On opening the meeting, the Chair advised that unfortunately the CAMHS Transformation/HeadStart Programme Manager had submitted her apologies due to ill health. It was therefore agreed by Members that the officers evidence would be deferred until the next scheduled meeting.
It was also highlighted that the Service Manager for Harrogate and District NHS Foundation Trust would present evidence on the 0-19 Healthier Together Service, as the Professional Lead had submitted apologies for the meeting.
The purpose of the meeting was for the scrutiny panel to receive a general overview/introduction of Mental Health in Schools, including:
Mental health statistics pertaining to Middlesbroughs primary and secondary aged pupils.
Information on schools responsibilities in relation to mental health.
Details of how schools identify pupils with mental health needs.
An outline of in-school support (universal interventions and targeted interventions) that promotes emotional resilience and positive mental health among pupils.
Research - Children and Young Peoples Mental Health and Emotional Wellbeing
The Director of Education provided the scrutiny panel with information on research that had been conducted, which focussed on childrens mental health and emotional well-being. Members heard that children were at greater risk of having mental ill-health if they: lived in a deprived area; lived in a single parent family; lived in rented accommodation; had a family member with poor mental health; had a family member who had low educational attainment; experienced stressful family situations; faced three or more stressful life events (three times more likely than other children to develop emotional and behavioural disorders); had a disability or impairment (physical or learning), or serious or chronic illness; or were a looked after child.
Mental Health Statistics
Members were advised that estimates from national prevalence figures for mental health in children and young people suggested that Middlesbrough should expect 2,178 (10.8%) children aged 5-16 years with a mental health disorder. The scrutiny panel was informed that 10.8% was higher than the national estimate of 9.6%. Furthermore, it was highlighted that, based on Public Health England estimates in 2013, Middlesbrough had 2,558 young people (aged between 16 and 24) with a mental health disorder and 2,755 with potential eating disorders and attention deficit hyperactivity disorder (ADHD) respectively.
The Director of Education referred to the content of Middlesbroughs Joint Strategic Needs Assessment (JSNA). It was commented that, in 2016, Middlesbrough had the highest proportion of secondary aged pupils with social, emotional and mental health needs at 2.97% versus 2.39% in the North East and 2.3% in England. However, in respect of primary data, Middlesbrough had the lowest proportion of primary aged pupils with social, emotional and mental health needs by a small margin, however, there was a consistent percentage of around 2% both nationally and regionally. In light of recent feedback received from schools, however, it was indicated that up-to-date figures would potentially demonstrate a higher proportion of primary aged pupils with social, emotional and mental health needs.
The scrutiny panel was advised that children and young peoples hospital admissions for mental health in Middlesbrough (together with rates for self-harm, alcohol specific conditions and substance misuse highlighted elsewhere in the JSNA) were higher than the national average, and had risen significantly in recent years.
In 2015/16, for children and young people aged 0-17 years, Middlesbrough had the second highest rate in the North East for hospital admissions for mental health conditions behind Sunderland. Furthermore, Middlesbrough had the third highest rate of hospital admissions for mental health conditions, in comparison with nearest neighbours, with 140.8 per 100,000 population. Members were advised that the figure was well above the average for the group of comparators (104.2 per 100,000), more than twice the lowest Walsall (63 per 100,000), the highest being Tameside with 163.3 per 100,000.
The Director of Education explained that, in respect of data collection, it would be beneficial for the scrutiny panel to receive information on the approaches and tools used by schools to identify mental health needs among pupils. There was a need to determine how data collection processes could be further enhanced to ensure that new data was published regularly on the prevalence of mental health conditions in children and young people. The data collected could then be used locally to determine trends, identify effective practice and highlight any gaps in provision. The collection of data across all schools would increase the overview of the needs of local children.
Child, Adolescent and Mental Health Services
In respect of Middlesbrough Child and Adolescent Mental Health Services (CAMHS), the scrutiny panel was advised that in 2016/17 CAMHS had received 2,030 referrals and accepted 1,018 (50.18%) of those for treatment. Referrals into CAMHS had seen a significant rise of 45.70% between 2012/13 and 2013/14 (from 1,282 to 1,868) and then remained between 1,800 and 2,030 in the years up to 2016/17. The trend in referrals being accepted demonstrated a consistent decline.
The Director of Education explained that the referral rates could have been affected by the change in referral system and the change in SEN legislation of 2014 with the shift in terminology that separated social, emotional and mental health issues from behavioural issues. It was added that locally, the CAMHS Transformation/HeadStart Programme Manager had been working with Catholic schools, particularly Trinity Catholic College on a 'triaging project' to examine the referral process and referral criteria. The work undertaken had demonstrated positive results in decreasing inappropriate referrals to CAMHS.
In 2012/13 almost two thirds of all referrals into CAMHS were for males, over the period to 2016/17 that trend had decreased so that males accounted for 54.19% of all referrals and the percentage of females had increased. White was the most common ethnicity in the individuals referred to CAMHS, accounting for around 90% of all referrals in each period.
Children Affected by Parental Influences
The scrutiny panel was informed that children were greatly affected and influenced by parental behaviour. Evidence demonstrated that there were an estimated 4,700 alcohol or drug dependent adults in Middlesbrough in treatment. Based on that, it was likely that there were a significant number of children potentially affected by parental alcohol and drug misuse. It was highlighted that 60% of adults in contact with alcohol and drug treatment in Middlesbrough were parents.
Members heard that children living in those circumstances were more likely to be living in poverty, not achieving at school, had emotional / mental health problems, were at increased risk of becoming dependent on alcohol / drugs themselves and were involved in the care / youth justice system.
Children and young people were at greater risk of misusing substances, if they lived in deprived areas; had a family member who misused such substances; had a family member who was unemployed, or had low educational attainment; lived in a single parent family; were a looked after child (four times more likely to use illegal substances); or were in contact with the Criminal Justice System.
Drugs and alcohol were major issues for children and young people within Middlesbrough, impacting on their physical and emotional well-being.
Engaging Parents and Families
It was highlighted that parents knew their children best and it was important that all professionals listened and understood when parents expressed concerns about their childs development. There was also a requirement for schools to listen to and address any concerns raised by children and young people themselves..
Members heard that when implementing strategies to support pupils, schools involved families and engaged with parents wherever possible.
Special Educational Needs
In terms of identifying Special Educational Needs (SEN) including emotional and mental health difficulties, the SEND Code of Practice (2015) stated that all schools should have a clear approach to identifying and responding to Special Educational Needs. The code of practice set out the 'graduated response' approach that schools and colleges were asked to implement when a member of staff spotted an emerging issue. Members were informed that all schools were required to have a qualified teacher who acted as the special educational needs co-ordinator (SENCO) to ensure that all adults working in the school understood their responsibilities to children with SEND. That included pupils whose persistent mental health difficulties meant they needed special educational provision. Schools needed to be alert to how mental health problems could underpin behaviour issues in order to support pupils effectively, working with external support where needed.
Identifying Children with Possible Mental Health Problems
In response to a Member's query regarding signs/indications associated with mental health problems, it was advised that negative experiences and distressing life events could have affected mental health in a way that could have brought about changes in a young person's behaviour (aggressive or oppositional) or emotional state (fearful, withdrawn, low-self esteem, tearful).
Early Identification of Needs
The Director of Education advised that it was important that children were provided with support as soon as a problem emerged, at any point in their life. Helping children and families get earlier support could help children thrive and achieve in schools. Providing early help was more effective in promoting the welfare of children than reacting later. The Director of Education explained early intervention was crucial and could be summarised as:
Prevention-creating a safe, calm environment where problems were less likely, equipping pupils to be resilient, including teaching pupils about mental health through the curriculum
Identification-recognising emerging issues as early and accurately as possible
Early support-helping pupils to access evidence based support and interventions
Access to specialist support- working effectively with external agencies to provide swift access or referrals to specialist treatment
The Director of Education advised that the benefits of early identification were widely recognised. Identifying need at the earliest point and then making effective provision improved long-term outcomes for the child or young person.
It was recognised that all those who worked with children and young people had a responsibility to be alert to emerging difficulties and respond early. In particular, when schools suspected a pupil had a mental health problem, a graduated response process (assess-plan-do-review) was required to put support in place. There was a need for schools to have clear systems and processes in place for early intervention and identification, referral to experienced skilled professionals and clear accountability systems.
In response to a Members query regarding early identification of needs, the Director of Education explained that all school staff had a responsibility to identify potential mental health needs through noticing changes in behaviour that might be a result of mental ill health. It was explained that teachers had the ability spot where bad or unusual behaviour could have a root cause that needed addressing. Data was also collected in respect of attendance, behaviour and academic progress and that was another mechanism for staff to identify potential needs. It was commented that schools were aware that there was a requirement to identify needs and provide support at an early stage. Members heard that schools had a responsibility to ensure they made appropriate provision for a childs short-term needs in order to prevent problems escalating.
Where there were long-lasting difficulties and concerns, there was a need for schools to undertake an assessment to determine whether there were any causal factors such as undiagnosed learning difficulties, difficulties with communication or mental health issues. It was highlighted, however, that persistent disruptive or withdrawn behaviours did not necessarily mean that a child or young person had SEN. If it was thought housing, family or other domestic circumstances could be contributing to the presenting behaviour then a multiagency approach, supported by the use of approaches such as the Early Help Assessment, could be appropriate. In all cases, early identification and intervention could significantly reduce the use of more costly intervention at a later stage.
The majority of children with SEN would have their needs met through mainstream education providers. As a result, Members were advised that schools were under a duty to identify and support pupils with SEN and meet their pupils special educational needs.
Access to Health Professionals
Members heard there was an expectation that, when required, parents and pupils would seek and receive support elsewhere, including from their GP, NHS services, trained professionals such as educational psychologists or voluntary organisations. However, where appropriate, schools could encourage the pupil and their parents/carers to speak to their GP or school nurse.
In response to a Members query, it was clarified that schools would not have access to a pupils medical records due to restrictions regarding patient confidentiality. However, it was explained that parents could choose to disclose a childs medical information, which would assist in enabling the school to provide the most appropriate support.
A Member commented that it would be prudent if appropriate measures were put in place to ensure that those parents who sought the advice of health professionals, in respect of their childs mental health, alerted the relevant school. The Director of Education highlighted that school staff spent time building relationships with parents and families to encourage them to inform the school of any problems.
Support for Children and Young People
The Director of Education advised that support for children and young people could be provided at a school level only e.g. additional pastoral support/School Nurse advice, or by seeking external support for the child within mainstream provision e.g. educational psychology or CAMHS support, or through external placement such as the Pupil Referral Unit (RTMAT) with therapeutic intervention or from a special school such as Holmwood.
A Member commented that, when mental health needs had been identified, some schools offered counselling and arranged for pupils to attend therapeutic sessions, which were delivered by trained mental health specialists.
Mental Health Policy
The scrutiny panel was advised that there was no requirement for schools to have a standalone mental health policy, although some did choose to. However, schools were required to produce a range of policies which could be used to promote and support mental health and wellbeing, either as a statutory requirement or good practice as recommended by the Department for Education. However, it was clarified that each school needed to be aware that it could be unlawful to apply a policy, which meant treating all pupils the same if a pupils disability made it harder for them to comply with the policy than other pupils who were not disabled.
The Director of Education made reference to a document containing non-statutory advice from the Department for Education entitled 'Mental Health and Behaviour in Schools'. The advice would be of interest to the scrutiny panel as it aimed to help schools to support pupils whose mental health problems manifest themselves in behaviour.
Local authorities were responsible for arranging suitable education for permanently excluded pupils, and for other pupils who because of illness or other reasons (including social, emotional and mental health needs), would not receive suitable education without such provision.
In terms of alternative KS1 provision, the Director of Education highlighted that, in 2018/19, new 10 place support provision opened at Holmwood Special School. The provision provided a short-term placement and assessment of the childs needs and difficulties in accessing education to identify both learning and SEMH (Social, Emotional and Mental Health) difficulties. Currently, 6 places were taken while awaiting the next round of referrals that were due in January. Referrals were currently coordinated through clusters of schools, however, work was being undertaken to manage referrals based upon needs across the town.
Members were informed that primary schools had expressed concern at the rising numbers of KS1 children presenting learning and very challenging SEMH issues. It was predicted that, in future, there could be a high demand for the provision.
It was commented that the cost of an alternative education place was 18k per year. Primary Schools paid from £31-£33 per day toward cost.
In terms of alternative KS2 provision, there were 16 Commissioned places at River Tees Multi-Academy Trust following Education Health Care Plan assessments, 14 places were taken by children who were eventually awarded a plan, which was an ongoing trend. Those children had a combination of SEMH and learning difficulties. To meet rising demand, an additional 8 places were commissioned by the SEND Department. Those additional places enabled the Alternative Education Team to access primary assessment and intervention places. Those children frequently had multi-agency involvement, support for learning and SEMH issues.
A discussion ensued regarding the transition from primary to secondary school and the life changes that could impact on pupils.
In terms of alternative secondary provision, there were between 170 and 190 children requiring alternative provision each year. Those children often had a range of SEMH issues and learning needs that had not been met. They were either permanently excluded or requiring intervention to help re-engage/ prevent exclusion.
Members heard that in December 2017, the Pupil Inclusion Panel (PIP) was set up to enable schools to refer children to a group of professionals where support, assessment of need and alternative provision could be discussed. There were 120 referrals from December 2017 to July 2018. Of those, 91 referrals went through to PIP and 75 were offered placements either in a school or alternative setting.
PIP had been dealing with high numbers of referrals, however, in recent meetings the numbers had reduced. It was commented that sometimes schools felt they had not been able to access early multi-agency support and had limited alternatives.
The Director of Education advised that there was a significant need for increased high-quality provision that would take those children on roll, a vocational and academic setting that would provide support services and specialist therapies. It was highlighted to the scrutiny panel that a free school application for SEMH pupils had been submitted on behalf of the 5 Tees Valley local authorities and it was hoped that the Local Authority would be informed, in the coming weeks, that the bid had been successful. The free school would help support the most vulnerable pupils and would be a model of shared expertise on SEMH with mainstream schools. If the bid was successful, the proposed location of the school would be in the boundary of Redcar and Cleveland and 100 places would be available for vulnerable pupils.
The cost of an alternative provision for secondary aged pupils could range from 14k to 18k per year. In some cases additional funding was required to meet special needs. Secondary schools paid from £41-£43 per day towards the cost.
The Director of Education highlighted to the scrutiny panel that although there had been a recognition by head teachers that a reduction in permanent exclusion numbers should be possible, recent data showed only a small decrease. Consequently, there was continued pressure on resources and reduced budget for highly vulnerable children who often had significant SEMH issues.
Members were informed that the Inclusion Strategy had now been agreed and an action plan had been put in place to support schools and their pupils in maintaining mainstream education where possible. It was added that workstream leaders were supporting multi-agency work to improve therapeutic services, training of staff and support for parents for children who were at risk of exclusion.
Educational Psychology Service
Educational psychology was concerned with helping children and young people experiencing problems that could hinder their chance of learning. It involved working with children and young people in educational and early years settings.
It was highlighted that the Local Authority's Educational Psychology Service had grown considerably over the past two years. A Principal Educational Psychologist had been appointed and a strong team of educational psychologists had been recruited. Educational psychologist was a registered title with the Health and Care Professions Council and all educational psychologists had followed an extensive training route over at least 6 years. Some of the Local Authority's educational psychologists were also qualified teachers, others had worked in other roles in schools supporting children and young people. All educational psychologists had experience of working in a range of educational settings, with a range of young people with differing needs. It was highlighted that an educational psychologists knowledge of psychology, child development and change processes enabled them to support schools, parents, and other professionals to best meet the needs of children and young people.
The scrutiny panel heard that local educational psychology services, who support children with SEND, could also be well placed to advise on emerging mental health needs and either provide direct intervention or signpost to other, more appropriate, forms of support. The Director of Education commented that the Local Authoritys Educational Psychology Service was now in a position where it was able to offer advanced support to schools.
It was highlighted that educational psychologists who worked for the Local Authority aimed to support the achievement and wellbeing of children and young people, aged 0-25 years. Furthermore, educational psychologists promoted the educational and social inclusion of any vulnerable groups of children and young people, including those with special educational needs and social and emotional mental health difficulties.
Educational psychologists worked in a variety of ways including observations, interviews and assessments and offered consultation, advice and support to teachers, parents, the wider community as well as the young people concerned. Educational psychologists tackled challenges such as learning difficulties, social and emotional problems, issues around disability as well as more complex developmental disorders.
The Director of education explained that the Local Authoritys educational psychologists delivered statutory functions on behalf of the Local Authority, as outlined in the Childrens and Families Act (2014). Those statutory duties were outlined in the submitted report. In addition to its statutory functions, the Educational Psychology Service was in a position to offer a wide range of additional core psychological support and interventions, which were provided at various levels depending on the bespoke needs of schools/ settings. The range of support and interventions included psychological work at the strategic level of the whole school (such as training or policy development), the small group level (delivering and evaluating projects and conducting research), and the individual pupil level (consultation and assessment). The service currently worked with partners in Local Authority schools, academies, and alternative provision settings (AP). Educational psychologists also researched innovative ways of helping vulnerable young people.
Within the AP settings, educational psychologists had delivered ELSA (Emotional Literacy Support Assistant) training to build capacity of school staff, participated in Pupil Inclusion Panel processes, developed local practice around managed moves and worked directly with vulnerable pupils placed within AP. The service had also provided direct crisis response work in settings and strategic work around suicide prevention, capacity building training to staff working with migrant families and post diagnostic (ASD) support (Early Bird Plus) to settings and families.
The recent development of data-dashboards within the Local Authority meant the Educational Psychology Service would be able to analyse service delivery trends in terms of presenting age groups, genders, and category of need etc.
The Inclusion Strategy presented an opportunity for the service to support the work of the Local Authority at strategic planning and capacity-building levels in areas linked to social and emotional mental health.
Middlesbrough Achievement Partnership - Emotional Wellbeing Support
The scrutiny panel was advised that, since 2014, Middlesbrough Achievement Partnership (MAP) had made a significant financial contribution to the HeadStart Programme and to the Reach Partnership, providing a total investment of £1,663,481.
In addition to being a key funder, MAP complemented and supported the work of the HeadStart Programme.
It was highlighted that the current MAP Delivery plan supported in-school interventions (universal and targeted) promoting emotional resilience and positive mental health among pupils and their families. The Director of Education advised that the MAP had recently been focussing on rolling out Restorative Practice in schools and training for all school staff had been completed in 11 schools (across the primary and secondary sector). 60 practitioners from schools had accessed the training delivered by the Local Authority. It was explained that restorative approaches enabled those who had been harmed to convey the impact of the harm to those responsible, and for those responsible to acknowledge the impact and take steps to put it right. Restorative approaches referred to a range of methods and strategies that could be used both to prevent relationship-damaging incidents from happening and to resolve them if they did happen. The offer continued to be shared with all schools and development sessions would be held in schools over the summer term to share best practice, key impacts and encourage additional schools to complete the training.
It was advised that work would be carried out with schools to measure the impact of the restorative approach, however, early indications demonstrated it was impacting positively on behaviour, attendance, relationships and emotional wellbeing.
It was also highlighted that, in October 2018, MAP appointed a Parenting Support Coordinator to work closely with a range of internal and external partners, schools, governors, senior leaders and parents/carers, families and children. The purpose of the Parenting Support Coordinators role was to deliver positive outcomes for parents/carers and families to enable them to support their childrens achievement and wellbeing. Since appointment, the Parenting Support Coordinator had delivered a number of interventions including Mindfulness for parents, techniques for parents to support childrens emotional wellbeing and emotional wellbeing support for teaching staff. The work had been undertaken to meet an identified need that had not been met through the current HeadStart Programme and work would continue to develop following requests from schools.
The Director of Education advised that Parenting Programmes were also available, in particular the Family Links Nurturing Programme. The Nurturing Programme aimed to help adults understand and manage feelings and behaviour and become more positive and nurturing in their relationships with children and each other. It encouraged an approach to relationships that gave children and adults an emotionally healthy start for their lives and learning. Members heard that positive feedback in respect of the programme had been received. However, it was added that outcomes of the programme would be monitored and it was anticipated that successful completion of the programme would have a positive impact on the emotional wellbeing of parents and their children.
The scrutiny panel heard that Globalbridge had been introduced into 9 secondary phase schools within Middlesbrough. Globalbridge was a unique platform that bridged the gap between students, universities and employers. The platform allowed young people to build online digital profiles to showcase their talents and achievements to educational institutions and industry. The Director of Education advised that it was evident that the process had built confidence and self-esteem in young people, supporting improved emotional wellbeing.
The scrutiny panel was notified that a new strategic group had recently been formed and was chaired by the Director of Public Health and Public Protection. The group aimed to bring together partners from the Local Authority and Tees, Esk, Wear Valley NHS Foundation Trust who were responsible for Childrens services and CAMHS. Initially, the aim of the group was to audit and map current services and to consider wider strategic development of mental health provision for young people. In the first instance, the group would be considering best practice from local authorities such as Camden in order to inform future developments in Middlesbrough. It was added that Camden CAMHS in Schools offer meant that clinicians were based in primary, secondary and special schools. Through co-location, clinicians were able to build strong relationships with the schools they worked with by integrating with the schools culture and developing an understanding of the schools needs. A Member commented that it would be useful for the scrutiny panel to receive regular updates on the work of the group.
Impact of Bullying
Following a query from a Member, a discussion ensued regarding preventing and tackling bullying. It was commented that bullying could happen to all children and young people and it could affect their social, mental and emotional health. In all cases schools had a responsibility to support children who were bullied and make appropriate provision for a childs needs. The Director of Education advised that, by law, all state (not private) schools were required to have a behaviour policy in place that included measures to prevent all forms of bullying among pupils. It was explained that at a recent regional meeting, information was submitted on the number of parental complaints received by Ofsted about schools. It was highlighted that Middlesbrough had the lowest number of complaints in the region, therefore demonstrating that Middlesbrough schools were performing well at meeting their pupils needs. The Director added that the introduction of restorative practice would help teachers and pupils to choose a respectful, considered approach to conflict resolution and anti-bullying.
0-19 Healthier Together Service
The Chair advised that during proceedings the Service Manager for Harrogate and District NHS Foundation Trust had left the meeting due to feeling unwell. Members were therefore in agreement that the evidence pertaining to the 0-19 Healthier Together Service would be deferred until the next scheduled meeting (18 February).
AGREED as follows:
That the information presented at the meeting be considered in the context of the scrutiny panels investigation.
That evidence from the CAMHS Transformation/HeadStart Programme Manager and the Professional Lead for the 0-19 Healthier Together Service be deferred until the next meeting (18 February 2019).