Report

by the Comptroller
and Auditor General

Department of Health & Social Care, NHS England and Health Education England

Improving children and young people’s mental health services

HC 1618 Session 2017–2019 9 October 2018

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Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 9 October 2018

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Sir Amyas Morse KCB
Comptroller and Auditor General
National Audit Office

8 October 2018

The report examines whether the government is on track to meet its ambitions for improving mental health services for children and young people.

© National Audit Office 2018

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The National Audit Office study team consisted of:
Alex Bowyer, Natalie Low, Juliette Mullin, Benjamin Osenius-Eite, David Raraty, Sarah Rollinson and David Williams, under the direction of Jenny George.

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Key facts

Summary

1 The government has acknowledged that, in the past, mental health services were seen as of secondary importance to physical health services. It has committed to providing ‘parity of esteem’ for mental and physical health services. Parity of esteem means that mental health is valued as much as physical health: an expert group, convened at the request of the Department of Health & Social Care (the Department), defined this as including equal access to care and an allocation of resources in proportion to need.

2 Mental health problems can affect both adults and children and young people. The most up-to-date estimates (from 2004) indicate that 10% of five- to 16-year-olds have a mental health condition, although as little as 25% of children and young people with a diagnosable condition actually access services. The Department is responsible for mental health policy, while NHS England is responsible for overseeing the commissioning of NHS-funded services, either directly or through clinical commissioning groups (CCGs). Various other government departments and arm’s-length bodies also have a role in funding and delivering these services (see paragraph 3.18 and Figure 18 in Part Three). NHS England and CCGs collectively spent £1.0 billion on children and young people’s services in 2017-18 (around 1% of total expenditure).

3 In 2014 and 2015, the government announced £1.4 billion of transformation funding for children and young people’s mental health services. In March 2015, it set out its vision for children and young people’s mental health services in Future in Mind. The main programmes taking this forward are:

the NHS’s Five Year Forward View for Mental Health (Forward View) programme, which covers all NHS mental health services in England, but with specific objectives to improve children and young people’s mental health services;

the accompanying health workforce development programme, Stepping Forward to 2020/21 (Stepping Forward), led by Health Education England;

since 2015, annual local transformation plans covering all mental health services available to children and young people in the area, including both NHS and non-NHS services. Since the plans were launched they have been incorporated in the Forward View programme; and

Transforming Children and Young People’s Mental Health Provision: a Green Paper (Green Paper), jointly published by the Department and the Department for Education in 2017 and due to be implemented from the end of 2018. It commits a further £300 million, with a focus on developing the links between schools and health services.

Various other initiatives also contribute to the delivery of Future in Mind. As Future in Mind is a cross-government strategy, some sit outside the remit of the Department and NHS. Some initiatives aim to support children and young people’s mental health, rather than have it as their primary focus, for example, the Troubled Families programme run by the Ministry of Housing, Communities & Local Government.

4 This report forms part of a wider programme of work on mental health, following our 2016 report Mental health services: preparations for access and our 2017 report Mental health in prisons. It examines whether the government is on track to meet its ambitions for children and young people’s services, taking Future in Mind as the starting point. We focus in particular on how the government decided to implement Future in Mind; whether it is on track to deliver improved mental health services to young people; and accountability for spending and outcomes.

Key findings

Planning for transformation

5 The government faces significant challenges in transforming children and young people’s mental health services, as part of its commitment to parity of esteem between physical and mental health services. The government acknowledges that historically mental health services have been seen as of secondary importance to physical health services. Its periodic survey of the prevalence of mental health conditions among young people allows it to estimate overall need, but historically it has treated far fewer young people than this. In 2015, the most up-to-date estimate indicated that only around one-quarter of children and young people who needed support from mental health services could access those services. The government has endorsed a vision for improving support for children and young people’s mental health, set out in Future in Mind. Delivering this vision will require coordinated action across different parts of government – for example, health, education, local government and justice – and between national and local bodies. Each of these has its own priorities, funding challenges and accountability arrangements. Experience in other sectors also suggests that raising the profile of mental health support and services and reducing the stigma of mental illness may uncover previously unidentified further demand (paragraphs 1.3, 1.7, 1.10 to 1.12, 2.28, 3.18, 3.22 to 3.24 and Figures 4 and 18).

6 The current programmes mark an important, but modest, first step towards tackling issues of parity of esteem. The Department told us that, given the historic under-investment in these services, it wanted to act as soon as possible to begin improving services and access to services. In practice this has meant initiating programmes of work to deliver improvements in key areas. For example, one major aim of the NHS’s Forward View programme is to increase the proportion of children and young people accessing NHS-funded mental health services from around 25% of those in need to 35%, between 2015-16 and 2020-21. This reflected the Department’s best estimate of what could be achieved with the funding provided and staffing constraints. Yet even if this was achieved there would remain significant unmet need for mental health services. The Department believes that the ambitions set out in the Forward View and the Green Paper will help deliver a step-change in improvement in support to children and young people. The latter introduces a new approach in schools, including the creation of new mental health support teams. However, the balance between pace, funding and need to test approaches means that the Green Paper will only be rolled out to 20–25% of the country by 2023 (paragraphs 1.10, 1.12, 1.16 and 2.23, and Figure 4).

7 The government has not set out and costed what it must do to achieve Future in Mind in full. Future in Mind identified 49 proposals on themes such as resilience and early intervention, access and workforce development. However, the current programmes to take this forward will not deliver its proposals in full. Our analysis highlighted that the programmes do not have explicit objectives for some proposals, particularly those related to vulnerable groups. The government has not yet identified what actions and budget it will need to implement each proposal in Future in Mind, what progress it has made so far, and what further work is required to deliver it in full (paragraphs 1.11 to 1.13 and 2.2, Figures 4 and 5).

Accountability and oversight

8 The government does not have cross-government accountability arrangements in place to ensure Future in Mind is delivered as intended. The government has formed an inter-ministerial group, and supporting cross-departmental group, to discuss mental health policy and share information. There are individual programme governance arrangements in place for the Forward View and cross-sector arrangements starting for the Green Paper. However, as the government is not managing Future in Mind as a single programme of work, there is no single governance structure for its delivery (paragraphs 1.10, 3.2 and 3.19 to 3.21).

9 NHS England cannot be certain all the additional £1.4 billion funding to date was spent as intended, and does not have strong levers to ensure that CCGs increase spending in line with their intentions. The government announced additional funding for transforming children and young people’s mental health services in 2014 and 2015. NHS England is not confident that data on CCGs’ expenditure on mental health are reliable prior to 2017-18 (that is, before the additional funding was made available and in the first years of the funding) and so cannot confirm that CCGs spent all of the additional funding on these services. Analysis of available NHS data indicates that annual expenditure by CCGs went up by about £170 million between 2015-16 and 2017-18 but NHS England accepts that this figure may not be entirely accurate. NHS England requires CCGs to increase their spending on all mental health services by a greater proportion than the increase in their total funding. However, this is not a strong lever for ensuring that all the transformation money for children and young people’s mental health services is spent as intended. NHS England told us that, from 2018-19, it will expect CCGs to spend their allocations on the purposes for which they were originally intended (paragraphs 1.10, 3.7 to 3.9 and 3.12, and Figure 16).

10 Local transformation plans set out how local areas intend to transform services but national accountability is weak. CCGs formed 122 local transformation plan areas to work with local partners across England, but these are not aligned with local authority geographies, or with the 44 Sustainability and Transformation Partnerships (STPs) which were subsequently formed. NHS England has annual assurance processes for these plans, but it continues to monitor spending and performance at CCG and STP level, rather than a local transformation plan level, in line with its responsibilities for NHS oversight. Since local transformation plans include non-NHS local partners, the national accountability arrangements are very limited. This is exacerbated by the lack of objectives relating to the quality of plans and the extent to which they focus on national priorities (paragraphs 3.4 to 3.6).

Understanding progress

11 The NHS is working to improve key information on how many children and young people receive mental health services, how much it spends on providing those services, and which treatments are most effective. NHS Digital, working with NHS England, NHS Improvement, commissioners and providers, is developing the Mental Health Services Data Set, which is the first comprehensive collection of data on NHS-funded children and young people’s services. NHS England had expected to use this data set to monitor access and waiting times from 2016-17 but, because of issues with data quality, it now intends to do so from 2018-19. NHS England has also worked to improve data on CCGs’ expenditure on mental health, which it considers to be reliable from 2017-18. Key strategy documents identified gaps in the information on what works in preventing and treating mental health conditions in young people. Since then work has been done to strengthen the evidence base and use of evidence-based care, for example the Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) programme (paragraphs 1.15, 3.11 and 3.15 to 3.17).

12 Significant data weaknesses limit the government’s ability to understand progress towards delivering its ambitions around access to children and young people’s NHS-funded services. In particular, the Forward View stated that by 2020-21, at least 70,000 additional children and young people each year should receive treatment, thereby increasing the access to NHS-funded treatment rate from approximately 25% to 35%. The NHS has reported being on track to meet the access rate target: a one-off data collection from CCGs indicated an access rate of 30.5% against the published Forward View target of 30%, which is encouraging. However, in our view, the NHS cannot reliably report progress directly against the 70,000 target: it has no robust baseline measure and we have further concerns about the equivalence of the 70,000 target to a 10% increase in access rates. It does not yet have consistent and reliable data available on the number and proportion of young people accessing treatment each year, so NHS England cannot be confident about the growth rates in access (paragraphs 2.5 and 2.6, and Figure 8).

13 The number of children and young people with a mental health condition who need help is likely to be higher than previously estimated, which will make it even harder to achieve the government’s ambition. The last survey of children’s mental health needs in 2004 found around 10% of five- to 16-year-olds had a mental health condition and the next survey is due to be published in late 2018. Stakeholders, including NHS England, widely anticipate that prevalence will be higher. If prevalence is, say, 50% higher than the 2004 estimate, this would mean NHS England would have to treat an additional 186,000 children and young people to achieve an access rate of 35% by 2020-21, or, as indicated in the Forward View, revise its target access rate. In either case this would have significant longer-term implications for how much work it has to do to reach parity in access to physical and mental health services (paragraphs 1.7 and 1.15, and Figure 6).

14 Slow progress on workforce expansion is emerging as a major risk to delivering the government’s ambitions, and understanding progress is significantly hindered by a lack of data. Transforming the mental health workforce is fundamental to creating sufficient capacity to transform services and deliver the Forward View commitments. The Stepping Forward programme aimed to increase the children and young people’s mental health workforce in England by 4,500 full-time equivalent staff by 2020-21, against a baseline of 11,300 staff. It was presented as a plan for the NHS workforce, but Health Education England told us that the document contained errors. It confirmed that the plan covers both NHS-employed staff and people providing NHS-funded services but not directly employed by the NHS. However, baseline information was very limited for non-NHS staff. Data on progress made in expanding the workforce are very limited: Health Education England does not expect to have data on the number of NHS staff working in children and young people’s services until 2019, and does not yet know when data on the non-NHS workforce will be available. Given these weaknesses and the lack of reliable baseline data for non-NHS staff in 2016, Health Education England will not be able to reliably monitor workforce expansion. All our case study areas cited difficulties in recruiting as a major concern and there are other indications that delivery is behind schedule, including:

the Forward View set out plans for the Department and NHS England to frontload funding for workforce development, to create capacity in the system, but in the first two years Health Education England underspent its funding against NHS England’s plan by £29 million (77%) and £9 million (23%) respectively; and

Health Education England intended that local areas would set their own detailed workforce targets, following Stepping Forward’s high-level ambition of an additional 4,500 staff. In March 2018, local areas reported that they were planning to recruit 3,410 NHS staff, some 14% below this ambition. There are no equivalent plans for recruiting non-NHS staff: local areas have not yet estimated how many they need (paragraphs 2.12 to 2.19 and 2.22 and Figures 4, 10 and 11).

15 There is still limited visibility of what public sector bodies outside the health sector spend on mental health services, and what services they provide. Future in Mind emphasised the importance of prevention and early intervention for children and young people’s mental health. However, there is very limited information on support available for children and young people’s mental health outside the health sector. A nationally representative survey of schools and colleges conducted on behalf of the Department for Education indicated that most schools provide some form of mental health support, but few provided clinical services. Our case studies suggested that CCGs found schools’ engagement could be positive but was variable. We also heard concerns about the impact of cuts in funding for universal services, such as Sure Start or youth centres, on demand for NHS mental health services (paragraphs 1.16, 3.18 and 3.21 to 3.24, and Figure 19).

Conclusion on value for money

16 The government has laudable ambitions to improve mental health services for children and young people. It started from a very low base when it developed its strategy and has prioritised improvement programmes which take an important, if modest, step towards achieving its aspirations. The government has not yet set out or costed what it must do to realise these aspirations in full and there remains limited visibility of activity and spending outside the health sector. While the NHS has worked to improve information on its activity and spending, significant data weaknesses are hampering its understanding of progress. Slow progress on workforce expansion to deliver NHS services is also emerging as a major risk to delivery.

17 The government must now ensure a coherent and coordinated cross-sector response, and that the right levers are in place to ensure local actions deliver the national ambitions. It has started to tackle issues of parity of esteem between physical and mental health services for children and young people, but it still has a long way to go, particularly as demand may be higher than originally thought, and an increased focus on mental health may uncover greater demand. Given these weaknesses and uncertainties, we conclude that the government cannot demonstrate that it has yet delivered value for money.

Recommendations

18 It is likely that mental health services, particularly for children and young people, will be one of the main priorities in the NHS’s next 10-year plan. The current programmes offer a good platform to establish a clearer trajectory and base against which to assess progress towards parity of esteem for NHS-funded children and young people’s mental health services.

19 Assuming that Future in Mind remains the vision for children and young people’s mental health services, the following recommendations are for the Department to lead, working in conjunction with NHS England and its other arm’s-length bodies, and other departments, including the Department for Education and the Ministry of Housing, Communities & Local Government. The Department should:

a Set out the scale of the challenge, and understand the characteristics and trends in the needs of young people requiring mental health services, building on the new prevalence data when available.

b Set out what actions and resources are required to implement Future in Mind in full, and the main long-term and interim objectives and outcomes. The plans should set out what different parts of government are expected to deliver, be clear about the main uncertainties and build in opportunities to review plans.

c Establish clear leadership of the portfolio and responsibility for taking it forward and bringing together the national and local bodies, and individual programmes, intended to deliver Future in Mind.

d Put in place mechanisms to improve understanding of spend and activity on mental health support across the system, particularly in schools and local authorities.

e Undertake work to better understand the impact of preventative services and early intervention for children and young people on the demand for more intensive or specialist mental health services.

20 With respect to the current programmes of work:

f The Department, NHS England, Health Education England and the Department for Education should review workforce plans in the light of progress to date and once the implications of the Green Paper are clear, to see whether additional actions are required.

Part One

The vision for transforming children and young people’s mental health services

1.1 This part introduces the government’s vision for children and young people’s mental health services, and how its different programmes of work are set up to realise its vision.

Background

The government’s vision for parity of esteem between mental and physical health services

1.2 Our 2016 report Mental health services: preparations for improving access cited the World Health Organization’s definition of mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.1,2

1.3 The government acknowledges that before 2011, mental health services had long been seen as of secondary importance to physical health services. However, as set out in the Health and Social Care Act 2012 and in the NHS Constitution, the government has increased its focus on mental health services, and has now committed to providing ‘parity of esteem’ for mental and physical health services. Parity of esteem means that mental health is valued as much as physical health. An expert group, convened at the request of the Department of Health & Social Care (the Department), defined this as including equal access to care and allocation of resources proportionate to need (that is, not necessarily equal inputs in terms of funding or staff numbers). Figure 1 sets out the main developments in the government’s plans to develop mental health services, including its provision for children and young people’s services.

1.4 Our 2016 report noted that, while there was a clear consensus that parity of esteem was a laudable objective, achieving it would be neither quick nor easy. The Department was responsible for policy but had not estimated how much it would cost to achieve parity of esteem. Furthermore, neither the Department nor NHS England had the detailed information needed to plan and implement a change programme of this kind. Given these challenges, the Department and NHS England have taken a pragmatic approach, looking at what they could aim to deliver within available funding.

1.5 The government has still not set out what parity of esteem means in terms of access, waiting times and patient outcomes. However, one indication of how much work needs to be done to achieve parity of esteem is the way in which the NHS measures access to physical and mental health services. It typically measures physical health services in terms of the waiting time between referral and treatment, implying that all those who need treatment will receive it, even if they have to wait. For many children and young people’s NHS-funded community mental health services (excluding eating disorders and early intervention in psychosis services) it measures access in terms of the proportion of people who need services that receive treatment, acknowledging that the majority may not receive any at all.

Children and young people’s mental health services

1.6 Mental health problems affect children and young people as well as adults. Future in Mind noted that more than half of all mental ill-health starts before the age of 14 years, and 75% has developed by the age of 18. The life chances of those individuals are significantly reduced in terms of their physical health, their educational and work prospects, their chances of committing a crime and even the length of their life. The most common types of mental health problem among children and young people are shown in Figure 2.

1.7 The last UK prevalence survey of mental health problems among children and young people found that around 10% of children aged between five and 16 years old had a mental health condition. The government and wider stakeholders have both stated that they believe this percentage is likely to have increased since the survey was completed in 2004. The corresponding adult survey in 2014 found that young women aged 16–24 had emerged as a high-risk group for mental illness. Some stakeholders believe an increase in prevalence may reflect factors such as increased awareness of mental health conditions and services, as well as specific factors such as the impact of social media.

1.8 NHS England oversees the commissioning of NHS-funded children and young people’s mental health services, primarily through clinical commissioning groups (CCGs). It also directly commissions specialised services such as in-patient beds. NHS England and CCGs collectively spent £1,042 million on children and young people’s services in 2017-18 (around 1% of their total expenditure).3 It also directly commissions specialised services such as in-patient beds. Figure 3 sets out the range of services and providers available to treat and support children and young people with a mental health condition. There is no nationally agreed definition of which age groups are covered by the term ‘children and young people’. This report is focused on NHS-funded services, which generally covers services for those aged 0 to 17-year-olds, but local services can vary in the age thresholds they apply.

1.9 This report looks at the government’s strategy for improving children and young people’s mental health services, and its progress to date. We look at the accountabilities, oversight and incentives across the system. We do not look in depth at children’s experiences in accessing services, as other stakeholders have recently covered this ground.4

The Future in Mind strategy and its implementation

1.10 In the 2014 Autumn Statement and the 2015 Budget, the government committed to providing an additional £1.4 billion of funding specifically for transforming children and young people’s mental health services. In March 2015, it set out its vision for children and young people’s mental health services in its Future in Mind strategy. The strategy estimated that as little as one-quarter of young people with a diagnosable mental health condition actually accessed support. The Department told us that, given the historic under-investment in children and young people’s mental health services, it wanted to act as soon as possible. The government planned a number of initiatives (detailed in Figure 4) to take forward its vision for better services:

local transformation plans from 2015;

from 2016-17, the NHS Five Year Forward View for Mental Health programme (the Forward View);

an accompanying mental health workforce development programme, Stepping Forward to 2020/21 (Stepping Forward), led by Health Education England; and

Transforming Children and Young People’s Mental Health Provision: a Green Paper (the Green Paper), the government has committed an additional £300 million to deliver the Green Paper proposals. The Department told us the proposals will be rolled out from late 2018.

The Department believes these programmes, in particular the Forward View and the Green Paper, will deliver a step change in improving support to children and young people.

1.11 The strategy sets out a broad vision of how children’s and young people’s services should be improved. It contains 49 proposals, made by a commissioned taskforce and accepted by the government. The taskforce stated that 35 of these proposals could be delivered by the existing government, while 14 would require additional funding from a future government. However, Future in Mind does not set quantified targets or define what actions and budget will be needed to implement each proposal. There were significant challenges to doing so, including gaps in information on children and young people’s mental health services and the need to plan over different spending review periods. Other areas of government have tried to address similar problems through, for example, the use of scenario-planning approaches, or defining long-term and interim objectives with set decision points.

1.12 The main programme underpinning the NHS’s ambitions on improving access is the Forward View. The programme set targets to increase the number of young people accessing mental health services by 70,000 annually, broadly equivalent to increasing the access rate from an estimated 25% to 35%, based on the 2004 prevalence rate. This target was based on the Department’s pragmatic estimate of what might be delivered with the additional transformation funding available. However, even if 70,000 additional children were treated by the NHS, on the basis of current prevalence estimates, only about one-third of young people with mental health conditions would receive NHS treatment, leaving still significant levels of unmet need. This is still a long way from parity in access for physical and mental health conditions, with potentially stark differences in young people’s experiences of accessing these services. Previous experience with programmes to improve access to services indicates it is likely that making mental health services easier to access, and reducing the stigma of mental health, may uncover further demand (see also paragraph 2.28).5

1.13 Our analysis of Future in Mind proposals and specific programme objectives (Figure 5) shows how collectively the current programmes will not yet deliver the whole of the strategy. The majority of proposals had corresponding objectives in at least one programme, although in general these objectives were short- to medium-term (around five years) so are not sufficient to achieve the proposal in full. The government has not yet set out and costed what further work will need to be done in the longer term to achieve each proposal. Our analysis highlighted some proposals, in particular those related to caring for vulnerable groups, did not have an explicit strategic objective, and it may be particularly difficult to track progress against theses proposals. There is some work under way to support vulnerable groups; for example, the recent Green Paper update set out intentions for mental health support teams to test approaches for working with vulnerable groups. However, the work does not directly address some of the specific Future in Mind proposals.

1.14 Translating a high-level strategy into ambitious but achievable programmes remains a challenge for national bodies. In particular, gaps in the evidence base, weaknesses in available data, resource constraints and interdependencies between programme objectives all make it harder to deliver the best results.

1.15 In developing its strategy, the government had to manage some important gaps in the evidence base. In particular:

there were no up-to-date data on the prevalence of mental health conditions among children and young people. The last prevalence survey in 2004 found that around 10% of five- to 16-year-olds had a mental health condition.6 The next survey is due to be published in late 2018. Many stakeholders, including NHS England’s chief executive, anticipate that the new survey will show an increase in prevalence since 2004. If the number of children and young people who need treatment is higher than the 2004 estimate, then the government will be further away from achieving a 35% access rate by 2020-21. It would either have to treat more children and young people to achieve the same access rate, or, as indicated in the Forward View, revise its target. In either case it would be more challenging to achieve parity of access with physical health services than previously thought, with implications for the workforce, time and money required to achieve parity. Figure 6 shows how increases in the prevalence estimates would affect how many children and young people the NHS would need to treat, if it is to achieve the access rate targets in the Forward View. For example, if prevalence was 50% higher than currently estimated, the NHS would need to treat an additional 186,000 children and young people to achieve the 35% access rate target;

both Future in Mind and the Green Paper identified gaps in the information on what works in preventing and treating mental health conditions in young people (for example, self-harm). Since Future in Mind’s publication there has been work to improve the evidence base and the current programmes also include proposals to test approaches and improve the evidence base. For example, the Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) programme encourages the use of regular feedback and outcome monitoring (Figure 7); and

some fundamental data about the number and type of services provided, spending and the clinical outcomes of patients have historically not been collected nationally, making it very difficult to plan services (see paragraphs 3.7 to 3.17 and 3.22).

1.16 The different work programmes underpinning the strategy do not always align to get the best outcomes, because of the timing of the interdependent parts. In particular:

the strategy emphasised the importance of preventing poor mental health and early intervention when it does occur. However, the objectives relating to these are mainly taken forward in the Green Paper proposals, which are only due to be rolled out to 20% to 25% of the country by 2022-23, due to the balance between pace, funding and the need to test approaches. This means many of the potential benefits of improvements to resilience and prevention, in particular reduced demand for NHS services, cannot be expected until after the end of the Forward View;

the number of in-patient beds is planned to increase by 150–180 beds to around 1,630 beds by March 2019, as part of a separate plan to open beds in underserved areas of the country and close beds in overserved areas.7 Although NHS England intends to close some beds, there has been a net increase of 96 beds since the beginning of 2017-18, and 83 more beds are planned to open by March 2019, while the number of bed closures has not yet been decided. This could work against its aim of reducing the overall use of in-patient beds; and

providing services for 70,000 more children and young people will require a redesign and expansion of the mental health workforce to see and treat these children. However, the Stepping Forward workforce strategy was published more than a year after the Forward View started. Another element of workforce expansion was the planned increase in trained therapists as part of the Forward View objectives. However, the annual targets were re-scheduled, with the biggest increases deferred by at least a year (see paragraph 2.21).

1 Comptroller and Auditor General, Mental health services: preparations for improving access, Session 2015-16, HC 492, National Audit Office, April 2016.

2 World Health Organization, Mental health: a state of well-being, August 2014, available at: www.who.int/features/factfiles/mental_health/en/#

3 The £1,042 million includes £355 million spent directly by NHS England, a small proportion of which was spent on learning disability services, rather than mental health services.

4 The Children’s Commissioner, Briefing: Children’s mental healthcare in England, October 2017; Care Quality Commission, Review of children and young people’s mental health services: Phase one report, October 2017; Care Quality Commission, Are we listening? A review of children and young people’s mental health services, March 2018.

5 For example, see Nuffield Trust, Meeting need or fuelling demand?, June 2014.

6 Office for National Statistics, Mental health of children and young people in Great Britain, 2004, 2005.

7 NHS England, Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report, July 2014, page 133.

Part Two

Progress in implementing the strategy

2.1 This section examines progress to date against the strategy and highlights the main risks to delivery.

Progress against Future in Mind

2.2 Part One of this report identified that the government’s vision for children and young people’s mental health services is set out in Future in Mind, but that many of its proposals do not have measurable objectives. We therefore use the Five Year Forward View for Mental Health (Forward View) as the principal means of assessing whether the government is achieving its ambitions for children and young people (paragraphs 2.3 to 2.11). We also examine data on progress in developing the workforce, which is fundamental to achieving the government’s ambitions (paragraphs 2.12 to 2.23) and consider local transformation plans in Part Three (paragraphs 3.4 to 3.6). The timing of the Green Paper means it is too soon to examine progress against its objectives. There are a large number of weaknesses in the available data which we cover in this part and in Part Three. We do not examine in depth the experiences of children and their families in accessing treatment, as this has been described by other stakeholders recently.

Progress against the Five Year Forward View for Mental Health

2.3 Appendix Three gives an overview of progress against the Forward View objectives for children and young people’s mental health services. We analysed whether the NHS could demonstrate that progress was on track for each of 15 broad areas. We rated two areas as red, nine as amber and two as green. We did not have sufficient information to rate two areas. Assessing progress against each objective is not straightforward given data quality constraints. In particular:

a many objectives do not have metrics or specific targets with milestones that allow for an objective assessment;

b there are significant data quality issues for some of the metrics; and

c some objectives relevant to children and young people are incorporated within broader ones for all-age mental health services, and performance is not reported separately.

Below we look in more detail at progress against three of the main objectives in the Forward View – access to services, waiting times for eating disorder services and in-patient care.

Access to services

2.4 Two important targets for the Forward View relate to improving access to services. By 2020-21, the Forward View aims for at least 70,000 additional children and young people each year to receive evidence-based treatment, with an associated increase from around 25% to 35% in the proportion of young people with a diagnosable condition who actually access treatment (the access rate).

2.5 Past and present data quality issues affect how well the NHS can understand progress against the access targets (as detailed in Figure 8). In particular it does not have a reliable baseline measure of the number of children and young people who were receiving treatment at the start of the programme. Consequently, it is unclear how many people the NHS needs to treat to achieve the target of treating an additional 70,000 children and young people. The NHS has not reported progress against the actual number of additional children and young people treated, but instead focuses on the access rate. This assumes that if it achieves the access rate target it will also achieve the target to treat 70,000 additional children and young people, but this may not hold (see Figure 8).

2.6 To measure both targets, NHS England intended to use the new Mental Health Services Data Set from 2016-17. However, difficulties with data accuracy (see paragraphs 3.14 to 3.17) meant that NHS England and NHS Digital had to carry out a one-off data collection from providers and clinical commissioning groups (CCGs) to report progress for 2017-18.8 On this basis, the NHS reported an achieved access rate of 30.5% in 2017-18 against the published target of 30% in the Forward View. While encouraging this access rate is not directly comparable to the Forward View target and baseline (see Figure 8). In addition to the national interim target against which they are held to account, CCGs also set their own local interim targets that would enable them to meet (or exceed) a 35% access rate by 2020-21. For 2017-18, these local targets aggregated to a national figure of 31.8%, which is slightly higher than the 30.5% access rate achieved for that year. Since no reliable information was available before 2017-18, the NHS cannot understand the exact growth rate in either the number or proportion of young people treated. NHS England acknowledged that it lacked reliable baseline data but told us that it took a pragmatic decision to use the best data available to estimate progress, otherwise it would be unable to monitor the NHS’s progress against access targets at all, despite receiving additional funding.

Waiting times for eating disorder services

2.7 The Forward View aims to improve access to community-based eating disorder services, so that, by 2020-21, 95% of children and young people access the services they need within one week for urgent cases and four weeks for routine cases. As of May 2018, close to 80% of children and young people were being seen within these waiting time standards. NHS England considers that this means it is on track to achieve its 2020-21 targets.

2.8 NHS England currently monitors performance against these targets through a specific request which asks providers and CCGs to submit limited data at an organisation level. Organisation-level data limits national bodies’ ability to provide insight through data analysis and to quality assure data. In the longer term NHS England intends to switch to the Mental Health Services Data Set so that it can obtain patient-level data.

In-patient care

2.9 NHS England has a broad objective to minimise the number of in-patient admissions, by providing care as close to home as possible and eliminating inappropriate in-patient placements. However, it does not specify any targets for reducing in-patient admissions or set out the metrics it is using to measure progress against this objective.

2.10 Data from NHS England suggest that since 2015-16, the total number of in-patient admissions of children and young people has remained steady, while the numbers of total, and ‘inappropriate’, out-of-area admissions have fallen (Figure 9).9 NHS England has not yet formally defined an ‘inappropriate’ placement, and currently uses a working definition based on whether the needs of the particular child or young person can be met by the most local in-patient unit, taking into account their clinical need, individual preference and any special circumstances. This is distinct from distance from a patient’s home because more specialised in-patient services would normally serve a larger geographical area.

2.11 NHS England has to manage potentially conflicting aims for in-patient care of children and young people. In July 2014 (prior to the Forward View) it identified the urgent need to open more beds in some parts of the country.10 NHS England also intends to close beds in overserved areas, but in March 2017, it set an interim objective of opening an additional 150–180 in-patient beds by March 2019 in underserved areas to support its aim of providing care closer to home. As of May 2018, it appeared on track to meet this, with a net increase of of 96 new beds since the beginning of 2017-18. However, this could work against its aim of reducing the overall use of in-patient beds.

Progress on workforce

2.12 Health Education England leads the main mental health workforce strategy, Stepping Forward to 2020/21 (Stepping Forward). This strategy sets out the workforce development required to deliver the Forward View commitments, both through existing roles, and the development of new ones, such as peer support workers. There are other sources of workforce objectives. The Forward View includes specific workforce objectives in the recruitment and training of staff, including working within the Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) programme (also reflected in Stepping Forward) and we discuss these separately (paragraphs 2.20 to 2.22). We also consider the workforce proposals set out in the Transforming Children and Young People’s Mental Health Provision: a Green Paper (the Green Paper) (paragraph 2.23).

Stepping Forward

2.13 Stepping Forward sets out the aim of increasing the children’s and young people’s mental health workforce by 4,500 full time equivalent staff by 2020-21 (Figure 10). It was presented as a plan to create new NHS staff posts, but Health Education England told us there were errors in the document. It confirmed that it covered both NHS-employed staff and people providing NHS-funded services but not directly employed by the NHS. Based on a one-off data collection, it estimated a 2016 baseline of 11,300 staff working in children and young people’s mental health services in England.11 However, Health Education England considered the estimates for non-NHS staff much less reliable than those for NHS staff.

2.14 Stepping Forward intends to increase the workforce through a mixture of recruitment, retention and transformation initiatives (for example, managing demand and overseas recruitment). The specific workforce expansion objectives were to be taken forward by STPs and revised depending on local assessment of need and plans. From March 2018, data from STPs on their local NHS mental health workforce plans showed that they expected to recruit 3,410 NHS staff between March 2016 and March 2021 (Figure 10). There are no equivalent plans for recruiting non-NHS staff. The data also showed a re-profiling of the projected recruitment, with higher numbers of doctors and allied health professional staff, but fewer nurses and clinical support staff.

2.15 If STPs recruit only the 3,410 NHS staff they have planned, this would leave 2,200 posts unfilled against the plan set out in Stepping Forward, equivalent to 14% of the planned workforce. To meet the Stepping Forward ambitions, local areas would therefore also need to source a quarter of their new posts from non-NHS mental health staff. Health Education England has established assurance processes for local mental health workforce plans but has highlighted limited engagement between STPs and non-NHS organisations. We consider there is a risk that local areas may set NHS workforce targets they are confident of achieving, without adequate knowledge of whether non-NHS workforce expansion will enable areas to fully deliver the objectives of the Forward View.

2.16 Health Education England did not set any interim targets for the delivery of Stepping Forward, and data are limited, which makes it difficult to measure progress. It plans to monitor the expansion of the NHS workforce against STP plans, but there are currently no data available on the numbers of NHS staff working in children and young people’s mental health services. Health Education England expects this to be available in 2019. Health Education England still lacks data on non-NHS staff which will limit its understanding about overall progress against the 4,500 recruitment target, even when NHS data becomes available. It told us that non-NHS staff will be included in a new data collection it is currently developing with NHS Digital, but it has not yet set a start date for this. Health Education England told us it will be able to monitor progress in expanding the NHS, and non-NHS workforces from 2016-17 separately. Given the use of different data sets at different time points (for both NHS and non-NHS staff), the very limited baseline data for non-NHS staff in 2016 and on the basis of evidence we have seen, we have concerns about the credibility of this claim. Any change in workforce numbers between 2016 and 2019 may be explained by the use of different data sources, rather than actual change. If baseline data for the non-NHS workforce are unreliable there is also a risk that Health Education England could mistakenly count non-NHS staff who were already employed in mental health services during 2016-17 as new staff, which would inflate progress against the expansion target.

2.17 Stepping Forward notes that there are long training pipelines for mental health staff, especially for psychiatrists, who take between 13 and 15 years to train. This may mean it is too soon to detect any increase in staff numbers. NHS Digital data showed that, at March 2016, there were 979 child and adolescent psychiatrists (full-time equivalent, all grades) and by March 2018, the number was 967, a fall of 1%. Between 2016 and 2018, the number of doctors enrolled in core training for child and adolescent psychiatry increased from 77 to 94. But the Royal College of Psychiatrists told us at the higher training grades almost 60% of posts remain unfilled as at August 2018. In the absence of interim targets, it is not possible to know whether sufficient progress has been made.

2.18 Other data on the mental health workforce do not yet show any noticeable increase in staff numbers. National data published by NHS Digital on the size of the mental health and learning disability workforce for adults and children show that there was very little change (a 1% increase) between the publication of Future in Mind in April 2015 and September 2017. There is some variation between different professional groups, with a 2% decrease in nurses and 8% increase in therapeutic staff (such as psychologists). Analysis of job advertisement data, also published by NHS Digital, also suggests a rise in the number of vacancies in children and adolescent mental health services, with an increase of 89% between April 2015 and September 2017 (from 169 to 318 advertised vacancy full-time equivalents, although data are unlikely to be complete). This may be partially explained by the planned expansion of the workforce.

2.19 All our case study areas raised difficulties in recruitment as a major concern, in particular psychiatrists and mental health nurses. This shortage of staff is creating a challenge to delivering the ambitions set out in the Forward View. To help manage the challenge of a shortfall in traditional roles, three of our case study areas were considering how they could best use their workforce including non-traditional roles. While this is in keeping with the national strategy it presents the risk that the future workforce will be decided by who can be trained, rather than by what roles are needed.

Recruitment and training objectives in the Forward View

2.20 The Forward View aims to train 3,400 existing staff, and to recruit an additional 1,700 therapists, by 2020-21 largely within the CYP IAPT programme (see Figure 7 in Part One).12 The Forward View scheduled two-thirds of its planned spend on workforce development in the first two years of the programme, reflecting the need for early development of the workforce to support planned increases in numbers of young people treated. The Forward View did not set a timescale for training the 3,400 existing staff, although Health Education England subsequently set internal targets.

2.21 As at May 2018, NHS England and Health Education England considered there was a risk that the Forward View targets for 2020-21 would not be met. Having struggled to recruit new therapists in 2016-17, Health Education England revised the schedule for the recruitment of the 1,700 new therapists, aiming to recruit more therapists in later years (Figure 11). With respect to the 3,400 target, at the end of 2017-18 1,368 staff had been trained, 29 short of the internal target, which means 2,032 staff will need to be trained between (the remainder of) 2018-19 and 2020-21 to achieve the target.13

2.22 Health Education England told us that it did not spend the full amount of Forward View funding planned by the Department of Health & Social Care (the Department) and NHS England in both 2016-17 and 2017-18. The Department and NHS England had earmarked £38 million, in each of these years, to train the children and young people’s mental health workforce. Health Education England did not spend £29 million (77%) of it in 2016-17 and £9 million (23%) in 2017-18. Health Education England told us the main reasons for this were: insufficient time to prepare for recruiting trainees; that the 2016-17 funding was provided too late in the year to allow it to recruit the required number of training places for that year; and difficulty in matching the funding (on a financial year basis) with the training places (academic year basis). The Department and NHS England returned the underspend to HM Treasury, in line with normal funding arrangements. Challenges in recruiting new, and training existing, staff include the need to fit in training on top of existing work, and some staff are required to travel long distances for training and supervision. Although NHS England provides funding to providers to allow them to cover staff undertaking training, local stakeholders told us that they cannot always find replacement staff, leading to higher workloads for the staff not in training, and the funding is not sufficient to cover the cost of more expensive agency staff.

Green Paper

2.23 The Green Paper sets out plans for two new roles linked to education: mental health leads in schools and mental health support teams. The former will be responsible for overseeing the use of the “whole school approach to mental health and well-being” and helping to identify children at risk of, or showing signs of, mental ill health. The support teams will provide interventions to address mild to moderate mental health conditions, supervised by NHS children and young people’s mental health staff. The government intends to initiate a number of ‘trailblazer’ pilots, due to start in 2019. It plans to roll out these initiatives to 20–25% of schools by 2022-23. A joint Health-Education Select Committee report criticised this schedule as lacking ambition.14

Change in services since Future in Mind was published

2.24 This section considers other information on changes in children and young people’s mental health services since the publication of Future in Mind, namely: inspection ratings and access to services.

2.25 The Care Quality Commission (the Commission) regulates healthcare services to ensure they meet safety and quality standards, and has published two thematic reports on mental health services for children and young people since October 2017.15 The Commission raised concerns that complexity and fragmentation in mental health services meant some children and young people were unable to access the support they needed, and others had a poor experience of care. In 2017-18, 67 in-patient beds across five wards were closed following concerns raised by the Commission over safety; of these, 28 would have closed under Forward View plans, but did so earlier than planned. Overall there has been a slight improvement in the inspection ratings of community mental health services for children and young people, while in-patient services are rated slightly worse than in 2017 (Figure 12).

2.26 There is evidence that access to services remains poor. The number of 0-18 year olds who go to Accident and Emergency departments (A&E) because of a psychiatric condition has continued to rise since the publication of Future in Mind (Figure 13). This increase has occurred as part of a general rise in attendance at A&E across age ranges and medical conditions, and some of the increase may be attributable to better recording of patients’ diagnoses. Nonetheless, proportionally more 0- 18-year-olds presenting at A&E are receiving a psychiatric diagnosis. In addition, reports from other organisations such as the Care Quality Commission suggest that some young people still struggle to access services until they reach crisis point (see paragraphs 1.9 and 2.25). Work is under way to improve access to mental health crisis care. In June 2018, as part of its work in the Forward View, NHS England completed an evaluation of eight sites established to provide urgent and emergency mental health care for children and young people (see Appendix Three).

Preventative services

2.27 As set out in Figure 4 in Part One, Future in Mind identifies preventative services as playing an important role in children and young people’s mental health. The Department monitors progress in rolling out some programmes that are intended to improve preventative services (such as mental health first aid training in schools). Public Health England provides guidance to help local areas incorporate prevention and early intervention into their plans. But the Forward View does not include any metrics relating to prevention and early intervention, and neither the Department nor any of its arm’s-length bodies can monitor whether preventative services are reducing demand for specialised services.

2.28 Future in Mind cites evidence that building resilience and preventing mental ill-health reduces treatment costs in the future. However, it is not clear that current actions to improve prevention will reduce demand for NHS services in the future, because:

as set out in paragraph 1.16, the timing and scope of the implementation of the Green Paper mean that existing NHS mental health services will see little benefit in terms of potentially reduced demand for services for some years; and

some case study areas reported that making services more accessible (for example, through a ‘no wrong door’ approach) increased demand on services by far more than was budgeted for. If effective prevention and early intervention services are not in place, the previously unmet need for specialist services could absorb additional funding before transformation can take place.

8 The access rate estimate derived from the Mental Health Services Data Set for 2017-18 was 22%; NHS England does not consider this to be reliable.

9 Some data on the number of children or young people with a mental health condition in adult wards are included in the Mental Health Services Data Set. However, this is still an experimental data set and the sharp peaks and troughs in the data suggest there may still be data quality issues.

10 NHS England, Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report, July 2014, page 133.

11 The figure of 11,300 includes 1,100 vacancies.

12 The Stepping Forward target to increase the workforce by 4,500 includes the 1,700 additional therapists.

13 The 1,368 therapists do not include supervisors or other forms of advanced training, Health Education England told us 240 such staff had been trained at the end of 2017-18.

14 HC Education and Health and Social Care Committees, The Government’s Green Paper on mental health: failing a generation, First Joint Report of the Education and Social Care Committees of Session 2017–19, HC 642, May 2018.

15 Care Quality Commission, Review of children and young people’s mental health services: Phase one report, October 2017; and Care Quality Commission, Are we listening? Review of children and young people’s mental health services, March 2018.

Part Three

Accountability and oversight

3.1 This part examines the accountability and oversight arrangements for the delivery of the Future in Mind strategy, and associated work programmes, both within the health sector and across government.

Health sector oversight and accountability arrangements

3.2 Figure 14 sets out oversight and accountability arrangements for the NHS’s Five Year Forward View for Mental Health (Forward View) programme. NHS England and other arm’s-length bodies jointly oversee the clinical commissioning groups (CCGs) responsible for local implementation of this programme.

3.3 Health Education England leads the workforce development strategy set out in Stepping Forward to 2020/21 (Stepping Forward), but a range of NHS organisations are responsible for delivering it. This reflects broader responsibilities for supplying NHS clinical staff.16 Oversight of Stepping Forward is broadly aligned with the arrangements for the Forward View. Health Education England runs a mental health workforce delivery group and reports key messages on the workforce to the wider performance and delivery group.

Local transformation plans

3.4 NHS England introduced local transformation plans in 2015, in which CCGs set out plans to work with local partners to deliver Future in Mind in their areas. There were 122 plans across England, grouped into fewer, and larger, footprints than CCGs. These transformation plans are not aligned with local authority geographies, or with the 44 Sustainability and Transformation Partnerships (STPs) that were subsequently formed.

3.5 In 2015-16 NHS England undertook a one-off exercise to gain assurance that local transformation plans were in line with national Future in Mind priorities. Plans for 2015-16 had to be assessed as satisfactory before CCGs could receive any additional funding. NHS England told us that it did not withhold transformation funding from any area due to unsatisfactory transformation plans, although some areas had to resubmit plans before they were considered satisfactory. After the first year, NHS England’s regional teams carried out assurance of the local transformation plans as part of its business-as-usual oversight of CCGs, and funding was provided to CCGs as part of their established funding settlement (rather than as a separate payment). NHS England also told us that each year it conducts an exercise centrally to gain assurance that local transformation plans have been refreshed. The regional teams review plans for each local area, with the assurance processes varying within and between regions. There are ‘key lines of enquiry’ issued each year to set priorities for plans, but there are no national measurable objectives relating to the quality of plans or the extent to which they meet the key lines of enquiry.

3.6 Despite NHS England’s processes to quality assure local transformation plans, its monitoring of spending and performance for children and young people’s mental health services remains at a CCG and STP level, rather than a local transformation plan level (in line with its responsibilities for holding CCGs and STPs to account for NHS spending). However, NHS England required CCGs to engage with local partners outside the NHS in developing their local transformation plans, and also required that plans were agreed by local health and well-being boards (local boards that include both local authority and CCG representation). This means there is very limited national oversight of local transformation plans in transforming children and young people’s mental health services. As part of the Forward View reporting, CCGs assessed their own performance in transforming services, including whether they had refreshed their local transformation plan and whether they had met key milestones in service transformation. By quarter 4 of 2016-17, 42% of CCGs reported via their self-assessment that they were fully confident in their own transformation.

Ensuring funding is spent as intended

3.7 In its implementation plan for the Forward View, NHS England set out its intention that the £1.4 billion of transformation funding for children and young people’s mental health services should be in addition to existing investment. Most of the funding was provided directly to CCGs as part of their baseline funding. NHS England planned to increase the proportion of funding given locally during the programme (Figure 15).

3.8 Before 2015-16, NHS England did not collect data on how much CCGs spent on children and young people’s mental health services, and it told us that it has low confidence in the reliability of CCGs’ expenditure data before 2017-18, especially for 2015-16. Analysis of these data suggest that CCGs’ spending on children and young people’s mental health services has increased since 2015-16 (Figure 16), although the actual figure may be higher or lower than the estimated £170 million increase.

3.9 NHS England cannot confirm that CCGs spent all of the additional funding allocated to them as intended prior to 2017-18 because it does not have reliable baseline data on how much was already being spent before additional funding was made available to them, or how much they spent in the first years of the additional funding. NHS England did not ringfence the additional money it provided to CCGs, nor did it introduce other restrictions, for example, an investment standard specific to children and young people’s mental health services. From 2018-19 it expects CCGs to spend funding on the purposes for which it was originally intended, and will monitor this as part of its annual planning process with CCGs.

3.10 NHS England told us that its focus was on managing performance against specified targets, rather than monitoring how money had been spent. The charity Young Minds made a freedom of information request to every CCG in England in 2015-16 and 2016-17, asking how they had spent their additional funding. Less than half of the CCGs that replied were able to provide full information about their spending.

3.11 Since 2015-16, NHS England has worked to improve data on CCGs’ expenditure on children and young people’s mental health services, by clarifying guidance and carrying out more intensive quality checks. It now considers 2017-18 data to be much more reliable. NHS England’s data indicate that, in 2016-17, 77% of CCGs had increased their overall spending on children and young people’s mental health services compared to the previous year, as had 71% of CCGs in 2017-18, (although NHS England cannot tell whether CCGs are spending the full transformation funding due to problems in establishing baseline spending, see paragraph 3.9). It also found large regional variations in spending trends (Figure 17). NHS England attributes these variations to differences in the baseline level of service provision, though it has very limited evidence to establish this, primarily drawing on its regional intelligence.

3.12 NHS England uses the mental health investment standard as an incentive for CCGs to invest in mental health services, but this is not a strong lever for ensuring that all the transformation money for children and young people’s mental health services is spent as intended. The standard requires each CCG to ensure its spending on all mental health services rises at a faster rate than their overall programme funding. It does not require an absolute minimum increase, so can be met with a very small proportional increase. In 2016-17, NHS England met the standard by increasing the proportion spent on mental health services from 12.5% to 12.7%. Changes to the planning guidance for CCGs in 2018-19 now require all CCGs to meet the standard (prior to this they were only required to meet it collectively). From 2018-19, it expects CCGs to spend funding on the purposes for which it was originally intended. It has provided CCGs with their allocation for children and young people’s mental health services and will monitor the spending of this allocation as part of its annual planning process with CCGs.

3.13 Accounts data for 2017-18 show that the 53 NHS mental health trusts had collectively underspent against budget (a surplus of £297 million against a planned surplus of £125 million) but had overspent their staff budget by £157 million (1.9%), largely due to a high use of agency staff, necessitated by high vacancy rates.

Performance metrics and data quality

3.14 NHS England sets out a number of objectives in the Forward View (see paragraph 2.3 and Appendix Three), but its programme monitoring, and oversight of CCGs for children and young people’s NHS-funded mental health services focuses largely on two areas. These are: the access rate for treatment (that is, the proportion of children and young people with a mental health condition who access treatment); and the waiting time targets for children and young people with eating disorders.17

3.15 NHS Digital introduced the new Mental Health Services Data Set in January 2016 to monitor these and other objectives. It is the first-ever comprehensive data set that includes children and young people’s mental health services. It follows on from previous attempts by NHS Digital to collate a specific children and young people’s data set. It covers patient-level data, including numbers of patients referred to and accessing services, how long they wait to receive services, treatments they receive and information about their clinical improvement.

3.16 NHS England hoped to start monitoring key performance data to the following timescales:

number of children and young people accessing services: by December 2016;

number of bed days: by September 2016; and

patient outcomes: in 2018-19.

3.17 However, because of data quality issues, all these milestones are behind schedule in providing reliable data and, as at July 2018, the data set remained classified as experimental. NHS England and NHS Digital identified the main challenges to data quality as being: some providers, particularly non-NHS providers, not submitting data, and concerns about the consistency and accuracy of some of the data submitted. NHS England, NHS Improvement and NHS Digital are working with commissioners and providers to improve the data. They now intend to use the data set to monitor patients’ access and waiting times from 2018-19, but do not expect the data set to report reliable patient outcomes data until April 2019. NHS England and NHS Digital still need to decide how to define some important variables. For example, they need to decide which vulnerable groups will be identifiable in the data set and how they will identify whether evidence-based treatment has been used.

Cross-government oversight and accountability

3.18 Future in Mind identified a range of stakeholders – in the NHS, public health, local authorities, social care, schools and youth justice services – as having an important role to play in supporting children and young people’s mental health (Figure 18). Each of these has distinct and different accountability mechanisms.

Schools play an important role in identifying and supporting children and young people with a mental health condition and from September 2020 all schools will be required to teach pupils about maintaining mental well-being, although schools have no statutory requirement to provide mental health support. In a nationally representative survey of 2,780 schools and colleges commissioned by the Department for Education in 2017, 63% reported that they provided information about mental health for their pupils or directed them to external support. The survey also indicated that most schools provided some form of mental health support, although few included clinical services (Figure 19).

Local authorities play an important role, in part through their statutory duties relating to public health, in promoting children’s physical and mental well-being. Universal services (services available to everybody, such as Sure Start Children’s Centres, schools, school health services, colleges, primary care and youth centres) can be important in preventing mental health problems.

Cross-government oversight

3.19 An inter-ministerial group, and supporting cross-departmental group, chaired by the Cabinet Office, discuss and share information on developing and implementing policy on mental health as a whole. As set out in paragraph 1.10, the government is not managing Future in Mind as a single programme of work, so there is no single governance structure for its delivery.

3.20 On collaboration between departments, the Department of Health & Social Care (the Department), the Department for Education and others have developed cross-departmental governance and accountability arrangements for the Transforming children and young people’s mental health provision (Green Paper). A sponsorship board, chaired by a director general, met for the first time in May 2018 and a working-level programme board reporting into the sponsorship board met in June and July. The Green Paper aims to improve the links between health and education, through its proposals for mental health leads in schools and health-based mental health support teams linked to schools. However, local government, although involved at a local level, does not feature strongly in the Department’s programmes.

3.21 At a local level, local transformation plans included provision to engage with schools to support children and young people. However, there was variation in individual schools’ engagement: in two of our four case study visits, the CCGs felt that most schools were engaged in the local transformation plan, while in the other two areas they felt the picture was more mixed.

Barriers to effective cross-government working

3.22 There are limitations to effective cross-government working, most notably, funding constraints and lack of data on expenditure and activity. It is not possible to understand and plan spending and activity on children and young people’s mental health services across government because schools, colleges and local authorities do not report direct expenditure on mental health support services. This lack of data limits the government’s ability to make informed decisions about the level of support offered to children in different areas of the country.

3.23 In our stakeholder interviews and case study areas, we also heard concerns about the impact of cuts to services outside the health sector on NHS mental health services for children and young people. The Department for Education told us that schools report that they take the mental health of their pupils seriously, but can feel constrained by limited resources. For example, a survey of 1,054 schools by the Association of School and College Leaders in 2017 found 50% had cut back on mental health support over the past 12 months. Further, the number of school nurses reduced by 16% between the start of the Forward View (April 2015) and January 2018.

3.24 Reductions in other areas also impact on mental health and well-being. Our 2018 report on the financial sustainability of local authorities suggested that, while local authorities have protected spending on children’s social care in areas where they have significant statutory responsibilities, spending on discretionary areas including Sure Start centres and youth services, fell sharply between 2010-11 and 2016-17.18 We have not found quantitative evidence of a direct causal link between reductions in such services and increasing pressure on mental health services for children and young people. However, in our fieldwork, we heard concerns that cuts to universal services were increasing demand for NHS mental health services, and examples of where CCGs were now funding services previously funded by local authorities or schools.

16 In particular, Health Education England is responsible for providing leadership and oversight of workforce planning, education and training. NHS providers are responsible for employing staff and supporting clinical placements. See Comptroller and Auditor General, Managing the supply of NHS clinical staff in England, Session 2015-16, HC 736, National Audit Office, February 2016.

17 NHS England also monitors access and waiting time standards for early intervention in psychosis services, which cover all age groups including young people aged 14 to 17 years old.

18 Comptroller and Auditor General, Financial sustainability of local authorities 2018, Session 2017–2019, HC 834, National Audit Office, March 2018.

Post publication this page was found to contain an error which has been corrected (Please find Published Correction Slip)

Appendix One

Our audit approach

1 This report forms part of a wider programme of work on mental health, following our 2016 report Mental Health Services: preparations for access and our 2017 report Mental health in prisons. This report examines whether the government is on track to meet its ambitions for children and young people’s services, taking Future in Mind as the starting point. To do this we reviewed:

whether the government has a clear, evidence-based strategy for delivering its ambitions on children and young people’s services;

whether there is strong accountability for spending and outcomes and whether this informs future planning; and

whether government action is on track in delivering the key elements of its strategy.

2 Our audit approach is summarised in Figure 20. Our evidence base is described in Appendix Two.

Appendix Two

Our evidence base

1 We reached our independent conclusions on whether children and young people’s mental health services are achieving value for money after analysing evidence we collected between March and June 2018. Our audit approach is outlined in Appendix One.

2 We analysed operational, financial and performance data, including:

expenditure on children and young people’s mental health services and eating disorder services;

estimates of the number of children and young people who need mental health services, and of the number who access them;

mental health workforce;

mental health support provided by schools;

number of children and young people presenting to A&E;

number of out-of-area admissions, number of inappropriate out-of-area admissions, and total number of in-patient admissions; and

Care Quality Commission ratings of mental health services for children and young people.

3 Data sources included:

Department of Health & Social Care;

NHS England;

NHS Digital;

Health Education England;

Care Quality Commission; and

Department for Education.

4 We conducted case study visits to four local transformation plan areas: Birmingham, Herefordshire, North West London and Surrey. We selected these areas to provide differing geographical locations, a mixture of urban and rural settings and differing numbers of clinical commissioning groups (CCGs) within the LTP areas.

The main aim of these case studies was to better understand how the national strategy is being translated and delivered at a local level. We carried out semi-structured interviews with members of the local transformation plan area which covered development of the local transformation plan, oversight from national bodies, funding, joint working across sectors, workforce, co-production, evidence base, pathways, prevention and early intervention, and crisis care.

For each case study, we also reviewed the local transformation plan and associated documents.

5 We conducted semi-structured interviews with individuals from a range of organisations. The interviews were designed to help us understand the work of stakeholder organisations and the challenges facing children and young people’s mental health services.

6 We spoke to those involved in the strategy, commissioning, oversight and delivery of children and young people’s mental health services, including the Department of Health & Social Care, the Department for Education, the Ministry of Justice, NHS England and NHS Improvement. Other stakeholders we talked to included Health Education England, Public Health England, NHS Digital, NHS Providers, NHS Clinical Commissioners, NHS Confederation, the Children’s Commissioner, Young Minds, the Youth Justice Board, the Youth Custody Service, the Ministry for Housing, Communities & Local Government, the Local Government Association, the Early Intervention Foundation, the Royal College of Psychiatrists, the Children and Young People’s Mental Health Coalition, the British Psychological Society, Action for Children, Professor Peter Fonagy and the Association of School and College Leaders.

7 We reviewed key documents. These included departmental and NHS England strategy and guidance documents relating to children and young people’s mental health services. For each case study area, as noted above, we reviewed the local transformation plan and associated documents.

Appendix Three

Five Year Forward View for Mental Health: objectives

See Figure 21.

Design and Production by NAO External Relations
DP Ref: 001040-001