There are some problems we can’t solve. For example, let’s take a big adaptive problem that needs lots of resource to solve, and coordinated national, local and community action. We call these problems wicked issues, and I think I’d put children’s mental health in this basket.
So how do we solve a wicked issue? As a commissioner we’d want to see some of the stats about the service quality, volume, needs and outcomes. A national joint strategic needs assessment if you like:
- 1,052,000 children with a diagnosable mental health condition
- 1,472,000 with an additional mental health need (lower level)
- 2,524,000 total with a need
- 230,000 service capacity in 2016 (projected 300,000 by 2020)
- 0.8% NHS funding for children and young people (vs 11% for adults)
- 70% of mental health need has developed by 18 years old
- 10 years that a child lives with a need before starting treatment
Are you shocked by these figures? Just think for a moment of the life experience of all the children and young people described here. We have services that can deal with only 1/10th of the potential demand. We spend 14 times more money on adult mental health, but most of the need is there by the time a young person is 18. It’s an average of ten years suffering with a mental health difficulty before children get help. And you might have expected some outcome statistics, but unfortunately most of what we measure is activity and not outcomes, which might be one of the reasons that mental health is a hidden issue in society.
What do young people say?
”It took a long time to get an appointment, then they expect everything to be sorted in four weeks”
”Mental health sounds negative, like crazy or being mental. There’s too much of a stigma attached to it”
”I want to help my friends to get better”
”You get spoken to like a child”
”I want help at 3 o’clock in the morning”
”I know we’re not equal, but they treat us like we’re not human”
”I would like to sit down with those high up and those most marginalised by the current mental health system to attempt to implement some changes”
So of all the challenges facing children’s services, mental health best fits the description of a wicked issue that will require big changes in national policy and funding, local service redesign, and changes in how the community supports emotional wellbeing.
What is a commissioner to do?
You might think there is little we can do to change the system, but I’m an optimist. First, schools, parents, young people and communities are getting better at recognising and supporting mental health. Second, the science behind treatments and therapies is improving rapidly. And third, whilst the extra funding is just a splash in the ocean, mental health is finally on the national agenda.
So we can begin to construct a commissioning strategy:
- Massive increase in universal and community support. As a commissioner, the only way we can meet the needs of 2.5 million children is because we mobilise communities, schools and friends to help each other. For instance through behaviour change, training, online materials and a local workforce that coaches teachers, young people and parents. Long-term we are aiming for a tipping point in awareness, resilience and support to increase local capacity and early help.
- Single point of access for both families and staff referrals – an empathetic telephone line and triage to the full range of community, universal, voluntary and specialist services. The triage function controls how the very limited resource in each area is used to meet demand, rather than relying on uncoordinated thresholds and cost shunting between providers. Long-term we want every enquiry to get a compassionate response, and support from the system of local services.
- Double the capacity of specialist services. It sounds a big task but new research from Peter Fonagy What works for Whom? lists the treatments and therapies that give the best outcomes. If we couple this to local knowledge of the cost of intervention, we can identify the best balance of services to improve productivity. Long-term if we can measure outcomes at each session, case manage based on these outcomes, and tweak the delivery model to include other agencies and parents, then we can significantly increase capacity to help our young people.
But the above strategy is challenging. Because this is a complex adaptive problem, the commissioning cannot be about changing a few contracts or pathways. Effective commissioning for mental health is about leading a transformation, engaging the whole workforce, and inspiring the community to think differently about children and young people. This is the approach described by Future in Mind and Local Transformation Plans — please give them your support and together we might solve the UK’s biggest wicked issue.
What Works for Whom? Second Edition: A Critical Review of Treatments for Children and Adolescents, Peter Fonagy, David Cottrell, Jeanette Phillips, Dickon Bevington, Danya Glaser, Elizabeth Allison, ISBN-13: 978-1462525928
Future in Mind: promoting, protecting and improving our children and young people’s mental health and wellbeing, 2015, DH, NHSE
First published by CYPNow https://www.cypnow.co.uk/features/article/commissioning-children-s-mental-health