Taxis pull up throughout the day outside the brightly painted Magpie Centre to drop off its growing cohort of school refusers. The former youth club, which became Leicester’s fourth hospital school site 18 months ago, is designed to look as welcoming as possible to entice anxious youngsters back into classrooms.
The average school refuser has been at home for 18 months before they arrive. One pupil has not attended school for three years. Rather than sterile hospital wards, learning takes place in homes and purpose-built ‘hospital’ alternative provision.
Magpie’s therapeutic curriculum includes board games and growing rhubarb. A large social space includes table tennis and foosball. Pupils are taught in classes of up to eight, where teachers usually go by their first names.
Most attend the centre part-time for 12-week ‘early intervention’ blocks while still enrolled at their mainstream school.
Historically, hospital school pupils typically had physical ailments or long-term illnesses.
But leaders say their cohorts are now increasingly made up of youngsters with complex mental health needs – school refusers who leaders and councils no longer know what to do with.
National data on hospital schools is hard to come by; some come under the alternative provision (AP) bracket while others are designated special schools.
Of the 21 hospital schools responding to a survey last May run by the MAT AP and SEND CEO Network, 18 saw an increase in referrals.
When asked for any changes in the health condition of referrals, half said mental health.
Nationally, one in five 8- to 16-year-olds have a probable mental health disorder, up from one in eight in 2017. And analysis published this week found a fifty per cent rise in the number of children being referred to emergency mental healthcare services in just three years. More than 600 youngsters are now referred every week.
‘Every bit of the system is falling apart’
Demand is also being stretched by a severe lack of capacity in specialist schools to meet soaring numbers.
Phil Arrowsmith, headteacher at Wirral Hospital School, believes his service is “being used to prop up the SEND system, which is taking away the ability for us to meet the needs of children in real mental crisis”.
However, it is a complex picture. Leicester Hospital School headteacher Stephen Deadman says autism can lead to social anxiety and spirals into “more deep-seated mental health problems”.
But hospital schools are increasingly being named on the education, health and care plans for children whose primary needs are SEND rather than mental health related.
Arrowsmith recently had to turn away a teenage boy who had just been moved to safety after threatening to kill himself. He has capacity for 80 pupils but already has 84 on roll despite being only halfway through the school year. The boy was one of seven self-harmers with “deep trauma” who Arrowsmith had to add to his waiting list that week.
“Despite me receiving clear guidance from a KC [senior barrister] that we cannot be named in an EHCP as the sole destination for a child, Wirral LA have continued to do so,” he adds.
A Wirral spokesperson said it values its hospital school services. All children with SEND it has placed in them were either after being instructed by a tribunal to do so or following advice from the Department for Education.
Of the 113 councils that responded to a freedom of information request, 18 (16 per cent) admitted placing children in hospital schools as part of an EHCP process since 2018.
Four councils placed SEND children in hospital schools without giving them the same top-up funding they would normally receive. In five areas, children were placed in hospital schools after SEND tribunal hearings, because parents sought those placements.
But Arrowsmith says in Wirral, this means children with the most severe mental health needs – who require discharging from tier four (acute need) CAMHS units – are then “bed blocking. There’s no education provision for them other than us.
“The risk here is for the entire system – every bit of it is falling apart.” He is afraid a youngster will take their own life this year while awaiting a placement.
The reasons behind demand spike
Referrals at Sutton Tuition and Reintegration Service (STARS) in London have “gone up dramatically” in the past year, with more than 90 per cent linked to mental health needs.
Steve Lowe, head of Oxfordshire Hospital School, received around 120 referrals in 2022-23, roughly 50 per cent more than the previous year.
Of the increasing referrals from home-educated pupils, “many” have been out of education for between 12 months and two years. “The majority” have anxiety, “often with comorbidity and very often diagnosed or undiagnosed autism”.
“Every service is compromising what they’re able to provide for those square pegs not fitting into the round holes,” he says.
Tara Bell, head of Wandsworth Hospital School and Home Tuition Service, says SEND children are her “biggest increasing cohort. I could open an AP tomorrow and fill it easily with children struggling to attend school.”
By November, Manchester Hospital School had seen twice the number of requests from schools for outreach support as the same time last year. The city does not have hospital AP for primary age children, but “if we did, it would be full,” says its head Janet Doherty.
“With the age at which mental health problems are presenting getting younger and younger there’s definitely a need for local authorities to provide that specialist provision at lower years… By the time they get to us, it’s almost too late.”
Back in Leicester, two more modular classrooms are arriving this week with another four on order to cope with record referrals.
Leicester Council has also asked the school to open another new provision for those with EHCPs around anxiety “in response to a shortage of special school places”, adds Deadman.
STARS is rolling out a new model to meet demand. It is having “significant difficulties in integrating pupils back into suitable long-term educational placements”, said its headteacher Beverley Williamson.
It will now have morning-only timetables at the centre, with afternoons used to support reintegration back to the referring school.
Two-fifths of the hospital schools and medical AP surveyed by MAT AP & SEND CEOs found that schools were less supportive of reintegration than they had been the previous year, with only one in 18 finding them more supportive.
At the bedroom door
Lowe says the “educational relationship” with his pupils often starts “underneath the duvet with their bedroom door closed, and our teacher sat on the landing passing notes underneath”.
“That then builds for that young person to take the duvet off their head and have the bedroom door open, then eventually come downstairs.”
Nikki Cole, deputy head of the Magpie Centre, adds: “We’re seeing more and more young people not just stuck in their homes, but stuck in their bedrooms. We’re battling to get them into school.”
The crisis appears to be impacting girls more than boys. On my lunchtime visit to Leicester’s Willow Bank Centre, which caters for year 10 and 11 pupils, there’s not a boy in sight.
Girls sit picking at their cafeteria food, which Deadman explains is free for all students to prevent “barriers to eating, particularly for those with eating disorders”. Another is petting Tally, one of two resident therapy dogs.
Three-quarters of pupils across Leicester’s hospital AP are girls. Across Wirral’s year 10 and 11s, it’s two-thirds. While the gender imbalance has “been the case for several years, it’s getting worse,” says Arrowsmith.
Some experts put this down to social media. American social psychologist Jonathan Haidt, for example, notes that girls’ mental health “plunged” in the early 2010s, when both Snapchat and Instagram launched.
Olivia, in year 8, has now been at the Magpie Centre for a year after she stopped attending school 12 months before that. She says “rudeness” in social media group chats made her anxiety worse.
“No one would directly say it to me, but people would message, ‘Olivia’s never at school, she’s always faking ill. It hurts and makes you feel embarrassed to go into lessons.”
In the four years up to 2020-21, girls and boys had roughly the same absence rates.
But after Covid, things changed. The percentage of girls missing at least one in ten sessions last year was 26.1 per cent, compared to 24.4 per cent for boys.
Clash with mainstream
Olivia and her mum worked with her mainstream school to get her back attending, but she said the school “just treated me like a normal student … they weren’t really focusing on mental health.”
Cath Kitchen, chair of the National Association for Hospital Education, said “rigid rules regarding attendance and attainment” in “many schools” is something they are increasingly concerned about.
She believes this is “driving young people out of school, and parents to opt to electively home educate rather than see their children suffer and feel like failures”.
They also claim the current “campaign messages” from DfE around attendance are “not helping”. Parent groups have said it is trivialising school attendance anxiety.
Williamson says her service is “really struggling” with reintegration. “Children just don’t want to go back” to mainstream schools.
But those who stay at the hospital school then remain “around children with high levels of anxiety and suicide ideation. There doesn’t seem to be any middle ground – like a small school, for kids who are a bit fragile”.
At Willow Bank, there are no uniforms and rules are gently enforced. English teacher Paul Gibson says teachers there “don’t have to be strict, because we don’t have the behaviour issues to deal with”.
The school has had to accept that some year 11s are “just not going to come out of the home. We just need to put in enough tuition so they can at least get exam results and hopefully in the future, they’ll move on.”
But there are lots of success stories. Deadman recalls one teenager for whom learning started with the teacher “talking through the bedroom door”. With the school’s support she overcame her anxiety, got a place in college and won a national filmmaking prize.
On the wards
But there are casualties, too. At Leicester’s 75-year-old hospital school, based inside Leicester Royal Infirmary, the atmosphere is subdued during my visit after a learner passed away overnight.
The school has a classroom, although much of the learning takes place out on the wards where masks are always worn. School head Sarah Fitzpatrick admits that makes “phonics quite difficult, trying to sound out the letters” but kids are “used to that” since Covid.
Senior play specialist Louise Ballard has worked at the hospital for 32 years and has never seen so many young people with mental health problems, and never as “complicated” or “extreme” as they are now.
“They’ve normally reached absolute crisis point when they come to us, some verging on psychosis.
“It’s really difficult to manage in this environment, because it’s not the right place for them… We’re a bit of a stopgap.”
Her office wall is covered in letters and cards from former patients and their families. One sticks in her mind, from a youngster who had been sectioned over self-harming and had been watched by carers at all times to ensure she didn’t run away.
She “desperately wanted to get outside”, but staff questioned whether she should be allowed to access the hospital’s rooftop play area. She promised they could trust her, and they did. The girl wrote to Ballard when she moved on, thanking her for that trust.
“Sometimes it’s just about building up that rapport. We’re lucky in our roles that we have the time to be able to do that.”