Youth Select Committee 2015: Mental Health – 3 July afternoon session

>> Chair: I will now open the fourth panel of the day. I am Rhys Hart, the Chair of the Youth Select Committee. A big thank you for coming and attending today. We know you are very busy and have lots to do, so we are very grateful for the time you are giving us. If you could introduce yourselves, please, and say a few words about the organisation that you are representing, that would be more than helpful. Dr McShane: I am Dr Martin McShane I work in the medical directorate in NHS England I am the medical director for long-term conditions NHS England is charged with commissioning specialised services and primary care and supporting and assuring the role of clinical commissioning groups, which commission community and other services – the bulk of services in local communities. We work in partnership with other ALBs – arm’s length bodies – like Public Health England, Monitor, the Trust Development Authority and the Care Quality Commission and other supporting organisations like the National Institute for Health and Care Excellence and the royal colleges. I hope that is sufficient >> Leanne Walker: My name is Leanne Walker, and I work for GIFT – Great Involvement Future Thinking. I am a young sessional worker. GIFT was commissioned by NHS England to support participation – getting young people’s voices heard – on a national and local level >> Professor Fonagy: My name is Peter Fonagy I am a professor of clinical psychology at University College London. I am also national clinical adviser for Children and Young People�s Improved Access to Psychological Therapies, which is a process of service transformation that has been going since 2011 to try to improve the quality of child and adolescent mental health services in England. I have a number of other academic positions at universities in this country and abroad. I have been an academic for 35 years. I am a professor – the definition of that is that I speak in other people’s sleep. I hope not to do that today >> Chair: Thank you so much. To begin, could you say in a few words what you believe the current quality of mental health services for young people to be? Would you like to start, Martin? >> Dr McShane: I have the good fortune of co-chairing with the Department for Health the taskforce on children and young people’s mental health service. I have also worked as both a GP and a commissioner over the past 25 years The current state of service delivery needs to be improved significantly. We evidenced that in the taskforce report. What is heartening is that we have a programme, to which Peter has already alluded, called Children and Young People’s Improving Access to Psychological Therapies, which is based on quality improvement in established services within the NHS. We have good evidence that improving services is deliverable, but we need to link them up with other important services across the spectrum of public services and voluntary, non-statutory services. I am talking about linking into education, local government, the NHS and justice Then, of course, there is a wide range of voluntary sector organisations. Leanne, would you like to comment on the state of services, and I will just sit back a little? >> Leanne Walker: I used CAMHS – child and adolescent mental health services. From my point of view, they have come a long way, but they still have a long way to go. As Martin was saying, communication between the different services is key. Voluntary, public and private services all need to link up and communicate more >> Professor Fonagy: I would obviously endorse what my colleagues said. I would emphasise that there is a massive unmet need, which everybody recognises, in relation to mental health, but particularly in relation to child mental health. At the moment, no more than

13% of adolescents with a clinical diagnosis are likely to get appropriate mental health treatment, particularly if they are male We obviously do not wish that state of affairs to continue. In some respects – I totally agree with Martin – the services are improving, but they have further to go. We need to make services more accessible and more appropriate for young people, so that they want to use them and feel comfortable using them. It gives them what I think is most important in mental health – GIFT has done magnificent work in this area. It gives them agentiveness – the capacity to make decisions for themselves – which anyone with a mental health problem is absolutely in need of. Therefore, our priority should be increased participation, incorporating young people in designing services for young people by young people >> Saskia Edwards: Hi, I am Saskia. Welcome to the Youth Select Committee. One of our witnesses last week, a doctor from Cardiff University, said that instead of people being seen early, they are being seen only at crisis point. We read that Baroness Tyler of Enfield last week in the House of Lords debate described mental health services for young people as the Cinderella of Cinderella services – completely swept to one side. In your opinion, why have mental health services for children and young people been allowed to reach the point where they are colloquially described as the Cinderella of Cinderella services? >> Dr McShane: I think that a number of factors have been at work. We should applaud the fact that over the past four to five years, there has been huge awareness-raising about the importance of mental health in children and adults across the whole life spectrum. What is encouraging now is that both the last Government and this Government have said that it is a priority, and NHS England has made it a priority There is also a growing awareness of the benefits not only to the health service but to communities and the economy of addressing mental health purposefully That speaks to why it has perhaps been a Cinderella service in the past, because it has not been tangible. We have not had data. We have not had measurement. We have not had awareness If you have got diabetes and you get complications, we have systems and processes to track those If you develop a psychotic illness in youth�what hit me very hard was the understanding that 40% or more of chronic mental ill health starts before the age of 18, and yet we have not heretofore understood or tracked the impact on people’s lives or on the resources we use People like Richard Layard and other economists have demonstrated that not only is there a moral and ethical duty for the individual, but, to back that up, there is a massive economic imperative to do this work. We need to have better measurement, which is what we called for in ‘Future in mind’ and will be delivered next year; we will have better measurement We need better transparency about investment, which we have called for and we are determined to achieve over the next five years. We have already laid down rules within NHS England about putting more money into mental health services We need to make a clarion call to society and continue to strip away the stigma about mental health. It takes great courage for people like Leanne to come and talk about their own personal experience. I often say in big meetings, ‘Can anyone in the room put their hand up who has not personally, or through someone very close to them, experienced

mental health problems?’ Certainly, my hand would not go up >> Leanne Walker: I think that there needs to be a greater emphasis on the fact that everyone has mental health. I think that the terms ‘mental health’ and ‘mental illness’ have become the same and associated, and that adds to the stigma. If there was more awareness about the fact that everyone in the room and everywhere has mental health, that would do a lot for reducing stigma >> Professor Fonagy: If I may just add to the stigma point, a recent survey by Place2Be showed that about a third of parents admitted to feeling embarrassed if their child or a young person whom they were looking after wanted to have counselling in school. About a quarter of them actually said that they would not encourage their child or young person to take advantage of an opportunity to have counselling. If the parent is saying that they are not in favour of child mental health, there is a major problem in society. I remind you of Nelson Mandela’s statement, which I deeply believe: there is no better revelation of a society’s soul than the way it treats its children. The fact that in this country we spend just over 6% of the mental health expenditure we have available to us on children and young people is perhaps a revelation of the soul of the society. That speaks to Martin�s point that, for us to do something about it, it is not enough for NHS England – my employer – to do something about it, or for social services and local authorities to do it: it has to be everyone’s business that children’s mental health, which is as much determined by the environment that children and young people are in as it is by the small contribution that the health service has to offer, becomes a national priority. That is the clarion call that I would like you guys to make >> Liam Islam: We have received lots of evidence over the past few weeks. One young person who gave evidence last week, Saadia Sajid, said, ‘many young people are not aware of the services out there for them.’ In my local youth council, I made a suggestion as to whether anybody had heard of CAMHS – Child and Adolescent Mental Health Services – and one of the girls did not even know what it stood for. We have had evidence that young people lack awareness about mental health and services available. Do you think that the treatment gap is down to the lack of services available or down to the lack of awareness of services that are available? >> Leanne Walker: I think it is down to lack of awareness. To use a personal example, when I was at school I did not know much about mental health, so I did not know the symptoms that I was experiencing. My teachers did not really know much either. The people around me – my peers, my friends, my family – had never heard of CAMHS, and neither had I, so this meant I could not access the services that I needed. If you increase the awareness, you increase the ability for people to get the help they need sooner. It has a ripple effect With GIFT – similar to what you were saying – we did mystery shopping on CAMHS websites. We went on Google and searched for ‘mental health services’ in different areas. It was hard to find mental health services for young people unless you knew the term ‘CAMHS’, and unless you have been in the service, or know someone who has, you do not know what it is. I am not saying CAMHS should be advertised on buses, or anything like that, but the word needs to be out there about what services are available >> Professor Fonagy: I endorse as strongly as I possibly can what Leanne has said, and add to it that there is currently an initiative to create in every school a mental health lead, who would be able to do exactly that kind of signposting, and maybe even better signposting. The fact that it has not existed effectively up till now, or has been very variable, is a shortcoming and a real indication of the problem. In addition, early intervention

is important. By the time your problem is serious enough to be referred to a specialist service, that in itself is a problem. Having levels of intervention that are appropriate to the young person’s needs or problems is not necessarily a simple diagnosis, after which you get referred. We really need the gradual input of appropriate care throughout, through the integration that Martin mentioned, with a number of agencies working probably in education, but with families and communities as well >> Dr McShane: Another problem is that you do not look for something until you need it The NHS has a great track record of using acronyms that are incomprehensible, sometimes even to people in the NHS. When I got involved in management, for a while I thought that an FBC of 5 million was a very expensive full blood count until I learnt it was a full business case We do have major problems with being able to signpost people appropriately and I think that is because sometimes we try to direct too many things from the centre. One of the points of ‘Future in mind’ we put forward was that transformation plans for improving the mental health support and access to mental health services for children and young people should be owned locally and designed against best practice and evidence. Having worked in a number of local communities as both a clinician and a commissioner, I know that there is a lot of local intelligence and those relationships have to be supported and enabled to improve things. The centre should do only that which the centre can do, and for the rest we should enable local communities to build relationships and trust and appropriate pathways of care or ways of working, because it will be different in Barnsley, Basingstoke and Barnstaple – they are very different places to Birmingham as well. I think that is really important for us >> Leanne Walker: I have a good example about awareness. It was in Kingston and 10 people from 10 local schools came together to have a conference. They talked about mental health, general awareness, stigma and local services – what local services are out there. That is very important. The young people were very interested, the teachers were interested and it really increased awareness >> Sophie Jones: This is for NHS England: you said in your evidence that transition is poorly planned, poorly executed and poorly experienced. Who is responsible for making sure that services communicate effectively, ensuring a smooth transition for young people? >> Dr McShane: I will walk straight into this: we are. That is why, first of all, when NHS England was formed, we created a national clinical director for young people and transition That is why we put an emphasis on the fact that transition should be defined not by an arbitrary age, but by a need in ‘Future in mind’. We have put forward the proposition to people that transition should be considered up to the age of 25, because somebody who is 17 might be ready to transition into adult’s services, but someone else might be a lot older before they are ready to transition services That is why we have actually created for the system specifications designed with the young people and parents – if you like, the working manual that people can apply locally to improve the way that transition happens. And I think as well as which we need to develop innovative

and new ways of supporting transition, especially harnessing the potential and power of children and young people themselves Peer support can be incredibly powerful. A good example from physical health – renal transplant – was published in a journal a few years ago. During transition, up to 25% of the young people who had had a renal transplant lost their transplanted organ, their kidney, because it had got muddled – they were adolescents – they had all the other things they were interested in and they were not taking their medication When they put in a peer support approach and facilitation, non-medical, to support that transition, over the subsequent two years, no child lost their kidney No child or young person should lose the gains they have made with support from the children and young people’s mental health service as they move into adult life. That is our ambition >> Leanne Walker: I was going to say something slightly different. I am not sure whether increasing the age range of leaving services is the answer. The problem is a lack of communication between services. To try to help with that, Gift and NHS England have developed a tool called the service user passport. The young person develops it with their therapist or counsellor, or whoever they are working with, and it is a summary of their own information�their problems and history and what helps them They write it in a document, however they want, and it gives them ownership of their own information that they can take to another service when they are transitioning or moving between services. It is up to them what information they want to share, or whether they want to share it at all. It is an attempt to combat some of the lack of communication and the feeling that the work that has been done is lost when someone moves between services It gets down to communication >> Pegah Moulana: My question is to Martin and Peter. In your written evidence you said that to ensure a smooth transition from CAMHS to adult services, local authorities and CCGs will use a model specification and a sample when they are discharged. How are you going to monitor whether local authorities and CCGs are actually using the service and that it is effective? >> Dr McShane: That was a timely reminder from Leanne, which is why we are working with people like her to challenge us and to help us to co-design the services. We need feedback from people about whether it is working. Too often, we look only at what I would call input data – have targets been met? That is quite important for people, but what is really important is their experience of the service I don’t think we have the perfect solution yet. For example, the children and young people’s service of the IAPT transformation programme has been built around building in outcomes that are reported by the customer owners -the people who help us to design the service because they are recipients of it. I am currently working on a dataset that goes right across the life course, we have to change this for adults as well as children – which reports back to us about whether best practice has been complied with. Are we there yet? No Will we get there? We are working on it. Does it need to be held to account? Yes >> Professor Fonagy: We agree entirely with Martin on the importance of measurement, the transparent reporting of outcomes and accountability, which I think your question implies >> Pegah Moulana: Yes >> Professor Fonagy: And public accountability – statistics that are publicly available. The IAPT programme has always been committed to public accountability To drill down slightly to the substance of your question about transitions, there are really important developmental reasons why

transitions from CAMHS to adult mental health services are so difficult. It is really to do with the nature of the beast. Young people have particular, specific needs at that age that are poorly met, by either CAMHS or adult services. Special provisions have been made in other countries. There is a lot of experimentation in this country – I am involved in a project in Camden called Minding The Gap; the title says it all – on how to create services that are appropriate for a young person between the ages of 16 and 25 with unique concerns, where mental health overlaps with a number of other issues I agree entirely with what Martin said: I don’t think that there is an overarching solution. The solutions will have to be local and, exactly as Leanne and Martin emphasised, they will have to be developed together by all the stakeholders, particularly young people Our responsibility is to facilitate and oversee that process, and to ensure that it results in something that is accountable >> Pegah Moulana: To go further with that, you have provided the guidance for the CCGs and local authorities to use, but will that be sufficient without adequate resources or proper training for them – if you give them the guidance without knowing if they are actually ready for it? >> Dr McShane: It points, again, to two of the five themes that we put into ‘Future in mind’, in terms of supporting training and development. Actually, Peter will speak to this more cogently than me, but that has been a major part of the transformation programme for CYP IAPT – the natty acronym we have for improving mental health services for children and young people On resourcing: absolutely. We are at a pivotal moment in the whole of what is called the comprehensive spending review, and commitments on resourcing, where we hope that the commitment about increased funding made prior to the election will be met. Also as we move forward, building on the blueprint we set out in �Future in mind -, as transparency about investment across the whole system – not just the NHS�becomes the norm, we can see how resilience in schools and the voluntary sector as well as services from the NHS is being supported >> Professor Fonagy: Just to pick up from Martin on the issue of training and CYP IAPT, the natty acronym; it has succeeded in training, if I am correct – I apologise if I get the numbers slightly wrong – about 872 therapists and about 250 supervisors, and 178 service transformation leads. We are trying. There is much more to do, but the training is the most important part of achieving the kind of transformation that I think we are all after On the resourcing side, I was very encouraged by the speech made yesterday by Alistair Burt to the Royal College of Psychiatrists. I do not know whether you had a chance to see it, but the first half of the speech was, in essence, about children and young people; and it appeared to be a clear commitment that he was making�at least recognition of the importance of the problem. It cannot be achieved without resources Those resources need to be appropriately directed Part of that needs to be training and part of it needs to be some kind of robust and transparent implementation that assures accountability

>> Francesca Reed: In the March 2015 Budget, extra funding was agreed by the Government for specific schemes, with the aim of transforming mental health services for children and young people. With regard to those extra funding commitments, do you have any specific concerns about whether the funding committed by the Government will be made available or how that money is going to be spent? >> Dr McShane: One of the things that we have got is a kind of cycle of commitments being made on funding, and that has come true; so we have money that we are investing this year in eating disorders and in increasing scope of CYP IAPT; but there was a major commitment, or intent, set out off the back of ‘Future in mind’. We anticipate and hope that that will be seen through; but we live in a democracy and there are multiple competing priorities One thing that will help us all is that we have set out that we want greater clarity about the money we have now, how it is being used and how effectively it is being used My experience of working on getting better value for health services over the past 10 to 20 years is that once you start looking at how we are spending the money, you sometimes find out quite quickly that we could do it better. Sometimes you need to kick-start that with some extra money, but the CYP-IAPT programme is a really good example of the fact that if we give people the training and skills in effective implementation of good quality services, they can often use the money we have now to better effect and reach more people We have to do both – we have to keep fighting and nagging for extra money, but we also have to be honest and transparent about how we are using the money we have now to best effect >> Professor Fonagy: One example is the £30 million committed to the development of community-based services specialising in the treatment of eating disorders among young people. I have had the privilege of chairing an expert reference group to design a blueprint for commissioners to deliver such a programme. As part of that, we want to ensure that any young person presenting with an eating disorder in an urgent case receives treatment within one week and a routine referral within four weeks. An emergency, one presumes, would be treated immediately This is a really good example of what Martin said about money being well spent It is not that up until now, money has not been spent on eating disorders. A massive amount of money is being spent on them, and on in-patient treatment of young people who present with them, and who are treated when their body weight is so low that their brains no longer respond appropriately to the treatment they are offered. Rapid feeding is then part of an effective protocol. We know that this treatment can be achieved effectively as part of a community service or an in-patient service, but if the community services are not there, referrals are made to in-patient services and are often delayed to the point where the money is no longer used as efficiently as it would be for a service that was available earlier. This is a long-winded way of answering your question, but there is much we can do There are probably no overarching answers, but there will be answers in specific areas

Eating disorders will perhaps be a good model of access and waiting time parameters and standards being appropriately used to improve overall effectiveness of treatment and cost-effectiveness�money better spent >> Rowan Munson: Hi, I’m Rowan. Barbara Rayment from Youth Access explained last week her experiences of increasingly limited funding and how, in her words, “voluntary sector organisations are being pitted against each other by the current culture of more contracting and scarce resources”. Sarah Kenyon from YMCA Surrey mentioned today that the use of voluntary and community sector organisations allowed more cost-effective service provision Are the savings being made by using the community and voluntary sector, reducing budgets and contracting then reinvested in other areas? Can we start with Martin? >> Dr McShane: One of the complexities of the current system is that benefit in one part of the system is realised in another, and the budgets are separated. If somebody does something down the road and I get a reduction in costs, am I going to walk down the road and give them that money? Well, obviously I would, but I believe that some people wouldn’t – maybe I wouldn’t, if I’m honest. Joking apart, that is the real problem, which is why we have asked. But it is your money – the taxpayer’s pound Somehow, we have to break through these perverse incentives, which is why in ‘Future in mind’ we talked about transparency of funding and said that ultimately we should be trying to pool budgets but not lose track of effectiveness This is one of the biggest things that the whole system is wrestling with. Local authorities have undertaken significant cost efficiencies We should acknowledge that, in many areas, they have done incredibly well to manage the tight constraints that they face. We need to learn how, when we realise benefit in one area, we can release some money for the area where the cost was accrued and feed it back to make it sustainable. The five-year forward view sets that out We need new models of care, new incentives and new measurements. In the 21st century, we have to learn to do things differently, especially regarding long-term conditions – an agenda of which mental health is a part. We are wrestling with that. I will not try to pretend that we have the answer, but increasingly people are focused on working out how we do this A great example is the devolution agenda in Manchester, where they are looking at pooling money. That reflects the fact that we cannot direct things from this small one-mile bubble around here. Westminster cannot pull levers and make things happen in areas around the country, but it can create an environment that enables the right thing to be done, and hold people to account for doing the right thing in local areas >> Professor Fonagy: It is a very good question I do not have very much to add to what Martin said extraordinarily eloquently. The issue is integration, as far as I can tell. As Barbara Rayment pointed out, voluntary organisations are suffering due to the withdrawal of funding, particularly from local authorities, for CAMHS What she says is the truth and an important point to take note of In CYPIAPT, we have been working hard to create

local partnerships that include commissioners, NHS service providers and voluntary sector service providers trying to work together to create a community that is, together, responsible for delivering the best care for young people My strong view is that while you can say, “Let’s pool budgets and hope that it’ll all happen by itself,~ it may or may not – I would not hold my breath on that one. You pool budgets and it looks like all the money is pooled, but then I could just hijack a little part of it all for me. Families have pooled budgets, but you notice that different members of a family keep money separately nevertheless The principle that will ultimately work is that we have to collaborate on shared outcomes If we are actually pushing towards the same goal, then somebody else succeeding means that we are all succeeding. If you play more like a football team and there is just one goal, it doesn’t matter whether you are the goalie or the striker; the whole team has to work together to win the match. As Martin says – I totally agree with him – we have some lessons to learn on that, but I think we are trying to work towards it >> Rowan Munson: So that is more of an aspiration than a current reality >> Dr McShane: I think so, yes. We have to be honest. That is what everyone around the country knows. There are many different pilots or attempts, but the principles have been clearly set out in ‘Future in mind’. We have guidance for local areas, which will be forthcoming this year, about assuring ourselves that people are taking this approach. We have put a lock in the system, so that any funding released is consequent on people having clear plans in place. We are not saying exactly what you need to do in that area, but we want to be assured that there is clarity about how you will do what is needed >> Ewan McCall: Hi, I am Ewan. In the written evidence we received from young service users, waiting times are often described as “very long”, and as exacerbating the condition being suffered from. There are also often disparities between the length of waiting times in different areas. Could you clarify whether standards on waiting times will be introduced across all child and adolescent mental health services, and when they will be in place? >> Dr McShane: That, again, is one of the things that we are working towards for next year. We do not have a national data set at the moment to give us that sort of information on a reliable basis, so we are working with the Health and Social Care Information Centre to establish that data set, both for children and for adults, and to have that implemented across the country so that we can measure waiting times. On improving access to psychological therapies, we introduced the first waiting times standards last year, and have been measuring ourselves against them You have raised an important point. Some people have said, “Well, you were achieving those waiting times already,” but having that transparency locks them into the system for the future, so that we cannot regress. Unfortunately we have evidence of that happening in the past – we have made investment and improved things, but then because we do not have that transparency things regress over time We are working towards that. Our aspiration over the next five years is to have that comprehensive data set, and for that to become as normal as it is for many areas of physical health at the moment >> Leanne Walker: I think waiting times are a really big issue. Part of that goes with that last point, in that services feel that they are competing against each other, rather than working together. If the different services made use of other services, such as voluntary services, and communicated together, that would help to reduce waiting times. I do not know how they would do that – perhaps it would be through joint training, so that different

services learned about each other and how they could work together >> Professor Fonagy: To pick up on your question about how it will be rolled out, if we take eating disorders as an example, on waiting times, we have heard that this year, which is the first year, 75% of cases will meet the targets; that will gradually increase to 95%, we hope, by the end of this Parliament What can happen, and what distorts the picture, is things like this: let us say that a social worker is asked to close a case in which they have developed a very good relationship with a young person. The council closes the case, but the person has a different mental health problem and is referred to child and adolescent mental health services. Although the case could quite easily be carried on, they close the case at that point to meet their targets, and then put the person on the waiting list for another service You could create very good waiting time statistics by closing cases and then churning the system, if you see what I mean. The point that Leanne makes is so important. If systems are working in a joint way – working together – the most effective programme of treatments can be designed for each person. That in itself will reduce waiting times and improve access; and as Martin says, that is what everyone in the field is currently working on >> Ewan McCall: What action would be taken if the waiting standards were breached? >> Dr McShane: First of all, there is accountability at local level. One of the things we have said is that there should be a lead commissioner, and a lead commissioner has responsibility and authority to hold providers to account Under the reforms in England, there are local health and wellbeing boards, where people come together. Also, as part of the governance and accountability, we have proposed in ‘Future in mind’ that there be that lead commissioning arrangement across health and the local authority, working with education, to hold the providers to account >> Chair: We still have quite a few questions left. Are you able to stay after 3 pm? >> Dr McShane: I am happy to stay >> Leanne Walker: So am I >> Professor Fonagy: So am I >> Chair: That’s great; thank you >> Laura Sheldon: Good afternoon; I’m Laura The Committee has heard evidence that there is a strong desire among young people to be involved in designing and promoting services Martin and Peter, you will be aware that the ‘Future in mind’ report states: “You”- that’s young people – “are experts in your care and want to be involved in how mental health services are delivered and developed, not just to you and those who support you, but to all the children, young people and families in your area.” So Leanne, what has been your experience of working with CYPIAPT? That’s the children and young people’s improving access to psychological therapies programme – such a mouthful! What has been your experience of working with CYPIAPT in relation to involving young people in designing and promoting services? >> Leanne Walker: I’m not just saying this: working with them has been amazing. I have sat in on board meetings, spoken at conferences, helped to design conferences and worked at local level and national level, and it has brought a different angle to the meetings I feel that as young people, we are very valued – maybe more than some of the professionals in the room. We are really listened to; they really take into account what we say. At local level, there is participation in the different services They run groups. I work with Derby’s participation group, and we work on small things, such as what the waiting room looks like for CAMHS, through to bigger things, such as sitting on interview panels for staff who will be employed there. With GIFT and CYPIAPT, it is the conferences and meetings. It’s really good, and I think it is the start of something brilliant. At the moment, it is new and is just being trialled to see how it goes, but I think it is very much the way forward >> Ryan Simpson: Hello, I’m Ryan. This question is for NHS England. Your March 2015 report

was principally about developing a five-year national strategy for mental health. Were any young people consulted, and if not, why not? >> Dr McShane: First, I would like to pick up on what Leanne said and give credit to the team led by Kathryn Pugh, and to the Department of Health, for the way the CYPIAPT programme was set up – on the principle of co-design I know Peter has been deeply involved in that I can take no credit whatsoever for that, but I will ride the wave of acclamation for it. This was reflected in the ‘Future in mind’ taskforce. I have some figures. Over 1,100 children and young people and over 400 parents responded to online surveys, and 800 mail respondents completed a poll. There were 17 discussion groups, as well as telephone interviews. Throughout, each of the taskforce working groups that we had had representation, engagement and involvement. It would be ludicrous for us to think that we could develop services for children and young people that were not informed by their insights and experiences That is where I will stop >> Professor Fonagy: To add to that, we followed Harry Truman’s advice to children and young people, which is to “find out what they want and then advise them to do it.” That is very much the CYPIAPT principle as well As I said in my opening remarks, we deeply believe that a very important part of recovery from any mental health problem is giving the individual who suffers from a mental health problem the agency to make decisions for themselves When you have a mental health problem, part of what feels worst is that you no longer have the kind of freedom of action that you thought you had; you feel that you have to do things in a particular way Part of this is about giving young people a voice in relation to their own care, doing what we call shared decision making about their care. We also introduce a routine outcomes measurement: at the end of each session with their therapist, they indicate whether or not it was useful. That is an enormously important part of their recovery, because they then feel that their response is taken very seriously by the therapist. If they say that something was not particularly useful, next time the therapist will do something different. It is useful not only because they have done something different, but because the young person have been taken notice of. That is a deep recognition that goes not only through the CYPIAPT programme but, under the leadership of Kathryn Pugh, Anne O’Herlihy and others, through the entire service transformation programme that is under way for children and young people’s mental health services. We are right there >> Liam Islam: I apologise, because I don’t think I introduced myself earlier: I am Liam Thank you for coming. Last week, we met some young people who gave evidence to the Committee On engagement, one panel member was talking about young health champions, and the other young person on the same panel had no idea what a young health champion was. Similarly, North Tyneside’s Member of the UK Youth Parliament, Rebecca Moore, spoke about a website called MindFull, whereas other people on the same panel and in the room had no idea what it was. We now know that MindFull is a charity providing online mentoring support for young people suffering with mental illnesses. What is the most effective way for the Government

and the NHS to involve young people in communicating and designing services? >> Dr McShane: Leanne, would you like to kick off on that? >> Leanne Walker: We should be getting young people involved in as many processes and steps as possible, if and when they want to. If you are designing a service for children and young people without their involvement, I always say that it is like getting dressed in the dark: you think that what you have chosen is appropriate, until you turn on the light >> Dr McShane: This is really important, and it comes back to exactly that point. By asking young people to test – to mystery shop – websites and the material put out by, for example, NHS services, we can tell the ones that have involved children and young people in their design and those that have been designed in back rooms as, “That is what children need.” >> Liam Islam: The reason I gave those two examples is that I think there might be a sense of confusion in the Government and the NHS in terms of liaison with young people That is the impression the Committee got last week from the evidence, as well >> Professor Fonagy: May I address one particular aspect of what you said? It is a really important issue. Ideally, information should travel around a single channel and should be coherent In the real world, young people access information in very many different ways. One important learning point for most of us is that by the time we get on top of a new channel it has already moved. It is not something that a system like Government or NHS England is able to respond to in a sufficiently nimble way – to make it mainstream, as it were I work with an organisation called Silent Secret. I don’t know whether you have come across it. It is a group of young people who have developed an app that young people can use to disclose their problem, and no one can respond to it. Everyone can read about it, but it is not something that anyone responds to. It is enormously popular with other young people, and we are trying to link an advice service to that. That is one particular application, and there are hundreds of applications What I am really concerned about – I do not know how you can make this part of your report, but I would really like you to take it seriously�is that we now know that internet use is actually positively associated with self-harm, depression and suicidality. The more time a young person spends on the internet, the more likely they are to have problems. I am not saying that there is a causality – it may be that a young person has problems, and that is why they are spending time on the internet – but a study in New Zealand, for example, has shown that 80% of young people who are self-harming got the ideas about self-harming from the internet. So before recommending the internet as the answer to everything, I think we have to be careful about these two aspects: the rapid change and the even greater problem of the internet’s toxic potential. I got on a hobby-horse slightly there >> Francesca Reed: Moving on to the topic of training, the ‘Future in mind’ report says: “Anybody who works with children and young people in universal settings such as early years provision, schools, colleges, voluntary bodies…should have training in children and young people#s development and behaviours”. What do you think should be the minimum level of training in mental health for those working with children and young people?

>> Professor Fonagy: We have a wonderful programme called MindEd, which gives a basic introduction to mental health problems for anyone working with a young person, be that a teacher, a youth worker, or someone working with the police or youth justice. It has been enormously successful, with, I believe, over 30,000 views already of the sessions that the programme presents, and 16,000 workers have registered with it. That has to be extended. I believe that there is a Department for Education initiative to extend it to parents. Parents work with young people, and they should have education in mental health Young people should have education in mental health. People like me used to think that as long as we dealt with parenting, and made parenting better for young people, we would protect them from a degree of harm. It turns out from a number of longitudinal studies, including one in this country and one in the United States, that adverse childhood experiences involving adults are no more risky than adverse childhood experiences from other young people That is to say that peers do more harm to young people. That needs to be part of the educational process, and it needs to be part of what teachers deliver for schools In terms of the professionals, there needs to be training in three key aspects of working with young people. First, there needs to be training in evidence-based treatments. Everyone needs to know what treatments work, because of the wastage of resources that we talked about. Secondly, there needs to be training in how you work with young people and share decision making – how you can activate a young person’s capacity to join you in a treatment programme. Thirdly, you need to be trained in how to observe the impact of your training and intervention on the young person whom you are working with. We have tried to encapsulate that in a training programme called enhanced evidence-based practice, in which I believe we have now trained about 300 people. I would like to spread that to every individual >> Dr McShane: One of the things that we need to mention is that this is work that we do with Health Education England. There is an arm’s length body that we work with, and part of the funding that we are seeking will be going to Health Education England to support this sort of training and change in behaviours, certainly within the NHS. There is the MindEd portal, which Peter has referred to, but I just wanted to clarify that for the Committee >> Terence Dobson: Hi. I am Terence. My question is specifically to Martin. There was a letter to The Times today from senior professionals across the health service about a proposed cut of £200 million to public health budgets Can you give the Committee any reassurance that these cuts will not fall on mental health services for young people? >> Dr McShane: Qualified. If I am honest with you, I do not know yet. What I would say is that that is exactly why in ‘Future in mind’ we ask for transparency, because unless we can, as citizens and as taxpayers, see where our money is going, I cannot answer that question I will be quite honest about that. I think that the profile given to this agenda by the previous Government and this Government, and what we set out in ‘Future in mind’, will help to militate against that, but we are going to have to be very vigilant about it I am not going to say yes, and I am not going to say no. I think it is a real concern

>> Chair: The final question is to each of you. If you could see one recommendation in our report, what one recommendation would you like to see? >> Leanne Walker: Following that, I would say more funding. Alongside that, I would say increased communication and integration of services >> Chair: That is great; thank you. Martin? >> Dr McShane: I would say for this, politically and policy-wise, to remain a high priority for the next five years at least >> Professor Fonagy: I would like to cite Antoine de Saint-Exupery, who said something very brilliant. He said that if you want to build a ship, you should not simply drum up men to collect wood and assign them tasks Instead, you should teach them to long for the endless immensity of the sea. What I would like you to do is to try to concentrate not only on the immediate things that people need to do, but on what we are trying to achieve here: a future where children and young people receive the mental health service that they deserve. That goal has to focus all our minds There is a tremendous opportunity to improve the world. We have a lever to improve everyone’s wellbeing through improving young people�s wellbeing. They influence one another. Therefore improving the wellbeing of one person who is suffering will improve everyone�s wellbeing Also, they are the future; they will improve the wellbeing of everyone else, going all the way until they get to my age – after which, forget it! Do not lose sight of the tremendous opportunity that improving the mental health of children and young people represents for all of us – not just those of us working in this field, but everyone around us, and not just now, but in the future >> Chair: That’s great. Again, thank you all ever so much for your time, and with that, I end the fourth panel of the day

>> Chair: Hello everyone. We now begin our sixth and final panel of the day. First of

all, welcome. I’m Rhys Hart, the Chair of the Youth Select Committee. Thank you for

joining us. We know you are very busy, so it is highly appreciated that you have come

here today to speak to us. Just to let you know, we are doing an inquiry into mental

health – specifically, young people’s mental health – and looking at the topics of stigma,

awareness, education and services provided At the beginning of this session, we will

mainly be looking at the topic of services, and then we will move on to the topic of education

Then we will branch out into the general realm of young people’s mental health. First,

it would be useful to us if you could introduce yourselves and briefly say what position you

hold and how it is relevant to mental health Would you like to begin, Minister Gyimah? >> Mr Gyimah: Thanks for having us here today This is a very important topic for the Government and, more importantly, for those who suffer from various forms of mental health need and are not getting the support they should. I am the Parliamentary Under-Secretary of State for Education and Childcare and the first Minister in the Education Department with a specific responsibility for mental health in their brief. That started towards the end of the last Parliament, so I have been reappointed into the job and am carrying on with what I see as one of the most important roles in my portfolio >> Alistair Burt: Good afternoon. I am Alistair Burt, the Minister of State at the Department of Health with responsibility for community and social care. That is quite a wide remit, covering everything about out-of-hospital care, from primary care right through to adult social care. Mental health is a distinct part of my brief and, as has been made clear by the Prime Minister and the Secretary of State, a priority for the Department. We are increasingly working in close co-operation with other Departments As the Minister said, we are very appreciative that you wanted to see us both, and we hope that our presence together symbolises something about the determination of how the Government plan to handle this. Thank you for seeing us and for the inquiry you are undertaking >> Chair: Thank you. Liam, would you like to begin? >> Liam Islam: Good afternoon, ladies and gentlemen. Welcome to the Youth Select Committee My name is Liam Islam. The Committee’s aim this year is to gain a greater understanding of the Government’s position on mental health What is the Government’s assessment of the quality and availability of mental health services for young people? Minister Gyimah, we would like to start with you first >> Mr Gyimah: Well, in terms of the quality of services, I obviously sit and look at it primarily within the Education Department, although this is an area in which the Health Department has a significant role. Your question pertains to our assessment of the quality To give you a brutally honest answer, I would say there is a lot to do in order to have a fully functioning mental health service that serves the needs of young people. That is why, in the Education Department, we have taken a number of steps in the past few months to begin to improve the nature of the service Apart from appointing someone specifically for the job, there was a joint taskforce at the end of the last Parliament between the Departments of Health and Education, in which we looked at some of the challenges and barriers in the system and services. I am sure that my colleague can talk about that in more detail In addition, the Education Department has funded the PSHE Association to publish guidance about the teaching of mental health in PSHE, alongside lesson plans that will be published very shortly. The reason for that is that we have to tackle this within the school system Mental health issues are a barrier to children fulfilling their potential within school and they affect a significant number of children – I think something like 10%. They are also the explanation behind some of the behavioural and attendance issues we see in schools. That is why funding the PSHE Association to teach and open people’s minds to the challenges has been very important to us Further to that, we made £4.7 million available

for 17 mental health projects, led in the main by voluntary and community sector organisations They include projects to promote positive mental health in schools and set up networks of young people acting as ambassadors in their schools. To round off, together with the Department of Health, we are investing £1.5 million in piloting a joint training programme with NHS England, so that we can develop lead contacts in schools and specialist services to make sure that the system works as smoothly as possible going from education into health >> Alistair Burt: May I give a slightly longer answer to this question than I will tend to for the others? It will put some things on the record right at the beginning, so if you don’t mind, I will read some of this My job is to support the development of mental health care in the United Kingdom – particularly children’s mental health care. First and foremost, I follow a very good predecessor, my Liberal Democrat colleague, Norman Lamb It is sometimes important to demonstrate continuity of care, particularly where other parties are involved. That gives people an impression that we treat this with the seriousness it deserves and that it is not a party political issue In my role, I am committed to transforming children and young people’s mental health and wellbeing across health, social care and education. That is backed by the recent investments we have made in eating disorders – £150 million over five years – and in improving children and young people’s mental health more generally with the £1.25 billion to be allocated over the next five years The ‘Future in mind’ report, published on 17 March 2015, sets out a vision for improving children and young people’s mental health and wellbeing that we intend to take forward We commissioned YoungMinds to survey 1,600 children and young people, so that their views could be represented in the report. The first major step for achieving sustainable system-wide transformation is the development of local transformation plans. Local areas will be asked to set out how progress will be made in each area across the country. We are working with partners, as I indicated a moment ago, across the NHS, local authorities, and the youth justice and education sectors to make this happen well A number of the 49 proposals from ‘Future in mind’ are already being delivered and developed, including the extension and expansion of children and young people’s access to psychological therapies programme, so that by 2018 all local services will be in receipt of this transformative programme; the commissioning of a new prevalence survey on mental health problems in children and young people, the first since 2004; joint training pilots between schools and children and young people’s mental health service providers to strengthen the mental health advice and support available in education settings; improved services for perinatal mental health and eating disorders, both of which will be addressed through work this year; plans for legislation to prevent any child or young person being put in a police cell as a place of safety during care in a crisis; and finally the development of a hard-hitting anti-stigma campaign The overall sense is that the development of services is very much work in progress As the Minister has said, we recognise the need to do more. That is why there has been a very strong public commitment to it, both political and financial. Services can vary in terms of delivery across the country – I am sure you will ask about the variability of practice – and part of my role is to try to ensure that the practice of the best becomes the practice of all In general, our sense is that these services need to be improved. That is why we have made the public commitment to do that for children and young people’s mental health services We have plans to do so, and those plans are being drawn up in conjunction with users, with those involved in the services, with the professionals, with those who depend on them, parents and carers. That will give us the blueprint to take forward. We have started on that process >> Ewan McCall: My name is Ewan McCall. Welcome to the Committee. The taskforce report, ‘Future in mind’, has shown that since 2011 NHS expenditure on adult mental health has increased, but the expenditure on young people’s mental health has gone down. Evidence to the Committee has shown that that has resulted in longer waiting times, stretched resources and mounting pressure for change. The recent Government spending commitments are welcome, but in what ways will they lead to tangible outcomes? Could you start on that, Minister Burt? >> Alistair Burt: Okay. It is hard to put a total figure on the amount of money that

is spent on children and young people’s mental health services. That is because part comes through the NHS, and part comes through local authorities, through CCGs and a variety of different sources The best figures I can give you are that we reckon that from the NHS mental health expenditure of £11.3 billion, some £700 million – that’s 6% of it – is the children and young person’s mental health budget. But that only represents the funding for tier 4 services and some tier 3 services. The rest of the funding – tiers 1 to 3 – comes through other sources, as I say, so it is difficult to get the full picture But your overall point, that we need to resource this better, is accepted by the Government, and that is what we have set out to improve; hence the commitment to the £1.25 billion over the next five years. As for what that already goes to, and what it might go to, funding is going initially to the IAPT programme – as you are aware, that is early access to psychological therapies. That is already proving really very interesting and exciting in the field, demonstrating that the earlier the intervention, the better, with profound consequences later on We are looking to expand the access to that Only 68% of the country has access at the moment; we need to complete that job. We also want to use the money for extension to new curricula to include nought to fives, autism, learning disabilities, counselling and combined treatments as well as supporting young mothers This is a programme that will last five years and, accordingly, it will be delivered year on year, so it is not detailed right the way through the five years. In essence, it is to transform children and young people’s services. That is where the extra resource will go: on meeting exactly the sort of criticism that you and the Committee will have >> Mr Gyimah: The only comment I would add to that from the Department for Education�s point of view is this: I mentioned that we gave £4.7 million in grants for 17 mental health projects; that is the first time that a Department has, within its total spend on grants, given mental health its own category For the first time, we have identified mental health as a separate category that we look to fund to ensure that we have voluntary service organisations coming up with ideas to improve what we are doing on mental health in schools >> Terence Dobson: Hi, I’m Terence. This question is specifically for Mr Burt: the professionals we have spoken to all agree that the investment is welcome, but it is only the tip of the iceberg or a drop in the ocean. Do you agree? If so, what do you plan to do about that? >> Alistair Burt: Well, even though I have been in my job for only six weeks, if I had a fiver for every time that people said £1.25 billion was a drop in the ocean, I would already be a wealthy bloke. Every service that we look at would make the same plea for extra resource – you are absolutely right to home in on that. As I said, I am responsible for GPs and for primary care services to everybody In terms of adult social care, by 2020 – five years’ time – there will be 1 million more people over the age of 70 in this country I take the point: anyone advocating for a particular group in society or for a particular need would say what you have said, and the professionals would say the same. I do think it is not unfair for Government to say, “Do set it in the context of a very large public expenditure bill on health already – £110 billion, which is real money. Therefore, the additional sums being put in are very genuine.” I start, as we have both done, by acknowledging that this determined change in approach from the coalition Government through ourselves is recognition that the services have not been appropriately funded in the past. We know we have catch-up and work to do. As I said in answer to the previous question, we will achieve this by using this money for access to psychological and other therapies I will also look at the variations across the country. One of the things your Committee has probably found out is that there are so many variables. Why are beds available in one part of the country but not another? Why is it that, in one place, a parent or carer

gets some of the service they want and, in another place, exactly the same provision could be made but is not? I am not entirely certain that that is always due to resource – it might be due to lack of information or different priorities. I think it is my role to try to see what I can do to ensure that those variations are evened out, and that the practice of the best becomes the practice of everyone, and I will be keen to do that Where we can see particular bits of investment, we will make it. For instance, last year we invested £7 million to provide 50 extra CAMHS tier 4 beds in the north-east and the south-west. There are individual bits of work that you can do for specific services to bring them up to a particular standard, but in essence, as I mentioned before, we will work very much with people locally – what are the services they think they need? What are the improvements they wish to see, bearing in mind the variations between themselves and another area? What is it they see being done in a neighbouring area that makes them want to say, “We want to get that done ourselves?” What is the process to bring that about? That, I think, is the way we will lever up standards all round, and I see my role as being part of a partnership with colleagues in government, as well as those outside, to make the changes and gains we want to see >> Rowan Munson: Good afternoon, Ministers; I’m Rowan. The Committee heard last week from Barbara Rayment of Youth Access. She said that she had seen “cuts not just in CAMHS, but across social services and in youth service generally.” She also said that many people call NHS CAMHS “because there is nowhere else to go” and “it has put other pressures on the system.” The impacts of cuts elsewhere on CAMHS was also mentioned by Professor Peter Fonagy of the CYP-IAPT programme. How will you ensure that future and current local authority cuts do not impact on the new funding that you explained at the start? Could we start with Minister Burt, please? >> Alistair Burt: In order that I do not do all the talking for the Department, I am going to ask my colleague from the Department, Flora, to say something about this in a second, because she has worked in this area for some time, but let me give a general political response As you are aware and as we indicated earlier, all the funding does not flow through the NHS and the Department; it does flow in other areas. Without a system that is totally directive�where a Minister is entirely responsible for what each area is doing and commands or directs what is to be spent – we have to leave it to local areas to respond to the needs in their area. There is a democratic system to do that. Part of the way in which we think the process is leveraged is by exposure, transparency and the like. That is one of the reasons why the Secretary of State for Health has been so keen to measure what services are providing – so that people can see what is being done, can measure one area against another and can see whether a particular subject is light in the way in which it is being handled. We feel that has been true in relation to mental health services generally. I also feel that local authorities will be required to explain differences between one local authority and another in what they are doing, and we hope to encourage them in the right way This is a difficult balance. We are responsible You are entitled, as colleagues in Parliament are, to ask about this. The whole process of accountability is to make us accountable at the end of the day. We do our work not by making everyone accountable to us on a direct line and saying, “You must do that,” but by saying, “What’s your response to this in your area?” Our work is about partnership and encouragement, but perhaps Flora could say a little about our relationship with local authorities and how we have handled this difficult issue in the past >> Flora Goldhill: I’m Flora Goldhill, the director for children, families and communities in the Department of Health, and children’s mental health is one of my areas of responsibility To add to what the Minister has said, we are expecting local transformation plans to be developed in partnership with local authorities, schools and local communities to ensure that people think about how to use the money that is coming on stream to change services, so that we do not have the problems that we currently have, with these services all pushed up to

the most acute level. It’s so that we invest much more in early intervention, in prevention and in building resilience in young people, and invest for the future in that way, so that fewer cases of mental ill health need access to NHS services. That is how we hope to transform services in the future, and that will involve a partnership with local authorities These transformation plans will be funded only if they can show genuine partnership and how they are going to change services on the ground >> Rowan Munson: I appreciate that, and I take on board the Minister’s real passion for ensuring this issue is dealt with. I know it is NHS England’s second corporate priority Is there any guidance that you could send out to local authorities? Only 6% of the mental health budget is spent on children and young people, but of course 50% of mental health difficulties arise before the age of 15 – I will have to double-check, but it is about that – and young people are 25% of the population, so could you do something in that respect and advise local authorities? >> Flora Goldhill: Our relationship with local authorities is less direct than that, but one of the things that NHS England is doing at the moment is preparing guidance that will go out through clinical commissioning groups and be shared with local authorities, which will need to be partners in the transformation plan process. That guidance is being prepared in partnership with the DFE, the Local Government Association and other partners that have influence with local authorities. The guidance should reflect our desire to see greater partnership at a local level to transform things on the ground. Partnership is key and responding to local need is key >> Alistair Burt: Can I tackle the arithmetical point you made? It is tempting. Statistics being as they are, any campaigning group will produce statistics to indicate that, percentage-wise, whatever is coming their way is not quite sufficient if you look at it their way. But you cannot carve up all the budgets that way, because you could take another individual condition or another age group and their tendency to particular illnesses and say, “Look at what a small percentage is being spent on that.” You cannot quite carve it up in that sense. However, your point and the Committee’s overall point, which brings us all here, is not denied by Government: in the determination to improve the country’s general mental health, the effort put into children’s mental health services has been deficient. You are perfectly correct in your understanding that early intervention makes a difference to adult mental health conditions. Because of that, the leveraging-up job is being done, but it will not be done overnight; it takes time and is done in conjunction with the other things people want to see changed around health, but that is the determination and that is what we are building towards >> Rowan Munson: I want to say, for the record, that those statistics were taken from the ‘Future in mind’ report >> Alistair Burt: Yes, we know them >> Sophie Jones: Hi, I�m Sophie. I have two questions. We have heard that money is not always used effectively and that agencies may choose to protect their own budgets rather than work together. What action can you take when service providers do not use money effectively and choose to problem-dump rather than co-operate? >> Alistair Burt: I have been introduced while doing this job to a phrase that I am sure you will have come across a number of times: the so-called perverse incentive. Because of how we pay for different services around the country – because local authorities have budgets, CCGs have budgets, NHS England has budgets and so on – and the way in which an individual might travel through the system, the expenditure on them will not always come from the one pot. I have to tell you that, life being what is, people look to protect

their own budgets. If some other budget can handle someone’s care, it is not unnatural for people to suggest that as the better way forward. I do not think it is the best way forward. What the system has to do is recognise that the patient’s journey is about the patient – their convenience and the improvement of their health – not the system One of the things that has come out of the ‘Future in mind’ report is the tier system and the perverse incentives that rather got in the way, as you said, of a clear intention to improve things, because the system became rather more important than the actual care We are hoping that, as Flora mentioned, the local transformation plans – as well as the work going on in other parts of Government to better integrate health expenditure in order to knock out the perverse incentives – will make sure there are no incentives for someone not to do something because someone else ought to pick up the bill. It might also help to deal with the variability in practice that we have seen We are aware of the danger, and I think that local transformation plans can start to make a difference to that, as well as our looking quite hard at whether the tier system should stay in place, whether it has had its day, or how to revise it somehow >> Ann Gross: Perhaps I could add something: specifically an example of joining up between schools and health services. I am Ann Gross from the Department for Education. I am the director responsible for various parts of children’s policy, including our interest in children and young people’s mental health One of the things we are working on jointly with the Department of Health and NHS England is some pilots in 15 local areas that are about training people in schools jointly with clinical mental health specialists, so that there is a better join-up. The aim is to see if we can develop a system where you have a lead in a school working with a lead in CAMHS, so that there is better co-ordination – CAMHS people are able to train people in schools and there is a two-way dialogue. We think that that sort of work is a better way of promoting good use of resource. It is about trying to develop partnerships and good ways of working, which I think is probably just as effective – if not more effective – as stepping in when things go wrong >> Sophie Jones: The second part of the question is about our visit to a CAMHS centre yesterday The service providers told us that they preferred local budgets to national budgets, as they provide a more effective service. Do you agree, and do you think that that is realistic? >> Alistair Burt: I am just getting into all this on budgets, so forgive me if I am slightly cautious about this. As I have already said, I am very interested in how the budget processes currently work, because the important thing for all of us as politicians and all of you as representatives is to ensure that finance is used, remembering its proper aim, which in the case of health is to provide the right treatment, and that things that are barriers to that, whether budgetary headings or the like, should be dealt with The central point that the more local it is, the better, is one that we certainly agree with. There are certain specialised services that are, however, always provided from the centre. I know in relation to the bed issue, for example, that there are certain key specialised services that a local area cannot be expected to finance itself and, therefore, there will be help from a central funding source like NHS England to cover something like that It should be seen as a seamless partnership, rather than a barrier to getting the right treatment, but, in general, the point about local provision and local budgeting as the better thing to do is one that we would agree with >> Francesca Reed: Good afternoon. My name is Francesca. For many young people with mental health problems, GPs will be their first point of contact. We have been told that young people�s experiences of going to their GPs are variable and, in some cases, they are so bad that they stop seeking support. What should GPs be doing to support young people who come to them about their mental health, Minister Burt? >> Alistair Burt: Again, this comes under the general heading of variability of service I am very conscious that there are some GPs who are very clued up on this. I have met parents who have both experiences: those of GPs who have known exactly where to signpost and those of GPs where that signposting has not been available and it has taken a long

time for a mother to get a child properly seen to and assessed because of this A couple of things are very much worth mentioning Firstly, we are working with general practitioners� representative bodies such as the royal college in order to ensure that there is greater awareness Secondly, all the work that has been done on parity of esteem and anti-stigmatisation, for example, is also having an effect on awareness, but we are interested in training I was speaking just two days ago to the Royal College of Psychiatrists – annual gathering at which I was made aware that they have got an increased number of young doctors in their training programmes to be doing a stint with psychiatry. Although that is not immediately a parallel, it is sufficiently close to give the sense that, as more young doctors are aware of what is needed in terms of psychological and psychiatric treatment, this is reflected in their recognition that it is needed at the earliest possible stage. It is certainly something that we are very keen to encourage GP practices to do. We will be having a lot of contact with them. I agree that general awareness is a key part of making sure people start as quickly as possible The growing awareness of this whole area and – as Rowan was quoting – the recognition of the need for early intervention is not a little piece of knowledge held by a small number of people. It is out there, and I expect a profession such as general practitioners are well on to this. We ought to see that variation in understanding eliminated over a period of time >> Saskia Edwards: Hi, I’m Saskia. Thank you for coming to speak to us this afternoon Following on from Francesca’s question about GPs, I would like a bit more detail. Minister Burt, can you start with this one, please? What guidance is currently given to GPs on detecting the signs and symptoms of mental illness in young people, and how are they educated about how to make young people feel welcome and supported? >> Alistair Burt: I don’t know >> Flora Goldhill: I think there’s a long way to go on that. We probably should write to you and let you know what the arrangements are. We have something called the “You’re Welcome” standards, which are about, for example, how general practice engages with children and young people and makes them feel welcome. We certainly want, from the perspective of the Department for Health – the standards are owned by us and Public Health England�to make general practice aware of them and implement them The other route that we could consider is what the Care Quality Commission could be doing as they inspect general practice. We should think about the perception of children and young people, particularly those with mental health issues, when they come into the practice, and how that could be supported Those are just two areas. In terms of the general approach to GP training, we would need to take some advice and write to you about that >> Alistair Burt: I don’t think it has necessarily been the role of the Department to issue guidance in such a manner as you describe. That tends to come through the education and training they get in any case, what the royal colleges say to them and any specific extra guidance related to things that come up where they need something new. We need to look at the variability of patients’ experience with GPs. I will find out what is already done and see whether that constitutes something that we could do further. You may want to consider it as one of the recommendations you make, bearing in mind that the initial contact of most young people with any health concern, or parents or carers on their behalf, is with the GPs. If you think that is an area that could be improved better, you might make a recommendation that better guidance is made available for GPs. I don’t know whether you have interviewed any GPs specifically on the training or guidance they have had, but it is certainly an area that you could consider. We would be quite interested in seeing it in your recommendations >> Chair: Thank you >> Pegah Moulana: Welcome to the Select Committee For this area, we are focusing on education mainly, but feel free to comment on it >> Alistair Burt: No, no, no. I think it is time for my colleague to – >> Pegah Moulana: As we know, in November 2014, the Government announced that there

would be new guidance with the PSHE Association There is obviously an evidence-based counselling strategy and the Ofsted inspection framework Government policy says that PSHE should remain optional. Earlier, we interviewed school nurses and other students. Some 90% of teachers believe that training should be compulsory – that comes from the Public Health Association My question to Minister Gyimah is, why has the Government decided it should remain non-compulsory, and from what age do you think students should be educated about mental health? As I said, I will be targeting the Education Minister, but feel free to comment on that >> Mr Gyimah: It’s a very good question Thank you very much. We made clear in the introduction framework to the new national curriculum that all schools – primary and secondary – should teach PSHE, but they should be free to teach it in the way that is appropriate for their pupils. We outlined that expectation in the introduction to the new national curriculum What is important is the quality of the teaching, which is why we have funded the PSHE Association to develop not only the guidance but the lesson plans The question I am often asked is not only about PSHE but about sex and relationship education; often, people want both to be made statutory. We want all young people to be prepared for adult life, and taking this issue seriously is very much a part of that. I agree with the Committee that high-quality PSHE is important and has a vital role to play, but the important thing is the quality of what is taught rather than making it statutory We want to allow schools to teach it in the way that works best for them >> Saskia Edwards: Following on from what Pegah said, there are lots of standards and targets to achieve regarding young people’s physical health and physical education. Why are there not standards and targets set out for mental health and mental education? >> Mr Gyimah: Again, that is another good question. Ofsted looks at what a school does around mental health education in its judgment, so mental health education is reflected in the accountability system that we have for schools. As I have said already, it is important that in PSHE mental health education is reflected there. But there is also school counselling Where we have tried to focus on at the moment is the practical things we can do to ensure that, where young people are at risk or are beginning to experience mental health problems, the practical help is there. We issued guidance on school counselling last year, in terms of how schools can do it better. There are some schools that do it very well and it is amazing the effect it can have. I was at Elizabeth Garrett Anderson School in Islington earlier this year and I saw, firstly, that there is no stigma associated with counselling. Young people felt very free and able to go and see the school counsellor; it was seen as being very much like going to see the school nurse For me, getting those things right now is the priority, but of course we know that schools do what is measured, which is what your question is driving at, and at the moment mental health education is reflected in the Ofsted judgment of schools I don’t know if you want to add anything to that, Ann >> Ann Gross: Yes. I think Ofsted is really aware that good schools have a really strong understanding that good mental health, wellbeing and resilience are very much linked to children�s academic attainment. Students do better if they have good mental health and wellbeing, and that is widely understood The recent Ofsted framework has a stronger emphasis on those issues and it includes what is called a grade descriptor for outstanding schools. It says, “In order to be an outstanding school, there needs to be evidence that pupils make informed choices about healthy eating, fitness and their emotional and mental wellbeing.” That is quite an important reference, I think, and it shows that mental health education is really embedded in a school being outstanding >> Alistair Burt: Can I just add one thing? I went to the Maudsley about three or four

weeks ago and I saw one of the pieces of work that it does in schools; it was appropriate to primary schools. The Maudsley has a one-morning course just to talk to primary schoolchildren about mental health and its importance. In very simple terms, the course addresses the sort of issues that children might see among their friends, to give them the sense that just as a child might fall down and hurt itself in one way, and be visibly hurt, sometimes children are hurt in a way that they cannot quite see. It is explained extremely well and it was said that the children were really energised. We saw a film or DVD that had been made showing this work and the children’s reaction, including what they said about the course afterwards. It was really interesting I think some of that work in schools also helps with destigmatisation, and schools that do it might be recognised for doing that sort of work >> Ann Gross: And I think we are really aware that raising awareness and understanding of the importance of mental health and wellbeing is important for children at all ages. Obviously, for very young children, that is about helping them to understand emotions and talk about their feelings; so, talking in quite simple but very important and practical ways. As young people get older, there may be a need for schools and teachers to be confident about helping young people to talk about particular conditions – eating disorders or self-harm, for example. Teachers need support to feel confident to do that. That is some of the work that we have been doing through the PHSE Association in developing lesson plans. We hope to be publishing those quite soon. I see Laura is from Shropshire. We have been piloting them and doing some of that work in Shropshire. There are quite a lot of schools involved, and we have been getting a very positive response. Those are some of the practical things that we want to do to help schools to gain confidence in working in those areas, as well as some of the things we are doing to involve young people, because we think that is really important. We can say a bit more about that if you like. There is a really important role for young people in supporting their peers and as peer counsellors >> Laura Sheldon: Good afternoon. I am Laura During a private evidence session with young people with mental health issues and a Committee visit to a CAMHS centre yesterday, the Committee was told that exam pressure is having a huge impact on young people’s mental health and that schools are not helping pupils to cope with the stress and anxiety that it causes In written evidence, one boy said that exam stress triggered his anxiety disorder and he had to receive treatment through a youth charity; there was simply no support in school for him. How will the Government ensure that schools offer support to pupils leading up to and during the exam period? Should that support be the responsibility of schools in the first place? Minister Gyimah, would you like to begin? >> Mr Gyimah: Again, a very good question, and I am glad that you framed it in the way you did – by talking about support rather than, “There’s exam stress, so let’s get rid of exams,” which is how someone else could have approached the question. One part of what the Department for Education aims to do is make exams rigorous to raise standards, so that pupils leaving school are well equipped and well prepared for life in modern Britain. In light of that, we are championing the EBacc, which is a requirement for schools now. We know that there are a small minority of pupils for whom EBacc would not be appropriate, and we need to look at what support they need For the vast majority of pupils who are taking the EBacc and have to go through those exams, we need to look at the right sort of support We need to look at two types of support. One is to do with teaching – the quality of teaching and helping teachers to prepare pupils in a way that ameliorates the stress, rather than increases it. The other, going back to my earlier point, is about having good-quality school counselling available onsite. My experience so far is that the quality of school counselling is highly variable. We need to work on what “good” looks like and find a way to embed good practice in all schools, so that whether it is exam stress or other stress – in some cases it is stress in the family – that makes it difficult for pupils to perform at school, there is someone onsite who can help >> Ryan Simpson: Hello. I am Ryan. All school staff must undergo child protection training

in schools, but in the ‘Future in mind’ report you said that “not every adult who works with children and young people can be a mental health expert.” Do you believe that teachers should receive mandatory training on mental health, as they do on child protection? >> Mr Gyimah: Well, teachers are not mental health professionals. Mental health is an incredibly complex area, but one thing that teachers can do is identify when there are changes in behaviour. You have a class of 30; you get to know them quite intimately; and you notice when someone is suddenly not eating or is close to a particular friend but then no longer associating with them Teachers are in a very privileged position to notice some of the changes triggered by mental health issues or lack of wellbeing, but we should not expect them to do the job of mental health professionals. What you need is the right professionals – pastoral support and certainly counselling services – in schools, so that teachers can help to refer children to those services, rather than the physics or maths teacher having to double up as a counsellor. It may be that the children do not want to discuss that with teachers, in the same way that they might not want to discuss it with their parents. Independence is also important, and that is another reason why I would not expect teachers to perform this role >> Ann Gross: The pilots I mentioned earlier, which are about joint training between schools and children’s mental health services, are really intended to help build awareness and confidence in schools and make sure that teachers know who to refer on to if they are aware that young people are experiencing difficulties We are really interested in developing that system Of course, in schools you have special arrangements for children with special educational needs You have a SENCO – a special educational needs co-ordinator – who has a role for that group of young people. The special educational needs code of practice has introduced a type of special needs – social, emotional and mental health needs – that is all about understanding the impact of mental health needs on pupils who are not making good progress. So there are already people in schools who have an understanding and can help with those issues >> Alistair Burt: I think there is a further point to make. Continuing professional education or continuing professional development matters in virtually every profession you mention People go online and find more resources to help them in relation to this. There is one particular resource that the Committee may be interested in: MindEd – a free online resource for teachers and others working with children and young people, including doctors and nurses It provides educational information on signs and symptoms, as well as suggestions for how to identify, address and support children and young people with mental health issues That sort of resource is also helping to make sure that people who are looking for extra support and things to assist them in their work – whether they are in a purely educational setting or in a position of care and responsibility with any of the uniformed organisations�are able to spot things. It is a beneficial use of what can be provided these days through modern educational methods that will help all of us >> Liam Islam: The Committee heard from Dan Doran from the University Mental Health Advisers Network, who praised the Department of Education’s guidance on mental health and behaviour in schools, particularly in relation to the whole-school approach. He said that the guidance �states that you need a whole-school approach to mental health, and within higher education I think there needs to be a whole-university approach to mental health.� Could the Department for Education work with the Department for Business, Innovation and Skills to issue similar advice and guidance for universities? >> Mr Gyimah: Again, it is a good question I hope that appearing here with my opposite number in the Department of Health demonstrates in the first instance that we understand this problem needs to be dealt with at a cross-governmental level. It has support at the very highest levels of Government That said, it is worth bearing in mind that

higher education institutions are autonomous bodies and are independent from the Government Obviously, they have legal responsibilities under the Equality Act 2010 to support students, including those with mental health conditions It is for higher education institutions to determine what welfare and counselling services they need to provide their students with in order to offer that support. I hope, given how important this is, that higher education institutions look at what is happening in schools, take note and make sure they do their bit, because it is just as important to deal with this in higher education institutions as it is in primary and secondary, as I outlined earlier >> Ewan McCall: Evidence submitted to the Committee suggests that, while good information on mental health is available online, young people and professionals do not always know and often cannot find sites they can trust One teacher described it as a bit of a “minefield” The solution proposed by the ‘Future in mind’ report was a kitemarking system to separate the safe and accurate sites from the others. My question to Minister Burt is, what plans do the Government have to help young people and those who work with young people to find trusted and appropriate information online? >> Alistair Burt: Our first port of call is the UK Council for Child Internet Safety, which is a group of more than 200 organisations drawn from government, industry, law, academia and the charity sector. It is a working partnership to keep children safe online. It produces guidance documents for industry, including on social networking, moderating, safe searching and chatting, and advice for industry on effective internet safety measures. That would include things such as taking people who might go to one website for advice – in particular, youngsters who might research something such as suicide, for example, taking them to a place asking, “Do you want to talk about this?” etc This is a genuinely tricky area. The risks and the dangers are huge. Again, it is something that I am sure your Committee has considered – the availability of the right sort of apps that might take people in the right direction, what new may be produced. I do not think that anyone’s information on this is in any way perfect at the moment. We are very conscious of the existence of some sites that might celebrate eating disorders, for example, and of how people who go into those might be led away to something better. The risk of something turning up that is even worse is always there, and some of the sites are truly bad and dangerous It is a serious priority for all of us in government to work right across the Government network and with charities and others to say, “What can we do?” and to work with the industry to find a way either to ensure that the worst of the websites are not there, if they fall foul of the law, or for those that keep themselves just inside the law, to ask what can be done to move people into a safer area or into a safer direction, and how to protect people who might have accessed such sites. It is an ongoing process. I hope that you will have something to say about this in your report, because we will be interested to see it >> Mr Gyimah: You have touched on a big issue here, which is how use of social media in this space actually in some cases causes harm, although in other cases it can be used to combat the very harm that is created. One of the things that we can do, and which we are doing, is to empower young people. The kitemark is one suggestion. For example, what we are doing in online safety, we have got new computing programmes now, introduced in September 2014, to ensure that e-safety is taught at all four key stages. It is incredibly helpful to young people to identify what is a site that we should not be trusting, or what is a site that we should be trusting To give a little more detail, that covers responsible, respectful and secure use of technology, as well as ensuring that all pupils are taught age-appropriate ways of reporting any concerns that they might have about what they have seen or encountered online. This is not the kitemark idea that you were probing about, but what this is doing is giving young people the knowledge and understanding to use online to ensure that they can make some of the judgments themselves as well

>> Alistair Burt: May I raise one more issue? I want to talk about the Buddy app – I do not know if you have come across this. It is a digital tool to support therapy services Clients use text messaging to keep a daily diary of what they are doing and how they are feeling, which helps the reinforcement of positive behaviours and the keeping of appointments. There is an example of a mobile application that is having a beneficial effect You might have thoughts about how further these could be developed Again, if I may say in passing, this is one of the areas in which those of us who are parents and, indeed, some of us who are grandparents are aware that our childhood was very different from that of others now. Principally, when you went home, home was a place of safety – you could not necessarily be chased there, if things had been difficult at school, but now of course you can be through cyber-bullying and things like that. This is a pressure that we did not have. It must be a real worry to you, and that is shared by us. The impact on young people’s anxiety, worries and everything else cannot be overstated >> Chair: We only have a few questions left Is it okay for the panellists to run a few minutes over? >> Chair: Thank you. A lot of evidence that has been submitted to us is from young people who do not know where to go when they have a mental health issue, nor do they know where to get the information. The ‘Future in mind’ report said: “Young people and their parents…need clearer awareness of how to recognise when they might have a mental health problem as well as where and how to get help.” I would like to ask you, Minister Burt, what plans the Government have to respond to this >> Alistair Burt: I think ‘Future in mind’ highlighted a number of issues, including the difficulty people have accessing services through the pathway, from the detection of symptoms, to assessment, to receiving treatment We are very hopeful that the findings of that work, which was compiled with many people involved, and the way in which we are processing this and developing local transformation plans, will have an impact on this. It goes back to something we were talking about earlier: the provision of information for GPs and in GPs’ surgeries. It is a constant process of increasing awareness and the like. We are quite sure that some of the recommendations being made in ‘Future in mind’, which we are developing, are going to address these things. It’s out there, and we are doing it >> Mr Gyimah: A commonly held idea is that one of the key ways of making sure young people can access these services and ensuring the services improve in a way that works for them is to include them in the service design It is all well and good for people in Westminster and so-called experts to try to dictate how these things are done, but one of the key principles that we used in our special educational needs reforms was to involve young people That required engagement, including setting up a clear and transparent local offer. I think we can learn a lot from how those services were redesigned when we look at designing services here to make sure young people can access the services in a place that is appropriate and works best for them >> Francesca Reed: Minister Gyimah, earlier you mentioned the benefits of social media�in particular, apps – in supporting young people with poor mental health. Just expanding on that, we have been told that young people would like to have informative and youth-friendly apps on mental health that have been quality assured. What will the Government do to make apps like that available to young people? >> Mr Gyimah: Well, in terms of making apps available, there are a lot of apps out there, some for good and others for ill. I personally think the Government shouldn’t be in the process of developing more apps for the market; they should be helping to identify the ones that work and ensuring that young people are directed to the ones that are a useful resource That is certainly one of the things we can look at as we go through the process of improving awareness and destigmatising mental health issues. We should make sure the online resources are available. Actually, for a lot of people who sadly suffer in silence, a lot of it happens online, so it is a place where we need to be to make sure children do not suffer in silence >> Ann Gross: Through some of the voluntary sector projects we are funding this year, we are putting some money into developing apps. For example, we are funding something called Silent Secret, which is about developing a platform for young people to share their thoughts. We would be rather interested in your views in this area. What do you think

would work? What would be most useful? It would be good to hear from you on that >> Alistair Burt: It’s like asking me to produce the next No. 1. I am not going to do this, but you are >> Mr Gyimah: I have hope in you, Alistair >> Alistair Burt: I’d like to sing the B side of my latest single, but that shows how old I am It is a combination of resource here. Bringing forward ideas has never been easier. If you want to publish something, you can anywhere Young people’s culture, in terms of music, art and everything else, is illustrated by people who have just taken the chance – the vloggers and people like that who have been able to get out there in a way that never would have happened in a previous generation The same is true with ideas for things that are affecting you – particularly for things such as mental health. The best ideas will come through combining what you are doing yourselves, working with the various charities involved and looking at other professionals who have spent their lives working in these areas. I suspect that some of the best ideas will be absolutely street-level and taken through. It is about finding the right thing Suddenly, millions of people will be zeroing in on it because it good. That is still likely I suspect that the best apps will probably come out of the most surprising sources >> Terence Dobson: Hi. My question is, we note, and welcome, the recommendation by the ‘Future in mind’ report for a hard-hitting anti-stigma campaign. What specific action will the Government take to involve young people in building this campaign? Will you start, Minister Gyimah, and then we will come on to Minister Burt? >> Mr Gyimah: Okay. Anti-stigma, and dealing with stigma, is absolutely critical to our efforts to tackle mental health for young people. We have got a range of things we are looking at. For example, we have seen the Time to Change campaign and how well that did. I think that is something that we can use, tailored for young people. But also I think within schools, as I touched on earlier, removing the stigma around going to access support the service if you are suffering from a mental health problem is absolutely key That is what the whole-school approach is about: if it is embedded in a school and it is totally normal, then people actually do not feel there is a problem. I think Alistair used an example, saying, “I’ve got an issue in this way and this is what it is making me feel. I’m going to see someone about it.” I think that whole-school approach is central to dealing with stigma within schools for young people >> Alistair Burt: We know that organisations and partnerships such as YoungMinds, Time to Change – the Minister mentioned that – Mind, HeadStart and many others are doing local work within schools, education settings and online to address stigma head-on by appointing their own champions to talk about mental health issues and encouraging others to do the same Zoella talks about her experience as a Mind ambassador, for example We are currently considering how we might develop a national social marketing campaign with a mechanism for dialogue, so that it is a genuine two-way conversation, driven as much by young people and carers as by anyone else. I think the efforts that have been made in combating stigmatisation over recent years have been quite successful in other areas of mental health. We have to keep the progress going and look for new ways for doing it, but you are right that this an area where developments are likely and necessary and we share your ambition for this. We are certainly going to continue our determined efforts to do all we can to combat it >> Mr Gyimah: I also think that this is an area where we have got to be open-minded in terms of what would work. One of the things that I have been very keen on since taking on this role is that we do not appear to think that we know all the answers within government In terms of your recommendations for what could be done, do not be bound by the ‘Future in mind’ report. If there are things that it didn’t cover but you think it should have, let us know, because that is how we will make progress >> Chair: Thank you. We notice that you are Ministers from different Departments. Do you plan to collaborate in future especially on mental health and how it could be improved and on improving communications between different Secretaries of State? >> Mr Gyimah: If I can answer on behalf of both of us, I suspect that we will be seeing too much of each other! As far as this subject is concerned, we have already got events planned

in the diary and round-tables planned through to October that both DFE and DH are working on together. We do recognise and acknowledge that that is the way to make progress here, and we are as one in terms of not just the mission, but how to get there >> Alistair Burt: In the process of government, whether local government or anything else, silos appear very easily, as I am sure you are incredibly aware. Our Departments have their different responsibilities, but the process of politics means that, at the level at which we operate, as Ministers, it is very easy for us to get together. It is very easy for us to bring our respective Secretaries of State together if we need to, but we do not because they share the same ambition As an example, I was stopped in the Lobby of the House of Commons just last week by Nicky Morgan – she is Secretary of State�who wanted to raise something about something we were talking about, just to have a brief word with me. Politicians respond to the things that the public bring to us as problems in politics – “Why do you people always do X, Y and Z?” One of them has often been, “Why do you seem to operate in silos? Why are perverse incentives in funding, for example, stopping people doing things?” Remember: we start as people like yourselves We start as representatives. We start as grassroots activists, asking exactly the same questions as you, and we do not belong to the administration of our Departments. We are in a different position, so we ought to be able to respond to the public’s concerns by saying, “What can we clear away if things are getting in the way?” Processes have their purposes; they make sure that the whole business of government is not just an arbitrary lottery. Processes are important, but where they do get in the way of things, you are quite right to ask, “What can be done to break them down?” Relationships between Ministers, making sure that there is no jealousy between Departments and that something is not done to the disadvantage of another – we are the sort of people who ought to be able to do that. We have picked it up. We have recognised it. We will do our best in this Government to deliver on that, from this Department right across all our other partners, in dealing with things like mental health >> Chair: That’s very useful. Thank you Is there anything else that either Minister would like to add? >> Alistair Burt: We thought through your recommendations, and I want to suggest one or two things we would be very interested to see from you, to help us in our deliberations: your views on ‘Future in mind’ and how we implement the proposals; your recommendations on how we can keep children and young people safe on the internet, as we just discussed; your ideas for future digital apps, but give us a credit and a percentage if you come up with anything really good; and how we can improve children and young people’s participation in policy making and planning for implementation We would also like your suggestions on the question that Minister Gyimah raised with me last week when we sat down together: what do good services look like? What does “good” look like to a parent in distress, a carer in distress or a youngster in distress? What do they really want to see from your point of view? To go back to the question asked earlier, how do we make sure that decisions are not made to suit the system rather than the individual? I know that is very idealistic, and I recognise that it will not always be like this, but how can you help in that process to make sure that we focus on what you think you and your friends need and have that at the forefront? If you have stuff like that in the report, we would all find it really helpful >> Chair: Great. Thank you >> Mr Gyimah: I agree with all of that. The only thing I would add is peer-to-peer support We have discussed what can be done at an institutional level – what happens within schools and in terms of services. There is some peer mentoring that I am aware of, but we can do a lot more on peer-to-peer support. Whether it is bullying – we did not touch on that today – or some of the other things that cause these issues in the first place, young people are there and see it happening to their friends. What can we do on a big scale to get peer-to-peer support working as part of our response in dealing with young people’s mental health issues? >> Chair: Thank you. This is our last oral evidence session, so we will now begin creating and finalising our report, which should be released by November. We look forward to presenting

it to you. With that, I close the sixth and final panel of the day. Thank you ever so much for joining us and giving up your time