The wider context: ‘Readiness’ for programme implementation

A key consideration in the exploration and planning stage of implementation is an assessment of the ‘readiness’ of the setting (Weiner, 2009). Not surprisingly perhaps, and as indicated in the previous two chapters, it was evident from a range of interviewee responses that many broader factors had posed an obstacle to successful HSP implementation. For example, most principals noted that the economic climate and budgetary restrictions had led to pay cuts as well as a reduction in staff numbers and these challenges had in turn impacted on the ability and openness of schools to support new initiatives. On the other hand, some teaching staff pointed out that reform under the Croke Park and Haddington Road public sector work agreements26 meant that staff were expected to complete additional school hours; thus any engagement with the HSP could be encouraged in this way. These differing perspectives suggest that whilst national budgetary constraints are important, adapting initiatives in a way that incorporates the needs of staff can help to increase their involvement and in turn provide greater support for an initiative such as the HSP.

“I’d say there would definitely be more uptake on [HSP staff training workshops] with these [new] Croke Park hours. [Teaching staff] are supposed to do this continued professional development so schools are dying to get things like that now…” [Teacher,

Focus Group, year 2]

26 _{The Croke Park (2010-2014) and Haddington Road (2013-2016) public sector work agreements are} agreements between the Irish Government and various public sector union concerning work practice efficiencies, reform as well as pay and employment protection.

186

Importantly, some stakeholders perceived that a current lack of Departmental support at a national level for a health promoting school approach in Ireland would limit the extent to which staff might engage with such initiatives. Examples of independent localised HP initiatives (e.g. the North Cork Network of Health Promoting Schools27) were mentioned by a few interviewees, but a lack of link-up between these established initiatives was believed to have impeded their expansion. As one health professional interviewee identified, without national level management, the impact of these types of initiatives on systems level improvements, such as health related policy, is limited. This finding reflects conclusions from previous studies that emphasise the importance of both Department of Health and Department of Education support to achieving sustainable health promoting school progress (e.g. Bruce, Klein, & Kelleher, 2012; Deschesnes, Trudeau, & Ke´be, 2003).

“If the Department [of Education] said to them [the schools], this is really important, and yes you need to be able to go to the meetings and you need…well of course it would take on a completely different… it has to be [driven centrally].” [HS Funding Team

Member, year 1]

“There’s no official Department of Education buy-in to Health Promotion in Schools [in Ireland]…until that happens... I think it was very obvious [in the Welsh HSP model]

that there was very strong commitment from the Welsh Assembly to drive this down through schools. And that’s why it worked actually … I just think if the Department of Education were to sanction it, if the principals had bought into it and if Health Promotion could link more closely with the schools and deliver training and all that sort of thing …then … it would … make [the HSP] more effective.” [Health/Educational

Professional, year 1]

“I think that’s one of the difficulties [for the HSP is that]... if there was a national endorsement of the basic principles behind it then it would gather momentum I think a

27 _{North Cork Health Promoting Schools Network is a network of 30 schools who have worked together} with the Health Service Executive to develop a health promoting school ethos in their schools

http://www.hse.ie/eng/services/news/2008_Archive/Mar_2008/Health_Promotion_celebrated_by_30_Nor th_Cork_schools.html

187

lot quicker than basically being on its own or being a front runner in the way so…”

[Health/Educational Professional, year 2]

However, health and educational professional interviewees as well as members of the funding team observed that the organic and holistic nature of the HSP created challenges in gaining support at a governmental level. In particular, these participants commented on the short-term nature of public policy and how this impacts on the potential of health promoting school strategies. As one external professional stakeholder noted, a general lack of enthusiasm by policy-makers for longer-term initiatives, in addition to the lack of measurable outcomes inherent in health promoting school initiatives, makes it difficult for policy makers to endorse them. It is likely that more clearly defined short-term targeted initiatives are more attractive to fund and support than the HSP model. Thus, developing a health promoting school model like Healthy Schools is challenging. Nevertheless, according to some participants, efforts have been made by the Department of Education to address this challenge of incorporating health promotion in schools. For instance, in recent years efforts have been made to address health promotion in a more definable way via the Social Personal and Health Education (SPHE) curriculum28. Indeed, some studies suggest that the SPHE model is a practical way forward for integrating health and education using a health promotion approach (e.g. Lahiff, 2000; NicGabhainn, Barry, & O’Higgins, 2010). However, as one educational professional noted, the SPHE initiative, as it is currently being implemented, is more limited in scope than the health promoting school model. Indeed, based on interview feedback, this programme is viewed primarily as part of the school curriculum and does not fully incorporate a ‘whole school’ approach to health promotion:

“There is no point in telling the government that in 10 years’ time you will see [health] gains…they will say well, four years will be the next election. The HSE in particular…everything is built around their planning in terms of their funding…the long term gets lost in all of that then…” [Health/Educational Professional, year 2]

28_{According to the Department of Education (1999) the aims of the SPHE curriculum are to: promote all} aspects of health and well-being of the child, support children in developing respect for themselves and others in society, as well as enable children in effective decision making. The curriculum is comprised of 3 primary themes: 1. Myself; 2. Myself and Others; 3. Myself and the Wider World.

188

“The whole vision for SPHE was that it would pull those things together…[However,] one of the things … [that] annoyed me with the department, having set up SPHE, they then set up separately an anti-bullying program...that dichotomy has always been there.” [Health/Educational Professional, year 2]

In addition to governmental support, effective collaboration between the education and health services is also central to the sustainable development of a national health promoting school strategy. For example, one external professional stakeholder with extensive professional experience in health promotion practices suggested that focusing on the development of partnership working with established structures could provide a more sustainable approach to the implementation of the HSP. However, in Ireland there is little history of health professionals (i.e. a school nurse or therapist) maintaining a presence in educational settings and as a result the Irish school setting is not designed to accommodate health workers. For instance, it was acknowledged at the steering committee meetings that efforts by the HSE to develop links with schools were limited due to the complex and individualised structures of the Irish education system. According to some members of the funding team and external professional stakeholders, the lack of flexibility in schools in general limits the potential of the school as a health promoting setting. Indeed, one HSC indicated that practical issues such as the two month closure of schools during the summer period created difficulties in terms of consistency for some of the HSC work. Similarly, the structured nature of the school day and fixed school working hours were found by many school-based participants and HSCs to limit the extent to which staff are available to support and engage with the HSP. On the other hand, a number of participants working on the HSP also believed that structural complexities within the health services further impeded the availability of adequate provision of children’s health services for schools. One external professional stakeholder, for example, pointed out that whilst the HSE HP would normally have approached schools with ideas for health promotion, ongoing changes in HSE HP structures had led to a shift in emphasis away from settings-based health promotion. Clearly, these broad structural challenges had been a factor in limiting school-service collaboration and establishing an effective and sustainable health promoting school model.

189

“I think that communication needs to happen, the schools need to talk to the service and say, “ok, how we can best work?”, rather than defend. I think both sides are defending themselves… and then the health services need to take some ownership of that. So I think it’s not just the schools in this area, it’s nationally…nationally, it’s a strategy that’s the health and education, the heads come and sit down together and, you know, find out a strategy.” [Healthy School Coordinator, year 2]

Several participants noted that a lack of collaboration between health and education services at a national level also negatively affects collaboration at a local level between services and schools. In particular, according to most of the interviewees involved at a professional level, current restrictions on information sharing between health services and education services are an ongoing major limiting factor. For instance the HSCs as well as members of the funding team observed that attempts by the HSP and HSCs to address the accessibility of children’s mental health services were hindered because of reluctance by health services to share information. As a result of a lack of overall governmental strategy on collaboration between health and education services, many participants described a dependency on individuals building links in an informal way. In some instances these links have proved effective for schools. However, it is difficult to assess the consistency or sustainability of this approach as such links are based on both the enthusiasm of individual services as well as school staff.

The responses of principals as well as the HSCs and funders, suggest that the area of health referrals is predominantly dependent on this approach. Again, according to a range of professional interviewees, both the Department of Health and the Department of Education need to take greater ownership in creating stronger links. As Brown and White (2006) note, a lack of effective integrated partnerships can lead to such services being viewed by schools as an add-on service and not a sustainable “overarching framework” for the delivery of child services. Importantly, this study also highlights the negative impact on child protection services, particularly if integrative collaboration between health and education agencies is not effectively managed (Brown & White, 2006). One member of the funding team in the current study pointed out that there were ongoing efforts to develop health and education links, but it was difficult to assess from the respondents’ feedback, to what extent these early-stage negotiations could support the HSP directly; this finding is not unique to the current study. For example, according

190

to Johnston and colleagues (2003), partnership studies often cite improvements in the number of collaborative meetings but with few measurable outcomes observed.

“[The mental health services] will only talk to you if the parent has given permission for them to do it….and they [parents] don’t necessarily want to come back to school and tell people that their child is going. Sometimes you mightn’t even know… originally when this whole role started it was based on [the HS funders] having an agreement with the HSE around sharing of information and that’s never came through.” [Healthy Schools

Coordinator, year 1]

9.2 Psychological health as a school priority: Identifying and understanding