Our findings and analysis are split into two sections: the first explores ‘problem representation’ and the pathways to anticipated changes in the policy, then we explore assumptions and effects of the problem representation.
Programme theory and problem representation
Transforming Children and Young People’s Mental Health Provision: a Green Paper ([
2] , p.3) states:
‘This green paper … sets out our ambition to go further to ensure that children and young people showing early signs of distress are always able to access the right help, in the right setting, when they need it.’
The ‘programme theory’ designed to achieve this ambition is developed across three main proposals that seek to improve access to early intervention for children and young people with mild-moderate mental health problems, in order to both reduce waiting times and the impact that mental health problems in childhood have on later life. The policy emphasises the additional cost of children and young people seeking medical intervention for mental health concerns from specialist NHS services and the longer term societal financial cost implications of children and young people struggling with mental health problems as key motivations for the policy. According to the Green Paper, the longer term costs of mental ill-health in childhood include: unemployment and becoming recipients of welfare benefits as adults, links between conduct disorders in young people and criminal activity in adulthood, higher costs to public services where mental health problems have progressed, and increased likelihood of lost working days due to stress, depression and anxiety [
2]. This focus may imply that saving public money is emphasised more strongly than a desire to reduce inequalities.
The first proposal sought to encourage all schools, through training ‘incentives’, to appoint a Designated Senior Lead for Mental Health. The Green Paper considers schools to be an ideal site for early (non-clinical) intervention and support, highlighting that some schools and colleges already have systems in place to successfully address this need [
2]. The ‘problem’ in Bacchi’s [
1] sense is thus represented to be a lack of support in schools for early intervention leading to greater pressure on NHS specialist services (i.e. implying inappropriate referrals of patients that would be better responded to in school settings, rather than a need for greater funding or capacity within NHS specialist support to respond to need). The premise explained was that parents and wider communities look to schools and colleges for help and advice about responding to children and young people’s mental health needs and so Designated Senior Leads also have the potential to be instrumental in supporting children outside of schools [
2]. The policy pathway implies that greater support in schools will result in less reliance on specialist NHS support.
The second proposal was to introduce Mental Health Support Teams to work with and between schools, colleges and the NHS, supervised by NHS mental health professionals.
‘
we anticipate that, in the long term, the creation of the new Mental Health Support Teams will lead to a reduction in referrals to NHS services, as earlier intervention prevents problems escalating.’ ([
2], p23)
As a result, it is expected that requests for specialist services would reduce, resulting in improved provision of specialist services in terms of efficiency and reduced waiting time for those who need it most [
2].
The third proposal was the introduction of a four-week waiting time trial for access to specialist NHS child and adolescent mental health services. The national average for waiting times at the time that the Green Paper was published was about 12 weeks but with significant geographic inequalities, for example, one provider has an average waiting time of 100 weeks between referral and treatment commencement [
2]. The introduction of mental health support teams and Designated Senior Leads is proposed to alleviate pressure on medical services, and therefore reducing inequalities in waiting times [
2]. The need to reduce pressure on services is presented in the Green Paper more as the result of inadequate joined-up working, rather than a problem related to socio-economic characteristics of place or lack of service delivery capacity. The aim to reduce waiting times by alleviating the number of NHS referrals presents the problem not as one that is based in place specificities or a lack of capacity but rather as a lack of joined-up working (discussed further in Section 2) and inappropriate referrals.
Assumptions and effects of problem representation
Here we extend the analysis of the Green Paper by focusing on what assumptions are made, and what potential effects are produced by the problem representation and programme theory outlined in section 1, and by drawing on responses to the Green Paper (Table S
1). A number of factors were identified as negatively impacting the capacity of health systems to respond to children and young people’s mental health problems. These include: ‘austerity’ (Table S
1:35) or ‘government cuts’ to Local Authority budgets, MH services, social services, health visitors and school nurses (Table S
1:18, 26, 27, 32, 35, 36, 37, 39, 43, 44, 49, 52) and cuts to school budgets reducing capacity to provide MH support through counselling and educational psychologists (Table S
1:14, 24, 25, 32, 35, 36, 43). By not acknowledging or engaging with the impact of cuts on services, the government ignores a significant contributory factor for the increased pressure on MH services and long waiting times (Table S
1:24, 38, 39, 52, 55). Instead, the Green Paper [
2] and the government’s response to the consultation [
45] maintain that ‘the problem’ is variable quality of provision in different areas, a lack of ‘joined-up working’, and that children and young people are accessing specialist services for mild and moderate mental health problems that may be better addressed in other settings.
The responses to the Green Paper questioned whether the capacity of the Designated Senior Leads will be sufficient due to already overstretched teacher workload (Table S
1:10, 25, 36, 44, 50, 55). There is an assumption that the senior lead role and the whole school approach can be successfully implemented and carried out using only training incentives rather than increased long-term funding for dedicated senior lead roles. Concerns were also raised about the appropriateness of addressing mild to moderate mental health problems in non-clinical settings and whether non-clinical staff can be as effective in prevention and early intervention (Table S
1:14, 23, 32). While a greater school focus on mental health is welcomed, the Green Paper is criticised for not integrating this in a wider and more ambitious strategy that responds to the rising demand for mental health support for children and young people (Table S
1:23, 32, 35, 36, 43, 46, 48) or by addressing workforce shortages and high staff turnover in CAMHS (Table S
1:7, 8, 9, 14, 23, 36) and youth work (Table S
1:29). Moreover, stakeholders have questioned the logic that Designated Senior Leads and mental health support teams will result in fewer and more appropriate referrals as the expansion of support in schools is likely to result in greater identification of need for specialist support (9). Furthermore, there is a risk that without the proper funding and extra staffing the new waiting time standard may result in fewer successful referrals and more limited support (Table S
1:1, 8, 27, 33, 46, 48, 49).
Despite that claim that one of the ‘burning injustices of our time’ ([
2] , p.3) is young people facing unequal life chances as a result of mental health conditions, the consultation highlights that the Green Paper illustrates a very narrow framing of the links between inequalities and mental health and wellbeing. The focus is on mental health problems exacerbating or leading to inequalities, with limited recognition of inequalities as a potential causal factor in mental health problems and no discussion of the role of poverty in mental health prevalence (Table S
1:2, 8, 9, 13, 16, 29, 31, 32, 43, 46, 48). Further, the Green Paper highlights families as both crucial to understanding the mental health of children and young people and in responding to mental health problems. For example, the Green Paper ([
2], p.32) states that, ‘good inter-parental relationships are another protective factor for child mental health, particularly for children living in poverty.’ However, the implication that appropriate parenting can protect against mental health problems reflects a limited understanding of the social determinants of health (Table S
1:9, 12, 17), which would address the significance of stressors and pressures outside the family that can result in mental health problems across a family (Table S
1:2, 8, 9, 11, 13, 17). The government ([
45] , p.16) responded to these criticisms by explicitly recognising that disadvantage can exacerbate mental health problems, and referenced investment in the Troubled Families Programme as a response to working with ‘the whole family to overcome their multiple and complex problems’. However, this programme has been heavily criticised for its framing of certain families as ‘troubled’, thereby individualising and reducing what are much wider societal problems to a selection of ‘problem’ families [
47,
48].
Stakeholders broadly agreed that schools are an appropriate setting for early intervention and provision of mental health support to children, highlighting that a school setting may work better for some children as a familiar setting without the discomfort or stigma that may be felt in some clinical settings (Table S
1:12, 40, 47, 49). However, some children will experience access barriers to non-clinical settings and not all children are able to access support in schools in the same way. For example, there may be particular barriers for the 48,000 (and growing) number of children who are outside of mainstream education who are more vulnerable to mental health problems (Table S
1:9, 29, 34, 37). 2 highlight that schools in more deprived areas will have higher demands. In response to concerns raised about the Green Paper’s school focus, the government’s official consultation response ([
45], p6) stated
‘we are committed to ensuring that the Mental Health Support Teams reach those most in need of the support, and are accessible to all, including those not in mainstream education and in independent schools’
However, the response provides little detail about how barriers to accessing services for children outside mainstream education will be overcome, other than signalling that the trailblazer approach (discussed further below) will address this.
Further access concerns were raised for different groups of children perceived to be overlooked in the policy (Table S
1:3, 8, 9, 11, 12, 16, 19, 20, 30, 37). Responses highlighted that some children are more vulnerable to mental health problems, such as young carers, refugee and asylum-seeking families, disabled, LGBTQ+ and looked-after children, some BAME communities and international students and that there needs to be greater focus on specific experiences and barriers faced within child and adolescent health systems (Table S
1:3, 8, 12, 30). In terms of race and ethnicity, the Green Paper highlights that white children are more likely to experience a mental health disorder than black children and that both white and black children are much more at risk than Indian children [
2]. However, the Green Paper ignores the complexity of cultural differences and disparities in access to treatment and experiences with mental health services (as seen in the Public Health England [
49] report on ethnic inequalities in health) in its recommendations. For example, children with disabilities and special educational needs may need support for access, communication and interaction with services for the policy to be successful (Table S
1:19). The lack of engagement with different access needs and ‘looked after children’, specifically, in the Green Paper has led to concerns about the extent to which their access requirements and specific circumstances are accounted for (Table S
1:37). The need to engage children and young people more generally in the consultation process was highlighted (Table S
1:15) to ensure that the issues that affect them most are understood and how they experience mental health service provision and need. Stakeholders recommend early intervention and prevention that is based on ‘proportionate universalism’ to cater for all children but targeted to need through proactive case finding, for example for children living in poverty, in order to reduce inequalities (Table S
1:4, 15, 18 20, 24, 44). Overall stakeholder responses were critical of Green Paper’s limited engagement with the importance of inequality, predominantly highlighting that mental health support should directly address inequalities and should be more varied and accessible.
A trailblazer approach (policy implementation in a selection of sites, before wider roll out) was chosen for implementation of mental health support teams and trialling the 4-week waiting time standard. The benefits of this approach stated in the Green Paper include: identifying local differences in need, provision, and structures which will impact on the implementation of the new proposals; sharing learning about implementation from trailblazer sites with other localities; and addressing and ironing out concerns identified in the implementation of planned policy changes. The use of a trailblazer approach, however, has been criticised by stakeholders for not being ambitious enough given the severity of need and gaps in mental health service provision for children and young people, as it limits any potential benefits of the policy to no more than a quarter of children in 5 years ([
5]; Table S
1:5, 6, 8, 17, 21, 24, 26, 30, 35, 41, 42, 45, 49, 52, 53, 54). The potential to increase inequalities by providing support in only a select number of trailblazer areas was also criticised in the discourse about the Green Paper ([
5]; Table S
1:6, 7, 22, 24, 26, 28, 32, 38, 50, 55).