Child mental health services in England: a continuing crisis

Abstract

Services for children and adolescents with mental health problems are failing to meet their needs, and a chasm exists between the services available currently and what is required. These are the dismal conclusions of a report on the state of children's mental health services by Anne Longfield, the Children's Commissioner for NHS England, released on Jan 30. An estimated 13% of children aged 5–19 years in England have a mental health disorder, but the true numbers of children affected are likely to be much higher. Children often face lengthy delays to access support and are frequently denied treatment because their problems are not considered serious enough. The average waiting time for those who successfully entered treatment with child and adolescent mental health services was 53 days in 2018 and about 8% had to wait more than 12 weeks. 34% of children were turned away after an initial assessment. Chronic underfunding has decimated children's community mental health services, leaving them unable to cope with the rising demand. Austerity cuts to local services have compounded the problem. Notably, funding for Sure Start children's centres, established to support families mainly in disadvantaged neighbourhoods, has been slashed by two-thirds in the past decade, leading to the closure of hundreds of centres and service cutbacks in many more. The centres were a source of much needed support for vulnerable families and have been shown to improve social development and behaviour and improve parenting skills. Moreover, cuts by local authorities to youth clubs and other services have led to increasing levels of isolation and insufficient support, particularly among youngsters living in the most disadvantaged areas. Cuts to community services have knock-on effects on crisis presentation. Instead of mental disorders in children being dealt with early, or better still prevented entirely, massive unmet needs can lead to an escalation of mental distress, often culminating in presentation at emergency departments after an episode of self-harm or a suicide attempt. Emergency departments are also dealing with a growing wave of children attending with psychosocial problems or unmet safeguarding needs that are then relabelled as mental health disorders. At the heart of the issue is the absence of parity not only between children's health and adult health but also between mental health and physical health (despite government pledges to the contrary). 75% of psychiatric conditions in adults originate during childhood and adolescence. Yet, on average, the NHS spends just £92 per child each year on mental health services, compared with £225 for each adult. With just 4·5 psychiatrists per 100 000 young people, the UK lags behind much of Europe, including Finland (36), Estonia (16·8), and Latvia (11·2). The low priority of children's mental health is epitomised by the government's targets for treatment of mental disorders in children: in its 5-year forward plan for mental health in 2017, NHS England pledged to treat 35% of children with a diagnosable mental health condition by 2020–21. Compared with conditions such as childhood leukaemia or asthma, would such a low target be tolerated? Responsive parenting, a safe and secure home life, and a positive learning environment are essential for building resilience and coping mechanisms in children and adolescents. A whole-system approach across the life course is crucial to improve mental health. Parenting-skills training, focused on development of social and emotional skills, and targeted school-based interventions can reduce depression, anxiety, and suicidal behaviour in young people. Community and youth programmes, especially for those at risk or living in disadvantaged areas, have also shown beneficial results. However, meaningful improvements in children's mental health outcomes will only be possible with long-term investment in health and social care and ring-fenced funding by local clinical commissioning groups. Innovative ways of delivering treatments—eg, via digital mental health interventions—might improve accessibility of treatment for young people. The findings of the Children's Commissioner come as no surprise. It is the latest of many reports warning about the parlous state of children's mental health services. Suicide is the biggest killer of people aged 16–24 years in the UK. Why, then, the continued failure to prioritise and invest in mental health services for children and adolescents? At best, this is a short-sighted decision. At worst, it is a politically motivated choice that punishes the most vulnerable members of society, who are not only disempowered in the current system but also do not have a voice to complain about their mistreatment.