Article · 24 August 2026
Everyone reported the million. Almost nobody read the waiting-time tables at the back, which describe a system with an emergency entrance that works and a front door that barely opens.
A child referred to mental health services in England because they are in crisis waits four days. A child referred for suspected autism waits three hundred and fifty-six.
Same country. Same year. Same service.
Those two numbers sit a few pages apart in the Children's Commissioner's fifth and final annual report on children's mental health services, published at the end of June. Most of the coverage went, understandably, to the headline. For the first time, more than a million children in England had an active referral to children and young people's mental health services in 2024-25. 1,048,965 of them, almost double the 563,639 recorded in 2018-19, and a rise of 9.5 per cent in a single year.
I wrote about that million at the time. What I have not been able to leave alone since is the waiting-time tables at the back, because they describe the shape of the system far more honestly than the headline does.
Look at which children get seen quickly.
Children referred while in crisis had a median wait of four days. Children referred with bipolar disorder waited seven. Drug and alcohol difficulties, eight days. Self-harm behaviours, nine. A suspected first episode of psychosis, fourteen. Eating disorders, seventeen.
Now look at the other end of the same table. Children referred for suspected autism who did eventually receive treatment waited a median of 356 days. Children referred for neurodevelopmental conditions excluding autism waited 176 days. Even children who already had an autism diagnosis in hand waited 67 days, roughly double the median wait for all children who got treated at all.
Read those two lists together and a design becomes visible. This is a service with an emergency entrance that works and a front door that barely opens. It is fast, genuinely fast, at the point of acute risk. It is close to static everywhere else.
I want to be careful, because there is a version of this observation that is just complaining. Triage is not a scandal. Any service under this much pressure should see the child in crisis before the child on a list, and a four-day median at the acute end is a real achievement by people working extremely hard in conditions nobody would have designed.
But triage is a way of ordering a queue. It was never meant to be the only way in.
When the only reliable route to help is deterioration, a system has stopped triaging need and started rewarding it.
Think about what this teaches the adults around a child.
If you are a parent watching your eight-year-old stop sleeping, stop eating properly, stop wanting to go to school, you will be told to wait. If that same child harms themselves, you will be seen inside nine days.
Nobody says this out loud. No parent consciously hopes for escalation. But people are not stupid, and systems teach. Over time, families learn which words open doors. Schools learn which forms move. Everybody in the chain learns that the language of crisis is the language that gets answered, and that the careful, honest description of a child slowly coming apart is the one that gets filed.
That is not a mental health service. That is a fire brigade that will only attend once the roof is well alight.
There is a second finding in the report that makes this much harder to read as an accident.
Twenty-five per cent of Black children and 16 per cent of Asian children referred to mental health services were referred while in crisis. For White children the figure is 7.4 per cent.
And here is the part that should stop us. Black and Asian children then have markedly shorter waits than White children do.
On a dashboard, that looks like equity. It is the opposite. Black and Asian children are substantially under-represented among referrals in the first place. Asian children are 12 per cent of the child population and 5.8 per cent of those referred. Black children are 5.7 per cent of the population and 3.8 per cent of referrals. They are not being spotted earlier and helped sooner. They are being missed for longer, and then arriving through the emergency entrance, which is the part of the building that works.
The report is careful here, and notes that once children are referred, they move through the system at much the same rate regardless of ethnic background. That is worth saying plainly, because it locates the failure. It is not happening inside the clinic. It is happening upstream, in identification and referral, in whether the adults around a child notice distress early and know what to do about it.
Which is precisely where the village used to be.
One more number, and it is the one I would put in front of a minister.
For 367,149 children, 35 per cent of every child referred last year, the NHS does not know why they were referred. The report attributes this to data quality and recording issues.
We have over a million children in a system and, for more than a third of them, we cannot say what they came for. Every argument about whether this is rising need or rising recognition, every debate about social media or the pandemic or diagnostic drift, is being conducted over a dataset with a hole in the middle of it the size of Birmingham.
The fastest-growing group is not who most people picture when they hear the phrase "children's mental health".
Referrals for suspected autism rose 47 per cent in a single year, from 65,530 children to 96,393. Referrals for neurodevelopmental conditions excluding autism rose 24 per cent, from 107,939 to 133,435. Between them, those two categories account for 62 per cent of the entire increase in children referred.
They are also the children the system serves worst. Seventy-one per cent of children referred for suspected autism were still waiting for treatment at the end of the year, and only 13 per cent received any. For other neurodevelopmental conditions, 64 per cent were still waiting and 19 per cent were treated.
Most of these families are not seeking treatment at all. They are seeking recognition, because in far too many schools support is unlocked by a diagnosis rather than by a need. So a clinical service built to treat illness has become the bottleneck for an educational question, and both queues are now the same queue.
Dame Rachel de Souza puts it more sharply than I can. It is time, she writes, to "stop asking children to prove they are unwell enough to deserve help."
Real spending on children's mental health services reached £1,106 million in 2024-25. Adjusted for inflation that is a 2 per cent real increase on the previous year, set against a 9.5 per cent rise in the number of children referred. You cannot run that gap for six consecutive years and then be surprised by the result.
The distribution is stranger still. Spend per child referred ranges from £569 in Kent and Medway to £2,410 in North West London. Whatever else that variation is, it is not a considered national position on what a child's mental health is worth.
Three things, and none of them are new ideas.
Support has to stop being gated behind a diagnosis. This is the Commissioner's own central recommendation and it is the one that would unclog the queue fastest, because a very large share of the children in it are there to be assessed rather than treated. A child who cannot regulate, cannot sit still, cannot cope with the dining hall, needs help with those things now, whether or not a clinician eventually attaches a word to them.
Capacity has to move to where children already are. Mental Health Support Teams in schools, early support hubs, wellbeing practitioners working at the low-intensity end. These are not consolation prizes for the children who do not qualify for specialist services. For most of the children in that million, they are the appropriate service, and they are the only one reachable without a nine-month wait. A service that takes nine months to answer is not a service. It is a caveat.
And the layer before all of it has to be rebuilt. Adults around a child who notice early, who know the child by name, who have somewhere to take a worry that is not a referral form. That layer is not a service and it never appears in an NHS dataset, which is precisely why its disappearance shows up as a million active referrals rather than as a line in a budget.
The four-day median is the system at its best. The 356-day median is the system as it actually is for most children in it. Between those two numbers is everything we have stopped doing before a child gets ill enough to count.
I keep coming back to this because it is the same pattern I find in almost every organisation I work with. The distress is real, the professionals are good, the money is not the whole story, and the thing that has gone missing is the connective tissue that used to catch people early. My book Rebuilding the Village, out in early 2027, is about how we put that back.
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