Racial-Ethnic and Gender Inequities in Cross-System Pathways between Mental Health-related School SEND Provision and Hospital Contacts among Children and Adolescents in England

Background: Systematic differences exist in Special Educational Needs and Disability (SEND) provision for Social, Emotional and Mental Health (SEMH) needs - the formalised pathway for mental health support in schools - and mental health-related hospital contacts. However, equity in coordination between these school and hospital systems remains poorly understood. Examining mental health-related pathways between these systems may identify opportunities for early intervention and equitable access.Aims: Developed in partnership with peer researchers and community stakeholders, we examined whether there are systematic differences based on gender and racial-ethnic group in cross-system pathways, between SEND-for-SEMH and mental health-related hospital contacts among school-aged children in England.Methods: Population-level analysis of linked school and hospital administrative data for 1.7m children aged 5-16 years attending state schools in England (2005-2018). We examined system recording patterns, contact intensity and risk ratios for the order of SEND-for-SEMH and mental health-related hospital contacts first and subsequently.Results: Substantial variation in experiences was found across gender, racial-ethnic groups, and at the intersection. Hospital-only identification was higher among girls, with nearly all girls significantly less likely to receive school SEND-for-SEMH first or following mental health-related hospital contact compared to White British boys. Among girls with mental health-related hospital contacts who were never recorded with SEND-for-SEMH, half (49.8%) had a mental health-related in-patient admission. All pupils with Asian, Black African, White Other, Mixed Other and Other unspecified racial-ethnic backgrounds were significantly less likely to be recorded with SEND-for-SEMHfollowing hospital contacts. Girls with White and Mixed race/ethnicity backgrounds were significantly more likely to have hospital contacts first and following SEND-for-SEMH.Conclusions: Findings reveal systematic coordination failures and intersectional discrimination in mental health pathways. Statutory integrated care pathways and mandatory equity frameworks are essential to address extensive unmet need and ensure equitable access to mental health support.