Oral evidence: Mental health and well-being of looked after children, HC 481Wednesday 13 January 2016
Oral evidence, 13 January 2016.
Witnesses
Barbara Herts, Director for Integrated Commissioning and Vulnerable People, Essex County Council, Wendy Lobatto, Service Manager, First Step, Tavistock and Portman NHS Foundation Trust, and Alison O’Sullivan, President, Association of Directors of Children’s Services, gave evidence.
Chair
Welcome to the second session of our inquiry. I think you were all in the audience before, so you know what we are looking at and you know that our themes are as I described at the beginning, so could you just say who you are and where you are from, Barbara?
Barbara Herts
I am Barbara Herts. I am Director for Integrated Commissioning at Essex County Council and I chair our Collaborative Commissioning Forum for all children in Essex.
Chair
Thank you. Wendy?
Wendy Lobatto
I am Wendy Lobatto. I am the Service Manager of First Step, which is a psychological health screening and assessment service for looked-after children in Haringey.
Chair
Alison?
Alison O'Sullivan
Hello, I am Alison O’Sullivan and I am the President of the Association of Directors of Children’s Services. We have in our membership 1,500 of the leaders in Children’s Services, including all 152 local authorities and the new Children’s Trust chief executives.
Chair
Thank you very much. To Barbara and Wendy, I am going to be asking about First Step in Haringey, and Essex County Council have adapted their mental health services specifically for looked-after children. What steps have you taken to improve your services to this vulnerable group? Barbara.
Barbara Herts
What we have done is we decided in 2014 that we were going to integrate our services across social care, health and education, so we went into a collaborative commissioning agreement across seven CCGs and three local authorities. Essentially, we recommissioned our services to bring together an early prevention, early identification approach, very much linked to our social care offer for vulnerable children and young people. We were pleased that in our collaborative commissioning that we were able to pool our budgets. We have very successfully pooled budgets with our clinical commissioning group colleagues and I oversee that budget, which means that we can operate flexibly and meet the needs of vulnerable children and young people in Essex. I think the previous system of having a lot of fragmentation and different organisational boundaries let our vulnerable children and young people down and now it means that we can bring that budget together, particularly with our health colleagues, and get that clinical expertise and use the additional monies much more flexibly and responsibly.
Chair
Wendy, do you have any comments?
Wendy Lobatto
In Haringey, I run a team that was commissioned by the London Borough of Haringey to provide a global emotional health screening assessment service, so my perspective is from the ground. I manage a service that works with looked-after children and I am very happy to describe to you how we do that.
Chair
Obviously Barbara has described a very ambitious approach for Essex in general, and bringing together agencies, which is something that we have been thinking about a lot. In terms of the leadership of that structure, you are obviously at the pinnacle, but what sort of impact has that had within the school system in Essex?
Barbara Herts
It is starting to have a very good impact, because we are clearly involving our schools in this new approach. Our approach is very much founded on the principles of “Future in Mind”, so we were absolutely delighted with its publication. We see schools being very much at the forefront of this approach, because we want all of our children in care clearly to be in schools. We know that across the country there is evidence that a lot of vulnerable children can end up on part-time timetables. That will mean that they are not even in school, let alone getting that essential treatment that they might need. What we particularly have focused on in our new service is that early prevention that Professor Fonagy talked about.
Chair
Can I just talk about CAMHS now, because we have been talking a lot about them, not least because the Health Select Committee talked about it at the end of the last Parliament, and obviously it has been something that has come up in our own inquiry quite a lot. Are CAMHS effective in supporting looked-after children with a wide range of mental health issues? Barbara.
Barbara Herts
We are clear in Essex that we want to see a very holistic offer for vulnerable children and young people and that is why we reshaped our services. We want to see that early intervention at a very early stage. Part of our system is having a specialist mental health professional that can provide on pathways, the evidence base and bringing that together across social care, health and education. We think it is terribly important to have this integrated approach, not least because in the health system, with the very great deficits in funding around the country, there is a real risk that that money might not be protected for children’s mental health, so we see the benefit very much of having this holistic system.
Chair
Alison, do you find the same enthusiasm for integration among your members?
Alison O'Sullivan
There is certainly an enthusiasm, but of course it is hard work and joining together the disparate parts of the system that have been described is not a quick journey and you have to make sure that systems are safe while you are changing them. Our perspective on the system generally is that is hugely variable if you look across the country. I think the “Future in Mind” document and the taskforce that informed it managed to flush out quite a clear picture of very variable practice, not just in terms of the levels of investment that there were in the system, but also clinical practice, the extent to which things were joined up and difficulties with access to service—so a huge variation, in some parts of the country very good, in other parts of the country frankly not acceptable. I think that is a problematic inheritance and you do not get to a new, better system overnight. I think the “Future in Mind” strategy is very helpful and very clear, but the importance will be on making that happen. The investment is welcome, but we have to recognise that is against a backdrop of other financial pressures that have been referred to, and also a history of disinvestment across the system for quite a number of years. This was not a high priority area across the system broadly.
Chair
A recurring issue is the initial assessment of mental health problems both in terms of timeliness and effectiveness. Wendy, do you think that is an issue that needs to be addressed?
Wendy Lobatto
Yes, definitely. What we are doing in Haringey is we are making assessments of the emotional well-being and mental health needs of all children when they come into care and then on an annual basis. We use the Strengths and Difficulties Questionnaire. We were listening in the last session to the thoughts about how the SDQs are used, and we use the Strengths and Difficulties Questionnaire very actively to triage the emotional needs of children as they come into care and then during their annual review. Would you like me to tell you more how we do that?
Chair
Briefly, because we have seven or eight more questions. Why don’t you drop us a line about it?
Wendy Lobatto
Yes, I am very happy to do that. It is in my written evidence so far and I am happy to send that to you again.
Chair
Okay, we have that then, so that is good. Thank you. Alison, variability is something you have already referred to. Is this something that you are thinking about in terms of assessment as well?
Alison O'Sullivan
It is. The Strengths and Difficulties Questionnaire is not used as broadly as it should be, as has been highlighted, but it is a screening tool, it is most effectively used, we think, for that kind of triaging. What you also need at early stages is the broader awareness across the workforce for people caring for children in all sorts of settings, including schools, to be able to notice when things are not right and know what kind of help to be able to look for. Also, you need the right access to specialist and professional assessment when that is needed and we know that that is hugely variable. It can be that there are long waits for that kind of assessment, up to many months in some cases, and clearly in the midst of a distress or crisis, that is not acceptable and certainly not helpful.
Chair
Barbara, do you have any final comments?
Barbara Herts
Similarly to Alison, I think it is about the wider workforce being aware, being able to pick up issues that they see, whether in schools, in social care or in health settings. I think the training of the workforce is absolutely vital in that regard.
Chair
Okay, thank you. Lucy, you are going to be talking about the transition out of the care system.
Lucy Frazer
I wanted to ask about Local Transformation Plans and the variability that I think a number of you have picked up on. Whose responsibility is it to try to achieve a bit more consistency? Because we heard in the previous evidence session from the NSPCC about some Local Transformation Plans excluding any reference to looked-after children at all. I wonder if I could start with you, Alison.
Alison O'Sullivan
Perhaps I can come in on that one. The guidance is very clear that health and well-being boards are the accountable body and that is where the leadership across the local system sits. It is important that those health and well-being boards at a local level truly hold to account the local system to deliver against those plans. Our health and well-being boards have not been established for very long and they are at different stages of development, so I think this will be an important test of their strength and the strength of local partnerships, so that is really important.
Lucy Frazer
Sorry, just to interrupt, there is the difficulty that you have so many different partner agencies involved in the health and well-being board that that sense of ownership is kind of diluted across the board or is it one single person that says, “Hang on a minute, we have to make sure that our Local Transformation Plan is consistent and coherent”?
Alison O'Sullivan
That is always the hazard with collective responsibility, isn’t it? I guess this is a good example. What is clear though is that there is a lead agency commissioning for this plan and that lead agency clearly carries the can, so it is important that that is reflected in the way that those boards operate. Within that, I would agree with the NSPCC’s concern, it is important that the specific needs of vulnerable children, and in particular looked-after children, are properly looked at and properly reflected. I was pleased to hear from the Department of Health that there is an analysis going to be done of the extent to which the Local Transformation Plans address the needs of looked-after children. I think that is important.
Lucy Frazer
As a separate section for children per se, yes.
Alison O'Sullivan
That is what I read into what was said and I welcome that. It is important we follow that through because the transformation plans are very broad and the challenges are very great in a number of areas, so it is important we do not lose focus on the needs of that particular most vulnerable group of children.
Lucy Frazer
Did you have anything on that?
Barbara Herts
A very similar comment. I think the health and well-being boards are absolutely critical for holding the Local Transformation Plan to account. I think that the role of the boards needs to be strengthened in a wider sense, but it is ultimately those boards that have to hold the plan to account and I very much welcome as well the Department monitoring looked-after children and vulnerable children in those plans.
Lucy Frazer
A good point. In terms of statutory guidance in promoting the health and well-being of looked-after children, is there more that we should be pushing for in terms of something that is a bit firmer and more rigid statutorily?
Barbara Herts
I think the guidance is very good and I think it is very strong, but I think we need to push for a real entitlement, that when a child or a young person comes into care that they have that entitlement to an assessment that helps them work out their situation and any needs that they have. I think now particularly in my area we are seeing more older young people coming to our attention, 16 and 17 year-olds with quite entrenched behavioural difficulties, so we need to make sure that we do not have this patchy situation around the country where there is a real entitlement to that mental health assessment.
Wendy Lobatto
Yes, I think the statutory guidance is very good. There is a requirement in the guidance for the emotional well-being and mental health needs of the child to be assessed at the point of initial health assessment, but I think what is less clear is who should be making that assessment. At the moment, it is either a GP or a paediatrician who is likely to be making that initial health assessment and I think they are not the right person to be assessing what the emotional well-being and mental health needs are of that young person. In Haringey, we make our own assessments as an integrated mental health service. I would like to see in the statutory guidance that all children should be entitled to have their mental health and emotional well-being needs assessed by a trained and experienced child mental health professional at the point at which they come into care and have their initial health assessment.
Lucy Frazer
Presumably resource-wise that is a very rare commodity, to have somebody with that expertise?
Wendy Lobatto
I think it is quite rare across the country, although I think we do it in a very lean way in Haringey, where we do assess the emotional well-being needs of all children when they come into care with a very brief service model that I think is nevertheless very effective and helpful in terms of informing care planning decisions.
Alison O'Sullivan
I think many of the elements of what is needed are there in existing guidance, but you have to put time and energy into searching them out and then joining them together. I think probably what would be helpful is if we do a trawl of what is in the various bits of guidance, including the NICE guidance on practice and all of the rest of it, and that we have that drawn together in a way that makes it accessible to Commissioners and those responsible for these services so that they can see what it is that they are trying to achieve and what the outcome should look like. It may be that when we do that there are some gaps, and in that case we should fill them. I think what I would suggest is that we look at whether a strategy is needed that draws together the existing best practice and maybe adds to it if there are any gaps or deficiencies.
Lucy Frazer
That is very interesting, thank you.
Chair
Thank you very much. Lucy, you are going to be talking about transitioning out of the care system, sorry about that mistake.
Lucy Frazer
How do you think looked-after children with mental health problems can be better supported after they leave care?
Barbara Herts
I think there is a need for much greater support because young people leaving care are dealing with a lot of very complex situations and I would like to see across the country particularly services that are more flexible. If a care leaver wants to stay with the CAMHS service rather than having to transition into an adult mental health service, I think that should be provided. I welcome some of the initiatives that are taking place to design 0 to 25 services, because adult mental health services can be very frightening places, there are very different systems of working and of course there are the budgetary and financial constraints as well, where a care leaver may or may not get the type of support that they need. I am very pleased that the Committee are looking at this area, but I think it needs a lot more work, and I am very pleased that “Future in Mind” is coming up with practical suggestions.
Lucy Frazer
Would you agree with the Professor’s comment in the earlier session that it should be permissive but not mandatory?
Barbara Herts
Yes.
Lucy Frazer
Alison?
Alison O'Sullivan
Yes, I would agree with that. I think when we are thinking about children leaving care there is the obvious focus on children growing out of care through age, if you like, and there is a welcome focus at the moment on care leavers and the support to care leavers. I know that that is an area that Government are looking at the strategy again and thinking of renewing that. That is very welcome; this needs to be part of that. But we also need to think about children leaving care because they become adopted or subject to special guardianship orders—so they may often be younger children and they have needs too. So I think when we have in mind what the needs are for children in care, we need to be thinking children in care, children who are adopted, children subject to special guardianship and care leavers who are growing out of care, and the sort of entitlement that has been described needs to spread to encompass all of those groups of children.
Wendy Lobatto
Could I just add that I welcome the fact that children are now more likely to be able to stay in their foster placements for longer periods of time, and for us not to forget that children who are likely to have suffered attachment problems and disruption in their relationships as either very young or middle school-aged children need continuity of relationships as they go through life. Our children have continuity of relationships with parents and I think the expectation that children leave care at 18 and then that it is it, they never see anybody again, is very unhelpful and unhealthy for them. I would like to see services that do put increasing emphasis on the importance of continuity of relationships for young people.
Lucy Frazer
For those who do not want to stay in the previous CAMHS system, should there be a dedicated CAMHS service for post-25?
Wendy Lobatto
I welcome the idea that services should go up until 25 if that is appropriate, but I guess the point I want to make about that is that CAMHS should be all of our business and that emotional and mental health needs for looked-after children cannot, I think, be sequestered off into this agency called CAMHS, which then has to manage all of the difficulties, but that they should be the concern of all of us, so foster carers, residential care staff, education staff, social care staff. All of us who are working with and looking after children as they grow into adulthood need to have an awareness of emotional well-being, because mental health services might not be welcomed or appropriate for that young person, but that is not to say that they do not have needs that can be met by other people in their professional networks.
Lucy Frazer
Barbara and Alison, do you have anything to add to that?
Barbara Herts
No, not really. I think it is important, as Wendy has said, that CAMHS is everybody’s business and that CAMHS very often comes at the end of the line, and I think we need to get in that early identification and we need to get in that early help offer. I think that is where the other agencies come in with providing that help at an earlier stage.
Alison O'Sullivan
I would just emphasise something that came up through a discussion with the previous panel about the importance of building personal resilience and equipping young people to deal with the ups and downs of life more broadly.
Chair
Thank you, Lucy. Marion, you are going to be talking about monitoring of care leavers and workforce development.
Marion Fellows
Yes, I am, thank you. Good morning. Barbara, in your written evidence, you recommended that the Government invest in outcomes monitoring of looked-after children. How could better monitoring of care leavers support their mental health and well-being?
Barbara Herts
As we have heard in the previous session, in this area of work outcomes and data are very patchy and very lacking, so I would recommend some very strong outcomes to do with resilience, to do with early help, to do with workforce development so that there is some effective monitoring of how effective services are. I think this is a very complicated area, particularly working with different organisations such as Health that might measure things differently from local authorities. But I think there is an opportunity from “Future in Mind” to develop a lot of stronger outcomes so that we can get to a better evidence base of what works in therapeutic care and treatment.
Alison O'Sullivan
I would add to that, because I think that—and this is one of the things that “Future in Mind” recognises—we do not have baseline data about either levels of need or what is being spent, let alone outcomes, and we need that across the whole system and we certainly need that locally. We do need that baseline information, and as Barbara says, we need to be clear about what the outcomes are that we want to see. We have some sort of prevalence information about populations in general, so we know 75% of children in care have some kind of emotional or behavioural difficulty, but that does not tell us enough, or nuance the needs of those people within that. We need to get to a point where we are clear at not just a population level, but also at a local level as to what the needs are, how effectively they are being met and what difference it is making.
Marion Fellows
Wendy, you are happy with that?
Wendy Lobatto
Obviously I think we need more data. One of things that we need more data about is what services are available around the country for looked-after children, because even that data isn’t available at the moment, as far as I am aware. I would like to get to a positive thought about what would a successful career in care leave you looking like, and I think it is something like when you get to your mid-20s, if you have something to do, someone to love and someone who loves you and somewhere to live, that is a reasonably good outcome and you have not had all sorts of unfortunate things occur to you in your life. It would be interesting to see how many of the children who go through our care system are able to claim those things when they get to be young adults and I certainly hope that we would see that many would be, but I think if we could measure that, then we could start looking at how services can be made more effective.
Marion Fellows
Yes, so we could look at the good practice and make that better. Could I ask, how could the current statutory guidance be improved to focus more heavily on transition out of care?
Alison O'Sullivan
I think what we need to see is a joining up of the work and thinking around support for care leavers and this area and collaboration across Government. I know that that is taking place, but I think we need to bring greater focus to joining that up.
Marion Fellows
Wendy?
Wendy Lobatto
I think if there is more provision for young people generally when they get to the age of 18 that young people who are leaving care can access, then that would be helpful for them. I think that those services should be more than just mental health services, that they should be wider well-being services, so a place where young people can go, where they can do education, training, sexual health, relationship talk, all the kind of things that young people need to be healthy and have well-being in their lives. I think if those services were available for young people more generally, then looked-after children could be part of the user groups.
Marion Fellows
And not be stigmatised almost?
Wendy Lobatto
Yes.
Marion Fellows
Barbara.
Barbara Herts
Yes, very much along the same lines. I do think that particularly for care leavers and for all vulnerable children, this needs to be within the rest of Children’s Services as well, so moving away from that stigma, the principles and that whole vision of “Future in Mind”.
Marion Fellows
Thank you. I am going to move on to workforce development, which is an important part, I think we could agree, of all of this. Do you think that—all three of you—is there enough training available for foster and residential carers, particularly on how to support children who have experienced a significant trauma, and how would you rate the quality of any training?
Alison O'Sullivan
Perhaps I should begin. I think this is an important area, and “Future in Mind” is quite ambitious in the scope of the training and awareness-raising that it envisages, from broad-based training for anybody who comes into contact with children through to more specialist focused training. Our experience in my local authority in Kirklees is that it is very helpful to equip people with a role caring for children, those with a professional role caring for children—residential carers and foster carers—with some tools that they can use, not just to understand mental distress and mental ill health in the young people that they may be caring for, but also then to know what to do about that. There are a number of programmes around. We have adopted the Pillars of Parenting approach, which supports those workers. We have started with the residential care workers and we are moving on to train and equip foster carers as well, but it gives them a framework to understand children and young people’s mental well-being, but also it gives them techniques to engage in terms of tackling difficult behaviour. They have told me that that is very empowering. There are other programmes of a similar kind, but I think we need to recognise that those people with a role caring for children who are inherently vulnerable need to be equipped and supported to know what to do and have the confidence to deal with that well.
Barbara Herts
I think there is a role as well for parents that are adopting to have that training. That is very much something that we are doing in Essex. We have a programme of therapeutic work for parents who are adopting, but also, I think, training the workforce so that these placements do not break down, because it is very, very difficult and time-consuming. We want the placements to last, so I think it is vitally important that the current programmes of training for foster carers and adoptive parents are sustained.
Wendy Lobatto
I would like to echo what both Barbara and Alison have said, but I want to add something, which is that while training is extremely important and relevant to assisting professionals to look after children, training tends to be kind of a one-off event and you have done it and then you are trained. The question is how you then operationalise it in your day-to-day working lives? That is what I think we need to be thinking about: individual children’s needs and bringing together parenting teams around individual children, where everybody in that team has had the training and understands the principles and practices of effective childcare with children who are vulnerable, but the teams of people come together to work together in parenting teams. Something that Professor Fonagy mentioned earlier was how fragmentation in systems can sometimes reflect the fragmentation of children’s inner worlds, and bringing people together who are charged with parenting that child in a group so that they are supporting each other with parenting, using the training that they have, but operationalising it for each individual child I think is inescapably important.
Alison O'Sullivan
I absolutely agree with that. It is important to embed that training and it is about developing new ways of working, not just one-off training, I absolutely agree.
Marion Fellows
So you think that this sort of thing would improve the current quality of the training that is available if this particular aspect was gone into?
Wendy Lobatto
I think it is an addition. There needs to be all the training that we can get for people, because it is very important, but on top of that there needs to be a practice of people working together, thinking about the needs of individual children and how to meet them.
Marion Fellows
Do you think the Government should commission core training in mental health for all professionals working with looked-after children? Should this be mandatory?
Alison O'Sullivan
It is always difficult, isn’t it, to say whether something should be mandatory or not. I think it would be very helpful if it happens, but I think that is important, that it is tailored to the particular circumstances. I think very often, by influencing existing training channels and existing training mechanisms and making sure that that is built in, that can be a more sustainable way. There is a danger with mandatory training, if it is not designed and embedded well, that it becomes a bit of a tick-box thing. I would favour embedding it in, but you need to have a systematic approach and you need to know that that is ongoing, that it isn’t just a one-off.
Barbara Herts
Very much along the same lines: I do think there is a gap here, but I think it needs to be perhaps thought about in local areas, perhaps as we are implementing in local authorities “Future in Mind” it would be very helpful to share plans, to share training and to think particularly about workforce gaps. But I am not sure about a sort of blanket tick-box mandatory approach at this stage.
Wendy Lobatto
I think I share those views, because obviously different areas already have different approaches to how they support their foster carers and it would be good to build on the best of those approaches. I think it would be helpful obviously if there was kind of vigilant oversight from Government to ensure that all areas are putting sufficient resource and attention into the needs of looked-after children and the needs of the workforce that support them.
Chair
Thank you, Marion. It remains for me to ask if there are any changes—perhaps one each would be a good idea—to improve provision of mental health care in the sector for children. Who would like to go first?
Barbara Herts
I would like to follow on from what Professor Peter Fonagy said, because I do think there is a need, with the transformation plans. I would like to see every area have that specialist that could be that sort of systems leader for mental health and well-being to identify appropriate pathways, to be thinking about evidence-base and research and how things can be done differently. I think for each area to have that systems leadership, and perhaps it would be a person or a partnership, and I think it would make a great deal of difference to the lives and futures of children and young people.
Chair
Would that be sort of in line with your approach to integration, which you have obviously developed so successfully in Essex?
Barbara Herts
Yes, it would be, and clearly we have a lot of GPs around the county that are fulfilling that role. I have to say it was a very enabling feature of our development, that we have had those systems leaders, but I know that around the country that is not the case, so I would like to see some consistency in having that approach.
Chair
So you are saying systems leaders with a special focus with an integrated system?
Barbara Herts
That is right, yes.
Chair
Okay, thank you. Wendy?
Wendy Lobatto
That is an interesting suggestion and I think that fits quite well with what my recommendation is, which is that I think we should have assessment services like First Step, which I manage in Haringey, in every local authority in the country assessing the emotional well-being and mental health needs of children when they come into care, giving advice on care planning and therapeutic input and then following up those children’s emotional welfare needs every year subsequently. I think without having dedicated services, however small they may be—we are not a big service, but we do have a remit for being mindful of the child or young person’s emotional health needs and making recommendations about what they need in terms of placement planning, contact with birth family, educational needs, therapeutic needs and other needs that that child may require, including debriefing on what has happened to them. I think if we had a service like that in every local authority in the country, maybe which could be headed or have a relationship with this CAMHS LAC lead or the kind of person that Professor Fonagy and Barbara have talked about, then I think we would be on the way towards improving outcomes for looked-after children quite quickly.
Chair
Thank you, Wendy. Alison?
Alison O'Sullivan
I would like us to find a way of making sure that we shine a spotlight on the needs of looked-after children, and when I say children in care, I mean adopted children, special guardianship and care leavers too, that we shine a spotlight on their needs within the breadth of the ambitions of “Future in Mind”. It is an ambitious and broad programme and we need to make sure that we do keep a focus on looked-after children in particular. That might be through drawing together from what is already there and enhancing to create a strategy. I would like to see an entitlement for children in care articulated as part of that, an entitlement. I would like to see us articulate what an entitlement would look like for children in care. I know that there are reservations about singling out particular groups for access to universal services like the NHS, but my challenge back would be which other groups are in fact the children of the state? I think we have a responsibility to those children over and above other children in the population.
Chair
Just to clarify, because obviously your role as President of the Association of Directors, when you say “we” and “shining a spotlight”, who?
Barbara Herts
I think the purpose of the Committee is obviously to make recommendations—[Interruption.] Can you hear me still?
Chair
I am still going to be here, because I am half-deaf, but carry on.
Barbara Herts
I will start again. I think Government should know how well we are addressing the needs of children in care and that is the purpose of the overview strategy that I was referring to earlier. But I think it would be very helpful for us all to articulate what an entitlement might look like for children in care to be a benchmark against which we should all be measured.
Chair
Thank you very much indeed for your answers to our questions and the three suggestions, all of which we have noted. Thank you very much indeed. Oral evidence: Mental health and well-being of looked after children, HC 481 21