Education, education, mental health: Supporting secondary schools to play a central role in early intervention mental health services

There is a crisis affecting children and young people’s mental health in England, with three children in every classroom experiencing a clinically diagnosable condition. Despite the growing number who require help, cuts to the funding of both NHS and local authority ‘early intervention’ services, which can prevent emerging mental health problems from escalating further, mean that increasing numbers of children are unable to access appropriate and timely support.

Early intervention mental health services for children and young people must be rejuvenated – and secondary schools should play a central role in this, complementing wider community and NHS provision.

There is currently a great deal of variation in both the availability and quality of school-based early intervention provision. This is due to four major barriers:

• schools’ inability to access sufficient funding and resources
• a lack of established mechanisms by which schools can influence commissioning decisions taken by clinical commissioning groups (CCGs)
• the inconsistent quality of mental health support available to schools to buy in directly
• a lack of external checks on the appropriateness and quality of the approaches taken by individual schools.

The government must find ways to overcome each of these four barriers if schools are to fulfil their substantial potential for meeting pupils’ emerging mental health needs, and play a central role in the transformation of children and young people’s mental health services. This should involve guaranteeing every secondary school access to a mental health professional who delivers targeted interventions on-site, and making school counselling a regulated profession.

Key findings

Secondary schools face a ‘perfect storm’

Demand for access to child and adolescent mental health services (CAMHS) has accelerated since 2010. The number of hospital admissions of 0–17-year-olds who had self-harmed increased by more than 50 per cent between 2009/10 and 2014/15.

At the same time, mental health services have faced growing financial pressures. In 2012/13, just 6 per cent of the total NHS spend on mental health went to services for children and young people.

The erosion of NHS and local authority early intervention services means that local CAMHS systems have become trapped in a vicious cycle that is reducing their ability to meet the growing level of need. The value of the ‘early intervention’ allocation received by local authorities fell from £3.2 billion per year in 2010/11 to £1.4 billion in 2015/16, a reduction of 55 per cent.

A consequence of cuts to services combined with a rising tide of mental ill-health is that secondary schools are being forced to pick up the pieces. In 2016, 90 per cent of secondary school headteachers reported an increase in rates of mental health problems such as anxiety and depression among their pupils over the previous five years.

The current picture

Secondary schools are well-placed to act as the hubs from which early intervention provision is delivered by health professionals, alongside wider provision elsewhere in the community. School-based services can:

• improve accessibility

• better address school-related stressors

• significantly ease pressures on specialist CAMHS

• facilitate a wider culture within schools that values mental health and wellbeing.

There is, however, significant variation in the availability of school-based early intervention mental health provision. Furthermore, where pupils are able to access these services within their school, they are often lacking in quality.

The government’s planned ‘transformation’ of children and young people’s mental health services has so far failed to give schools the central role that was envisaged. Some CCGs are failing to direct transformation funding to frontline services, and just half of secondary schools expect to contribute to the local transformation of services.

Four barriers to improvement

1. Funding
Schools largely lack the funding required to provide pupils with targeted mental health support. They have long been unable to access funding, or services paid for by health providers, that would allow early intervention services to be provided on-site.

2. Commissioning and representation
In an increasingly academised school system, schools often lack the internal expertise they need to commission mental health support effectively. Schools also lack established mechanisms through which to influence commissioning decisions at a CCG level.

3. Quality
The quality of mental health support (particularly school counselling) available to schools is inconsistent, and schools do not receive sufficient guarantees that the specialists they commission or purchase have suitable levels of training and experience.

4. Accountability
Ofsted inspectors are not routinely assessing schools’ mental health provision, despite recent changes to that end. This means there are insufficient external checks on the appropriateness and quality of the particular ‘professional mix’ that individual schools bring together to meet their pupils’ mental health needs. Just one third of a sample of Ofsted reports published since the changes were introduced make explicit reference to pupils‘ mental health and/or emotional wellbeing.

Key recommendations

Funding

• By the end of the current parliament, all secondary schools should be guaranteed access to at least one day per week of on-site support from a CAMHS professional who is able to provide targeted mental health interventions to pupils, rising to two days per week by 2022/23.
• By 2020/21, this should be funded from within CCG budgets but delivered on school sites. In the interim, this should be phased in gradually using transformation funding. NHS England should stipulate that transformation plans are updated accordingly, with a portion of non-CCG transformation funding also set aside to enable schools to be granted the right to request outreach CAMHS support.
• As well as funding universal services, headteachers should top-up this ‘basic minimum’ in early intervention provision using their own budgets, on the basis of ongoing assessment of pupil need.

Commissioning and representation

• Transformation funding allocated to CCGs should be ringfenced.

• Local transformation plans should be subject to more rigorous processes of assurance in order to protect funding that should be directed towards children and young people’s mental health services from being subsumed into other CCG expenditure.

• All CCGs should be required to convene a headteachers’ mental health forum for the local area, to sit at regular intervals each year. This would ensure that secondary schools are able to influence funding decisions in a more systematic and meaningful way.
• All CCGs should be required to identify ‘beacon schools’, selected according to their pupils’ ability to access high-quality mental health provision. These schools should be used as a means of spreading best practice within local areas.

Quality

• The government should set out a roadmap towards making counselling a regulated profession, with a clear ‘specialist’ route for working with children and young people in school settings. In the short-term, this should involve the following.
• A national recruitment drive for school counsellors, to ensure that the spread of counselling provision to all schools is not held back by the number of counsellors available.
• An assessment of available training courses, with a view to raising entry requirements in line with other professional qualifications regulated by the Health and Care Professions Council.
• Introducing a new ‘school-ready’ kite mark that demonstrates counsellors’ specific knowledge on, and experience of, working with children, young people and families in a school setting.

Accountability

Ofsted must ensure that inspectors actually assess schools’ mental health provision according to the changes to the framework that were introduced in 2015/16. Inspectors should be instructed to assess schools according to the presence or quality of the following key features:

• processes for monitoring pupils’ mental health and wellbeing, and identifying pupils who are at risk of emerging problems
• an effective internal system of triage, conducted by professionals who have the appropriate level of mental health expertise
• arrangements for the clinical supervision of mental health specialists
• the strength of referral pathways to specialist services
• an appropriate mix of expertise and professionals operating within the school
• evidence of the effectiveness of school-based interventions
• the strength of schools’ links to CCGs.

Ofsted should work with the Care Quality Commission to undertake ‘joint targeted area inspections’ for children and young people’s mental health (as recommended in the Mental Health Taskforce’s 2016 report, The Five Year Forward View for Mental Health).