Children and young people’s mental health COVID-19 and the road ahead

Introduction 

Children and young people’s mental health services (CYPMHS) have long been regarded as a ‘Cinderella’ service: poorly funded and with long waits for those referred. However, over recent years, policymakers have been increasingly recognising and prioritising children and young people’s mental health. The Five Year Forward View for Mental Health (2016) set out plans to improve access to CYPMHS, which was followed by commitments in the NHS Long Term Plan (2019) to increase funding at a faster rate than overall NHS funding. The plan promised increasing funding by £2.3bn a year, which would allow an additional 345,000 children and young people to access support, alongside plans for a 4-week waiting time target.

Identifying poor mental health and providing appropriate support and treatment is essential for children and young people, as half of all mental health conditions start by the age of 14. Without appropriate care, there is a risk that conditions continue into adulthood. Since the beginning of the pandemic, disruptions to school, home and social environments have affected many of the support systems young people rely on and may have worsened their mental health and wellbeing, with the potential to impact their later life.

It is therefore essential to better understand how children and young people’s mental health has been impacted and to learn more about their experiences of getting support throughout this period. This is an area where the Health Foundation’s Networked Data Lab can provide much-needed insights. Working in a collaborative network with five local partners in England, Wales and Scotland, we are using linked datasets, open analytics, and patient involvement to help understand and tackle challenges in health and care. The Health Foundation’s Young people’s future health inquiry has also focused on young people’s mental health, including research into how emotional support enables young adults to achieve their life goals and better health.

This is the first in a series of analyses from the Networked Data Lab that will examine the evidence on this topic, to be followed by analyses using linked patient-level data. Here, we explore what we know about the state of children and young people’s mental health services using administrative and survey data published by NHS Digital and Health Education England.

How many children and young people are struggling with their mental health?

Analysis of the survey Mental Health of Children and Young People in England shows that the number of children and young people with a mental health condition has risen dramatically. These results are based on responses to the Strengths and Difficulties Questionnaire (SDQ), a validated tool that can be used to assess different aspects of mental health, including problems with emotions, behaviour and hyperactivity. Based on this, responses were then categorised into ‘probably’, ‘possibly’ or ‘unlikely’ to have a mental health condition.

Between 2017 and 2021, the proportion of 6 to 16-year-olds with a probable mental health condition increased from one in nine (11.6%) to one in six (17.4%). While increased awareness and recognition of mental health conditions in children and young people may have contributed to these changes, they indicate that the prevalence of mental health conditions is likely increasing.

This rise in prevalence approximately corresponds to an additional 500,000 children and young people experiencing mental health problems (a 60% increase since 2017, which is significantly higher than the 7% demographic growth in this age group). As a result, these young people may have required support from CYPMHS or other services.

The survey’s findings for adolescent girls are particularly troubling: almost one in four girls aged between 17 and 19 (24.8%) had a probable mental health condition in 2021, almost doubling from about one in seven (13.4%) in 2017. For boys in the same age group, there was no statistically significant change.

The survey data also highlights financial insecurity as a significant risk factor for children and young people experiencing poor mental health. In 2021, children and adolescents with a probable mental health condition were twice as likely to live in households newly falling behind on bills (12.8%, compared with 6.7% of 6 to 16-year-olds without a mental health condition).

How have services responded?

New referrals

The rate of new referrals to CYPMHS initially slowed after March 2020, when schools closed due to COVID-19 restrictions and families had to navigate changes in access to primary care. In April 2020, a month after the first lockdown started in England, new referrals were 35% lower than a year before and they did not recover to previous levels until July 2020. After this point, they rapidly accelerated and subsequently reached a record high of 100,000 new referrals per month in May 2021.

Number of first contacts

The data show encouraging signs that CYPMHS capacity has also expanded to treat an increasing number of children and young people, as shown by the number of first-time appointments for those younger than 18. In 2020, during the first COVID-19 wave, the number of first contacts initially slowed but later recovered to previous levels. In 2021, based on data from January to September, there were on average over 55,000 first contacts per month, an increase of 17% compared with the same period in 2020.

Overall number in contact with CYPMHS

According to NHS Digital monthly mental health statistics, over 340,000 children and young people were in contact with CYPMHS in July 2021, meaning they were waiting to commence treatment or currently receiving treatment – the highest number ever recorded. Comparing the period between January and September, the number of people in contact with CYPMHS was 24% higher in 2021 than in 2020, and 44% higher than in 2019. This increase is partly related to changes in reporting, with the number of providers submitting data increasing over time. Changes in reporting methodology have created additional challenges in determining the extent to which the CYPMHS caseload has increased.

Waiting times and number of people waiting

There are no openly available data on the number of young people waiting to be seen by CYPMHS, but NHS Digital monthly statistics show an increasing number of people in contact with the service, which includes those waiting to be seen. Given how many children and young people are currently being referred, those waiting to be seen will grow in number, which could have a knock-on effect on waiting times to access services.

Statistics on waiting times obtained by the Children’s Commissioner for the financial year ending March 2021 show that the average waiting time for those accepted into CYPMHS was 32 days, down from 43 days the year before. However, this average masks significant regional variation in waiting times, with children and young people in some clinical commissioning groups waiting as long as 12 weeks.

For specialised services, such as support for those younger than 18 with eating disorders, newer NHS Digital waiting times data covering the pandemic period show that fewer than 50% were being seen within target times in September 2021 (1 week for urgent and 4 weeks for non-urgent cases).

Importantly, average waiting times for CYPMHS only include children and young people who received treatment but do not take into account the 61% who, in the year ending March 2021, were still waiting or had their referral closed (either rejected or directed to another service). Therefore, those reported averages do not accurately represent the true experience of waiting to access CYPMHS.

The rise in first contacts with CYPMHS over 2021 points to an expansion of the service over time to accommodate the growing demand for support. However, the number of open referrals to CYPMHS also reached a record high recently – highlighting that growing demand increasingly outstrips service capacity. The recent increases in new referrals during 2021 mean that the number of young people waiting, along with waiting times, might increase further.

Has the CYPMHS workforce grown enough to keep up with demand?

The expansion of CYPMHS to treat the growing number of young people with poor mental health has been underpinned by an increase in its workforce, as shown by a recent workforce survey by Health Education England (HEE). The total mental health workforce (in full-time equivalent, or FTE) supporting children and young people increased by 39% between January 2019 and April 2021 across the NHS, independent sector, local authorities, voluntary sector and youth offending teams. This increase is proportionate to the increase in people in contact with CYPMHS, which went up by 42% over the same period. HEE reported large increases in staff across a variety of disciplines, including new roles such as children’s wellbeing practitioners and education mental health practitioners.

Other data sources suggest that staff numbers in highly specialised roles have increased at a slower rate: according to NHS workforce statistics, over the same period, the number of FTE clinicians in child and adolescent psychiatry increased by 8.4% (with about 630 FTE consultants in England as of May 2021). Vacancies, as a proportion of workforce, have remained stable at 9%, with most of these in the nursing profession.

While the growth in workforce and capacity is encouraging, it should be seen in the context of a poor starting point, as highlighted by both HEE and the Children’s Commissioner report in 2020. A comprehensive workforce strategy is needed for CYPMHS to continue expanding and to meet the rising need among children and young people.

Future research from the Networked Data Lab

Primary care providers, hospitals, the ambulance service, local authorities, schools, social care providers and the independent sector all play a role in providing children and young people with support for their mental health and wellbeing. While open data can illustrate some common challenges, linked data will be essential to provide a fuller picture of young people’s experiences and how these might vary across different groups and geographical locations.

The Networked Data Lab has invested in linking in new datasets on children’s mental health that will enable novel types of research – including how young people interact with the ambulance service in a mental health crisis, how socioeconomic differences affect access to CYPMHS and which factors had the biggest impact on deteriorating mental health during the pandemic. Find out more about the analysis plans of our five local partners on GitHub and watch out for our briefing planned for later in 2022.