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Jeff Thomas discusses the implications of policy developments in children's emotional wellbeing and mental health affecting primary schools

There is a window of opportunity to improve children’s mental health.

During 2018 there has been much speculation about primary schools’ responsibilities and activities in respect of their pupils’ emotional wellbeing and mental health. This has been caused by a stated commitment by the Government to: commit an additional £1.4 billion for children and young people’s mental health over five years; recruit 1,700 more therapists and supervisors; train 3,400 staff already working in services to deliver evidence-based treatments by 2020/21; and the publication of a Green Paper to enable this funding to be used appropriately. It has stimulated a plethora of organisations offering services to meet the future demand, causing confusion. We’ve just been through a similar situation with GDPR, where poor advice is still being given. Too many organisations left their planning too late which led to too many uninformed decisions. This article aims to describe the current situation, what might happen in the next twelve months and what considerations schools should start to take into account.

Schools’ responsibilities 

The starting point is to review the school’s main responsibilities for the emotional wellbeing, behaviour and mental health of their pupils. As well as being a social and moral issue, it’s also an educational one. Pupils with behaviour and mental health problems cannot learn effectively, affect other pupils through their conduct and put teaching staff under stress causing them to suffer poor mental health. It’s also important to recognise both treatment and preventative issues. Every child has to go to school, making it the main service delivery channel for children’s mental health; it’s a big responsibility.

 Schools’ responsibilities here can be summarised as fitting into one of two main groups:

  1. individual support for pupils who have identifiable problems that prevent them from fulfilling their full academic and social potential; these account on average for 20 per cent of all children; the severity of their issues can be easily assessed by teachers and parents by using the Goodman Strengths and Difficulties Questionnaire; translated into more than 80 languages, it is easy to complete by teachers, parents and carers and can then be scored by a trained professional. For pupils who score above a certain rate on the Questionnaire, the therapeutic services of a therapist, such as a play therapist, or a counsellor trained to work with children, will be needed; as well as treating the current issues, there is a preventative role in lessening the chances of problems becoming worse as the children grow into teenagers and adults

  2. educating all pupils in emotional wellbeing and mental health requires teaching; when done well, this also prevents problems developing but it will not help those in group 1 (above).

Some schools are performing well for both groups but many more are concentrating on group 2 at the expense of group 1. This is usually because of limited funds and the temptation to use a quick fix to show that some efforts have been made. Some schools are not attending to either group. Even more worryingly, some are using unqualified staff, without clinical supervision to undertake therapy for those in group 1. This leaves large numbers of schools who could do better under the present legislation and who are likely to be required to do soon. 

It’s up to each school to decide how to balance both sets of needs.

What’s likely to happen next? 

The main driver of policy changes is the Government’s Green Paper, Transforming children and young people’s mental health provision. This document was published in December 2017 and opened up to a public consultation which closed in May 2018. Although the intentions were good, there were omissions in key areas and a lack of practical detail in how the proposals could be implemented at the sharp end. Over 2,700 responses were submitted. This large number has caused worries about how well they were all sifted to identify the most relevant recommendations. There are also concerns from some that the consultation was just another “ticking the box” exercise.  It is too late now for further responses by schools to this consultation but there are other opportunities.

Apart from the Green Paper consultation, another way of influencing legislation, in the process of turning the Green into a White Paper, is to influence MPs. This can be done by lobbying on an individual basis or through reports prepared by All Party Parliament Groups (APPGs). A sub group of the Fit and Healthy Childhood APPG published a report on 26 June 2018 – Mental Health in Childhood. This contained 73 recommendations, many aimed at improving the Green Paper. It’s been widely circulated in parliamentary circles. It is suggested that every primary school contacts their MP drawing attention to the APPG report recommendations and how they will help local children.

Main proposed policy changes

In considering the proposals, there were concerns that increased funding could be wasted on ineffective and in some cases unsafe practice and that arrangements that work very well in many schools will be discontinued. Four crucial areas have been picked out: 

Appointment of mental health leads in primary schools
The proposal is that every school should appoint a “Designated Senior Lead for Mental Health to oversee the approach to mental health and wellbeing. All children and young people’s mental health services should identify a link for schools and colleges. This link will provide rapid advice, consultation and signposting.” 

I believe this is a good proposal provided that the job specification is developed in detail and competencies are defined so that adequate learning objectives may be derived for training.

Schools need to plan ahead to consider who is the best placed member of staff to take over this role.  Recruiting someone from outside has the disadvantage of a lack of specific knowledge of the pupils and being more of an unknown quantity. 

Service delivery channels 

However, the recommended appointment of a Senior Lead for Mental Health is followed by a more contentious one. The Government “will fund new Mental Health Support Teams, supervised by NHS children and young people’s mental health staff, to provide specific extra capacity for early intervention and ongoing help. Their work will be managed jointly by schools, colleges and the NHS. These teams will be linked to groups of primary and secondary schools, providing interventions to support those with mild to moderate needs and supporting the promotion of good mental health and wellbeing”. 

It seems that this is step backwards. Many schools are already carrying out these services satisfactorily, so why change? Those that are not should consider if their pupils will be better off in their known school environment, don’t have to travel to another centre, have less of a risk of being stigmatised, probably have less waiting time and whether there’s less administrative burden and better budget control as compared to using the proposed method of referral to an external team. Indeed, the Government’s response to the consultation, published at the end of July 2018, does agree that services that work well in schools should be continued. 

Regulation
I believe this area was a striking weakness of the Green Paper. No reference was made at all to regulation that is aimed at safeguarding children with psychological or mental health problems. Play therapists and school counsellors have had registers accredited by the Professional Standards Authority since 2013. Art, music and drama therapists have been registered with the Health and Care Professions Council (HCPC) even longer. These are professionals with good standards of practice and are a part of the health and social care workforce. The APPG report covers this serious omission by recommending that all counselling must be delivered by suitably trained practitioners who are on a professional standards authority accredited register or are included on the HCPC register. The Green Paper consultation results still appear to ignore this point.

Schools also need to consider risk management. If the work is carried out by a registered therapist, the risk of complaints by parents and others to the school is avoided or minimised because the professional organisation who manages the register are responsible for resolving these complaints. This protects the reputation of the school.

Evidence based practice 
The Green paper makes a simple, some would say glib, statement committing to recruiting 1,700 more therapists and supervisors, and training 3,400 existing staff to deliver “evidence based treatments”. Again, the intention is good but the devil is in the very important detail. It is essential to specify exactly what evidence based practice means for therapeutic work with children. The current medical model with a high reliance upon random control trials (RCT) is inappropriate, mainly because of the “crisis of reproducibility” with this research method. RCTs have their place in showing efficacy – a potential to improve practice.

 Practice based evidence collected over a number of years is a better way forward. This shows effectiveness and efficiency under real life conditions with all their complexity. The problem is that this requires patience, persistence and a standardised data collection procedure to build a good evidence base. Case studies may provide some knowledge but are not of great value in an evidence base because the circumstances of each case are unique and may not be repeatable. One model of play therapy, integrative holistic, has achieved this with over 59,000 outcome observations by parents and teachers. It shows that overall 77 to 84 per cent of the children show positive outcomes. The variation is due to differences in presenting condition, age, gender and number of sessions.  

Although there is on-going work in progress to make sound recommendations to the Government, schools should consider carefully which model of therapy is chosen, what practice based evidence exists and how they are going to compare their results, including cost effectiveness, to the national pattern.

The window of opportunity may not stay open long and may be obscured by the Government’s preoccupations with Brexit. But all schools can help by thinking through the issues raised above for them, then lobbying their MPs to get the best legislation for children in their constituency.

Further information

Jeff Thomas is Registrar of Play Therapy UK, the UK society for play and creative arts therapies:
www.playtherapy.org.uk

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