Issued: 20 February 2018

Transforming Children’s and Young People’s Mental Health Provision: A Green Paper

Response from the British Association of Behavioural and Cognitive Psychotherapies (BABCP).

The BABCP is pleased to comment on this Green Paper. The BABCP is a multi-disciplinary professional organisation focused on the science and practice of Cognitive Behavioural Therapy (CBT). BABCP has over 11,000 members and accredits CBT training programmes and Cognitive Behavioural Therapists.

The BABCP broadly welcomes the government’s proposals to extend and improve child and adolescent mental health services. We agree that prevention and early intervention could make a marked improvement to the mental health and wellbeing of children and young people. The aspiration of the Green Paper to establish parity of esteem between physical and mental health is laudable although without adequate ring-fenced funding for mental health services (including school-based mental health teams) this will remain an aspiration. The BABCP also notes that funding cuts to local authorities and schools, who provide key services to children and families, have had a marked negative impact on children’s wellbeing and increased demand for Child and Adolescent Mental Health Services (CAMHS). The BABCP believes it to be crucial that the emphasis on mental health support and intervention in schools does not replace existing CAMHS (sometimes referred to as Tiers 2-4).

The BABCP also strongly recommends that interventions in schools are selected on the basis of high-quality evidence and that implementation is supported in terms of appropriate training. The Green Paper provides the opportunity for innovative service development and for this reason the BABCP is very much in favour of carefully selected and well-evaluated ‘Trailblazer’ sites.

The Green Paper proposes to introduce three ‘pillars’ to improve children’s and young people’s mental health

1. A designated senior lead for mental health in every school (with training).
2. Mental health support teams to work with schools and other relevant professionals.
3. A four-week waiting time for access to NHS mental health services.

1. A designated senior lead for mental health in every school (with training).

The BABCP strongly supports the proposal for a designated senior lead for mental health in schools. The BABCP agrees that this must be a senior role within a school and that specific knowledge about common mental health problems and the supports available will be required to equip staff for the role. This training should be developed in collaboration with mental health specialists familiar with school settings and follow agreed national guidelines. This role should not have responsibility for delivering formal mental health assessment or specialist interventions. The BABCP also considers it essential that senior leads for mental health in schools have ongoing support, supervision and CPD. This will help maintain their skills and ensure they are not over-burdened. In some schools (especially larger schools) a small team may be a more sustainable long-term arrangement

In addition, as the Government is aware, there is a high turnover of staff in schools, so it is important that the schools have ongoing access to training at no cost to the school when a senior mental health lead leaves.

2. Mental health support teams to work with schools and other relevant professionals.

The BABCP also strongly supports the proposal to develop and deploy mental health support teams to work in and with schools. The Green Paper accurately identifies the needs of schools for additional, specialist assessment and treatment, and improved access to NHS CAMHS. The proposed school-based mental health teams could provide a more accessible mental health service and facilitate better links with NHS CAMHs, including onward referral and liaison as well as building relationship and visibility within schools.

The BABCP also agrees that teams will need to collaborate with other professionals e.g. educational psychologists, schools nurses, social workers, and counsellors to ensure partnership rather than competing working.

BABCP members are involved in a number of relevant projects where mental health clinicians are deployed in school settings – for example in London, Devon, Oxford, and Berkshire (e.g. with examples including the Anna Freud National Centre for Children and Families, the Charlie Waller Institute and other examples of good practice across England and the wider UK to draw upon). These staff provide consultation and training to schools on mental health issues, deliver brief evidence-based treatments to children and young people, support staff and parents and provide a direct link to NHS CAMHS where necessary. For this reason we are confident that School Mental Health teams have the potential to offer a high quality service to complement existing NHS CAMHS.

The BABCP strongly welcomes the suggestion that School Mental Health teams are evaluated in a number of Trailblazer sites – further details about the number of sites to be selected would be welcome. In addition, the initial criteria and proposed methods that will be used to evaluate these sites should be explicit.

The Green Paper suggests that School Mental Health teams will provide at least three different types of support and treatment:

• brief evidence-based interventions for common mental health problems, e.g. anxiety, depression, behaviour problems.
• support for children and young people who experience traumatic events, bereavement etc.
• ongoing support for vulnerable children and young people including those excluded from schools, engaged youth offending teams, and those from troubled families.

Poor quality interventions that are not evidence-based or delivered skillfully can increase distress and deter children and young people from seeking further help. To ensure that each element of the support provided is delivered at the highest possible quality, and to maximise the efficiency of teams the team must include specialist mental health professionals with a range of seniority and experience. This should include a clinically qualified and experienced manager/lead clinician.

1. Brief evidence-based interventions should be delivered by specially trained staff including Psychological Wellbeing Practitioners (CYP WPs) and accredited Cognitive Behavioural Therapists (CBT).
2. Support for children experiencing life events e.g. bereavements can be supported by professionals trained in non-directive supportive counselling. This would be an opportunity to incorporate existing school counsellors into a team, to extend the current provision of school counsellors, and to provide more professional support to counsellors.
3. Ongoing support for vulnerable children and young people requires professionals trained to work in a range of community settings, and with expertise in outreach, social work, and systemic and family interventions e.g. clinical psychologists, social workers.

Some children (e.g. those with eating disorders, complex PTSD, emerging psychosis, or those where medication is indicated) will not be suitable for treatment in school and will require referral onwards to specialist NHS CAMHS or services such as specialist Eating Disorder services. The School Mental Health Team must be able to identify and assess this group and refer promptly to NHS services as needed.

The BABCP suggests that ongoing evaluation of outcomes from therapy and support is essential. This should be achieved by requiring School Mental Health Teams to incorporate Routine Outcome Measures in each intervention session (similar to IAPT). Routine Outcome Measures monitor symptoms severity and change and risk and ensure, via supervision that interventions are delivered to a high standard. The outcome measures will allow services to be assessed as well as monitor individual outcomes.

3. A four-week waiting time target for NHS CAMHS

The BABCP also agrees that waiting times for NHS CAMHS are too variable, and in most cases too long. Children and young people require and deserve rapid responses to their distress. We therefore agree with the general aim of reducing the time that children, young people and their families wait for an assessment and treatment by NHS CAMHS.

However, the BABCP is extremely concerned that introducing a target of a maximum four weeks waiting time, without significantly increasing the number of staff who can assess and treat, will introduce unhelpful distortions to the referral and ongoing support processes. We believe that with current levels of need and service provision this target will simply be impossible.

Possible unintended consequence of a four-week waiting time target consequences include

1. Delays in assessment of non-urgent referrals.
2. Assessments within four weeks lead to subsequent longer waiting times for treatment.
3. Difficulty for some services in providing evidence-based treatments recommended by the NICE guidelines because these involve more sessions that the services are able to offer, meaning that services are forced to offer sub-standard non-evidence based short term interventions.
4. Introduction of a two-stage assessment process including an initial but brief contact (e.g. triage) to meet the four-week target, followed by a full assessment later. If done badly or inconsistently this could give a semblance of access whilst missing cases requiring greater input, so a consistent responsive design would need to be implemented if this approach was used.
5. Adding to the burden of stress and potential for burnout in staff who work in these challenging environments.

4. Some final observations

It is important that teachers are not expected to act outside their teaching role. They are not mental health therapists and cannot be expected to work as such.

There is a clear need for serious mental disorders to be identified and supported. However, clarity needs to be maintained between the aims of general wellbeing support and the specific widening of access to specialist mental health services for treatment of serious disorder. It is important to avoid unnecessary diagnosis/medicalisation of those with milder self-limiting symptoms such as distress.