MHW0050

Written evidence submitted by the Department for Education and the Department for Health
 

Summary and background

1. The English children’s social care system is underpinned by the legal framework set out in the Children Act 1989. This sets out the powers and duties on local authorities in relation to safeguarding and promoting the welfare of the children they look after.

The challenge

2. The number of looked-after children has increased steadily over the past seven years.  There were 69,540 looked-after children at 31 March 2015. Some 60% of children become looked after as a result of abuse or neglect. They have poorer educational outcomes than non-looked-after children and nearly 67% have some form of special educational needs (SEN) compared with less than 18% for the general population. The most common type of SEN for looked-after children is ‘behavioural, social and emotional difficulties’, which in 2014 accounted for 49% of looked-after children at School Action Plus as their primary need and 39% with a statement. 

3. Research by the NSPCC in 2015[1] indicated that looked-after children are at greater risk of experiencing poor mental health than children in the general population. Looked-after children are just over three times more likely to have a diagnosed mental health disorder than disadvantaged children and over five times more likely to have a diagnosed mental disorder than non-disadvantaged children.

4. The high rate of behavioural disorders among looked-after children is concerning because research suggests that children with disruptive and hyperactive behaviours are at particularly high risk of placement breakdown.[2]

5. Children become looked after for a variety of reasons. ‘Abuse or neglect’ accounts for the highest proportion of children entering care (61%) and while not every child who has been abused or neglected will have mental health problems, it is clear that many will and are likely to need specialist help as a result. 

6. The consequences of poor mental health for looked-after children are far-reaching. It is distressing in itself and it also increases the risk that looked-after children will experience a range of poor outcomes, and yet too many such children can find it hard to access the necessary support. At the heart of the Government’s drive to improve child and adolescent mental health is a clear focus on the needs of children and young people who are identified as vulnerable, including looked-after children.

7. The Department for Education (DfE) and the Department of Health (DH) are working together with NHS England to implement the proposals of the Children and Young People’s Mental Health and Wellbeing Taskforce as set out in Future in mind.

Roles and responsibilities

8. The DfE is responsible for setting the overall policy framework for education and children’s services in England. It is responsible through national policies and legislation for:

• teaching and learning for children in the early years, primary and secondary education in schools and in further education colleges for young people under the age of 19;

• supporting professionals who work with children and young people;

• helping disadvantaged children and young people, including looked-after children, care leavers and children with special educational needs, achieve their potential;

• making sure that local services protect and support children, including in relation to intervention by the Department where a local authority is failing to deliver its services to an acceptable standard.

9. Local authorities have statutory responsibilities for the delivery of children’s services locally, including those for looked-after children and care leavers. Statutory duties set by Parliament and supported by statutory guidance set out the roles and responsibilities of local authorities.

10. The role of the Department of Health (DH) is to help people to live better for longer. It has four responsibilities:

• to lead across health and care by creating national policies and legislation, providing the long-term vision and ambition to meet current and future health care challenges

• to support the system by providing funding, assuring the delivery and continuity of services
• to champion innovation and improvement by supporting research and technology

• to encourage staff in every health and care organisation to understand and learn from people’s experiences.

11. NHS England leads the National Health Service (NHS) in England. It:

• sets the priorities and direction of the NHS and encourage and inform the national debate to improve health and care.

• distributes funding and holds organisations to account for spending it effectively

• commissions health care services in England, including GP contracts

• supports local health services that are led by clinical commissioning groups (CCGs).

12. NHS England has an assurance and system leadership role for safeguarding in the NHS, for which it issued a revised accountability and assurance framework in July 2015. NHS England gains assurance and oversight of issues concerning looked-after children through its National Safeguarding Steering Group, which has a sub-group which has a specific focus on looked-after children.

13. The Care Quality Commission (CQC) and Ofsted are responsible for the inspection of services. 

• CQC inspects local health service arrangements for safeguarding children and for Looked-after children and care leavers. These inspections look at the contribution of health services to promoting and improving the health and wellbeing of Looked-after children, which includes carrying out health assessments for and providing appropriate services to these children.

• Ofsted inspects local authority services for children in need of help and protection, looked-after children and care leavers.  As part of the inspection they focus on the experiences and progress of looked-after children, including adoption and fostering, the use of residential care and children who cease to be looked-after and return home to their families. Ofsted’s framework[3] and evaluation schedule for the inspection of services for looked-after children states that a local authority is likely to be judged good where ‘children are in good health or are being helped to improve their health and their health needs are identif

• ied. Child and adolescent mental health provision, therapeutic help and services for learning or physically disabled children and young people are available when needed and for as long as they are required’.

14. The National Institute for Health and Care Excellence (NICE) publishes guidance, advice, quality standards and information services for health, public health and social care. This includes a quality standard for the health and wellbeing of looked-after children and a public health guideline (number 28) on looked-after children. NICE is shortly to publish a DfE commissioned guideline on the identification, assessment and treatment of attachment difficulties in children and young people who are looked-after and those who leave care as a result of adoption, or special guardianship.

Future in mind: transforming mental health services for children and young people

15. Children and young people’s mental health is a priority area for Government. The DH is committed to delivering the vision set out in Future in mind, the report on the work of the Children and Young People’s Mental Health and Wellbeing Taskforce set up under the previous Government. This report established a clear and powerful consensus about change across the whole system, including health, social care and education.

16. A national programme of work is underway, which includes the extension and expansion of evidence based intervention, a campaign to tackle stigma, work to improving data leading to greater transparency and accountability and the development of a workforce with increased capability and capacity. Active engagement with children and young people underpins the national work.

17. Future in mind devotes a chapter to children with greater vulnerability to mental health problems, including looked-after children. This chapter explains that many vulnerable children find it difficult to access help and support from specialist services. Looked-after children told the taskforce that services were not accessible to them, for example, they were not delivered in a way that felt comfortable or they could not get the help that they needed.

18. Future in mind identifies a number of aims in relation to vulnerable children that local areas should consider when planning and developing their emotional and mental health services for children:

• Co-ordinated services should be provided in ways that will build the resilience of children and young people and enable them to feel safe through offering evidence-based interventions and care, drawing on the expertise and engagement of all the key agencies involved.

• Children, young people and their families who have additional vulnerabilities and complex mental health needs should not have to fight for services, nor be offered services that are well-meaning, but are not evidence-based or which fail to meet their needs.

• ‘Not attending’ appointments should not lead to a family or young person being discharged from services, but should be considered as an indicator of need and actively followed up.

• Staff who work with vulnerable groups should have access to high quality mental health advice and support when and where it is needed.

Scope of the statutory guidance

19. The Children Act 1989 and associated regulations and statutory guidance provide the framework for arrangements that local authorities should make in relation to care planning, placement of looked-after children. They set out in broad terms what a child’s care plan should include, timings for the review of their cases and the support that care leavers should receive as they make the transition to adulthood. 

20. The DfE and the DH published joint revised statutory guidance on Promoting the health and wellbeing of looked-after children in March 2015. This guidance is issued to local authorities, Clinical Commissioning Groups (CCGs) and NHS England under sections 10 and 11 of the Children Act 2004 and they must have regard to it when exercising their functions. The guidance is also issued under section 7 of the Local Authority Social Services Act 1970. Local authorities must comply with this guidance unless there are exceptional reasons for departing from it.

21. This guidance is only one source of information about the Government’s expectations in relation to meeting looked-after children’s mental, emotional and physical health needs. Local authorities, CCGs and NHS England should use it alongside other relevant statutory guidance and advice. This includes:

• Public Health England(PHE)/DH guidance on commissioning services for 5-19 year olds

• DH/ PHE pathway advising schools and school nurses on how best to plan for and meet the needs of looked-after children

• The special educational needs and disability code of practice 0 to 25

• Mental health and behaviour in schools

22. The revised statutory guidance on Promoting the health and wellbeing of looked-after children replaced existing guidance issued by both Departments in 2009 and reflects NHS reforms introduced by the Health and Social Care Act 2012. It is divided into two distinct parts. Part one explains the joint strategic responsibilities that local authorities and health have towards all looked-after children. Part two describes broadly how services should be planned and provided in order to promote the individual health and wellbeing of looked-after children. Together, both parts set out the way in which local authorities, CCGs, NHS England and service providers should discharge their statutory responsibilities within the broad framework of primary and secondary legislation. 

23. Following consultation between  November 2014 and January 2015, the guidance was revised to:

• make explicit that promoting the health of looked-after children included their mental and emotional health as well as their physical health (parity of esteem)[4]

• highlight the high proportion of looked-after children who have poor mental health, as well as the number with special educational needs; and

• highlight messages about the importance of addressing the mental and emotional health of looked-after children because of the longer term impact on their education outcomes and life chances.

24. The guidance sets out clear expectations that all looked-after children should:

• have a health assessment and associated health plan that will address their emotional and mental health as well as physical health

• be able to participate in decisions about their health care within a culture where they are listened to and their views are taken into account

• have targeted and dedicated support through child and adolescent mental health services (CAMHS) and other services, according to their need, arranged by CCGs, local authorities and NHS England

• never be refused a service, including for mental health, on the grounds of their placement being short term or unplanned

• be able to obtain the healthcare they need when leaving care.

25. The guidance states that the health needs of looked-after children should be taken into account by local areas when developing their Joint Strategic Needs Assessment (JSNA) and Joint Health and Wellbeing Strategy (JHWS).

26. Specific considerations should also be given to looked-after children as set out in the mandate to NHS England and the Guidance for local areas preparing Local Transformation Plans for Children and Young People’s Mental Health and Wellbeing.

Implementation of the guidance: wider children’s mental health reforms

27. The overall context within which this guidance sits is the Government’s commitment to raise awareness of and prioritise mental health support for all children, and to improve mental health. This is set out in the vision of Future in mind, the Government’s report of the Taskforce on Children and Young People’s Mental Health and Wellbeing.

28. Future in mind sets the scene for a transformation of mental health care for children and young people, and sets out a series of proposals for local areas to explore such as the use of embedded mental health professionals in child health and social care teams. One of its key themes is care for the most vulnerable who will benefit from transformational work in areas including: promoting resilience, prevention and early intervention; improving access to support – a system without tiers; accountability and transparency; and developing the workforce.

29. The Government’s commitment to mental health was further demonstrated by mandating NHS England to ensure services provide parity of esteem for both physical and mental health. For looked-after children this means when they have their annual health assessment, or visit the GP or other health professional they can expect their mental health needs to be taken as seriously as their physical health needs, with appropriate accessible advice and treatment being offered. Looked-after children can also expect public understanding of children’s mental health to increase through a child focused ‘Time to Talk’ campaign. They and their carers, social workers and teachers will also know more about the places they can go to for help. Health Education England will support and improve the training of professionals which will mean that looked-after children are treated and supported by professionals who better understand their specific needs and vulnerabilities.

30. £1.25 billion of new funding over 5 years has been identified to support the development of improved, more accessible services for children and young people’s mental health and wellbeing. A large proportion of this funding will be distributed to local CCGs following approval of their Local Transformation Plans for children and young people’s mental health and wellbeing.

31. The plans are expected to cover the full spectrum of mental health issues from prevention and resilience building to support and care for existing and emerging mental health problems, as well as transitions between children’s and adult’s services. Plans should also address the needs of the most vulnerable, including looked-after children and care leavers. Plans will be appraised through a bespoke assurance process which will be concluded by the end of the year. Funding will be released if plans are sufficiently developed to secure the delivery of service transformation. From 2016-17 onwards, plans will be integrated into the mainstream CCG planning framework, with an expectation that CCGs will continue to work with key partners to refresh their plans and monitor improvements.

32. The transformation planning process is designed to empower local partners to work together to lead and manage change to deliver the national ambition set out in Future in mind, to:

• promote good mental health and wellbeing, prevention and early intervention

• deliver a step change in how care is provided – moving away from a system defined in terms of the services organisations provide towards one built around the needs of children, young people and their families

• improve access so that children and young people have easy access to the right support from the right service at the right time and as close to home as possible. This includes implementing clear evidence-based pathways for community based care to avoid unnecessary admissions to inpatient care

• deliver a clear joined up approach: linking services so care pathways are easier to navigate for all children and young people, including those who are most vulnerable

• sustain a culture of continuous evidence-based service improvement delivered by a workforce with the right mix of skills, competencies and experience

• improve transparency and accountability across the whole system - being clear about how resources are being used in each area and providing evidence to support collaborative decision making.

Improving mental health services for looked-after children and care leavers

33. The way in which mental health and wellbeing services are provided for looked-after children and care leavers and the quality of those services are determined locally. Future in mind sets out that children’s mental health services should be developed locally with those who use them, that they should be flexible and responsive to need and that they should consider issues of inequality, access and parity of esteem between physical and mental health care. Local plans should show how they will address the needs of these groups so that they are able to meet the needs of looked-after children by offering services as and when they are needed. 

34. Future in mind also describes a number of innovative service models aimed at improving access to services for vulnerable children and improve outcomes. The ‘Consultation and Liaison’ model (Future in mind paragraph 6.9, page 53) sets out a model whereby the professionals who have the closest relationships with the child are supported and trained by experts in mental health and neurodevelopment, some of whom may be working in regional or sub-regional centres. This enables these professionals to provide support to the child competently and confidently, drawing on the available experience and expertise of specialist staff as needed. 

35. The ‘embedded practitioner’ model (Future in mind paragraph 6.10, page 53) sets out how mental health professionals placed in teams who work with children in the community may help to improve outcomes. The advantage of this model is that it enables basic mental health skills to be imparted to the team’s staff, while also allowing the mental health practitioner to build relationships and trust with children who use the service. This is particularly important for looked-after children who often find it hard to engage with more conventional services.

36. An embedded approach was successfully tested in two children’s homes in Kensington and Chelsea, where a CAMHS practitioner supported the children as their ‘life coach’ and also supported staff training and supervision around the children’s mental health. The sessions with children covered planning for setbacks, dealing with loss, problem solving skills, self-belief, understanding anxiety, managing panic attacks and understanding relationship patterns. The project reduced the pressure on the young people of being in a ‘service’. They reported they were able to come ‘in their pyjamas’ and ‘just talk’.

Data

37. Looked-after children will benefit from the move to far greater ‘parity of esteem’ between physical and mental health. For the first time, waiting times are being introduced in mental health. On 1 April 2015, early intervention in psychosis waiting times came into effect. 50% of people who experience first time psychosis should receive a NICE approved treatment within 2 weeks. There is also new guidance from the National Collaborating Centre for Mental Health / NHS England on the development of evidence-based community eating disorder services for children and young people to support preparation for implementation of access and waiting time standards for eating disorders.

38. A new mental health services dataset is being implemented that will (from 2016) begin to allow benchmarking of local services at national level. This will provide better data on outcomes, length of stay for in-patient care, the source of referral, waiting times, location of appointment and demographic information (including whether the child is looked-after) enabling far greater analysis of whether vulnerable children and young people are able to easily access services. We will closely monitor this new data to establish year on year improvements in service access for looked-after children, enabling us to evidence ‘closing of the gap’ between looked after and non-looked-after children.

39. As part of implementation of Future in mind, the DH are working with a wide range of partners, including children young people and their families, to develop a consensus on a set of metrics for the mental health and wellbeing for children and young people in the population to measure progress towards achieving the improvements set out in the report. A draft set of proposals for wider testing will be in place this year.

Workforce

40. ‘Achieving emotional wellbeing for looked-after children’ published by the NSPCC (2015), sets out four priorities, one of which is to ‘Embed an emphasis on emotional wellbeing throughout the system’[5]. The report sets out the need to improve the workforce’s understanding of looked-after children’s emotional wellbeing, ensuring that looked-after children receive high quality support from all carers, social workers and other professionals.

41. The workforce strategy being put in place through Health Education England and NHS England and investment in extending the children and young people’s improving access to psychological therapies (CYPT IAPT) programme to all areas, will mean that professionals delivering an NHS commissioned service will receive information and training to help them better understand the mental health needs of looked-after children and care leavers.

42. The workforce strategy will address the need for improved training in areas such as trauma-focused care and sensitive enquiry to find out about a child’s history of abuse or trauma. The CYP IAPT programme will be expanded to include new curricula covering, for example, treating mental health issues in children with learning disabilities and autism and children aged 0 to 5.  As a result, looked-after children should experience support and treatment from professionals who deliver NHS commissioned services, who better understand their history and are more aware of the experiences that they have undergone before coming into care and the impact this may have had on their mental health.

43. The Royal College of Nursing and the Royal College of Paediatrics and Child Health published an updated intercollegiate framework that sets out the knowledge, skills and competences expected of healthcare staff working with looked-after children and care leavers. The framework urges health service planners, commissioners and provider organisations to recognise the importance of staff to accessing education and training, as well as flexible learning opportunities to acquire and maintain knowledge and skills to improve outcomes for looked-after children.

44. The Department for Education has been consulting on the knowledge and skills statements for child and family social work Practice Supervisors and Practice Leaders. These statements will form a trio of definitive standards for a practice-based career pathway in child and family social work. They will be embedded into training and practice and will be the basis for a new national accreditation system.  The statements focus strongly on practice and emphasise a commitment to looked-after children so that they can thrive and receive the support to which they are entitled. The Knowledge and Skills Statement for Approved Child and Family Practitioners states that child and family social workers should, among other things, be able to: take account of typical age-related physical, cognitive, social, emotional and behavioural development over time; assess the effect of loss, change and uncertainty in the development of resilience; identify the impact of adult mental health and substance misuse and their effect on children; and prioritise children’s need for emotional warmth, stability and a sense of belonging, particularly for children who are looked-after.

The role of foster carers

45. Support to foster carers is also integral to ensuring the children they care for have good support for their emotional and mental health and wellbeing. Birmingham are currently piloting work with foster carers which trains them to understand and help address any emerging mental ill health issues, such as symptoms of psychosis and more serious established illnesses such as eating disorders and / or personality disorders in the children they care for. Local areas should take into account the training or resource needs of parents and carers when planning mental health services and support for children for their local transformation plans.

46. The Department has supported 24 local authorities to implement KEEP (Keeping foster and kinship carers trained and supported). KEEP is a group based training programme which aims to increase the positive parenting skills of foster and kinship carers in responding to children’s difficulties, reducing placement disruption and enabling children to be successful in childhood and adulthood. This included a specific programme (KEEP Safe) for carers looking after adolescents as well as KEEP P, which was designed for carers looking after children aged between 3 and 6. Between 2009 and 2014, 1168 carers entered a KEEP programme in England.  Through the Children’s Social Care Innovation Programme the DfE continues to support local authorities to implement this programme, specifically through funding for a further five KEEP Safe sites as part of the adolescent strand of the Innovation Programme.

47. Through the Innovation Programme, the DfE is also supporting The Mockingbird Programme. The Mockingbird Family Model is run by the Fostering Network with eight delivery partners, seven of which are local authorities in England.  It introduces the model of a dedicated ‘hub home’ of specifically recruited and trained carers offering respite care, peer support and regular joint planning activities to a ‘constellation’ of six to ten families of foster and kinship carers living in close proximity. Independent evaluation of this model in the United States demonstrates increased placement stability, more successful transitions to permanency, enhanced birth family and sibling relationships, improved retention rates for foster carers and an increased sense of community for carers and children alike.

Residential care

48. The children’s homes regulatory framework underwent significant consultation and review in 2014 to enable the development of new quality standards that must be achieved for looked-after children living in children’s homes.

49. As part of the new quality standards introduced in 2015, expectations were set out for looked-after children’s health and wellbeing, (as defined in the regulations as ‘a child’s emotional, mental and physical health’). The registered person for the home must ensure that the health and wellbeing needs of children are met; children receive advice, services and support in relation to their health and wellbeing and children are helped to lead healthy lifestyles.  

50. The emphasis throughout the quality standards is on staff helping and supporting the children they care for by being skilled to address any worries or able to sign post and enable appropriate action for any presenting mental health concerns.

51. The Prime Minister announced on 28 October that Sir Martin Narey will lead a review into residential care for looked-after children. Sir Martin will report his findings and recommendations in spring 2016. The overall purpose of the review is to set out the role of residential care within the wider care system, and to make recommendations about how outcomes for children who are currently placed in residential care can be improved. Given the proportion of looked-after children with poor mental health it is likely that the review will explore mental health and wellbeing of looked-after children in residential settings.  

Crisis care

52. The Government has announced plans to change legislation to prevent police cells being used as a ‘place of safety’ for young people who may be suffering a mental health crisis. The DfE and the DH are working with the police, the NHS and other partners to ensure suitable alternatives to police cells are available ahead of the legislative changes. It is recognised that not all of these children will have a mental health problem:for some, it may be that their underlying problems are broader, such as the breakdown of a social care placement.

53. Local areas must respond appropriately to the guidelines in the Crisis Care Concordat to ensure that children in mental health crisis are placed in the most appropriate setting to keep them safe and meet their needs. The Home Office is making £15 million available to local areas who lack crisis care provision to improve and increase capacity for children and adults who need a place of safety.

54. Local Transformation Plans should include details of how local areas will enhance or develop their community eating disorder services in line with new guidance. If any capacity is freed up by the new community teams, it should be redeployed to improve crisis and self-harm services.

55. Future in mind aims, in the long term, to reduce the use of specialist mental health facilities. By identifying children vulnerable to mental health problems earlier, they can be supported to develop greater resilience, reducing the likelihood that they will experience mental ill health or a mental health crisis. This is particularly relevant to looked-after children who may have had adverse experiences during their childhood that may impact on their emotional and placement stability and their education and health outcomes.

56. The 14 secure children’s homes across England offer support and care for some of the most vulnerable looked-after children, many of whom have complex mental health needs. Triggered by the recent pressures on welfare placements, DfE has been working jointly with Association of Directors of Children’s Services (ADCS), the Local Government Association (LGA), NHS England and secure home representatives to consider how the system can be better co-ordinated and joined up nationally to meet changing needs. Strengthening homes’ capacity to respond to mental health needs, improving access to specialist mental health support, and building clearer pathways between secure and in-patient mental health care have all emerged as strong themes. Ministers will be considering the recommendations of this joint work and there will be an announcement on the way forward in due course.    

Transitions to adulthood

57. Looked-after children who are experiencing mental health issues or are receiving treatment in their late teens become especially vulnerable as a move to adult services is discussed. Discharging or transferring a young person who is scared and / or ill at aged 18 can be devastating and potentially fatal. Some looked-after young people have reported experiencing a ‘cliff-edge’ - a gap in care during transition, or no service at all because they do not meet the threshold for adult mental health services. The cliff-edge leaves looked-after or care leaving young people unsupported or in a new service that does not meet their immediate needs.

58. To support improved transitions between children and adults services, NHS England published new service specifications for commissioners, giving guidance and best practice on transition from CAMHS to adult services (or elsewhere). These specifications intentionally do not stipulate an age threshold for transition (for example, 18) but state that transition should be built around the needs of the individual, not focussed on age.

59. Future in mind also recognised that transition at aged 18 years is not always appropriate and proposed that there should be flexibility, with transition based on individual circumstances rather than absolute age, supported by joint working and shared practice between services to promote continuity of care.

60. Improving outcomes for care leavers continues to be a Government priority.  DfE is building on the achievements of the first cross-government care leaver strategy published in 2013 and is working with other government departments, including DH, and NHS England to raise awareness about the needs of this particular group and how best to meet their needs.

Coordination of education, social care and health

Identifying effective practice

61. Practice is most effective where professionals work together across agencies and professional backgrounds to support the mental and emotional wellbeing of looked-after children.  Recent Single Inspection Framework Ofsted reports of services for looked-after children and care leavers  identified the following examples:

• in Trafford ‘the co-location of social workers with health staff and CAMHS workers supports good access to services for children with complex needs’ and  these arrangements have resulted in continual improvements and better outcomes for children. 

• in Warrington the Strength and Difficulties Questionnaire (SDQ)[6] outcomes are monitored by a specialist nurse, who supports social workers to identify appropriate service responses.

• In Hartlepool dedicated staff located in the multi-disciplinary placement support and therapeutic team provide a broad range of interventions to help children with their emotional wellbeing. There are many examples of these contributing to good outcomes such as building resilience, improved progress socially and academically and contributing to stable placements.  A looked-after children nurse based in the ‘through-care team’ is available to talk to children and care leavers who visit the office or use the drop-in facility and refers them to specialist health services as necessary.  Ofsted reported that young people said they value this service. The use of SDQs helps assess the emotional needs of looked-after children, including through the use of the self-reporting SDQ, which can be completed by the young people themselves.  

62. There are other examples of effective evidence-based services.  The Central Manchester University Hospitals NHS Foundation Trust has a specialist CAMHS team that works with children, including those who are looked-after and adopted, up to the age of 18, family members and other key adults to understand their problems.   The team delivers local services in North, South and Central Manchester and Salford by providing assessment and treatment. It also includes outreach and social workers who give ongoing support. Among the services provided are cognitive behaviour therapy, family therapy and courses for parents and carers as well as young people.

Care planning and health

63. The process of planning for the care of a looked-after child and making sure that every aspect of care works effectively for the child, his or her carers and birth family is crucial. This requires everyone involved in making decisions that impact on the lives and wellbeing of looked-after children (including commissioners, carers, social workers, Independent Reviewing Officers (IROs) Virtual School Heads and teachers to designated nurses and doctors) to work together to ensure that the education, health and social care needs of the whole child are met in a timely and effective way.

64. All looked-after children must have a care plan that describes how the local authority will meet their needs. The elements that a care plan should include are outlined in the Care Planning, Placement and Case Review (England) Regulations 2010 and accompanying statutory guidance.

65. Social workers are responsible for coordinating the overall care plan, which sets out what the child’s assessed needs are and how they will be met.  The assessment and plan must address seven aspects of a child’s developmental needs: health, education, emotional and behavioural development, identity, family and social relationships, social presentation and self-care skills. 

66. As part of the care planning process, social workers must make arrangements to ensure that in relation to health every looked-after child has:

• their physical emotional and mental health needs assessed

• a health plan developed from the report of that assessment, describing how those identified needs will be addressed to improve health outcomes

• their health plan reviewed in line with care planning requirements or at other times if the child’s health needs change. 

67. The statutory guidance Promoting the health and wellbeing of looked-after children makes clear that a looked-after child’s health assessment should be informed by use of the Strength and Difficulties Questionnaire (SDQ)[7] to assess their emotional wellbeing. The questionnaire exists in three versions: for parents or carers, teachers and children aged 4 to 17 and should be used to screen for any problems related to a child’s emotional wellbeing and to help social workers and health professionals form a view about a looked-after child’s behavioural and emotional health. The guidance goes on to state that if the SDQ completed by the carer[8] suggests that the child’s total difficulties score is outside the normal range (i.e. a borderline score of 14-16 or a score of 17+ considered as giving cause for concern), the child may benefit from triangulating the scores from the carer completed SDQ with an SDQ filled in by the child’s teacher and the child themselves.

Care planning: the importance of health in relation to educational attainment

68. As well as having a responsibility to promote the health and welfare of the children they look after, local authorities have a particular duty to promote their educational achievement, wherever they are placed.  This is integral to promoting their overall wellbeing.  All looked-after children should also have a Personal Education Plan (PEP), which like the health plan is an integral part of the overall care plan. Like other strands of a care plan the PEP should address the range of education and developmental needs to ensure looked-after children reach their full potential. This includes support needed in relation to school attendance and, if necessary, with behaviour as well as access to out-of-school learning activities and leisure interests.

69. Where a looked-after child is identified as having special educational needs (SEN) requiring an Education, Health and Care (EHC) plan or is undergoing a statutory assessment, the statutory Special educational needs and disability code of practice 0 to 25 describes the links that should be made between EHC and care planning processes. The EHC plan is specifically intended to bring together the full range of support required by a child. It should therefore include any necessary mental health support. The Children and Families Act 2014 placed new duties on health services to engage with the EHC plan process and with joint commissioning of services in support of it.

70. Not all pupils with SEND will require an EHC plan. The code of practice states that schools should take a ‘graduated approach’ when they identify that a pupil has an issue and/or is making less than expected progress. The code is clear that schools should look beyond presenting issues such as behaviour to see whether there is an underlying issue such as a mental health problem. We introduced a new Social, Emotional and Mental Health (SEMH) category of need to reflect this. The code states that schools should work with carers and young people themselves to decide what SEN support to put in place, including whether any specialist provision is needed. Under the code, schools should publish in their SEN Information Report their arrangements for supporting looked-after children with SEN, including those with SEMH needs.

Virtual School Heads (VSHs)

71. The Children and Families Act 2014 required local authorities to appoint an officer (commonly known as a Virtual School Head (VSH)) to ensure that the authority’s duty to promote the educational achievement of its looked-after children is discharged as if all the children were in a single school. This includes working with schools (particularly in relation to managing Pupil Premium Plus funding for looked-after children) and those in local authorities who are responsible for school admissions and exclusions and SEN. There are regional networks of VSHs.  The national steering group of VSHs includes a representative from each of the regions.  The networks are increasingly aware of the relationship between mental health and emotional wellbeing, including attachment, and educational outcomes.  Further information on the work VSHs are doing with schools is described below.

The role of Independent Reviewing Officers (IROs)

72. A looked-after child’s care plan, including the health and education strands of it, must be kept under regular review. This review is chaired by an IRO, who is responsible for monitoring whether the child’s needs, including those in relation to health, as set out in their care plan, are being met. IROs should, as part of the child’s case review, ensure that the child is involved in their review and have their wishes and feelings respected. The IRO should:

• note any actions and updates to ensure that the health plan continues to meet the child’s needs and 

• be proactive in bringing any deficiencies in the quality or delivery of the health plan to the attention of the appropriate level of management within the local authority.    

73. Specifically on social care DfE has been working with the Council for Disabled Children and IROs on how the care planning and EHC processes should be used to ensure there is a holistic approach to meeting the education, health and care needs of looked-after children.

Mental health in schools

74. Mental wellbeing is crucial to children’s readiness to learn and reach their potential and build their resilience. The vast majority of schools already teach pupils about mental health, wellbeing and resilience. The Centre Forum report in December 2014 found that 94% of secondary schools surveyed promote positive mental health through lessons such as personal, social and health education (PSHE).  To support schools and colleges, the DfE funded the PSHE Association to produce guidance and lesson plans on mental health and wellbeing. These plans support age appropriate teaching about dealing with emotions and talking about anxieties and worries. For older children, the lessons cover more specific teaching about mental illness. Nearly 2,000 pupils have been involved in developing these materials.

75. Effective support for children’s and young people’s mental health, particularly for looked-after children, involves more than just what happens in lessons.  Looked-after children may need more targeted support ranging from counselling to more specialist help. In March 2015, the DfE published guidance on counselling.  This guidance, developed with experts, gives advice on how to deliver high quality school-based counselling. It emphasises how counselling works best as part of a whole school approach to wellbeing and provides schools with practical, evidence-based advice and how to make referrals to specialist services.

76. The Department also published advice for schools on pupils’ mental health and behaviour. This is aimed at designated teachers amongst other staff and reminds schools that some children, such as those who are looked-after, are more vulnerable to mental health difficulties and gives schools advice on how to make referrals to specialist services if needed.

77. Since August 2015 Natasha Devon has been the DfE’s first ever mental health champion. Through her personal experience and understanding of the real issues that children and young people are facing, she will make a difference in encouraging them to talk more openly about them, and help get out the message of how important the Government thinks it is for schools to focus on mental health.

78. A national awards scheme was launched to reward and showcase schools and organisations that demonstrate their commitment to building character and resilience in young people aged 5 to 16. Twenty-seven schools were announced as regional winners in March 2015.  King’s Leadership Academy, a secondary school in Warrington, which has experience of supporting a number of looked-after children to make good progress, won the national award.  

79. All maintained schools and academies are required to have a designated teacher for looked-after children. Designated teachers have an important role in acting as a source of advice and expertise about the needs of looked-after children, promoting a culture of aspiration and in making sure they have a voice in setting their learning targets. The DfE’s statutory guidance on the role of designated teachers includes advice about their role in promoting the health of looked-after children on the school roll and in providing effective pastoral support. 

80. DfE will continue to promote awareness of potential mental health issues and support the development of schools and teachers’ knowledge. MindEd, funded by the DH, has been developed to enable all adults working with children and young people learn more about mental health problems and how to support them. In 2015-16, the DfE has given MindEd a grant of over £550,000 to create additional resources for families. DfE is also working closely with the sector to improve further the quality of teachers’ initial training and support their continued professional development.

81. The DfE is running (with NHS England) a CAMHS and schools link pilot project in 22 areas covering 27 CCGs. Five of these CCGs will also extend the pilot to focus on vulnerable children, two of which have highlighted looked-after children as a focus of their pilot. These are: South Cheshire (also involved in the New Belongings project[9]) and Birmingham South Central, which will be training school staff and foster carers in mental health and wellbeing issues as part of their Forward Thinking Birmingham initiative.

82. The aim of the pilots is to: improve the knowledge of mental health issues amongst school staff; improve CAMHS understanding of specific mental health and wellbeing issues within schools; and support more effective joint working between schools and CAMHS. Within each pilot will be a named lead in the school responsible for mental health. The lead staff member will also be responsible for developing closer relationships with CAMHS in support of timely and more appropriate referrals to mental health services. As part of the joint training the single point of contact in CAMHS will set out how referrals work in the local area and work with counterparts to establish how initial support can be delivered, for example in schools and better processes for securing specialist support. Following the training, the single point of contact will work with counterparts in schools, colleges and children’s services to ensure that referrals are appropriate and are dealt with in a co-ordinated way.

Promoting attachment awareness and wellbeing in schools: the work of VSHs

83. Poor mental health and wellbeing are contributory factors to the poor educational outcomes of looked-after children relative to those who are not looked after.  Improving the emotional wellbeing of looked-after children is essential to equip them with the emotional resilience necessary to succeed in school.  VSHs recognise this and are acting to address the challenge. To that end:

• The head of the virtual school in Bath and North East Somerset has worked with Bath Spa University to produce resources for schools about attachment awareness[10].  Virtual School Heads and Bath Spa University have also worked with the National College for Teaching and Leadership on raising awareness of attachment issues[11].

• VSHs in Stoke-on Trent, Dudley, Leicestershire and Haringey – with others joining – have also been working with bath Spa University and Kate Cairnes Associates to build on the work done with Bath and North East Somerset. This action research project involves: whole school training on attachment, trauma and strategies to support children facing these issues; proactive involvement of senior leaders; and an impact analysis based on tracking outcomes for looked-after children in relation to attainment, reduction in exclusion and improvements in attendance and wellbeing.  We understand from VSHs involved in the project that small scale results – not yet available - are encouraging.

• The Tri-borough (Westminster, Kensington and Chelsea and Hammersmith and Fulham) is rolling out a training programme and attachment aware schools project to develop whole school practice in meeting the needs of looked-after and vulnerable children. This is in direct response to feedback from schools for a core training offer and can be accessed at three levels:

1. A guaranteed termly visit from the Virtual School to the school’s designated teacher for looked-after children to support their role and carry out an evaluation of practice

2. A bespoke training package devised by the Virtual School to meet the needs of a particular school. The training will have an attachment/trauma focus but will also cover practical support that looked-after children as well as effective use of Pupil Premium funding.

3. A twelve month Attachment Aware School Project delivered in partnership with Kate Cairns Associates.

84. Preliminary evaluations of Bath and North East Somerset’s Brighter Futures Nurture Outreach Service undertaken by Bath Spa University suggest that there is a significant difference pre and post intervention with improvements in attendance, behaviour academic attainment and social and emotional progress.

85. There are examples of other VSHs involved in promoting mental health more generally.  In North Tyneside, as well as authority-wide attachment training for the children’s services workforce to develop a shared language and understanding  and the provision of a one day Attachment Friendly Schools course:

• SDQ questionnaires are completed by teachers and the young people and are monitored by the Virtual School alongside health professionals in the Raising the Health and Education of Looked-after children (RHELAC) Team

• There is a clinical psychologist within the RHELAC team who reviews the mental health services North Tyneside’s looked-after children access.

86. North Tyneside’s VSH has used Pupil Premium resource to fund additional educational psychologist time to deliver more bespoke interventions for schools.  She has also used Pupil Premium funding to provide a counsellor to address the needs highlighted in SDQs that don’t necessarily meet thresholds for CAMHS or other specialist services and to provide a drop-in service after more intensive intervention.  

87. The VSH in North Yorkshire is part of the authority’s overarching CAMHS strategy. The VSH reports that a significant piece of work being undertaken currently is to ensure that designated teachers complete SDQs for looked-after children on the roll of their school and have access to SDQ scores at meetings where the child’s personal education plan is reviewed. The Virtual School has also worked in partnership with the Local Safeguarding Children’s Board to provide training on attachment and trauma.

Involving looked-after children, their carers and care leavers in service design

88. Listening to the views of children and young people is fundamentally important in developing services that will meet children’s needs. 1500 children, young people, parents and carers contributed to the work of the Children and Young People’s Mental Health and Wellbeing Taskforce and subsequently their experiences were central to guiding and shaping the Future in mind report.

89. Guidance[12] on the development of local transformation plans states that plans must be ‘designed with and built around the needs of children, young people and their families’. The plans should have regard to the need to reduce inequalities between individuals in access to, and outcomes from, healthcare services. They should address the full spectrum of need including children and young people who have particular vulnerability to mental health problems for example, those with learning disabilities, looked-after children and care leavers, those at risk or in contact with the youth justice system, or who have been sexually abused and/or exploited. The plans should be agreed by the relevant Health and Wellbeing Board(s) demonstrating evidence of input from children and young people, including looked-after children and those who care for them as well as care leavers. 

90. One interesting example of getting children and their carers more involved in service design is the Improving Access to Psychological Therapy programme Services (IAPT). Services within IAPT must all be committed to hearing the views of children, young people, parents and carers and, most importantly, acting on them to make improvements and share good practice. The services use ‘session by session’ monitoring to ask children and young people to feed back about every session they attend. This helps to guide the therapy in the right direction so that it is as useful as possible. Children and young people are really in favour of and value this.

91. The refresh of the leaving care strategy will be an important opportunity for care leavers and those approaching care leaving age to have their say about transition to adult services, and to suggest models of care which may work better for them. Whilst the views of care leavers should be taken into account locally through the pathway planning process and children in care councils, there is little doubt that adult and children’s services need to work harder to support young people during this key and difficult transition. Both DH and DfE welcome ideas from children, young people and their carers on this.

92. DfE is working with a range of interested parties, including young people to  develop further our approaches towards mental health. DfE held the second round table with young people (including from groups such as the Youth Select Committee, Time to Change and YoungMinds Activists) on the 21 October 2015 and heard how they think services can be improved. DfE will be holding a roundtable for stakeholders on the 5 November with whom the Department has worked closely in the past, for example on the development of projects such as DfE guidance documents on counselling and behaviour and SEN reforms.

Innovation and pilots

93. The DfE is providing funding worth £4.7m, through the dedicated mental health strand of the voluntary and community sector grants programme, to support 17 projects delivering a wide range of support for children and young people with mental health issues. These include: 

• Youth Access (leading a consortium of nine Youth Information, Access and Counselling Services (YIACS)) to increase access to counselling and other psychological therapies to young people aged 16+, including care leavers, asylum seekers and refugees, particularly at points of transition. Typically the service supports improvements in referral pathways and assessment processes; helps reduce the risk of young people falling through service gaps; and encourages more joint commissioning between child and adolescent and adult mental health services to improve capacity to work across age boundaries

• Get Connected, which supports an interactive helpline

• Metro Centre to raise awareness of, and providing a mental health service for lesbian, gay and transgender young people

• Prince’s Trust, which is supporting social work students to provide emotional wellbeing support and guidance to those young not in employment, education or training (NEET) who are participating on their support programmes

• CentrePoint, which is training its staff to have a better understanding of mental health issues amongst young homeless people.

94. The Children’s Social Care Innovation Programme has provided £100 million to support the development, testing and sharing of more effective ways of supporting children and families who need help from children’s social care services. Over half (59%) of authorities in England are either leading or a partner in one of the projects and there is an increased appetite for innovation. Some of the projects being funded will help address some of the most challenging mental health problems experienced by young people in and on the edge of care including:

• Priory Education Services working with Suffolk Council (£1 million) to pilot a new type of residential home that combines education, care and mental health support. Staff include a mix of residential care professionals, children’s mental health nurses, teachers and therapists. The aim is to offer an alternative to inpatient treatment for children in or on the edge of care that is delivered in the community, closer to home, which helps to maintain links with family, community and continuity of social work support as well as care and educational placements. The model includes the use of therapeutic interventions, including high intensity CAMHS when appropriate. Once the child is ready, the Care and Education team liaise with the child’s home, school and care provider to manage their transition back into their family or care and education placements.   

• The National Implementation Service (NIS) (£4.1 million), which operates as a partnership between King’s College London and two NHS Trusts, is testing and building the sustainability of evidence-based interventions in the United Kingdom for programmes that support children in and on the edge of care. These include Multi-systemic Therapy, KEEP (a training programme for foster carers) and ResULT (a therapeutic training programme for residential care staff). The project aims to establish NIS as a sustainable UK centre of excellence, moving to a fully traded services model by the end of the funding period and to strengthen and expand the range of services that have been adapted and trialled in the UK.

• Action for Children and the local authorities of Barnet, Harrow and Hounslow (£3.3 million) have tested a suite of evidence-based programmes (Functional Family Therapy, Multi-Systemic Therapy and Multi-dimensional Treatment Foster Care) to transform the support available to adolescents in West London.

95. The DH has awarded a three-year grant to the Care Leavers Association between 2014 and 2017 to deliver its ‘Caring for better health’ project. The aim of the project is to improve the mental and physical health of care leavers by drawing directly on their experiences in the development of resources that should inform the commissioning and delivery of services.

October 2015