Dear Editor,
We fully agree with Fonagy that mental health outcomes are shaped by a complex interaction of factors, including poverty, discrimination, social isolation, schools, workplaces and wider environmental influences.(1,2) He also stressed that improving mental health will require action across government and across society, and that many of the strongest influences on mental health lie outside the healthcare system.
In his 599-page report for “mental health conditions, ADHD and autism”, he advocated many positive proposals.(2) However, we would like to recommend and prioritise three key actions.
Firstly, there needs to be increased funding for early years support including for additional health visitors who should be in a prime position to support autistic children and their families.(3) Key roles include early identification, developmental reviews, and coordinated care from birth until school age. Health visitors provide support for children, and parents when necessary.
In recent decades, most areas of England have witnessed a substantial drop in health visitor numbers.(4) In some areas, services are so stretched they are finding their workloads consumed by safeguarding. There needs to be a radical increase in numbers so that health visitors can fulfil their potential in relation to the Healthy Child Programme.
Secondly, we recommend the creation of a national strategy for Health Promoting Schools.(5-8) This evidence-based approach creates environments that help to maintain and improve health, shifting the responsibility for health away from being solely on individuals.
Five elements of a health promoting school are:
1) Health and well-being are promoted through the ‘hidden’ or ‘informal’ curriculum e.g. school policies (such as mental health, dress codes, attendance rules, and disciplinary guidelines);
2) Health topics are taught through the formal school curriculum;
3) School health services actively support;
4) Links are made with families, outside agencies and the wider community, and
5) Health and well-being of staff are promoted.(8)
Very early on, teachers need to define social, emotional, and mental health needs, and recognise common indicators in pupils, including the links between behaviour and emotional needs. And, if teachers are to understand their roles in supporting pupils with specific needs, within a whole-school approach, then many will need to be trained so that they are competent and confident. Overall, a safe and inclusive learning environment needs to be developed for all pupils.
Thirdly, and very importantly, as a society we need to recognise individuals’ strengths and assets alongside needs. These aspects can then be developed through supported engagement in strengths-based school activities, signposting to appropriate community groups, and/or social prescribing when necessary.(9) Empowerment through personal skills is an important factor in the development of healthy individuals and healthy societies.(8)
We fully agree with Fonagy’s key recommendation for Government and local systems that there should be an ambitious approach to prevention, early intervention and improving public mental health and wellbeing.(3,6) However, we are concerned that over the decades, and with successive governments, we have heard this call, but funds very rarely follow to support the suggested interventions. Without sufficient money, there is likely to be little change.
For the aspirations of the Fonagy report to be realised, an ambitious, cross-government strategy must focus on a step change from a focus on deficit and disorder, to promoting, resourcing and measuring health and wellbeing as a priority. The health and education workforce should be equipped with the capacity and skills to create and oversee inclusive, healthy environments that evidence shows us can enable the next generation, and therefore society, to thrive.
References
1) Furneaux R. ADHD and autism review: NHS must move away from diagnosis linked support system, report says. BMJ. 2026;395:e101104.
https://www.bmj.com/content/395/bmj-2026-101104
2) Fonagy P. Independent review into prevalence and support for mental health conditions, ADHD and autism: final report. London: Department of Health and Social Care. 9 Oct 2026.
https://www.gov.uk/government/publications/independent-review-into-menta...
3) Watson M C and Neil K E. Sure Start principles: opportunities to have a real impact. British Medical Journal Rapid Response 7th October 2026.
https://www.bmj.com/content/394/bmj-2026-100999/rr
4) Department of Health & Social Care. Children’s public health nursing: workforce and activity report, 2025. London: Department of Health & Social Care.; 2026.
https://www.gov.uk/government/statistics/childrens-public-health-nursing...
5) World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Making every school a health-promoting school – Implementation Guidance. Geneva: World Health Organization and the United Nations Educational, Scientific and Cultural Organization, 2021.
https://www.who.int/publications/i/item/9789240025073
6) Watson M C and Neil K E. Children’s mental health—pivotal roles for teachers and school nurses. British Medical Journal Rapid Response 5th October 2023.
https://www.bmj.com/content/382/bmj.p2243/rr
7) World Health Organization. How school systems can improve health and well-being. Topic brief: mental health. Geneva: World Health Organization, 2023.
https://iris.who.int/server/api/core/bitstreams/c4b9acfc-f4d3-4a15-99be-...
8) Watson, M. C., & Neil, K. E. The Ottawa Charter: a lasting guide for public health. International Journal of Health Promotion and Education, 2026, 1–16. https://doi.org/10.1080/14635240.2026.2743584
https://www.tandfonline.com/doi/full/10.1080/14635240.2026.2743584
9) The Kings Fund. What is social prescribing? London: Kings Fund, 2026.
https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-pres...