As Children’s Commissioner for England, Anne Longfield OBE spends a lot of time talking to children, many of whom have experienced trauma. The role is to bring about long-term change and improvements for all children, and in particular the most vulnerable, with a special focus on those in care. She tells Anna Scott, editor of New Psychotherapist, where the system is failing.
‘In both current provision and government vision there is a chasm between what children need and what is currently provided,’ says Anne Longfield, Children’s Commissioner for England. ‘This is particularly the case with community and school-based mental health support.’
Despite findings from the most recent (2017) national survey of children and young people’s mental health that one in every eight children in England, aged from 2 to 19, has some form of ‘mental disorder’, between April 2017 and March 2018 just a quarter of those who need help accessed CAMHS, Longfield says. And in the following 12 months, up to March 2019, more than 405,000 children were referred to the service, but only 33% received treatment within the year, 34% were turned away and 34% were still waiting at the end of the year.
‘A failure to provide care to those with lower-level mental ill-health, such as anxiety and emotional disorders, will have clear consequences,’ she says. ‘And local and lower-level intervention services are, on the whole, patchy and inadequate.’
The situation for in-patient child mental health services is slightly better: NHS data from 2018 shows improvement in CAMHS in most areas of the country, with acceptance of referrals increasing, and the amount of time spent in in-patient settings decreasing. ‘But worrying trends remain around the local variability of this improvement,’ Longfield says. ‘Three areas had an average waiting time of less than three weeks, while 18 had an average waiting time of three months or more.’
Provision and funding of services is complex and variable – schools in some areas are providing targeted help, in others NHS Clinical Commissioning Groups will fund it, while some local authorities fund mental health care through the High Needs or Public Health budgets.
‘This means there is an enormous postcode lottery for children requiring mental health support, and there is very little in the way of accountability or transparency between bodies,’ Longfield says. ‘Gaps in our knowledge remain about who is supposed to be providing low-level mental health support, and what is expected of each agency.’
This has a huge impact not just on children with low-level behavioural, emotional and mental health issues, but also on those who have experienced trauma through Adverse Childhood Experiences (ACEs). As Children’s Commissioner for England, Longfield has a legal duty to promote and protect the rights of all children, particularly those in and leaving care, living away from home or receiving social services.
‘My role is to listen to children growing up in adverse and chaotic environments,’ she says. ‘They may be born into families troubled by addiction, mental health issues or domestic abuse; or raised away from their families, bereaved, abandoned, excluded from school – the list is long.’
Many of these adversities often cluster in children’s lives, and inevitably any of these factors will profoundly affect a child’s emotional wellbeing, school life and relationships. ‘These children are forced to find ways to cope and often grow up too quickly, making it much harder to be happy, healthy and succeed in life.’
Children may not meet the expected levels of language and communication, they are more likely to be excluded from education and leave school without qualifications and, as they grow into adolescence, they are more vulnerable to gang violence and sexual exploitation.
‘We know that the number of kids involved in violent gangs is on the rise, 50,000 are not in any kind of education, the age profile of kids entering care is rising, and the suicide rate among girls aged 15–19 is at an all-time high,’ she adds.
Schools themselves are not necessarily helping. ‘I have seen a worrying rise in the use of “zero tolerance” behaviour policies in schools – such as isolation booths – which are not accommodating of children who have experienced trauma and may be displaying challenging behaviour as a result,’ Longfield says, adding that she is concerned that Ofsted’s new inspection framework makes no mention of individual children’s needs in the behaviour criteria. ‘I want to see behaviour policies that look at the reasons underlying challenging behaviour, and do not set certain children up to fail,’ she adds. ‘The children I speak to are tough and resilient, but most are simply unable to thrive in structures that are not designed to support them.’
A joined-up service
And herein lies one of the problems. Longfield welcomes some of the government’s commitments set out in the NHS Long Term Plan – including a promise to treat an additional 345,000 children a year and the introduction of waiting time targets – and some of those in the 2018 Green Paper, Transforming children and young people’s mental health provision. ‘However, the NHS Long Term Plan disappointingly echoes the Green Paper in its lack of ambition to deliver truly joined-up CAMHS, from low-level intervention to high-needs patient provision,’ she adds.
The government promises to provide mental health support teams in or near schools in between a quarter and a fifth of the country by 2023–2024, but this is neither fast nor ambitious enough, Longfield says. In addition, the Green Paper only commits to 20% implementation of a plan to use Mental Health Support Teams, supporting clusters of schools that aim to meet the needs of the one million children with ‘diagnosable mental health conditions’ and the one million with ‘prediagnosable’ conditions.
‘The NHS suggested in evidence to the Public Accounts Committee that it would revisit the possibility of full implementation after 2024. But even then the majority of children would see little improvement over the course of their secondary school life. I don’t think children should have to wait five years before plans are revisited,’ she adds.
Therapy in schools
The goals set out in the Long Term Plan can only be achieved if they come alongside significant investment in school-based and community provision. UKCP is currently part of Health Education England’s workforce stakeholder group, which offers the opportunity to push for adequate provision of psychotherapists and counsellors in the People Plan – the workforce document supporting the delivery of the Long Term Plan.
And, in the Manifesto for Children published by Longfield’s office in September 2019, she calls for a counsellor in every school. ‘From speaking to children, parents and professionals, it’s clear that convenient and high-quality therapy provision in schools would go a long way in removing the stigma from mental ill-health and support,’ she adds. ‘Children and parents want access to mental health support quicker and more conveniently and it’s also clear that many kids would prefer to get help in schools, where it would attract less stigma.’
Therapy should come alongside high-quality education on mental health in schools, Longfield says, to address the additional pressures brought on children by 24-hour access to the internet and social media. ‘A counsellor would be a huge aid for kids with mild to moderate mental health issues such as anxiety, mood and behavioural difficulties. I hear from many young people who tell me that these “lower-level” issues can be crippling,’ she adds.
Longfield also believes school-based counsellors are well-placed to act as a referral function for children in need of more intensive CAMHS support.
And for those who don’t go to school? ‘All children should by right have quick and easy access to mental health care, regardless of their circumstances or where they live,’ Longfield says. ‘Indeed it should be a matter of routine that all custodial settings have counsellors attached to them.’
The last two years have seen Longfield collating data from every clinical commissioning group in England, the Director of Children’s Services and the Director of Public Health. She has found that the current system is patchy, inconsistent and lacking in clarity.
In order to address the lack of transparency she will convene a senior-level group to address questions of expectations and accountability in the provision of low-level services. And she remains committed to listening and responding to the needs of children who have suffered trauma. Difficult childhoods become difficult adulthoods and the costs ‘ricochet through society’, she says.
‘Children who fall through the cracks will eventually make themselves heard. It should not take a child making the headlines before we help.’