that this access problem could be because services are putting in place high thresholds for treatment. Something has to go drastically wrong before some services will accept a referral; the antithesis of an early intervention approach. For example, in one area the criteria states that for a referral to be accepted, the condition must have “a major impact on the child’s life such as an inability to attend school or a major breakdown in family relationships”. Another suggests that those hearing voices should seek specialist help only if they “heard voices that command particular behaviours”. One service would not accept those who had expressed a desire to commit suicide unless this had happened on more than one occasion. : The median waiting time for all providers was one month for a first appointment and two months until start of treatment. There was wide variation in average waiting times for different providers, from two weeks in Cheshire to 19 weeks in North Staffordshire. The average waiting time in Gateshead is five times as long as for those in nearby Tyneside. Similarly, waits in London vary widely from two months in Kensington and Chelsea to nearly six months in neighbouring Brent. : This average waiting time conceals longer ‘hidden waits’. CentreForum has uncovered that the median of the maximum waiting times for all providers was 26 weeks (6 months) for a first appointment and nearly ten months (42 weeks) for the start of treatment. Some providers did not measure waiting times at all, meaning that some patients could even be waiting longer than this. CentreForum also analysed existing data sources for this report. This uncovered concerning trends: : Our analysis of NHS Benchmarking data finds that the average of the maximum waiting times for all providers has more than doubled since 2011/12. : CentreForum examined NHS England data on expenditure. Our analysis finds wide variation in expenditure on children’s mental health by region. There is a higher level of expenditure in the North compared to the South and East of the country, which contrasts with the higher prevalence indicated in the South and East and the potential capacity problems uncovered in the South. For example, since April 2015 there were over 50 days on which no beds were available in the whole of the South West. Mental health problems are linked to premature mortality and can also be life-limiting. Young people with an emotional disorder are more likely to smoke, drink and use drugs than other children3; more 1 According to the most widely used prevalence data: Mental health of children and young people in Great Britain, Office of National Statistics, 2004http://www.hscic.gov.uk/catalogue/PUB06116/ment-heal-chil-youn-peop-gb-2004-rep2.pdf 2 9.6 per cent of 7.5m children aged 5-16 in England - Population Estimates, Office of National Statistics, 2014 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationesti- matesforukenglandandwalesscotlandandnorthernireland 3 Mental health of children and young people in Great Britain, Office of National Statistics, 2004 5 likely to have time off school and fall behind in their education; and are more likely to earn less money as adults or to experience unemployment4. As well as the personal cost, the estimated long term cost to the economy of mental health problems is £105bn a year5. Despite this significant impact, children and young people face substantial difficulties in getting help. Only 0.7 per cent of NHS funding is spent on young people’s mental health, and only 16 per cent of this funding is on early intervention. This report demonstrates a stark inequality within the NHS where, unlike those who are physically ill, children and young people with mental health problems are still not always getting the right treatment, at the right time, in the right place. While this issue has become a policy priority in recent years (as outlined below), there is still a long way to go before there is equality for mental health in the NHS in England. CentreForum’s Commission will seek to explore the risks and barriers to effective implementation of the current policy agenda and then to make recommendations to government and local commissioners in order to support the process of transformation over the next five years. 4 Childhood mental health and life chances in post-war Britain Insights from three national birth cohort studies, Richards et al, 2009: http://www.rcpsych.ac.uk/pdf/life_chances_summary%20(2).pdf 5 The Five Year Forward View for Mental Health, NHS England, 2016 https://www.england.nhs.uk/wp-content/uploads/2016/02/Men- tal-Health-Taskforce-FYFV-final.pdf 6 Introduction CentreForum has established a Commission chaired by former Mental Health Minister Rt. Hon. Norman Lamb MP on child and adolescent mental health. The Commission aims to understand and explore progress in transforming children and young people’s mental health care in England since the publication of Future in Mind, a government strategy to improve services published in March 2015, alongside a commitment to invest £1.25bn over five years.