Mental health and well-being of looked-after children Contents

6Service integration, leadership and local implementation

Revision of the Government’s statutory guidance

65.The DfE and DH new statutory guidance says that local authorities, CCGs, NHS England and Public Health England must cooperate to commission health services for all children in their area. On the same day The Children and Young People’s Mental Health Taskforce published its report Future in Mind.83 The taskforce was co-chaired by NHS England and DH. It provided a broad range of recommendations across the education, health and social care sectors aimed at improving the mental health of children and young people.

66.Several pieces of evidence told us that the current statutory guidance should be reviewed in light of the more ambitious proposals contained in the Future in Mind report. Dr Ingrassia stated:

The presence of a statutory guidance is helpful and a useful starting point. The guidance needs to be strengthened to ensure that its aspirational aim to prioritise the mental health needs and well-being of children in care and care leavers becomes a reality, particularly in the current financial climate. In light of the Future in Mind report and the plans for CAMHS transformation, a review of the guidance or the publication of additional guidelines to help prioritise resources and investment at a local level would be highly beneficial.84

67.In written evidence Sarah Brennan spoke of the Future in Mind report as creating a “new vision” for children’s mental health.85 CYPMHC similarly told us that the Future in Mind proposals which focus on vulnerable children should be incorporated into the statutory guidance.

68.Alistair Burt confirmed that they would be revising the statutory guidance in the light of the Future in Mind proposals.86 However, in follow up written evidence, Mr Burt clarified:

We are waiting for the outcome of your inquiry before making any firm decision on amending the statutory guidance and I am sorry if that was not clear in my response.87

69.We recommend that the statutory guidance on promoting the health and well-being of looked-after children be revised and strengthened to incorporate the recommendations made in The Children and Young People’s Mental Health Taskforce report Future in Mind.

Local Transformation Plans

70.One of the clearest proposals from the Future in Mind report was that all local areas should develop Local Transformation Plans:

These Plans should cover the whole spectrum of services for children and young people’s mental health and well-being from health promotion and prevention work to support and interventions for children and young people who have existing or emerging mental health problems, as well as transitions between services.88

71.According to Future in Mind the plans should be created locally by the CCG, working with the Health and Well-being Board and local authorities. Lead commissioners should also work with schools to contribute to the development of the plans. Future in Mind proposes that during 2015/16 every area should develop a Local Transformation Plan which outlines their local offer for children and young people’s mental health and well-being.89 Professor Fonagy told us:

We have at the moment, with Future in Mind, a real opportunity for bringing services together because the principles that Future in Mind sets out are the integration of education, social care and health at the level of clinical commissioning groups and their key partners. This creates an absolutely ideal platform for dealing in a coherent way with the needs of children who are in care.90

72.The extent to which Local Transformation Plans will focus on looked-after children and young people is yet to be established. Lisa Harker from the NSPCC commented:

They are very variable in terms of their understanding of and focus on looked-after children. Some are excellent and have really innovative ideas in them, but some of them barely mention looked-after children at all.91

73.Alistair Burt confirmed that the plans varied in the extent to which they focus on looked-after children:

Clearly what we have seen is that some plans are better and stronger in those areas than others, so the process that we are going through now to evaluate these—and by March we will have done a study that will be qualitative as well as quantitative—will enable us to identify precisely, as a theme, what has been done right through the country with these local transformation plans in terms of looked-after children.92

74.Ms Bethel also told us that NHS England had commissioned an analysis of the Local Transformation Plans, including an examination of how well they covered the needs of looked-after children.93 A quantitative report which provides an analysis of data on spend, and number of referrals for 2014–15 has been published and qualitative analysis is due to follow in spring 2016.94 Ms Bethel added that she “very much hope[d]” that some of the £1.4 billion funding which has been allocated for Local Transformation Plans will “be used to improve outcomes for looked-after children”.95

75.The Children and Young People’s Mental Health Taskforce Vulnerable Groups and Inequalities Task and Finish group report was published in conjunction with Future in Mind.96 It set out specific proposals for vulnerable children and young people, including those who are looked-after. The report recognised failures in joint commissioning and the need for clearer pathways to services and support.97

76.In addition to this taskforce report and Future in Mind the DH have announced an expert group to take forward its proposals for looked-after children:

The aim of the expert group will be to design care pathways and flexible integrated models of care that can be used by all bodies and individuals involved in meeting the mental health needs of looked-after children.98

77.Since the publication of the Children and Young People’s Mental Health Taskforce report last year, and the more recent independent Mental Health Taskforce report, the Government has committed to both a qualitative analysis of Local Transformation Plans and the creation of an expert working group on the mental health needs of looked-after children. We look forward to seeing both pieces of work.

78.Looked-after children will only benefit from Local Transformation Plans if their needs are addressed and funding allocated for their care. We recommend that all plans state the services they provide specifically for looked-after children and the funding assigned for them.

Implementing integration in local authority areas

79.We heard descriptions of the failures of social care, health, and education services to work together in local authorities to jointly commission integrated services. The NSPCC told us that effective support for looked-after children could only take place where “institutions operate in a co-ordinated manner”.99 NICE guidance recommends that Directors of Children’s Services and commissioners of health services should:

Jointly commission services dedicated to promoting the mental health and emotional well-being of children and young people who are looked-after […] These services should be structured as integrated teams (virtually or, ideally, co-located), and have a mix of professionals who will vary according to local circumstances […] As a minimum, ensure these services have local authority children’s specialists, dedicated health and mental health (including CAMHS) professionals, and education specialists working with looked-after children and young people.100

80.We received evidence from several local authorities who are successfully offering an integrated service for looked-after children with strong links between health, social care and education. Barbara Herts, Director for Integrated Commissioning and Vulnerable People at Essex County Council, described the process by which Essex County Council set up a “collaborative commissioning agreement across seven CCGs and three local authorities” in 2014.101 Ms Herts said:

We have very successfully pooled budgets with our clinical commissioning group colleagues and I oversee that budget, which means that we can operate flexibly and meet the needs of vulnerable children and young people in Essex. I think the previous system of having a lot of fragmentation and different organisational boundaries let our vulnerable children and young people down.102

Box 1: Case study: Trafford Metropolitan Borough Council

We visited Trafford Council as part of our inquiry, as an example of a local authority that has developed a fully integrated children’s social care and health service.A We met senior council officers, CAMHS practitioners and psychologists, heads of services, the Virtual School Head and a group of foster carers. We also visited a children’s home.

In December 2014, 338 children were being looked-after by Trafford Council, which is a rate of 63.8 per 10,000. This is above the national average of 60 per 10,000. Ofsted rated children’s services in Trafford as ‘good’ overall, with ‘outstanding’ ratings for its leadership and the experiences of its care leavers. Since November 2013 76% of local authority children’s services have been rated as inadequate or requires improvement. Ofsted’s 2015 inspection of Trafford’s children’s services noted:

The success of the local authority is characterised by the highly effective partnership work and in particular the joint working arrangements between the local authority and the health service provider. This is underpinned by a fully integrated children’s social care and health service; a delivery model which provides a highly effective response for children and families.B

On the subject of co-location Ofsted reported that:

The co-location of social workers with health staff and child and adolescent mental health service (CAMHS) workers supports good access to services for children with complex needs. These arrangements and the authority’s long-standing commitment to innovative and evidence-based practice have resulted in continual improvements and better outcomes for children.C

During our visit we were impressed with the level of integration Trafford had achieved through co-location. Their open plan office accommodates a large number of front-line staff meaning that many teams and individuals are within sight of each other. Senior managers are located in the same building.

The council is also coterminous with the police command unit and the clinical commissioning group. Greater Manchester (GM) Police has operational boundaries which are aligned with the metropolitan local authorities within GM. The Pennine Care Health Trust, which covers six local authorities, also has a Trafford division which is coterminous with the local authority.

The Committee met staff in the Multi-Agency Referral and Assessment Team (MARAT). They are the ‘front door’ to Trafford’s services and complete initial assessments once referrals have been made. MARAT seeks to identify problems early and conduct suitable interventions.

Leadership appeared to be strong throughout the service, with clear accountability, and continuity of key staff through low turnover. The Chief Executive was able to confidently articulate the benefits of a fully integrated service and she was well supported by a strong management team. At least one member of the management team attends every corporate parenting board and this personal involvement in the lives of looked-after children is considered to be very important.

A Since we visited Trafford Council they have announced that the Pennine Care NHS Foundation Trust will take responsibility for the day-to-day provision of children’s services. They sent us a statement describing how this new arrangement will operate (MHW 75).

B Ofsted, Inspection of services for children in need of help and protection, children looked-after and care leavers and review of the effectiveness of the local safeguarding children board (May 2015), p 6

C Inspection of services for children in need of help and protection, children looked-after and care leavers and review of the effectiveness of the local safeguarding children board, p 20

Out of area placements and movement of looked-after children

81.The Children’s Services Development Group (CSDG) told us that there are particular problems in service commissioning for looked-after children and young people who have been moved outside their local authority.103 They state that “a child placed ‘out of area’ is often unable to access services, as neither local authority will accept responsibility for the commissioning and funding of the service”.104 This can lead to a looked-after child being without care for extended periods of time and often being placed on the end of a waiting list. CSDG considered the joint DfE and DH statutory guidance to be “unclear” on this topic and advised that it should be revised to provide clarity on who is responsible for a child or young person who has moved area.

82.Dr Ingrassia told us that agreements on funding can delay access to care for children in out of area placements.105 She and others emphasised that children placed out of their area were particularly vulnerable and required more support rather than less:

Ofsted’s 2014 thematic inspection looking at children living out of area found that delays receiving CAMHS support could be most often attributed to a lack of local capacity, poor liaison between different local authorities and clinical commissioning groups, and lengthy disputes about funding. The varying cost of CAMHS provision across health boundaries often contributed to these funding disputes.106

83.NICE guidelines also address the specific problem of looked-after children moving out of the local authority area:

Children and young people placed out of the local authority area are less likely to receive services from CAMHS in their new location. Looked-after children and young people should be regarded as a priority group for specialist mental health services, especially when moving from one area to another.107

84.No looked-after child should face a delay in accessing services after moving local authority area. We recommend that the Government amend its joint statutory guidance to clarify the balance of responsibility between local authorities when looked-after children and young people are placed out of area.

The role of local leadership in service commissioning

85.During our visit to Trafford Council we witnessed the effectiveness of strong, local leadership. The vision of an integrated service articulated by the Chief Executive and Directors was compelling and well implemented by front line teams. Edward Timpson told us that he saw local leadership as a key part of effective service provision:

Leadership. This is going to require people at the top telling others, “This is something that we have to all play our part” and where we see that happening, places like Croydon, places like Essex, places like Haringey where they have co-located or they have integrated services, it is because there is leadership saying, “this matters”.108

86.According to the statutory guidance, the Health and Well-being Board should play a leading role in considering the needs of looked-after children. Every Health and Well-being Board should comprise “a representative from each CCG whose area falls within or coincides with the local authority area, the Director of Children’s Services, the Director of Public Health, the Director of Adult Social Services and a representative from the local Healthwatch organisation”.109

87.The role of the Health and Well-being Board in local leadership is described in the Future in Mind report:

The local plan itself should be derived from the local Health and Well-being Strategy which places an onus on Health and Well-being Boards to demonstrate the highest level of local senior leadership commitment to child mental health. Health and Well-being Boards have strategic oversight of the commissioning of the whole pathway or offer regarding children and young people’s mental health and well-being.110

88.Alison O’Sullivan, President of the Association of Directors of Children’s Services (ADCS), told us that Health and Well-being Boards “are where the leadership across the local system sits”.111 Barbara Herts agreed and stated that Health and Well-being Boards are “absolutely critical for holding the Local Transformation Plan to account”.112 She added that their role should be strengthened. Essex’s written evidence said that Health and Well-Being Boards are “well placed to provide co-ordination and leadership locally”.113

89.Several pieces of written evidence told us that aside from existing leadership structures, there should also be a role for “a designated mental health professional for looked-after children and young people” Professor Fonagy said:

We currently have designated doctors, who are usually paediatricians; we have designated nurses for looked-after children. We do not have a designated mental health professional. I think maybe we could consider having someone in the system who is there to co-ordinate mental health input for looked-after children, who can identify genuine mental health needs, who is aware of alternative care pathways, who can oversee mental health literacy and training and has a perspective of mental health and holds that perspective in a powerful way.114

90.Ms Herts responded to Professor Fonagy’s proposal, agreeing that every area should have a specialist “that could be that sort of systems leader for mental health and well-being to identify appropriate pathways”.115 She described the approach which Essex County Council had taken:

Part of our system is having a specialist mental health professional that can provide on pathways, the evidence base and bringing that together across social care, health and education.116

91.Integration of education, social care and health services should be driven by strong local leadership. The Health and Well-being Board should have ownership of this agenda and strategic oversight of the commissioning of services for children and young people in their care. We recommend that each local area employ a senior, designated mental health professional with expertise in the diagnosis and treatment of mental illness and awareness of the broader risk factors common in looked-after children.

84 Dr Antonina Ingrassia (MHW 70) para 6

85 YoungMinds (MHW 71) para 9

86 Q213

87 Department of Health (MHW 73) para 10

90 Q70

91 Q11

92 Q212

93 Q81

94 NHS England sent us the following comment: A quantitative report of Local Transformation Plans which provides an analysis of data on spend, and number of referrals for 2014-15 has been published by NHS England. This will form the baseline by which progress will be measured. This report does not include information on outcomes and effectiveness of treatment. This will come, in time, from the Mental Health Services Dataset. A qualitative analysis against agreed themes will follow later in the spring. These will provide information taken from all the Local Transformation Plans and will highlight interesting practice and examples of particular services or groups that local areas have prioritised. One of the themes will look at “vulnerable groups”, which includes looked-after children, children adopted from care and care leavers.

95 Q71

98 Department of Health (MHW 73) para 4

99 NSPCC (MHW 43) para 24

101 Q99

102 Q99

103 The Children’s Services Development Group (MHW 26) para 2

104 The Children’s Services Development Group (MHW 26) para 4

105 Dr Antonina Ingrassia (MHW 70) para 7

106 Ofsted (MHW 64) para 4.4

108 Q218

111 Q105

112 Q105

113 Essex County Council (MHW 25) para 2.6

114 Q97

115 Q117

116 Q101

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Prepared 27 April 2016