The Missing Middle: Why we must fund children and young people’s mental health services

Too many young people are falling through the mental health support gap. How do we fix the "Missing Middle"?

As a GP working in a socially disadvantaged area, I see the human fallout of the mental health crisis impacting children and young people daily. Families facing low health literacy or language barriers struggle to navigate a fragmented network of care. There is widespread recognition that the current system is not working – but what are the alternatives?

The core issue is a gulf in support. Local, school-based services are often short-term, overwhelmed by increasingly complex presentations, and bogged down by long waiting lists. Meanwhile, the high thresholds for specialist Child and Adolescent Mental Health Services (CAMHS) mean only very severe presentations will qualify. Teachers and GPs, worried about children and young people stuck in this gap have nowhere to refer, increasing pressure on education and primary care as they try to support families as best they can.

Last September, I co-ordinated a roundtable of frontline teachers, GPs, and CAMHS professionals working in socially disadvantaged areas. Participants gave a name to this vast, empty space where vulnerable young people all too easily slip through the cracks: the “Missing Middle.”

Our current system lacks the capacity to intervene early to prevent moderate anxiety and depression deteriorating into a crisis. Young people do not exist in isolation. In deprived areas, mental health struggles are deeply intertwined with poverty, housing instability, and financial stress. Families at breaking point are often forced to navigate disconnected services; an exhausting process, which can become heartbreaking if they do not fit strict criteria.

In this context, the importance of trust and relationships cannot be underestimated and was highlighted by all three sectors. Additionally, local, authentic, trusted third-sector groups are invaluable. When rooted in the community, they can help families manage wider stressors. Peer support, when properly supported, can be invaluable in this context. Yet, as local authority budgets face unprecedented pressure, these are the exact services being cut.

One solution our roundtable proposed was the creation of Multi-Agency Community Support Hubs, initially piloted in socially disadvantaged areas, and located within or near schools. Jointly funded by Health and Social Care Partnerships and Education these would:

• Provide immediate, low-threshold access for schools and general practices, offering initial psychological therapeutic support while allowing for escalation to CAMHS if needed.
• Streamline navigation by co-locating services, making it easier for young people and families to get the help they need in the same place (including financial, social and housing support).
• Foster an ethos of “working with” rather than “doing to” families, drawing on rich third-sector and lived, experience.

By shifting some of the resources from specialist services into the community, and designing care from the ‘ground up’, we could ensure that the focus is on earlier intervention and support, and on building relationships. This would not only be more effective and timelier for our young people and their families, but would also reduce CAMHs waiting lists, and allow our specialist CAHMs colleagues to be able see more of the complex cases that they are trained to manage.

It has been said that insanity is doing the same thing over and over again and expecting different results. We need to change what we are doing.

Shifting our focus to the “Missing Middle” is not just a moral imperative in our current financial climate, it also makes absolute economic sense. We must invest in community-led intervention and protecting and sustaining the mental health of our young people. For them, and for their families, we simply cannot afford not to.

The full report GPs at the Deep End Roundtable Report 45 Children and Young People’s Mental Health in Deep End communities with further information on the roundtable and a summary of the wider issues identified, and solutions proposed, is available here.

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