Podcast: Nick O’Shea and Charlotte Rainer

26 January 2022

For too long, children’s mental health has been underfunded. Children face a postcode lottery when it comes to mental health care, despite the clear moral and economic benefits of early intervention. In this episode, Thea hears from Nick O’Shea, the Centre’s Chief Economist, and Charlotte Rainer, Lead of the Children & Young People’s Mental Health Coalition, about our new research, ‘Time for action’. It sets out the need for a strategic investment strategy for 0-25 year olds to prevent more young people falling through the gaps. Nick and Charlotte highlight what support is needed at each age, and how we’ll be working over the next year to fight for children’s mental health.

Listen to the episode on Spotify or iTunesThe full transcript is available below.

Show notes: 

Music by scottholmesmusic.com




Alethea Joshi (AJ): Hello and welcome to Centre for Mental Health’s podcast, where we explore ideas around mental health, equality, and social justice. I’m Thea Joshi, and this podcast is a place where we talk to people with lived experience of mental health problems, people working in a specific area of mental health, or some of our own team, to discuss how we’re engaged in the fight for equality in mental health. A few weeks back, I spoke to Nick O’Shea, the Centre’s Chief Economist, and Charlotte Rainer, who’s the Lead of the Children & Young People’s Mental Health Coalition, to talk about investing in children’s mental health. So we have done a lot of work on children’s mental health over the decades, including on the economic case for investing in support for children. And back in December we launched a new report called Time for Action, calling for an end to the postcode lottery of care, and also setting out how strategic investment could improve children’s mental health. So Nick and Charlotte kindly sat down with me to discuss all this and more.

Hello, it’s wonderful to be here in 2022, the beginning of a fresh year. And I’m delighted to be here with Nick O’Shea, who is the Centre’s Chief Economist, and Charlotte Rainer, the Coalition Lead at the Children and Young People’s Mental Health Coalition. Hello!

Charlotte Rainer (CR): Hi Thea!

Nick O’Shea (NOS): Hi Thea. Lovely to hear your voice.

AJ: So I’m with Nick and Charlotte, we are over Zoom today because of working remotely, but the joys of technology, we can still connect, which is wonderful. So we wanted to get you on today to talk about a really critical area of our work, which is children’s mental health, and specifically about investing in children’s mental health. And so as you guys will know, we launched a report back in December called Time for action, which I’ll link to in the show notes, which looks at how we can end the postcode lottery of care through strategic investment. So Charlotte, I’m going to dive right in and just put you on the spot a little bit. Could you set the scene for us about children’s mental health in the UK at the moment?

CR: Yeah, of course. So, recently, we have sadly been seeing a rise in the prevalence of mental health difficulties. So NHS Digital, they have their recent prevalence surveys, they did one in 2017, 2020, and most recently in 2021. And what that survey has shown is that the rate of mental health difficulties has increased from a prevalence of one in nine children in 2017, to one in six 6-16 year olds in 2021. So we have seen an increase. And this does relate to common mental health problems such as anxiety and depression. The data from last year has also shown that we’re seeing an increase in other disorders such as a rise in eating disorders. So these were up from 7% to 13% in 11-16 year olds, and from 45% to 58% in 17-19 year olds. So we are really seeing this increased rate of prevalence. Then we can’t forget the COVID-19 pandemic as well, which has had a massive impact on the mental health and wellbeing of children and young people.

The Centre’s own research has shown that 1.5 million children under the age of 18 could need new or increased mental health support as a result of the pandemic. So we are really seeing this increase. At the same time, we are seeing services now struggling to cope with demand. Children and young people’s mental health services have been historically underfunded and under-supported, which we’ll talk about later on I’m sure in the podcast, but they’re starting to really feel the squeeze and the pressure. Young people typically find it really hard to access the support from mental health services. There’s really long wait times – I think wait times range from eight to 82 days, depending on what area of the country you’re in. And there’s just really a lack of early intervention support as well. So for some young people, it means that being referred to specialist services is their only option, but they might not need specialist care, it just might be the early onset of mental health difficulties. So kind of all of that mixed together means it can be really challenging for young people to get the mental health support they need and the support they need at the right time.

AJ: Yeah, thank you so much for that insight, Charlotte, for just that really clear, plain overview. And I think we just can’t deny that this is really worrying and really shocking. It’s distressing to hear that our children and young people are not getting the support that they need. And whilst this has been a historic issue of underfunding, at the same time, I think we are seeing, as you’ve alluded to, just the impact of the pandemic, and the increasing disparities as well. And it’s both worrying and it makes me very angry. But we will use that anger, we will use anger to fuel our work.

NOS: I think Charlotte summed it up very well. And I think looking at it from an economic perspective, you know, there is this sense of with children and young people and babies and so on between 0 and 25, what you want to have is consistency if you can. So we make sure that every child has access to a midwife when they’re born and then checks and so on, and they go to school, and it’s standardised and you get a curriculum and this is what happens. And I think it’s surprising when given what Charlotte has been saying, that there just is that complete lack of standardisation when it comes to mental health. And that we don’t say, well, actually, here’s the baseline and wherever you are, this is what you’re going to get. And that really is the basis of any investment strategy. So I think my conclusion for what it’s worth is very much that lots of the right things are being said, I think we really understand what’s needed, I think we understand the research about it. We know that there’s a problem and we know what we need to do about it. What is lacking is then a strategy that says: and here is the money that comprehensively answers that question, as well as we can. So that is, I think, where I would sort of see it from the money aspect.

AJ: Thanks. Yeah. And that is also infuriating to hear – infuriating in the best way. And again, we will use that information. But I mean, one statistic we mentioned in the recent report was from the Children’s Commissioner highlighting that NHS spending on mental health for adults is £225 versus £92 for young people. So there is a clear kind of disparity there where we’re not addressing early on the mental health needs of young people. And we know that doing so early on could really change the whole trajectory of people’s lives. So, again, very difficult to hear. But Nick, would you be able to just let us know a little bit more about the Time for action report and some of the key findings?

NOS: Sure. So in this, we tried to take a systematic and a systemic approach and really look across the board, from 0 to 25, and ask what’s the dream? And in some ways, it is quite helpful to be able to look back at the recent history of this country and compare and contrast, maybe coverage that was there at the beginning of the 21st century and that now. But really, it’s to sort of say, well, okay, trying to give somebody a seamless, consistent, methodical outcomes based intervention across a time span, a long time span, requires looking at where children, young people, babies get that state intervention already. So what we’ve done is to say, what is it that happens around the first 1000 days? We know the number of health visitors has fallen by 20%. We know that workloads are going up, caseloads are going up. So, okay, what we actually need to do there is make sure that we are investing in these services. And what’s been interesting about the spending review from 2021 is that it’s very much offering big sums, so £300 million towards that period of time, £500 million overall. But actually, it’s this lack of consistency – again. It’s this sense of: some of you are going to get this and some of you aren’t. And I’m not quite sure when that became acceptable. Because it didn’t used to be.

And so yeah, that’s sort of what we do, then we move into schools and saying, between 5 and 16, you’ve got the majority of that population in similar provision, pretty much. There are some people who are not in school but you know, largely, they’re in a building, having a pretty similar day. And this is therefore actually an excellent way to intervene – a moment to intervene over a long period of time. And we know things like trauma, illness, and so on, it all begins, you know, it can come up during these years. So, a really good time to do that. But what we also see is that a lot of schools, very quietly, have had their funding for mental health hollowed out. So I’ve been a school governor for 22 long years, and I’m Chair of the Finance Committee so I see the money. And what you see, though, is the amount being given to children that have additional needs falling, falling, falling, at the same time as responsibility from the school is going up. So we’re having to do more as a school but with less money. It’s basically saying, we can take things like whole school approaches, which are very reasonable actually, and actually get in there at this point where children are in that same place at the same time.

AJ: Yes, on that point, Nick – whole school approach – this is a term that we talk about a lot at the Centre, but it might not be super familiar to many of our listeners. So Charlotte, I wonder, could you just give us a very whistlestop tour of what we mean by whole school approach?

CR: Yeah, of course. So when we talk about a whole school approach, we can also call it a whole school and college approach, a whole education approach. But what we mean is it’s a multi-component approach that looks at all areas of the school and how mental health and wellbeing is embedded within it. So there’s eight principles of a whole school or college approach. And these look at different areas. So ranging from culture and ethos, the school environment, targeted support, staff wellbeing, and how through those eight principles, mental health and wellbeing can really be embedded within the school culture. So it is about every part of the school looking at mental health and wellbeing and making sure it’s supported. We did some work with Public Health England and the Department of Education to recently update the whole school and college approach guidance for education settings. And that provides a really good overview and really good advice and guidance for schools and other education settings on how they can implement the whole school and college approaches. So I’d recommend looking at that as well.

AJ: Yes, and we will definitely stick that in the show notes. So Nick, you were talking to us about the amazing opportunity that we have to support children’s mental health while they’re in school. What about children and young people who are not in school?

NOS: Yes, exactly. And I think between 16 to 18 is where you really just see this diffusion of opportunities. So, some people go to amazing sixth forms, some people go to miserable jobs and apprenticeships, and others go to great apprenticeships, some people join the army, some people go to prison. And actually, there’s a lot of different outcomes for people, but the point that’s of interest to us when thinking about policy is that it’s then much harder to track those people. So just as with our mental health forecasting work that Charlotte mentioned, we were able to tell the numbers that we think are going to be needing services, but we can’t tell you where in the system you’re going to find them. So it’s all very well saying it’s all about 17 year olds, but actually, you don’t know where they are, and which ones it is and how to find them quickly. It could be too late by the time you do. So, it’s this idea about systems which listen, and how do you track down the struggling 19 year old? How do you find that person quickly? And who are the organisations that will find them? So this is really the idea.

I think it contributes to the Fund the Hubs work, which is the early intervention hubs, and how those are something that can be a port of call that may be different to and better than the police, the fire brigades, and the accident and emergency crew. I mean, of course, when I was young we had these everywhere, but then that was a long time ago. But I think, again, the hubs is really interesting, just from a cold hearted economic perspective, it’s very difficult to see how there’s going to be blanket coverage nationally, it’s also very difficult to see what a fixed model is because each area responds, correctly, to its own needs. But I think these are the kinds of things that the campaign has really been trying to highlight that just getting some money through the doors and letting professionals get on with it is usually quite a helpful approach.

AJ: Yeah, definitely. And Charlotte, I wondered if you want to tell us a little bit more about the Fund the Hubs campaign, because I know it’s something we’ve been working on a lot as well as the Coalition.

CR: Yeah, so the Fund the hubs campaign, it all began last year. And it’s a coalition of different organisations: Centre for Mental Health, the Children and Young People’s Mental Health Coalition, Young Minds, Youth Access, Black Thrive Global, the Children’s Society, and Mind. And we all came together last year to develop this campaign to call for early support hubs. So we’ve recognised that there’s a real gap in early intervention support for children and young people’s mental health. In most areas we have schools and we have Child and Adolescent Mental Health Services (CAMHS), but actually, we have nothing that’s based in the community that’s really accessible for young people to access support. And so the campaign calls for these early support hubs, which is bases within the community where young people can drop in at a time that’s right for them and access immediate support with their mental health.

So the hubs are aimed at young people with emerging mental health needs, or (I really hate this phrase but I can’t think of another phrase) ‘low level’ mental health needs, so that mild to moderate need. And it’s about young people being able to access that immediate support and having a brief intervention. We know there’s around 60 of these hubs that already exist across the country. And what the Fund the hubs campaign has really been calling for is long-term and sustainable funding to not only set up hubs in those areas of the country that don’t have them, but also to make sure that those areas that do have hubs have the funding to sustain the services and to keep them going. We know that early intervention support can be a really important lifeline for children and young people. And if we intervene earlier, then we can avoid more costly pressures being placed on specialist services later down the line. And we already know that specialist services are really struggling. So yeah, it’s all about increasing that availability of early intervention support in the community.

AJ: Yes, exactly. And I think that it’s worth saying at this point that in none of this work are we pitting adult mental health services against young people’s mental health services. We’re definitely in no way saying that we should be taking money away from adult services, rather saying that if we gave young people the support they needed when they needed it, we might be able to prevent some of these later problems. And the previous work that we’ve done at the Centre, called Missed opportunities, which again, I will link to, we highlighted there’s a 10 year gap – that’s on average – between people first displaying symptoms of a mental health problem to actually getting any support. And that’s definitely been the case for a lot of people I can think of – myself included. And it is again, there’s a theme of anger coming out here, but it’s infuriating to see this pattern revealing itself generation after generation, and to see that we’re not investing where we really could make a massive difference. So I guess it’s worth saying as well that our work with Fund the hubs, we were really, really keen. And we were really calling on the Government to invest in these early support hubs across the country. And we are yet to see that investment but we fight on basically, we will continue calling for that, because we know it will make a real difference to young people and their mental health.

NOS: So thinking about people after 18, so the 18-25 bracket. Again, you know, very different life experiences – I think I was probably living my best life at about 21, I think I probably was, but I was very difficult… Anyway, there is this thing of how do we support people when they’re coming into these challenging times? Between 21 to 35 can be massively stressful. You don’t understand the working environment, again, you can be in prison, your first relationships may have completely gone wrong, you may have been a victim of a horrific trauma. How do we get to people so that actually, they’re not 40, they’re not my age, and basically still picking up the pieces of what happened 25 years ago. And that is really the pinnacle of any invest-to-save argument. Which is: we know this, folks, we absolutely know this, we need to just fund it now. And it is infuriating. And whilst I can’t draw on first hand experience for that, it’s very obvious just from the numbers, and therefore I just don’t really understand why it’s not purchased. Because you see it’s quite obvious even if you don’t care, and you’re dispassionate about it, and you don’t understand it, here’s some really obvious numbers.

AJ: Yeah, exactly. And I guess that’s also what we’re doing with this report, isn’t it? We’re saying, obviously, there’s a very clear moral and ethical argument for preventing children from suffering and promoting their mental health. But even if you have the hardest of hearts, even if you’re purely based on the numbers, investing in children’s mental health literally makes economic sense. So there’s literally no good reason why we aren’t doing this. And in failing to do it, I would say we are letting down another generation. But that’s maybe a little bit too bleak this early in January, sorry, guys. I think the positive thing I would say about this is we’re not just saying here’s a massive problem, no one’s doing anything, grumble, grumble, grumble. We are saying there are actually things that can be done, here’s how you can do them, here’s how we can put this into place. So I wonder if you guys could talk me through some of the key things you’d say need to happen as a result of this work, what we’re calling for.

CR: I think it’s important to note that what we’re calling for isn’t new stuff. It’s stuff that is happening in parts of the country, or stuff that we’ve seen before and it’s been dropped, and it hasn’t been reinvested in. So actually what we’re just calling for, I think really simply, is investment. And for, as Nick said earlier, that really consistent approach across the life course. So it’s not reinventing the wheel, it’s just building on what we’ve already got, like Fund the hubs, building on those services that already exist, and making sure they’re consistent and kind of tackling this postcode lottery and provision that we’re seeing at the moment. So the overarching recommendation from the report was creating an investment strategy for 0 to 25 year olds’ mental health. And that was a really good opportunity for the Government to set out what could happen at each life stage, where the money can be invested, what needs to happen. And the report really successfully sets out what we can see happening at each life stage, as Nick has just gone through. But there’s also opportunities where we’re going to be seeing the new Mental Health Plan being published, hopefully in the next couple of months. So attaching an investment strategy to that plan and making sure that things are properly funded and invested in I think is really important. And I think having a strategy create that accountability, that actually, we’ve set it out now, now we need to do it, and we need to act on it. Because I think that’s another issue at the moment that there isn’t really that accountability about spending on mental health.

NOS: I think the thing that has been interesting for me about this as an economist is you become a bit of a social tourist. So you get to see things that I’m unfamiliar with, you know, acute wards, I’m not familiar with. And the thing I was massively impressed by was the commitment, skill and intellect actually of a lot of the people that are working with young people, and particularly struck with the clinicians working in the new care model approach, which is about trying to get people out of acute beds, especially when it’s hundreds of miles away from your home, which is what we’re now seeing beginning to happen actually, more recently, suddenly all this is going up again. But what was fascinating about it was yes, you can save lots of money, tons of money. But it was the the risk that these people were having to manage, often at the end of their careers, that they’re like, my whole reputation, my whole career, is all on this. I’m putting it all on red. And it was really stunning, because you thought well actually, yeah, if I was in that situation, I’d want someone like you to take that risk for someone like me, and to get me back home, frankly, and to offer me something that is going to be really structured and look after me. But in doing that, what I was unprepared to see was people having to take these sorts of enormous “it’s all on you” risks. “If you say so on a Friday afternoon, you’re going to put this person back in the community, alright”… Whereas actually it’s so much safer just to do the same thing. And I think this is where someone being the adult, if you like, and the Government just having a strategy that says, yes, we agree positive risk taking is a good idea. Yes, we agree clinicians actually do know what they’re doing. Yes, we agree we should ask the person involved who’s receiving the treatment what they think and do something about it. It would just help everyone to have legitimacy about then pursuing that. And that’s why you see islands of great practice, rather than nations of them, I suppose.

AJ: Yeah, thank you so much for that both of you, that’s really helpful insight into kind of, as we’ve said, this need for a really comprehensive investment across the board and across the country. And as you said, at the beginning, Nick, this idea that, you know, when did it become acceptable, socially acceptable, morally acceptable to deliver such a disparity of care across the country? 

So I wanted to thank you both so much for that really helpful insight. The report’s on our website, we’d encourage you to go and read it, share it, share it with everyone you know. And I guess I’d just love to know, what are we going to be doing as a result of this because we know that for us at the Centre, we don’t do a piece of research, publish it, and then leave it to fester on a shelf. Our work almost begins where our report is launched, because that’s where we start trying to implement the changes we are recommending. So Charlotte, I wonder if you could tell us a little bit more about what the Centre, what the Coalition are going to be doing over the coming year or so to really put this into practice?

CR: Yeah, so everything that has been published in the report or the issues we’ve spoken about, are issues and concerns that our members and ourselves have long been campaigning on. So now the fact that we’ve got this report, and we’ve got it all in one place, from an economic perspective, is a really helpful guide and resource for us to use going forward. We’re going to be seeing lots of change over the next year in terms of mental health. And this report provides a really good basis for us to start influencing work from. As I mentioned earlier, we’re going to be having a Mental Health Plan from the Government, which is going to set out a vision for mental health and mental health care over the coming years, looking at preventing mental health problems, through to early intervention, through to mental health care, through to crisis support. And the report provides a really good basis for that. So at the Coalition we’re going to be influencing and working on that. We’re also going to be seeing some changes in the education sector. We’re expecting the schools white paper, the publication of the long awaited SEND review. We’ve also got other things happening such as the care reviews being published, and at some point we’ll be having a levelling up white paper as well to kind of match the levelling up agenda that the Government talks so frequently about. There’s some real opportunity over the next year to create change. And we can use this report, its findings and its recommendations to help us achieve that. At the Coalition we’ll continue to work with our members to promote their work and put their voices and young people’s voices at the centre of what we do.

AJ: Thank you, Charlotte, that’s a really encouraging note to end on. We know there are some big issues here, and we will continue to fight for them at the Centre and at the Coalition. But Charlotte, Nick, it’s been a real joy to sit down with you and talk about this. Thank you so much. It’s been lovely to speak to members of our own team. And so thank you for your time. And yes, you can check out everything we talked about in our show notes, and do let us know what you think about the report what you’d like to see us talking about next. Thanks!

We really hope you enjoyed the episode. To join the fight for equality in mental health, please support our work at www.centreformentalhealth.org.uk/donate. See you next time.

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