31. A review in 2016 found that “talking therapies” could help victims and survivors of child sexual abuse in a number of ways. These include helping with their self-esteem, learning coping skills and strategies, and developing “choice, control and empowerment”.[1] More recently, the All-Party Parliamentary Group for Adult Survivors of Childhood Sexual Abuse survey in 2020 found that nearly half (47 percent) of victims and survivors thought that the most important form of support was specialist voluntary sector counselling or therapy that is trauma-informed.[2]
32. The Inquiry’s Victim and Survivor seminar in July 2017 heard reference to a study which estimated an annual shortfall in provision of over 57,000 places for children in therapeutic services.[3] While the Home Office’s 2019 commissioning guidance recommends that holistic therapeutic intervention should be considered when commissioning support services for victims and survivors of child sexual abuse,[4] in September 2021, the Ministry of Justice acknowledged that research conducted to date indicated that “availability of specialist provision for children and young people is not sufficient to meet the level of need”.[5]
33. When asked what form of support victims and survivors felt they would benefit from but were currently unable to find or access, counselling and psychotherapy accounted for nearly half of the responses.[6] Victims and survivors also referred to the importance of therapeutic help being immediately accessible when it was asked for:
“It would be nice to have – I know it’s like a dream – an immediate offer of service. At that point when you ask for it, you’re desperate.”[7]
34. While obtaining accurate figures is difficult, available data suggest that support services are required to deal with large numbers of new child victims and survivors each year.[8] This is compounded by the legacy of supporting large numbers of adult victims and survivors who were not supported when they were children, were not able to disclose the abuse as children or were supported as children but require long-term support into adulthood.
35. Evidence from victims and survivors and those individuals responsible for commissioning support services indicates that there is considerable unmet need for all forms of support services. Forty-three percent of adult victims and survivors who participated in the Inquiry’s Support Services Research Project said that they currently had an unmet need for support services associated with their experiences of child sexual abuse.[9] One local authority in the East Midlands told the Inquiry that it had commissioned a service designed to support 800 individuals per year, but received over 800 referrals in the first three months of the contract.[10]
36. The Inquiry’s Support Services Research Report noted that some of those who had no experience of support described being unsure of how to seek help.[11] Other victims and survivors said that they had to “fight” to receive help, often asking for support multiple times and encountering professionals who seemed reluctant to assist them.[12] A Truth Project participant summarised the problems encountered by many victims and survivors:
“the impression that I got was that there were some [support services] out there but you had to [be] prepared to fight tooth and nail for them. And for a person who is actually genuinely and consistently struggling, that’s nearly impossible to get to”.[13]
37. A report commissioned by the National Society for the Prevention of Cruelty to Children (NSPCC) found that children and young people did not always “have a clear picture of what services there are for them or how they will be treated if they try to ask for help”.[14]
38. A number of problems with access to support were identified.
38.1. Signposting or referrals: Victims and survivors are not consistently directed towards relevant support services by institutions connected to the abuse, or by other statutory bodies. Health providers, social care or education providers each have different statutory duties and referral mechanisms. Victims and survivors may also encounter difficulties in being referred to support services by their GP.[15]
38.2. Eligibility criteria: Support may be inaccessible to those without a qualifying medical diagnosis or the right circumstances (such as a stable home life). There can be a particular problem for young people seeking support through CAMHS because of the access criteria for these services in some parts of England and Wales.[16] The Centre for Social Justice report noted that one CAMHS provider said that:
“Unfortunately it’s no longer enough to have experienced a trauma like sexual abuse. We can only see children with a severe mental health condition requiring therapy.”[17]
In 2015, a letter from a service in London showed that the only children who would be accepted during a six-month period would be those exhibiting “psychotic presentation, significant depression, serious self-harm, suicidal ideation [and] severe OCD [obsessive compulsive disorder]”.[18]
38.3. Availability: There is variation in the availability of support services nationally and locally. Generally, the Inquiry heard that there is a ‘postcode lottery’ in the provision of local services and in the ability of existing support services to meet the need.[19] If there is no local provision, this can result in victims and survivors having to travel long distances to access help.
38.4. Specialist advice: Individuals may seek help through general health services, which do not have any specialism in helping victims and survivors of child sexual abuse and may not be trained in trauma-informed responses. Support provided to victims and survivors of child sexual abuse should be tailored to their particular needs, which may vary according to a number of factors, including sex, ethnicity, sexual orientation and age. Some victims and survivors from ethnic minorities described how important it had been to have support from someone who was able to understand how their culture would have reacted to their experience and the impacts of the abuse.[20] Others told the Inquiry that where support services (including interpreters) are part of the same ethnic minority community as the victim and survivor, the fear of disclosure getting back to families and communities meant that victims and survivors are less likely to disclose child sexual abuse.[21]
38.5. Waiting lists: Victims and survivors can often experience long delays waiting for support, ranging from months to years.[22] The Inquiry was told that although there was regional variation, it could take six to eight months to see a therapist at a Rape Crisis centre.[23] Some child victims and survivors in Lambeth waited six to nine months for support through CAMHS.[24] A recent survey of GPs found that in some areas it took children and young people two years after being referred by their GP to start receiving help.[25] Others told the Inquiry that they waited much longer than this for help.[26] The Care Quality Commission confirmed that “sometimes children and young people and the families reach the crisis point before they end up getting help”.[27] Some may give up waiting.
38.6. Time limits on amount of support provided: The number of sessions available differs dramatically, depending on the type of support accessed and where in the country the support is being accessed.[28] Participants in the Inquiry’s research made clear that therapeutic services should be both free and available for as long as victims and survivors need them, offering ongoing support.
39. The Inquiry also heard about the difficulties that victims and survivors can face in accessing support due to their sexual orientation. One Victims and Survivors Forum member told the Inquiry that their sexual orientation impacted their ability to seek help because they feared facing discrimination.[29] Many LGBTQ+ people told the Inquiry that as young people they did not feel comfortable or welcomed by child sexual abuse support services aimed at the general public and instead sought out services specifically targeted at the LGBTQ+ community, as it felt safer.[30] Some who accessed non-specialist support considered that sometimes issues related to their sexual orientation were poorly understood.[31]
40. The problems many victims and survivors experienced when trying to access support are in part due to the fragmented and complex funding and commissioning of support services across England and Wales from the public, private and third sectors.
41. Public sector support services use public money either to provide services directly to victims and survivors or to commission other organisations, typically third-sector groups, to provide support.
42. Funding used for public sector services derives from a range of sources. The Interim Report of the Independent Inquiry into Child Sexual Abuse (the Interim Report) recommended that the UK government and Welsh Government should establish the levels of public expenditure and the effectiveness of that expenditure on services for child victims and adult survivors of child sexual abuse in England and in Wales.[32] The UK government’s response, published in February 2020, provided an expenditure review for services which provide support to victims and survivors.[33] This review illustrated the complexity of funding.
43. Third-sector organisations also provide services that are funded by donations and grants. Some victims and survivors of child sexual abuse access these services directly. The All-Party Parliamentary Group on Sexual Violence described the demand for specialist sexual violence and abuse services as “unprecedented” even before the COVID-19 pandemic.[34]
44. There needs to be a focus on identifying the level of need and the resources to match the identified need for support services for child victims and adult survivors of child sexual abuse in England and in Wales. A long-term funding model is also needed for the future.
45. In evidence to the Inquiry, concerns were expressed that commissioning arrangements need to be simplified. A recent inspection of the police and Crown Prosecution Service’s response to rape heard that applying for a public sector commissioning contract is “resource intensive”: “one provider told inspectors that they employ two full-time staff with the sole responsibility of preparing for the commissioning process”.[35] Third-sector service providers told the Inquiry that the commissioning process was overly complicated and time-consuming.[36]
46. Public sector support services are commissioned at both a local level (such as CAMHS) and a national level (for example, SARCs). A number of public commissioning bodies, across sectors including health, criminal justice and social care, have different but sometimes overlapping areas of responsibility for commissioning support. These commissioners are also responsible for different, and sometimes overlapping, geographical areas. Some sectors are the responsibility of the UK government whereas others are devolved matters, the responsibility of the Welsh Government. There is a lack of clear and concrete differentiation between the aims of the services commissioned by these different bodies. For example, police and crime commissioners are responsible for services for victims of crime, which include victims and survivors of child sexual abuse. However, local health commissioners (now part of integrated care systems, partnerships between the organisations that meet health and care needs across an area) are also responsible for services “that understand the specific needs of victims and survivors of sexual assault and abuse”, including those that treat post-traumatic stress disorder.[37] There is no requirement or incentive for these services to work together, despite the Home Office recognising this as good practice.[38]
47. This fragmented and complex commissioning landscape is problematic for service providers and, more importantly, can make accessing support difficult and confusing for victims and survivors.[39] The Ministry of Justice has acknowledged that the support available to children and young people who have experienced sexual abuse encompasses a wide range of services, funded by several different national and local commissioners, and that complicated commissioning and funding processes can lead to variations and inconsistencies in local provision.[40]
48. It is clear that the current system for commissioning support services is not working well. Multidisciplinary services with a single point of contact can provide better support for victims and survivors. NHS England is in the process of commissioning ‘Enhanced Mental Health pathfinder’ sites across England. The sites aim to improve care for victims and survivors of sexual assault and abuse with complex trauma related mental health needs. The Inquiry was told that it was establishing these sites to reflect that:
49. There is scope for the UK government and Welsh Government to require the introduction of single local commissioning partnerships for support services for child sexual abuse. The commissioning partnerships could bring together all relevant commissioning partners, such as police and crime commissioners, local authorities and integrated care systems. Currently, commissioners have individual responsibilities that are relevant to services for child sexual abuse but there is no requirement for these bodies to work together. In order to be effective, the commissioning partnership would need to use a single, pooled budget.
50. Some local authorities and police and crime commissioners told the Inquiry that they already try to work collaboratively. Merseyside’s Police and Crime Commissioner described that joint commissioning had taken “concerted effort and strong will” to ensure that all commissioners were working to a “single service specification, single reporting standards and contract management meetings”.[42] Others noted that there were challenges to working collaboratively with other partners due to fragmentation throughout the support services system, such as in the varying aims of different funding sources. One local authority in the South West described collaborative work through a partnership oversight board which involves NHS England, the police and crime commissioner, the police, public health services, two councils and commissioned services. They are currently working to simplify access to support services.[43]
51. The UK government and Welsh Government should support and encourage the collaborative working which already exists. This would make support services more coherent and accessible to victims and survivors.
52. Local commissioners should also consider the introduction of a single local point of contact to coordinate access to support services. Victims and survivors would have the same referral point irrespective of where they made a disclosure. The simplicity of having a single contact point, as well as the multiple potential referral routes to this point, could increase clarity and awareness amongst the public about how to seek support. Victims and survivors told the Inquiry that a central agency that could ensure that victims and survivors are signposted to the most appropriate and comprehensive support available would be helpful.[44]
53. Navigating access to support services can be difficult for victims and survivors where they are not accessing support from the institution itself or as part of the criminal justice system, via a SARC for example. The experiences and needs of victims and survivors should be at the centre of the design of support services.
54. In addition to the Child House model, there have been other examples of child-centred approaches. The Centre for Social Justice referred to a service in York which was a specialist child sexual assault assessment centre where play therapists worked alongside paediatricians to put children at ease and reduce their anxiety.[45] Similarly, in 2021 the Children’s Society established the Support Rethought programme, funded by the Home Office with referrals from the police, social services, GPs, and parents or the child victim.[46] It offers child victims of sexual abuse one-to-one support within six weeks of reporting abuse, as well as support for parents (where the parent was not involved in the abuse). Project workers provide emotional support, suggest coping strategies, assess the child’s needs and act as advocates.