A number of challenges were identified among the pilot areas, when reflecting on the situation before the programme. While not common to all areas, the qualitative interviews suggest that the recurring issues raised by NHS CYPMHS included:
• highly variable working relationships with individual schools, resulting in
inconsistencies in staff and young people’s access to specialist advice and support
• a propensity for schools to refer via general practitioner (GP) surgeries, in areas where it was not necessary to do so, for example, in the belief that this would increase the chances of success
• difficulties posed by parental consent for sharing information on referral outcomes with schools
• lack of visibility of mental health provision within schools, as a result of perceived inconsistencies in the management, staffing and funding of mental health support
From the perspective of schools, the principal challenges included:
• a perception of too much indirect or impersonal contact via letter-writing or email communication, resulting in misunderstanding, with insufficient post-referral feedback
• complex and fragmented commissioning, resulting in inconsistencies and poor links between providers and provision that formed part of the NHS CYPMHS offer
• perceived inconsistencies in the response to schools from NHS CYPMHS services, resulting in variations in the service offered within the same authority
Furthermore, both schools and NHS CYPMHS respondents cited a common barrier relating to the frequent hand-offs between services. This was sometimes reported to have led to situations in which young people were passed backwards and forwards between schools, GPs and NHS CYPMHS, resulting in delays to the time taken to receive treatment.
The baseline surveys for the evaluation provide further insights to the views and
experiences of schools and NHS CYPMHS, prior to taking part in the pilot programme. Online surveys were conducted with lead contacts for pilot schools, and NHS CYPMHS, prior to the initial workshops. The survey data is particularly useful in understanding schools’ perspectives on access to mental health services, and overall levels of self- reported knowledge and confidence. In total, 166 school lead contacts were surveyed, representing almost two-thirds (65%) of all pilot schools and therefore providing a robust sample for the purpose of understanding the range of views within the cohort.
When asked about mental health support within their school (Figure 1), the lead contacts reported largely positive views on leadership and management arrangements, with a considerable majority of respondents (97%) agreeing or strongly agreeing that children and young people’s mental health is afforded a high priority by the school leadership team (base = 166). Views were less strong, but still very positive, regarding satisfaction with support available from specialist colleagues within the school (73% agree or strongly agree) and the adequacy of resources allocated for specialist colleagues (64% agree or strongly agree). The overall picture, therefore, is one of a fairly high baseline level of confidence in school-level arrangements. As we go on to discuss further in the next section, this is perhaps indicative of an “above average” profile of the pilot schools regarding expertise and capacity for mental health support.
Figure 1 To what extent do you agree with the following statements about mental health support within your school? (school lead contacts)
Base: 166 respondents.
Turning to measures of individual professional knowledge and confidence (base = 16620),
school lead contacts similarly expressed high overall levels of confidence in their abilities to identify risk factors and behaviours21 (76% agree or strongly agree) and in signposting
students to appropriate support22 (70% agree or strongly agree). However, they were
less confident in their knowledge of different types of mental health issues23 (54% agree
or strongly agree) and of supporting children with different mental health needs in the classroom24 (16% agree or strongly strong agree/agree). The survey results reflect a
theme that emerged during the qualitative interviews at the subsequent case-study stage of the evaluation that school staff were considerably less confident when talking about what were perceived to be “clinical” mental health issues, despite often being much more comfortable in their knowledge and awareness of working with students with complex needs or challenging behaviours.
20 To what extent would you agree/disagree with the following statements about your knowledge of children
and young people’s mental health?
21 I am aware of a range of risk factors and causes of mental health issues in children and young people 22 I know how to help pupils with mental health issues access appropriate support
23 I am knowledgeable about a wide range of mental health issues
24 I know all I need to support children with different mental health needs in my classroom
Figure 2 Overall, how satisfied are you with the way that referrals were handled during the past school year?25 (school lead contacts)
Base: 166 respondents.
The baseline survey also allowed for a consideration of schools’ perceptions of referrals to specialist mental health support (base = 166). Overall, school lead contacts reported the highest overall satisfaction with referrals to specialist mental health support available within their school, such as counsellors or educational psychologists, with over half of respondents (53%) either ‘fairly’ or ‘very’ satisfied (Figure 2). In contrast, they reported the lowest level of satisfaction with NHS CYPMHS referrals, with just over one-third of respondents (35%) either ‘fairly’ or ‘very’ satisfied. They reported the lowest level of
awareness of referrals to other mental health services, with nearly two-thirds of
respondents (62%) unable to comment. This response is likely to include a proportion of respondents who did not make any such referrals within the past year.
The main reasons given by school lead contacts who were ‘not very’ or ‘not at all’ satisfied with referral arrangements included: perceived high levels of unsuccessful referrals, long waiting lists/times, inability to refer directly to NHS CYPMHS and lack of communication. These views largely concur with the issues reported by NHS CYPMHS, as described previously.
The same question was asked in the surveys of school and NHS CYPMHS lead
contacts, regarding the main barriers to providing effective mental health support. This allows for a comparison between the perspectives of these 2 stakeholder groups (Figure 3).
25 The baseline figure refers to the 2015/2016 school (academic) year, covering the 12-month period from
September 2015 to September 2016.
Figure 3 Significance of potential barriers to providing effective mental health support(combined – school and NHS CAMHS/CYPMHS lead contacts)
Base: 166 respondents (school lead contacts), 18 respondents (CAMHS/CYPMHS lead contacts).
While it is necessary to exercise caution, owing to the differences in numbers of professionals providing the lead contact role in schools and NHS CYPMHS (and therefore also in the survey respondents, at 166 and 18 respectively), the results show some interesting areas of similarity and difference. NHS CYPMHS held a slightly more pessimistic view overall, across most types of barriers. While these differences tended to be fairly small, there were 2 notable exceptions. NHS CYPMHS lead contacts assigned considerably greater importance to school-related barriers, including negative attitudes among school staff and the influence of the school inspection regime.
A baseline survey was also undertaken with a cross-section of school staff at different grades and levels of seniority, within a sub-set of 48 pilot schools (n = 552 respondents). This ‘whole school’ survey provides an insight to the views and experiences of school staff beyond the immediate lead points of contact. The top-line findings are as follows:
• As might be expected, less than half of respondents reported having attended training in issues related to children and young people’s mental health (43%). Of those who participated in training, over half had done so within the past year, and well over three-quarters within the past 2 years. Training was sourced from a diverse range of sources, including local NHS CYPMHS, and local or national
independent or third sector providers. Almost one-quarter of respondents (24%) had completed training online, purchased externally to their school.
• School staff were aware of referral procedures for mental health issues affecting students from a variety of different sources, including written protocols (52%), inductions for new staff (41%) and special briefings (41%). However, 2 in 10 respondents were unaware of how procedures regarding children and young people’s mental health were communicated in their school.
The survey also casts some light on how school staff engage with students and parents and carers on the subject of mental health and well-being. The results show quite frequent discussion with students. Nearly two-thirds of respondents (63%) reported talking to students about their mental health and well-being at least monthly, and over three-quarters of staff felt confident in doing so (76%). Just over one-third of respondents (35%) reported talking to parents and carers with the same frequency, while one-quarter (25%) never talked to parents and carers about these issues. On average, school staff were less confident in talking to parents and carers about mental health issues than they were with students.
Figure 4 How confident do you feel about talking to students about their mental health and well- being? (whole school survey)
Figure 5 How confident do you feel about talking to parents and carers about the mental health and well-being of students in your school? (whole school survey)
Base: 391 respondents.
In summary, therefore, the baseline survey shows that institutional barriers to joint working within schools were a particular concern to NHS CYPMHS in the period
immediately prior to taking part in the pilots. The school surveys raised some questions about the confidence of school-based staff in managing ‘risk’ around identification and referral of young people with mental health issues. They also showed some gaps in confidence at discussing mental health issues with parents and carers, and varying levels of awareness of referral procedures and protocols. Later, in Chapter 4, we review the extent to which positive changes were reported at the follow-up survey stage, post implementation.