BORN in SOUTH LAKELAND – Developing Emotionally Resilient

BORN IN SOUTH LAKELAND –

developing emotionally resilient children

Glenys Marriott, John Asher, Zoe Butler

15th June 2014 Page 1 of 127

Independent Review of services supporting children and adolescents with mental ill health

“There is growing evidence that the false dichotomy between physical and emotional factors is incorrect and unhelpful. Emotional factors are as great a risk factor as obesity & smoking and severe childhood adversity can result in grossly abnormal brain development. We are experiencing a global rise in suicide rates and the UK has the highest rate of self-harm in Europe.

Suicidal thoughts are more common than people realise but stigma prevents us from talking about suicide. We not only need to tackle the stigma we need to eradicate stigma and also eradicate the silos which result in poor co-operation between departments and sectors which can have a negative impact on outcomes.

Developing better emotional resilience is about enhancing wellbeing, emotional literacy, coping skills, emotional and social connectedness. It can be compared to putting on a seat belt at the start of a car journey, something we all do even though we are not expecting a head-on collision, an action which may well save our lives. Emotional resilience should be just the same. We need to ‘suicide proof’ our young people by helping them to build resilience at an early age to prepare them to cope with challenging events and adversity that we all face.”

Dr. Alys Cole-King Clinical Director and co-founder of Connecting with People 1

1 http://www.connectingwithpeople.org/

Independent Review of services supporting children and adolescents with mental ill health

Foreword by Tim Farron, MP for Westmorland and Lonsdale

It is a cliché to say that mental health is a taboo – but it’s true all the same. People will much more happily talk about a physical condition than about how they are feeling. Mental health conditions come in as many different shapes and sizes as physical health conditions, so it is vital that we don’t patronise, generalise or make assumptions. It is also vital that our approach to mental health is based on evidence. In my role as a member of parliament I come across professionals and volunteers who work directly or indirectly supporting people with mental health conditions. I also work with many constituents who have mental health conditions and who use relevant services. As a result, I have formed a view of the quality and accessibility of our mental health services that is based on extensive experience of meeting with and speaking with those who are most involved. My experience of our mental health services has been that we have some excellent professionals working very hard, alongside third sector bodies who are really committed to meeting local needs.

My experience is also of a significant number of people, especially young people, who don’t get the support they need as quickly as they need it, or else they or their families do not know which way to turn.

I am always personally affected by the anguish that my constituents feel when facing personal difficulties, whether it be housing need, poverty or a health condition. Some events have a particularly profound and lasting effect. The deaths of young people who have struggled with mental health conditions affect me deeply. These tragic events and the circumstances surrounding them have made me aware that there appear to have been serious flaws in the way in which we support our young people. I have been involved in supporting and responding to the individual needs of around a hundred young local residents with mental health conditions. My experience of dealing with these cases demonstrated the need for a fresh look at our local services and for significant improvements to be made. I wanted to do something practical that would make a difference to young people in South Lakeland, to their families and to the professionals and volunteers who support them.

As a result I asked Glenys Marriott to chair a review in mental health support for young people in South Lakeland. Glenys has a wealth of experience in health and social care, amongst her current roles she is Chairman of Headway South Cumbria and of the Cumbria Neurological Alliance. Glenys was joined by John Asher and Zoe Butler who between them comprised the review team. John Asher’s involvement with the Survivors of Bereavement by Suicide is alongside a long and varied experience in mental health provision. Zoe Butler is a Young Advisor with South Lakeland Inspira who has also been doing work on mental health issues with her fellow students at Queen Elizabeth School in Kirby Lonsdale.

Glenys, John and Zoe have been outstanding in their commitment to this work; I am immensely grateful to them. In a voluntary capacity, Glenys, John and Zoe have put in dozens upon dozens of hours into this work. I owe it to them to make sure that I pursue the recommendations that have been arrived at, with a vigour that matches their commitment.

I am also hugely grateful to the many people who have given evidence as part of this review, often sharing very painful experiences with the review team. There is no way that this report and its recommendations could have been compiled without their contribution.

No one struggling with a mental health condition should fall foul of a lack of access to or awareness of the services that could help them and transform their lives. Likewise, those services should be of the highest quality. By presenting the experiences of young people and their families, and of professionals and service providers, I hope we will be able to give a clearer picture of the state of our

Independent Review of services supporting children and adolescents with mental ill health local mental health services and the extent to which young people are currently able to access them. I also hope that we can draw out of these experiences some evidence based and realistic recommendations for how we can help build emotionally resilient young people in our community through services that meet their needs and are easy to access.

As a father myself, and as MP for around 15,000 people who are under the age of 18, I am determined that we should have mental health support and services available for all our young people that meet their needs at exactly the moment they need it. If we are to value our young people, mental health must not be a taboo. Let’s talk about mental health, and let’s commit to do those things that will make our mental health, and our mental health services, the best they can be.

Independent Review of services supporting children and adolescents with mental ill health

Foreword Tim Farron MP Page 4 Index Page 5

1. Executive Summary Page 6 2. Recommendations Page 8 3. What works well? Page 13 4. Background to the review Page 16 5. The review team Page 16 6. Aims of the Review Page 17 7. How the review was carried out. Page 18 8. Putting the review into context. Page 21 9. How do we build a generation of emotionally Page 25 resilient children? 10. The re-commissioned Child and Adolescent Tier 3 Page 30 mental health service (CAMHS) 11. Triage Page 42 12. Suicide Page 46 13. Self Harm Page 51 14. Autism and Asperger’s syndrome Page 54 15. Foster carers Page 58 16. Schools in South Lakeland Page 59 17. The Brewery Arts Centre Kendal Page 67 18. Special Residential Schools Page 68 19. Inspira Page 71 20. Bullying Page 71 21. Eating Disorders Page 72 22. Lesbian Gay, Bisexual or Transgender issues Page 72 23. Substance misuse including alcohol Page 73 24. The internet and mobile technology Page 7 25. Sexual Health Page 76 26. The Voluntary and Charitable sector - the 3rd Sector Page 76 27. The needs of the GP Page 84

APPENDICES

Appendix i Key Statutory organisations & committees within the county Page 88 Appendix ii Adult mental health service themes Page 97 Appendix iii The Big Lottery Fund’s Fulfilling Lives: HeadStart Page 109 Appendix iv Asset-based community development Page 110 Appendix v Key statistics about children and young people in Cumbria Page 111 Appendix vi Submissions by Survivors of Bereavement by Suicide Page 113 Appendix vii Useful Information: Mental Health and Emotional Wellbeing Page 121 Appendix viii Schedule of consultees/respondents Page 124

Independent Review of services supporting children and adolescents with mental ill health

1. Executive Summary

Cumbria has a large geographical footprint, with a single County Council, a co-terminous NHS Clinical Commissioning Group and NHS Partnership Trust providing for its residents. In undertaking this review care has been taken to recognise and link in with work already being done by other groups such as the County Local Safeguarding Children’s Board and the Health and Well Being Board and others which appear in appendix i.

South Lakeland statistics show that its residents have in many areas a more privileged footprint than other areas in Cumbria and it is important that these findings are considered in the context of the needs of the whole county, especially as people responded from Barrow, Eden and Carlisle. The review was not aimed at attracting more resources to South Lakeland at the expense of other areas; rather we wanted to take a snapshot in time of what exists in the area and how it can be supported to work better.

In the spirit of openness and collaboration, throughout the review I fed back regularly to service providers to enable real-time improvements to be made and it has been useful to note that some of our recommendations have already been considered and actioned.

The review chairman took a qualitative approach based on personal responses from over 100 self- selecting volunteer residents and over 100 other people from statutory and voluntary agencies. Initial interviews with residents in South Lakeland had a snowball effect on others they knew and, as such, the numbers interviewed expanded outside South Lakeland and into Eden, Carlisle and Barrow. Responses were received between November 2013 and the end of May 2014. Many sent written responses, others were interviewed and notes taken of their issues. In some cases group meetings took place, and one group gave access to its closed Facebook group. Everyone gave permission for comments to be included in this report.

To listen to the views of children, their parents or carers was the focus of the review and it is important that their voices are now heard. There are also many dedicated people delivering support and services who have an important voice and their contributions were invaluable. They are all crucial to improving emotional resilience not only for the current child population but also for those not yet born.

Mental illness is common. It affects thousands of people in the UK, and their friends, families, work colleagues and society in general. Most people who experience mental health problems recover fully, or are able to live with and manage them, especially if they get help early on.

There is still a strong social stigma attached to mental ill health, and people with mental health problems can experience discrimination in all aspects of their lives. Many people’s problems are made worse by the stigma and discrimination they experience, not only from society but also from families, friends and employers, and the everyday language we use. Stigma and discrimination have a profoundly negative effect on their lives. Stigma and discrimination can also worsen someone’s mental health problems, and delay or impede their getting help and treatment, and their recovery.

Social isolation, poor housing, unemployment and poverty are all linked to mental ill health. So stigma and discrimination can trap people in a cycle of illness.

Independent Review of services supporting children and adolescents with mental ill health

The main themes emerging from this review are:

1. We all need to aim proactively to eradicate stigma, talk about our feeling and fears about mental health, including suicide, and raise awareness of what help is available.

2. We need to ensure that good mental health is equally as important as having good physical health and that it receives equal treatment and funding.

3. We need to value people for what they can contribute, whatever their mental health status, to include them in our lives, and not reject them because they are ‘different’.

4. We need whole systems change and all organisations will face challenges trying to develop and support children to become emotionally resilient; we need to talk about this now and regularly.

5. We need to make mental health everyone’s business.

6. The roll-out of the Headstart Project will support all of the above, with shared learning being rolled out across the County and it is essential that we all learn about it and give it our full support.

GLENYS MARRIOTT Independent Chairman 15th July 2014

Independent Review of services supporting children and adolescents with mental ill health

2. Recommendations

Whilst recommendations are directed at certain groups of organisations it is clear that they need universal support in activating change. Feedback has been given throughout the review and it is excellent to see that some of these recommendations have already being acted upon.

A. NHS England

i. NHS England should expedite commissioning plans to extend urgently Tier 4 provision both in the North West and nationally.

ii. NHS tariff arrangements are limited to Initial and Review Health Assessments and do not give any guidance on reasonable costs for other health services; therefore guidance on this subject would be welcome from NHS England.

iii. Tier 4 service. The current arrangements should continue for South Cumbria whereby the referral for young people needing Tier 4 services should be to the Lancashire Care NHS Foundation Trust services in Preston and Lancaster, in the first instance.

B. Health and Social Care commissioners and Public Health

iv. Joint Commissioning. The excellent proposal to have joint commissioning of CAMHS services by the CCG and County Council by April 2015 should be expedited to address outstanding issues and to clarify pathways for Children Looked After (CLA). Commissioners should be focused jointly on developing a ‘whole systems approach’ to add value to their sizeable respective statutory investments.

v. Sure Start Children’s Centres and rurality. Ofsted demands on Children’s Centres do not reflect the rural aspects of their work in Cumbria, or the subsequent pressures on their available contact time. When the County Council contract review takes place in 2015, commissioners should take these aspects into full consideration to contract for more time for work in remote rural villages.

vi. Sure Start Children’s Centres and Birth data. Ofsted recommendations for Children’s Centres should be implemented immediately to enable new birth data to be transferred to the Centres in a timely manner. Consideration should be given to this being provided by midwives and backed up after the birth by health visitors.2

vii. A Self-Harm working group similar to the Suicide Prevention Strategy group should be introduced. It should agree a working protocol based on NICE guidelines that all organisations working with children and young people sign up to and implement clear pathways for managing the care of children and young people who self-harm. It needs to be integrated not only with HeadStart but also with the Tier 2 project and the mental health workforce development plan.

viii. Children placed out of area. Cumbria County Council should routinely advise the Cumbria Clinical Commissioning Group (CCG) when they place a child out of area. The Cumbria NHS Partnership Foundation Trust will be made aware through the Children

2 Ofsted recommendation Kendal West Sure Start Children’s Centre http://www.ofsted.gov.uk/inspection-reports/find-inspection-report/provider/ELS/21646

Independent Review of services supporting children and adolescents with mental ill health

Looked After nurse but the CCG should also be informed. This will enable engagement with the responsible commissioners to ensure that there is a plan to have each child’s health needs met. 3

ix. Training. Many parents suggested that there is a need for more training courses for parents, carers, children and the public on mental health, suicide prevention and child sexual exploitation. Good work already started should be applauded and expanded not only for parents and young people but for professionals and 3rd sector organisations.

x. Sustainability of the 3rd sector services. Services are increasingly on the decline as funding is reduced or removed. Time diverted to fundraising takes more time away from service delivery. This creates a vicious circle and funding bodies like councils and the CCG need to be aware of the impact of their funding decisions and to reverse the trend if it is their intention that the 3rd sector should continue to play an effective part in the delivery of services.4

xi. Transition to adult services. The current arrangements for the transition of patients from CAMHS to Adult Mental Health and other services have been unsatisfactory for a number of years. Whilst urgent work has been funded by the CCG to address the backlog it is essential that patients who require continuing treatment beyond 18 years and 3 months of age should exit CAMHS after an assessment by adult Mental Health services. The CCG should continue to ensure that such services are in place.

C. All organisations

xii. A single point of contact to access services was the number one priority for parents and it was also raised as a top issue for most statutory and voluntary sector respondents. Consideration should be given to every professional who feeds into the mental health system taking personal responsibility, if approached, for finding the most suitable service. The proposal to have primary mental health care workers acting as ‘navigators’ at Tier 1 giving access to a comprehensive model of mental health service will address this initially, but all organisations need to take this responsibility.

xiii. Referral Processes. All organisations should put in place referral processes that ensure that any young person is connected to statutory services or alternative services so that they can access the support they need. Connecting services and pooling resources to ensure all young people are supported is a key element of the multi-agency implementation of a whole system approach to emotional and mental health, and part of the wider aim to shape system change enshrined in Cumbria HeadStart Big Lottery Funded Initial Project. 5

xiv. The longer term support for communities bereaved by suicide is already built into the county strategy for suicide prevention. Organisations providing personal support to individuals thereafter need to extend this automatically to key people associated directly with the trauma of the suicide. All immediate response teams should be aware of where this support is available and it should be on offer up to and after the inquest.

3 The chairman is led to understand that this has recently been agreed. July 2014 4 In support of this recommendation Cumbria CVS published its Welfare Commission Report on 9th July 2014. http://cumbriacvs.org.uk/news/welfare-commission-report/ 5 See Appendix iii

Independent Review of services supporting children and adolescents with mental ill health

xv. Developing an emotional resilience programme. To meet the needs of children and young people and to develop a robust emotional resilience programme it is vital to include children’s centres, youth workers from all agencies and 3rd sector organisations, plus primary, secondary and academy schools across Cumbria. Work already started in the Headstart programme should be given high priority and extended to include Independent special schools within the county.

xvi. Clinical governance and managing risk. When extending Tier 1 and Tier 2 services to support CAMHS, consideration must be built in to the contract to examine and confirm explicitly which organisation is managing the risk for each service user if the young person is then placed on a waiting list. At present, various 3rd sector organisations are holding long waiting lists of referrals made by statutory organisations who themselves are not able to respond to the need of the service user. Charity trustees should examine this urgently and ensure they have agreements in place to manage risk effectively.

D. Statutory organisations providing services

xvii. Children accessing Tier 4 out of county should be robustly case managed by the Cumbria Partnership Foundation NHS Trust (CPFT). This is especially pertinent when some are many miles from home.

xviii. Tier 4 service outreaching into South Cumbria. Some excellent outreach work already being done by the Lancashire service offers the opportunity to extend its work further in support of the Cumbria Tier 3 service. Continuing work should be extended to enhance this.

xix. Pathways. Work has started within CPFT to clarify the link between Tier 3 CAMHS and tiers 1 and 2. Relevant pathways should be developed with both primary care and 3rd sector input and should be widely shared when they are agreed.

xx. Triage. There was sufficient feedback for the statutory leads to review the working of the Triage system. It is important therefore that all agencies are clear about their own responsibilities and those of other agencies for addressing the needs of children. Within this context the use of an early help/Common Assessment Framework (CAF) is a key tool for use across all agencies.6

xxi. A Mental Health Hospital Liaison Service for 16+ is needed urgently and should be implemented across the county in A and E departments to support the management of people who are suicidal and /or have self harmed. This has been commissioned and should regularly be reviewed.

xxii. Work by the Suicide Prevention Strategy Group highlights the need for a systematic, consistent, post-suicide response to prevent suicide contagion. Lead agencies responsible for suicide prevention and safeguarding should agree responsibilities for developing and implementing the required guidance and protocols, through Cumbria's LSCB and Health and Wellbeing Board. Agencies should commit resources to develop, disseminate and embed this guidance.

6 This response to the draft paper was made 11th July 2014 by CCC: “The Triage service has been reviewed (in April 2014) by a team from another LA via the LGA. Their recommendations are being addressed. In addition, the LSCB has established a programme board to oversee the development of the service into a full Multi-Agency Safeguarding Hub (MASH); the purpose being to ensure that children about whom there are concerns receive the right level of service at the right time.”

Independent Review of services supporting children and adolescents with mental ill health

xxiii. The Cumbria Autism Partnership Board should reconnect with its members in the south of the county, update its website and address the issues raised in this report by parents.

xxiv. Autism and Asperger’s Syndrome. Further training should be provided for Job Centre Plus staff about the special needs of young people on the Autistic spectrum or with Asperger’s syndrome as they report poor assessment, inadequate understanding and inappropriate work referrals.

xxv. Tribunal reports of all successfully challenged Statements of Special Educational Need should be shared with CPFT and reported to the County Council Scrutiny Committee.

xxvi. Cyber / digital technologies. New communications media used by children and young people and their access and use of the internet has been acknowledged nationally as a possible environment for risk taking behaviour. There is good work being done with children and young people to raise awareness of these risks but it is not a universal county-wide programme and needs extending.

xxvii. There are also positive social interactions and health messages which can be delivered by digital means and organisations need to take cognisance of and embrace a rapidly changing world and work with young people to deliver strong messages of support and information.

xxviii. Intergenerational work should be given higher profile within county strategies. This would be particularly valuable in supporting elderly parents of adults with long standing mental health problems, bridging the generations and raising awareness and understanding for all groups.

xxix. Staff. A final important recommendation relates to staff who are expected to deliver high quality appropriate services. NHS organisations and the County Council are employers of thousands of staff and joint consideration should be given to the quality and level of mental health support available to them. The health needs of GPs is also vital (see the submission in section 27 from the Local Medical Committee).

Staff surveys such as that for the Cumbria Partnership NHS Foundation Trust in 2013 show the percentage of staff suffering work-related stress in the last 12 months to be higher than average when compared with similar trusts.7 The same survey for staff at the University Hospitals of Morecambe Bay NHS Foundation Trust also outlines levels of stress as assessed by staff.8

The County Council survey results in April 2014 (not yet released to the public) “received a response from 48% of employees in Children's Services and found that whilst there are issues about morale, as there are in any public sector service given the current context of redoing resources, staff are clearer about the expectations of them, have good contact with their line manager and are kept informed.”9

It is clear from our interviews that these organisations are working hard to improve care for staff who are all facing big challenges. Working together in the Cumbria Health and Care Alliance organisations should proactively identify joint ways to improve these

7 http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2013_RNN_full.pdf 8 http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2013_RTX_full.pdf 9 Response received from CCC 13th July 2014

Independent Review of services supporting children and adolescents with mental ill health

survey outcomes.10 They should address these similar needs focussing on the early identification of staff needing help and support and by actively removing any stigma associated with mental ill health.

“Who cares for the carers?”

“...there are the significant costs of the risks of presenteeism (attending work but underperforming due to ill health), which is estimated at 1.5 times the cost of sickness absence. (DOH, 2009) Presenteeism in practitioners poses significant risks to patients through medical errors, underperformance, and team dysfunction.”11

“The workforce is changing both in demographics and in the demands placed on it. Workers’ mental wellbeing is an important factor when attempting to improve the mental capital of economies and societies.” 12

10 Response to the draft report by CCC 13th July 2014 stated “A number of facilitated workshops were held in May to proactively identify ways of improved joint working across all services. These involved staff from all levels of the partners and the output is now being shared with the Alliance.” 11 Response to the review from Cumbria Local Medical Committee – section 27 12 Beddington et al., Mental Capital and Wellbeing 2008. 13 This Wordle cloud was generated from all the text in this report. The cloud gives greater prominence to words that appear more frequently in the source text.

Independent Review of services supporting children and adolescents with mental ill health

3. What works well?

1. There are many dedicated people across the county working to deliver a good service, often in a stressful and ever changing environment. They care deeply about their work and want to work collaboratively.

2. The school nursing team, when available, is well regarded in schools and has built strong relationships. There is concern from education respondents that their general presence and support may be diluted.14

“CPFT is working closely with Cumbria County Council as the commissioners for this service, within the resources available. They have commissioned ‘the Lancaster Model’ to support the implementation of the Healthy Child Programme for 5-19s which is focused on identifying health needs at an individual, school and community level, and alerting the school nurse to provide an early targeted response for individual children and young people in relation to their need. School nursing time is now allocated to this focused way of working and capacity and skills to manage other ongoing health needs are now being developed elsewhere in the Children & Families Care Group.”

3. Experienced uniformed police officers are given consistently good assessments by respondents living with adult relatives who have long standing mental illness. They are perceived as being well trained, sympathetic and supportive, acting in a timely manner and giving families the confidence to manage difficult situations.

4. Sure Start Children’s centres are greatly appreciated by parents but they are working to demanding contracts and are under pressure to address the targets set by Ofsted.

5. SAFA, now working county-wide, takes referrals of self harm from individuals, schools, GPs, CAMHS, other agencies and social workers. It was highly rated by those who refer to its services.15

6. Innovative work is already underway in some schools to address emotional resilience. An example of a holistic approach to wider stakeholder engagement in supporting and developing children and young people’s emotional resilience is the work with Queen Katherine School, Kendal. The proposal focuses on the development of an integrated emotional health and wellbeing team incorporating school pastoral staff and Tier 3 CAMHS practitioners.

7. The substantial work already done at a county level on suicide prevention has been reviewed and updated.

8. ‘Transformation’ nights run by youth workers for younger people in rural areas about identifying and addressing homophobia are innovative and address stigma.

9. Use (and abuse) of social media is an area of increasing concern to teachers, youth workers and parents. Cumbria Constabulary regularly monitors internet and new media content for anything that may put children and young people at risk of suicide. They have also initiated dialogues with young people (either directly or using friends as third party intermediaries

14 Department of Health Getting it right for children, young people and families Maximising the contribution of the school nursing team: Vision and Call to Action https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216464/dh_133352.pdf 15 www.safa-selfharm.com

Independent Review of services supporting children and adolescents with mental ill health

under police supervision) when a friend or contact has noticed that they are in distress on Facebook, to help identify their whereabouts.

10. Practitioner forums have been developed across the county to bring front-line staff together to discuss issues, share practice and feed up ideas to the Local Safeguarding Children Board (LSCB). 16

11. Improving relationships were apparent between leading directors in both health and social care and the willingness of local and county councillors was strong to work together to minimise risk and maximise good outcomes for young people.

12. A survey by young people via youth workers “Young Cumbria Reform of the Emotional Health and Wellbeing Service for Children and Young People (CAMHS) Research” commissioned by the NHS Cumbria Clinical Commissioning Group (CCG). This research was delivered by the Cumbria Children and Young People’s Voluntary Sector (CCYPVSRG) and managed by Cumbria Youth Alliance.

13. The survey undertaken by Zoe Butler, review team member, and other students at Queen Elizabeth School Kirkby Lonsdale supported by Inspira, and their subsequent robust approach to building emotional resilience is to be congratulated.17

14. Representatives from NHS Trusts in Cumbria, Cumbria Health on Call (CHoC) and the Cumbria Clinical Commissioning Group (CCG) have joined together in an integrated approach to attracting new talent to the county to fill vacant posts.

15. Some good training programmes exist for professionals, especially around suicide prevention.

16. There has been sound development work done by CPFT together with CCG partners to extend the Tier 3 Child and Adolescent Mental Health service. Relationships have been made with a wide range of organisations and this will contribute to building trust and confidence in the service provided the links are fostered, extended and maintained.

17. The Junction, Tier 4 CAMHS service in Lancaster employs dedicated transition workers to facilitate successful return home of its clients.

18. The work done by the South Lakeland Schools Federations in supporting children to ensure they don’t drop out of education but achieve the most fulfilling role possible; holding regular Inclusion meetings together and for taking ownership of the challenges their pupils face. The inclusion team is seen as key to supporting children in imaginative ways and is an excellent advocate.

19. The Brewery Arts Centre in Kendal is a key partner in helping to build emotional resilience and should be acknowledged for its in-house expertise and the range of children and young people it tries to support.

20. Leaders across the county are working towards implementing the Asset-Based Community Development (ABCD) approach (appendix 4).

16 http://www.cumbrialscb.com/elibrary/Content/Internet/537/6683/6684/4168413251.pdf 17 www.queenelizabeth.cumbria.sch.uk

Independent Review of services supporting children and adolescents with mental ill health

21. Bereavement care via Child Bereavement UK with a child bereavement counsellor 18 and Survivors of Bereavement by Suicide (SOBS) offer excellent support in South Lakeland.

22. Exciting and important work is being done by members of the Lakeland Youth Council, funded by Cumbria County Council. Their magazine Blink is worth reading to raise awareness of issues facing young people.19 They have made mental health their priority for the coming year. Linking with them should be a priority for all groups working with young people in the area.

23. The provision of flexible, professional and sympathetic education and support given by the hospital and home tuition service deserves special mention. Its pupils often have complex needs and poor experience within main stream schooling and listening to their individual progress was impressive. The staff demonstrated a real understanding of building emotional resilience.

24. The power of self-help groups and the support they can give individuals should be acknowledged and their skills and commitment congratulated.

25. The work done by Age UK South Lakeland trying to bring the 3rd Sector together and to raise the importance of intergenerational work should be recognised and supported.20

26. The Cumbria County Council ‘Children in Care Council’ organised a "Care Cumbria" award ceremony in May 2014 to raise the profile of the achievements of looked after children and young people and their carers.

Respondents also requested specifically that the following be included:

“Kendal MIND was good.21 I had to wait to see a counsellor but it really helped.”

“Thank goodness I was referred to Growing Well.22 I don’t know what would have happened to me if I hadn’t had their support.”

“We have a very good senior learning disability nurse who looks after my son really well.”

18http://www.thewestmorlandgazette.co.uk/news/10327378.Support_worker_Christine_meets_bereavement_charity_s_royal_patron/?r ef=nthttp://www.thewestmorlandgazette.co.uk/news/10327378.Support_worker_Christine_meets_bereavement_charity_s_royal_patron /?ref=nt 19 www.lakelandyouthcouncil.co.uk 20 www.ageuk.org.uk/southlakeland 21 www.southlakelandmind.org.uk 22 www.growingwell.co.uk

Independent Review of services supporting children and adolescents with mental ill health

4. Background to the review

This independent review was instigated by Tim Farron MP because of his concerns about complaints from residents reported to him during 2012-13 about mental health services, and the deaths of two local children. It was carried out between November 2013 and May 2014.

Tim Farron asked Glenys Marriott to chair the group and agreed that it would be fully independent and the review group would be free to decide the parameters of the review. No fees or expenses were charged by any member of the review panel.

The review team took an ‘asset-based community development approach’ as the philosophy underpinning the review, considering all the good things that exist ‘on the ground’ in Cumbria and considering ways to enrich their contribution to building emotionally resilient children.23

This approach was recommended in Dr. John Ashton’s Public Health Report ‘Living Well in Cumbria’ in 2011 and has gradually been gaining credence locally and nationally.24 It was also highlighted in the extensive work done by Dr John Howarth, a GP in Cockermouth and Director of Integration with the Cumbria Partnership Trust.25

5. The review team

Glenys Marriott is an Independent Health and Social Care Consultant and chairman of Headway South Cumbria and the founder chairman of the Cumbria Neurological Alliance in 2013. She chaired the review team.26 Glenys has long experience of working in health and social care, initially as a social worker, and both as chief executive of a health authority and more latterly as chairman of a major teaching hospital trust in the north east. She led the review of neuroscience services in Greater Manchester, followed by the review of tertiary children’s services in the same area. Both resulted in major change and the development of specialist services at Salford Royal and the Central Manchester University Trust. Glenys subsequently reviewed the various mental health services in Manchester which resulted in the formation of a single Manchester Mental Health and Social Care Trust. She has recently been appointed as the patient/carer/public representative on the Greater Manchester, Lancashire and South Cumbria NHS Strategic Clinical Network for Neurological Conditions.

In 2002, as a non executive director in Hambleton and Richmondshire PCT she chaired the Mental Health Act Manager’s meetings and heard many applications.27 In her consultancy Glenys worked regularly for 8 years in the Republic of Ireland developing strategies for improving the health of young people.28 She spent 9 months in London supporting the review of the Department of Health. From 2009 until the emergence of the CCGs in 2012, Glenys chaired the North East Neurosciences Commissioning Network for the PCTs and has close involvement with the subsequent model of new NHS Senates which absorbed her previous work. She was a Trustee of the Motor Neurone Disease Association for 3 years and is keen to ensure that appropriate and timely care pathways are in place for patients. She has undertaken a large number of reviews and investigations for other health organisations and charities and undertook this piece of work ‘pro-bono’.

2323 ABCD – see appendix iv. 24 Living Well in Cumbria 2011 A report for the Director of Public Health and the Cumbria Intelligence Observatory Supporting Cumbria’s Joint Strategic Needs Assessment http://www.nwpho.org.uk/cumbria/LIVING%20WELL%20IN%20CUMBRIA%20REPORT.pdf 25 http://www.cumbriapartnership.nhs.uk/uploads/WorkingTogether/John%20Howarth.pdf 26 Headway South Cumbria www.headwaysouthcumbria.wordpress.com 27 http://www.rethink.org/living-with-mental-illness/mental-health-laws/discharge-from-detention/mha-managers-review 28 http://www.lenus.ie/hse/bitstream/10147/44900/1/6550.pdf

Independent Review of services supporting children and adolescents with mental ill health

She was supported by John Asher a retired and well respected principal social worker with a long standing interest in mental health and now actively involved with Survivors of Bereavement by Suicide (SOBS).29 John’s experience county-wide in the field of mental health and as a trustee of the Cumbria Mental Health Group has been important to ensure key people were included in the review. John’s ongoing work since retirement with Survivors of Bereavement by Suicide (SOBS) means he is actively involved in supporting people.

Zoe Butler, the third member of the team is a 6th form student and a Young Adviser with South Lakeland Inspira. 30 She contributed the work she has been doing on mental health issues with students at Queen Elizabeth School, Kirkby Lonsdale and GPs. She advised on the needs of young people as articulated by her peer group and brought a vital understanding to the review, ensuring that the perspective of young people was acknowledged accurately.

The report will be made widely available to all organisations and individuals who responded.

The team felt it was a great privilege to work with Tim Farron MP and his team and to gain some insight into the role of an MP’s case manager. Adrian and Hannah exhibited enormous dedication to sorting out a wide range of problems for constituents and a tenacious dedication to getting acceptable resolutions.

The team wishes to extend particular thanks to Governors of the Cumbria Partnership NHS Foundation Trust, Jim Bradley, chairman of the mental health special interest group, Elissa Robinson and Professor David Galloway, chairman of the children’s special interest group for their support and interest in the review. Sincere thanks go to Dr. Alys Cole-King who has offered external wisdom and clinical guidance throughout the review.

In addition the team wishes to thank the 234 people who have given their time to responding to the review, some of whom submitted written responses but were not interviewed. We hope they recognise their comments here.

6. Aims of this Review

The team chose to explore the emotional health and well being needs of children and young people from 0-18 years in South Lakeland, and to identify ways of supporting the development of emotional well-being. This included identifying both good practice and gaps in service, organisations who felt they played a part in offering support and by listening to a wide range of people to record their views and ideas. It aimed to give a useful insight into community issues not covered by the external report on CAMHS in 2012 and subsequently agreed in 2013.

The following key issues formed the basis of the review:

i. Depression. ii. Eating disorders in both males and females. iii. Bullying including physical and verbal, via social media or text, homophobic, sexual or racist bullying. iv. Self harm. v. Drug misuse including alcohol impacting on risky behaviour or mental ill health. vi. Suicide. vii. ADHD.

29 SOBS www.uk-sobs.org.uk/ 30 Inspira Cumbria www.inspira.org.uk

Independent Review of services supporting children and adolescents with mental ill health

Additional issues were added on 6th December 2013 after responses were received from the public. viii. Children on the autistic spectrum and those with Asperger’s Syndrome. ix. “Children Looked After”. x. The needs of foster carers. xi. Independent residential schools for children with special needs. xii. The sustainability of the 3rd Sector.

The review team is keen to stress that this review was not undertaken to gain additional resources specifically for the South Lakeland area. It was anticipated that issues raised in South Lakeland would not be exclusive to this area and that recommendations are likely to reflect needs county- wide.

7. How the review was carried out.

The review team took cognisance of major policy changes, local initiatives and the fact that new leaders were being appointed within the county. The team was conscious that it did not want to replicate work already done, by external organisations such as the Care Quality Commission (CQC) or the Office for Standards in Education, Children’s Services and Skills (Ofsted) or the internal county wide committees. Members wanted to enhance that work building on identifying ways in which grass root contributors to mental well being in South Lakeland could be identified and acknowledged for the skills and resourcefulness they bring to a child-focused partnership. The team sought to enable a sustainable approach to be developed which can enhance the mental health resilience of our children and adolescents.

At the end of October 2013 Tim Farron MP announced via email to constituents the intention to launch an independent review and the chairman did a radio interview with BBC Cumbria to stimulate interest.

Early in November 2013 the review chairman completed an audit of 86 mental health complaint files managed by Tim Farron’s case managers over the previous 15 months. This audit identified that 2/3rds of the complaints focussed on adult mental health services.

The issues which had been flagged up in the audit of complaints formed the basis of this review and were added to after an initial meeting with CAMHS leads Dr. Luisa Sanz Villanueva, CAMHS Clinical Director, and Teresa Waleboer. When interviewed they requested that attention deficit hyperactivity disorder (ADHD) be added to the priorities to reflect pressures in their inherited case load. 31

Tim Farron then issued a ‘call for evidence’ invitation during anti-bullying week on 20th November. That resulted in 94 responses on day 1 of the review. More continued to be submitted over the next month and came from clients, carers, parents, professionals and 3rd sector organisations. They were received by the chairman and prioritised, collating adult issues separately. She then arranged to meet with selected respondents over a 4 month period. This was extended as even as late as May more requests for interviews were received. All respondents were asked if their comments could be used in the report anonymously. All agreed to this.

Some respondents submitted substantial evidence in writing which was acknowledged and collated. Others were visited and interviewed at length and notes made of their comments. Where issues

31 ADHD - Attention deficit hyperactivity disorder

Independent Review of services supporting children and adolescents with mental ill health were raised they were triangulated with others for additional confirming evidence and fed back to practitioners for clarification where necessary. It was anticipated that only residents in the MP’s constituency would respond, but this snowballed across the county as groups passed on information about the review.

As this review focused on the needs of children and young people, the chairman met with Cllr Rod Wilson, Chairman of the County Council Health Scrutiny Committee to agree a strategy for dealing with any adult issues which emerged.32 It was subsequently agreed that the Scrutiny Committee would make adult mental health a priority for review in 2014-15. She met also with Dr. Jim Hacking, mental health GP commissioning lead for South Lakeland CCG and CCG directors who also had plans to review adult services. The themes emerging from this audit and other subsequent interviews were shared with the statutory organisations at the end of March 2014 to enable them to plan their reviews and are now contained in Appendix ii to this report. Subsequently People First launched a 2 week review on mental health at the request of the CCG.33

In addition: a) A desk top audit was carried out of the top policy reviews available. b) The review based its initial work on the National Institute for Health and Clinical Excellence (NICE) Guidance which had already published a number of guidelines to benchmark best practice.34 These included:

I. Depression in children and young people (CG28) II. Self-harm (longer term management) (CG133) III. Psychosis and schizophrenia in children and young people (CG155) IV. Conduct disorders in children and young people (CG158) V. Attention deficit hyperactivity disorder (ADHD) (CG72) VI. Social anxiety disorder (CG159) VII. Depression in children and young people (CG28) VIII. Self-harm (longer term management) (CG133) IX. Psychosis and schizophrenia in children and young people (CG155) X. Social anxiety disorder (CG159) XI. Autism - management of autism in children and young people (CG170) c) A range of organisations involved in supporting young people and promoting their good mental health were approached. These included schools, colleges and youth clubs, the voluntary sector and charities and the Public Health Suicide Prevention lead. During the review a refreshed version was issued of ‘Children and young people Emotional health and wellbeing in Cumbria: Joint strategic needs assessment.’ 35 This is a key document and recommended reading. d) The review team was keen to consider the views of GPs via the CCG leads and the school survey developed by team member Zoe Butler’s in-school team. e) The chairman visited a large number of parents/carers and listened to their statements about trying to access appropriate services in a timely fashion and their views on their needs for

32 http://cumbria.gov.uk/scrutiny/healthandwellbeing/healthscrutinycommittee.asp 33 http://www.peoplefirstcumbria.org.uk/2014/05/mental-health-and-wellbeing-services-survey/ 34 NICE – National Institute for Health and Clinical Excellence www.nice.org.uk/guidance/ 35 http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/6164/41696135154.pdf

Independent Review of services supporting children and adolescents with mental ill health

support. All interviews were recorded in writing and permission gained to use the comments in this paper. f) In view of the low morale articulated by some practitioners the team also wanted to consider and highlight the good practice experienced by young people or parents /carers and to share this with staff during the review period. g) A number of training needs, continuous development, research or supervision issues were raised. h) Alternative peer support approaches were considered such as Community Champions Self Help Nottingham.36 i) With support from Jackie Daniel Chief Executive and Sue Smith Director of Nursing at Morecambe Bay Hospitals NHS Foundation Trust the chairman considered the number of young people reporting to A and E departments for self harm, their subsequent treatment and discharge pathways. j) Via John Asher, review member, the team listened to the needs of survivors of bereavement by suicide in the SOBS support group. Their responses are included in Appendix vi. k) Whilst this review has no statutory powers it has offered all those involved an opportunity to contribute their views and ideas, and over 180 people have been interviewed and over 50 have submitted written views. Almost everyone approached to contribute has agreed and for this we are greatly appreciative. The team considers this to be one of the strengths of this qualitative approach. l) During the review regular feedback was shared with organisations and one of the most useful outcomes has been the large number of introductions made by the chairman to key people across the full spectrum of care. In these times of great change, redundancies, retirements and reorganisations practitioners were finding their normal networks no longer existed. m) A literature review of recent publications was carried out. Some are included as footnotes in the body of the report and the remainder can be found in appendix vii. These covered publications by statutory organisations, local and national charities and parent groups, national policy documents, NICE standards and major review bodies including the latest advice from NHS England and commissioners. The excellent bibliography included in the Joint Suicide Prevention Strategy provided additional references when needed. n) Responses to this review are indented in blue. Respondents all gave permission for the inclusion of their comments anonymously in this report. o) The panel also considered the use and impact of safeguarding, bereavement and self harm prevention policies in schools. p) Statutory organisations had the opportunity to submit comments on the report prior to publication and we are grateful to those who not only did so but made changes to their working practice as a result of some of the recommendations.

36 http://www.selfhelp.org.uk/home/

Independent Review of services supporting children and adolescents with mental ill health

“Child mental health - this is a very significant area to consider. Policies in themselves are not sufficient to ensure that students' well-being is supported in a school setting. It is the quality of leadership, management, ethos and front line pastoral care that will determine the quality of care and support for young people.”

“I would imagine that social network issues will figure significantly within the context of this area of "stay safe" (Every Child Matters policies and aims etc). In my experience, those schools with very good safeguarding provision incorporate innovative and up to date technological applications that provide a safe, school-time alternative to Twitter and Facebook etc.”

“I’ve worked in schools and I know some of them just download a policy – there are loads available. They don’t all grow their own though and if something goes wrong they can find their policy is not appropriate.”

8. Putting the review into context. a) The organisations supporting and building emotional resilience in children and the issues underpinning this review are given in some detail in appendix i as it was clear that many respondents did not have a clear understanding of the organisational context in which they were trying to access services. This resulted in great frustration for them and a delay in them getting the right support. They wanted a simple approach to getting help. In addition some staff found the structure underpinning their work complicated to understand in a rapidly changing environment.

“I just want a single point of entry to services, with a map and flow chart that I can understand”

“I no longer know who is left in the service or where they are. I used to be pleased at how good my network was but it has become fragmented.”

“I feel I am doing a big jigsaw where half the pieces are missing and I don’t know what the picture is about.”

Organisations face the challenges of providing high quality, integrated and accessible services that reflect the needs of the population, offer choice and improve health and well being. These challenges are faced across the UK. However, the scale and nature of the challenge in Cumbria is compounded by geography, an ageing population and the expected pressures on rural communities. Meeting these challenges requires radical change. For this reason we have included a number of items which we consider have a bearing on services in the county.

Over the past 3 years statutory organisations in Health and Social Care in Cumbria have had a number of external reviews of their work, some of them showing a critical gap in the provision of children’s services. Immediately before the review started Sir Michael Wilshaw, Ofsted’s Chief Inspector, listed Cumbria among 20 English councils “where the standard of child protection is unacceptably poor and judged to be inadequate”.37

37 Inspection of local authority arrangements for the protection of children Cumbria County Council Inspection 13-22 May 2013 Lead inspector Mary Candlin HMI http://www.cumbria.gov.uk/news/2013/June/24_06_2013-094320.asp

Independent Review of services supporting children and adolescents with mental ill health

This paper from the Cumbria Partnership Foundation Trust outlines these complexities:

b) Before the review started in November 2013 the NHS Cumbria Clinical Commissioning Group (CCG) 38 responded to Government plans to change the way money was allocated. (Monday 21st October 2013).39

‘Charles Welbourn, chief finance officer at NHS Cumbria Clinical Commissioning Group (CCG), described how the proposed new national formula, used to calculate how much each area gets, would not give extra funds to deprived areas as is currently the case. This means Cumbria stands to lose about £60m, while more affluent areas could gain. Mr Welbourn told a meeting of the CCG Governing Body that although not set in stone, the proposal was a cause for serious concern. He said they would therefore be pleading Cumbria’s case at a national level. “If we do not stick up for Cumbria nobody else is going to. The formula doesn’t take into account the cost of providing services in a geographically remote area like Cumbria,” he explained. “People from outside think of Cumbria as the Lake District, of small rural settlements, when in actual fact 40 per cent of our population live down the west coast. To get to the nearest hospital it can take over an hour. Landmass is as big as the rest of the north west put together. We don’t believe these issues are reflected in the formula. “If it were implemented as suggested – in one fell swoop taking £60m off an area like Cumbria – it would have catastrophic consequences. It is the equivalent of what we pay the Cumbria Partnership for mental health services.” 40

38 Cumbria CCG www.cumbriaccg.nhs.uk/ 39 http://www.newsandstar.co.uk/news/catastrophic-if-60m-cut-from-cumbria-s-health-budget-warns-finance-chief-1.1092566 40 Cumbria Partnership NHS Foundation Trust www.cumbriapartnership.nhs.uk/

Independent Review of services supporting children and adolescents with mental ill health c) The Joseph Rowntree Foundation report ‘Serving deprived communities in a recession’ explored how budget cuts will affect the capacity of local government to meet the needs of more deprived households and communities.41 The report outlined real concern that more deprived groups will suffer the most. This report provided early, systematic evidence of the scale of the cuts and of how local councils are grappling with these issues. A key focus of the research was on how the cuts would affect the capacity of local government to continue to serve deprived households and communities. This is very important in the Cumbrian context as suicide rates are higher in deprived areas. d) The County Council announced a consultation about further reductions to services and on 13th February 2014 agreed £24m cuts. The County Council has to save nearly £90m over three years on top of £88m it has already had to save. e) On 17th February 2014 Michael Cladingbowl HMI Regional Director, North West for Ofsted wrote to the County Council stating:

“There are too few good secondary schools in Cumbria and things are not improving. There is little evidence of an effective shared strategy improving the quality of education across the county.” f) Leadership across the County. In addition to these important issues there were also some key changes in local leaders. Inevitably this has impacted on staff and services as each new leader wishes to review urgently what they have inherited. It has also been greeted in some organisations with great enthusiasm.

 At North Cumbria University Hospitals NHS Trust (NCUH) Ann Farrar joined the Trust as Interim Chief Executive from Northumbria Healthcare NHS Foundation Trust in September 2012 and became substantive Chief Executive in October 2013.  A new CEO Jackie Daniel was appointed to the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) in October 2012. Subsequently a new chairman and board members were appointed.  Steven Dalton, CEO left the Cumbria Partnership NHS Foundation Trust CPFT) in November 2012 and Claire Molloy was appointed as the new Chief Executive in March 2013.  The Cumbria CCG was established in April 2013. The clinical chair is Hugh Reeve and Nigel Maguire Chief Officer, taking over the statutory duties of the previous Primary Care Trust.  Professor John Ashton Director of Public Health (DPH) left in spring 2013 after he was appointed to lead the UK Faculty for Public Health (FPH) of the Royal College of Physicians. Rebecca Wagstaff was acting DPH followed by Colin Cox taking up post in April 2014.  Russell Norman started as Head of Children’s Services with the Cumbria Partnership Trust in January 2013. Russell had been the Chief Executive at the Howgill Family Centre, West Cumbria.  Other key changes also took place within the County Council and social care teams including the early retirement of Cumbria County Council Chief Executive Jill Stannard announced in April 2013. She was replaced by Diane Wood in the interim, who was previously the County Council’s corporate director of resources. She was appointed Chief Executive in September 2013. Jill Stannard was appointed as a non-executive director with the Cumbria Partnership NHS Foundation Trust from 1st April 2014.  The Local Safeguarding Children Board (LSCB) appointed Richard Simpson as interim chairman in June 2013 and in March 2014 announced the appointment of a new chairman Gill Rigg.

41 http://www.jrf.org.uk/sites/files/jrf/communities-recession-services-full.pdf

Independent Review of services supporting children and adolescents with mental ill health

 John Macilwraith took over as acting corporate director for CCC Children’s services in October 2013. g) Some key Government initiatives were also introduced.

i. Integrated care and support

NHS England is one of the key partners on the National Collaboration for Integrated Care and Support. In May 2013, NHS England signed up to a series of commitments on how it will support local areas in delivering integrated care and support in the first ever system-wide ‘shared commitment’.42

“For health, care and support to be ‘integrated’, it must be person-centred, coordinated, and tailored to the needs and preferences of the individual, their carer and family. It means moving away from episodic care to a more holistic approach to health, care and support needs, that puts the needs and experience of people at the centre of how services are organised and delivered.”

“National Voices, a national coalition of health and care charities, has developed a person- centred ‘narrative’ on integration. This is an agreed definition of what is meant by ‘integrated’ care. It provides a guide to the sort of things that integrated care will achieve, such as better planning, more personal involvement of the person using services, and free access to good information. It also provides some clarity over what local areas should be aiming to achieve practically, in their efforts to integrate services. It is written not just for the experts, but for patients, people, families and carers. It shows them what they have a right to expect, so they can then demand the most helpful care and support.”

ii. Better Care Fund (previously the Integration Transformation Fund)

The £3.8bn Better Care Fund (BCF) was announced by the Government in the June 2013 spending round, to ensure a transformation in integrated health and social care. The BCF is a single, pooled budget to support health and social care services to work more closely together in local areas. The BCF not only brings together NHS and Local Government resources that are already committed to existing core activity, but also provides a real opportunity to improve services and value for money. Whilst the fund itself does not address the financial pressures faced by local authorities and CCGs, it can act as a catalyst for developing a new shared approach to delivering services and setting priorities. It should be stressed however that this is not new or additional funding. The BCF is a critical part of, and aligned to, the 2 year operational plans and the 5 year strategic plans.

“The health system currently costs more money than it is allocated. Although the CCG itself will achieve financial balance in 2013/14, some of Cumbria’s main providers have had to access external financial support, and will continue to need to do so in 2014/15. Cumbria needs to develop a clear plan to live within its means. This challenge is very much shared with the county council across social care.” 43

iii. ‘No Health without Mental Health’ 44

England’s Mental Health Outcome Strategy ‘No Health without Mental Health’, February 2012,

42 ‘Integrated Care and Support: Our Shared Commitment’ https://www.gov.uk/government/publications/integrated-care 43 Cumbria CC and NHS Cumbria CCG plan submitted 04.04.14 44 ‘No Health without mental health’ https://www.gov.uk/government/news/no-health-without-mental-health

Independent Review of services supporting children and adolescents with mental ill health highlighted the link between good mental and physical health. Cumbria launched its own Strategic Framework, ‘Working Together for Wellbeing and Mental Health’ in October 2011. Its twin objectives were to have more people have good mental health and wellbeing, and more people recover sooner from mental health problems.

It also sought to:

a. Provide a focus on priorities and outcomes for mental health and wellbeing during the crucial transition period 2011-2014. b. Promote wellbeing and early intervention to prevent mental health problems c. Champion the integration of mental health into primary care to address people’s mental and physical health needs together d. Ensure high quality, recovery-focused specialist services are available to all when needed e. Empower citizens, service users and carers and improve their experience of care.

“Mindfulness training is increasingly recognised as highly effective in improving the wellbeing that is essential to effective performance and productivity in the workplace. Some of the world’s leading companies, recognising the need for a fresh approach to organisational development, are investing in mindfulness training for their employees, including Google, Barclays, Deutsche Bank, London Transport, Apple Computers & Yahoo. We need to consider this as part of an integrated approach to support our staff.”45

“The issue of stigma is critically important as this deters people from seeking help and talking about their problems. The way forward for young people is building life skills to develop their resilience, and skills in coping with life pressures. In State of Mind we would ideally seek to enable professional Rugby League players undertaking training alongside a health professional, who understands child development, working with young people in schools, colleges and at sports clubs. The sportsman would bring credibility and overcome stigma/prejudice. Malcolm Rae.” 46

9. How do we build a generation of emotionally resilient children?

The review team considered which elements of services offered in South Lakeland contributed to mental wellness and thereby supported the development of resilience. a. Resilience

Resilience refers to the process of, capacity for, or outcome of successful adaptation despite challenging or threatening circumstances. Children who experience chronic adversity fare better or recover more successfully when they have a positive relationship with a competent adult, they are good learners and problem-solvers, they are engaging to other people, and they have areas of competence and perceived efficacy valued by self or society.47 Masten also describes resilience as ‘ordinary magic’.

Much has been written and researched about the elements that contribute to resilience in children. Robert Brooks, a Harvard Medical School professor and a leading authority on self-esteem and resilience maintains that resilient children possess certain qualities and / or ways of viewing

45 Ondy Willson in her response to the review http://www.wellseeingconsultancy.co.uk/ 46 http://www.stateofmindrugby.com/cmspages/features/the-team-behind-state-of-mind-2/ 47 Ann S. Masten, Karin M. Best and Norman Garmezy (1990). Resilience and development: Contributions from the study of children who overcome adversity. Development and Psychopathology, 2, pp 425-444. doi:10.1017/S0954579400005812.

Independent Review of services supporting children and adolescents with mental ill health themselves and the world that are not apparent in youngsters who have not been successful in meeting challenges and pressures.48

Brooks identified 10 guideposts that form the foundation of a resilient mindset.

I. Teaching empathy II. Effectively communicating III. Believing in the worth of a child IV. Creating opportunities for ownership/developing a sense of community V. Setting realistic goals/orchestration of success VI. Teaching children to learn from mistakes VII. Developing responsibility, compassion for others, and social conscience VIII. Teaching children to make decisions and solve problems IX. Disciplining in ways that promote self-discipline and self-worth X. Creating a close alliance between home and schools

A large body of research suggests that the presence of at least one caring person provides support for healthy development and learning, and a caring relationship with a teacher gives youth the motivation for wanting to succeed. Schools that establish high expectations for all youth and give them the support necessary to achieve those expectations have high rates of academic success and lower rates of problem behaviours than other schools. In addition, practices that provide children with opportunities for meaningful involvement and responsibility in the school foster all the traits of resilience. These practices include asking questions that encourage critical thinking, making learning hands-on, and using participatory evaluation strategies.49

In the light of these indicators of a resilient mindset it was also important therefore to examine the challenges facing children in their daily lives.

The World Health Organisation (WHO 2004) defines mental health as a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. In these terms, mental health for children is fundamental to the achievement of other positive outcomes in life. A range of terminology is used to talk about mental health. Some prefer to avoid the term ‘mental health’ and use terms such as emotional health or wellbeing. Mental health is not the same as being unhappy; unhappiness can be seen as a natural and normal reaction to many kinds of experience.

Mental Health problems are evident when individuals are not able to cope emotionally with the experiences they have or when their reactions to their experiences themselves become a problem. This can include withdrawn behaviour as well as challenging behaviour. The World Health Organisation (WHO 2004) defines mental health as a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. In these terms, mental health for children is fundamental to the achievement of other positive outcomes in life.

In Spring 2011 the Cumbria Partnership NHS Trust included in its Journal of Research, Practice and Learning a piece “Foresight Mental Capital and Wellbeing reports” by Professor Dave Dagnan. He flagged up two important issues from Beddington’s work:

48 Brooks, R.B & Goldstein, S. (2001) Raising resilient children. Chicago, IL: Contemporary Books. 49 Benard, Bonnie Fostering Resilience in Children. ERIC Digest Number: ED386327 1995

Independent Review of services supporting children and adolescents with mental ill health

 Early detection of mental disorders. There is great potential in improving diagnosis and treatment and in addressing social factors such as debt.  Changing needs for a changing workplace. The workforce is changing both in demographics and in the demands placed on it. Workers’ mental wellbeing is an important factor when attempting to improve the mental capital of economies and societies. 50

Professor Dagnan went on to recommend

“The content of the Foresight review is of utmost importance to the Cumbria Partnership NHS Trust and its partners. It will be valuable and challenging for us to explore how these activities can form the basis of a healthy lifestyle for employees, service users and carers.” 51 b. Fulfilling Lives: HeadStart Big Lottery Funding

At the start of the review the team met with Dr. Jane Mathieson in the Public Health department, now part of Cumbria County Council and with Anne Sheppard, Strategic Manager, Emotional Wellbeing and Mental Health Services. Anne’s secondment is jointly sponsored by CCG and CCC to implement a whole system approach, overseen by the Emotional Wellbeing and Mental Health Partnership (chaired by Steve Wilkinson since May 2014). The Emotional wellbeing and Mental Health Partnership Group functions as the collective programme management board in terms of the implementation of a ‘whole system model’ in relation to the emotional and mental health of all children and young people in Cumbria.

The model was developed in partnership by multi-agency stakeholders during 2013 and sets out how organisations will work in partnership and alongside children, young people, their families, carers and communities to ensure that their emotional and mental health needs are understood and supported at all stages.

They made an important bid for Big Lottery Funding on behalf of the cross agency Cumbria Headstart Partnership. This exciting proposal has far reaching opportunities and the review team considered that it was an excellent vehicle for building emotional resilience in children.52

They are being funded to carry out an ‘Initial Project’ between 2014 and December 2015 that is essentially a ‘test and learn’ process to find out what is going to be most effective in building young people’s resilience. It is important that those 10 – 14 year olds identified through the project as needing more targeted support then do go on to receive it and that the impact of that provision is also evaluated.

Connecting services and pooling resources to ensure all young people are supported is part of the wider aim to shape system reform. This is included in the recommendations in this review. Across the county there are already a number of initiatives to support the emotional resilience of young people and this project plans to bring them all together, through collaboration and partnership working. Cumbria has a long history of investing in and supporting emotional health and wellbeing. Schools have been very active with nurture groups, SEAL, Incredible Years, rolling out a TaMHS toolkit, and developing a nationally recognised anti-bullying resource.

Over the last 3 years funding from the Health Gains pot has been used to support and encourage projects delivered by the Children’s Centres, the 3rd Sector providers as well as extending and

50 Beddington et al., Mental Capital and Wellbeing 2008. 51 Dagnan Professor Editor, The Cumbria Partnership Journal of Research, Practice and Learning Vol 1 Issue 1 Spring 2011. 52 A presentation about the scheme can be found at www.cumbrialscb.com/eLibrary/view.asp?ID=57122

Independent Review of services supporting children and adolescents with mental ill health developing work in schools. There are 32 emotional wellbeing projects across the county monitored against specific outcomes and targeted vulnerable groups like young carers.

Initial work has resulted in learning that

 It is challenging for services to work differently to place the needs of children and their carers at the centre of the support offered.  They need to involve parents more in the design of support services to promote emotional resilience and support mental wellbeing.  The issue of stigma and being seen as different is very significant for some children and young people.  By linking up outdoor education and sports and leisure providers more closely with services better support can be offered. c. The Voice of the Child

Ofsted published ‘The voice of the child: learning lessons from serious case reviews’ in April 2011. 53 This report provides an analysis of 67 serious case reviews that Ofsted evaluated between 1 April and 30 September 2010. The main focus of the report is on the importance of listening to the voice of the child.

Unicef states that ‘Every child has the right to a voice on matters that affect them and to have their views taken seriously – in accordance with their age and maturity.’ 54

The United Nations Convention on the Rights of the Child (UNCRC, 1989) enshrines the right of children to be involved in all decisions that affect their lives. In England there is also national legislation and guidance stressing the importance of involving children in decision-making, specifically in child protection cases (Children Act 2004; DCSF, 2010).

The NCB research centre flagged up that one way of ensuring the child’s voice is heard in child protection is to provide an advocacy service, which should enable children to put across their views and ensure their rights are protected. There is some evidence showing the benefits of providing advocacy to children and national guidance recommends that the child’s voice should be meaningfully represented during the child protection process.55

The Children's Commissioner for England promotes the views and best interests of children and young people in England.56

Services such as advocacy are therefore crucial. Advocacy helps to ensure that the rights and choices of some of the most vulnerable people using statutory services are protected. At a time of large scale changes to social care provision, and of social care providers, advocacy can ensure that people do not fall through gaps.

In Cumbria six Youth Councils are in place, these are co-terminous with City and District Council areas. Young people are supported to take part in elections; campaigns; research; consultation; budget management; needs assessment; assessment and evaluation of youth programmes; and

53 http://www.ofsted.gov.uk/resources/voice-of-child-learning-lessons-serious-case-reviews Ref: 100224 54 http://www.unicef.org.uk/UNICEFs-Work/Our-mission/Childrens-rights/Voice/ 55 http://www.ncb.org.uk/media/756988/research_summary_7.pdf 56 http://www.childrenscommissioner.gov.uk/

Independent Review of services supporting children and adolescents with mental ill health work alongside local decision-makers. Each youth council can nominate members to take part in the Cumbria Youth Council, and North West Regional Forums to ensure that the voice of Cumbrian young people influences policy, strategy and commissioning.

In addition the County Council runs a ‘Children in Care Council’ with three groups (Carlisle and Eden, Allerdale and Copeland and South Lakes and Barrow.) Each has a young apprentice who works with the young people together with staff from the Council's participation service to enable looked after children to influence the development of services for them. The Children in Care Council organised a "Care Cumbria" award ceremony in May 2014 to raise the profile of the achievements of looked after children and young people and their carers. NYAS has a contract to provide advocacy services for looked after children and as part of this they visit young people living in residential units and attend some children in care council events.57 d. Independent & Community Care Advocacy Services

At the County Council Cabinet meeting on 15th December 2011 an effective cut of around 50% of advocacy provision was agreed. Existing contracts ended in July 2012. At that time it was estimated that those contracts were valued at around £470k per annum. Around £37k of that was funded by the then Cumbria PCT for a mental health contract. 3rd sector organisations flagged up their concerns at that time as advocacy can help protect very vulnerable people in the care system. People First and Mind had also “drawn in over £1.5m of additional advocacy related grant funding in the last 3 years to the county.” 58

Some advocacy services are still available. Both the County Council and the Cumbria Partnership Trust flag up on their websites that advocacy is available but include different information.

 Your Voice in Penrith offers a service for older adults, people with physical disabilities and people with mental health issues in Cumbria.59  Bestlife independent advocacy is a scheme run by People First for people with Learning Disabilities and mental health issues.60  Cumbria Multi Cultural Service offers help for people from Black and Ethic Minority Backgrounds.61

Best Life Advocacy runs 3 projects offering advocacy to promote equality, social justice and social inclusion. Its services are offered to clients through telephone, e-mail, web chat, face to face contacts and in outreach surgeries/drop-ins in 5 venues across the county.62 e. Another important service Citizens Advice South Lakeland shut down its services in March 2013 due to financial problems. This was greeted with shock by many organisations which signposted service users to its services. It had helped an estimated 7,000 people in the previous year in the two towns but had encountered financial problems caused by the end of certain grants and being unable to meet its capital running costs. While the chief funder, South Lakeland

57 www.nyas.net/ NYAS is a UK charity providing socio-legal services and offering information, advice, advocacy and legal representation to children and young people. 58 http://www.peoplefirstcumbria.org.uk/wp-content/uploads/2012/01/leaflet.pdf 59 www.yourvoicecumbria.org 60 http://www.cumbria.gov.uk/equalities/cmcs/ 61 http://www.cumbria.gov.uk/communityinformation/communities/mcs 62 http://www.bestlife.org.uk/mental_health

Independent Review of services supporting children and adolescents with mental ill health

District Council had continued to contribute around £47,000 annually, the cessation of other government and service contracts had affected the charity's income. It is reopening in June 2014. 63 f. The Cumbria Advice Network (CAN) is a Big Lottery funded project focused on enabling people in Cumbria to access quality advice when they most need it.64 The project aims through partnership working in Cumbria, to improve referral processes between 3rd sector advice agencies, and to facilitate the sharing of expertise and provide shared training opportunities.

The project began in 2009 and is funded by the Big Lottery over 5 years. The initial partners (the 7 Citizen Advice Bureaux in Cumbria, Shelter Cumbria and the Cumbria Law Centre) entered into a partnership agreement to deliver the project on behalf of the Big Lottery. The project Network and Development Champions within the initial partners have a key responsibility to engage with the wider network of 3rd sector advice organisations in Cumbria (and related organisations who refer people for advice), so they can join the network. As organisations join, the project becomes a network of organisations throughout Cumbria, working for the benefit of people seeking advice. The project has three main themes:

 Improving referral processes.  Assisting organisations to maintain and improve quality of advice and organising Cumbria-wide training opportunities  Campaigning for change on issues that affect service users in Cumbria on a county- wide basis.

Where parents and young people have accessed advocacy services they reported good service, but a larger number were not aware they existed. In addition, comments were received that advocacy services have received large funding cuts just at a time when their services were most needed. This reflects the need once again to have effective signposting services.

10. The county-wide, re-commissioned Child and Adolescent Tier 3 mental health service (CAMHS)

As already mentioned an external clinical review on mental health identified gaps in Cumbria Child and Adolescent Mental Health Service (CAMHS).65 In re-commissioning the CAMHS service the Cumbria Partnership Foundation Trust (CPFT) and Clinical Commissioning Group (CCG) recognised the need for significant change to specialist Tier 3 CAMHS and careful consideration of wider support systems in which these children and families services operate. Both organisations accepted in full the findings and recommendations in the review. Both organisations were committed to implementing the recommendations fully with ‘determination, pace and the full involvement of primary care and other stakeholders.’

There were 4 main areas of action outlined in a CPFT board report in April 2013:

“Task 1 Reforming the staffing model; recruiting to new Consultant posts; resourcing and implementing a new staffing and skill mix structure; introducing a consultant-led service model; introducing an extended hours CAMHS.

63 http://www.bbc.co.uk/news/uk-england-cumbria-27291840 64 http://www.cumbriaadvicenetwork.org.uk/can/index.php?option=com_content&view=article&id=61&Itemid=27 65 http://www.cumbriapartnership.nhs.uk/mobod-april-2013.htm Cumbria Partnership NHS Foundation Board report April 2013.

Independent Review of services supporting children and adolescents with mental ill health

Task 2 Agreeing an evidence-based service specification for CAMHS; producing and implementing referral criteria, pathways and protocols based on NICE clinical guidelines; undertaking a workload review; agreeing and publicising the links and pathways between tier 3 and tiers 1 and 2.

Task 3 Appointment of a Clinical Director; improving CAMHS management capacity (including pathways and service management); implementation of a training needs assessment; job planning; developing a ‘pan Cumbria’ service; reviewing accommodation.

Task 4 Caseload review of all ‘6 months+ cases’ and ‘over 18 years cases’; review of services for specific groups (particularly Children Looked After and Eating Disorders); development of robust transition arrangements, assessments and services; development of plans for enhanced tier 3 services; developing a ‘consultancy and training’ approach.”

These commitments gave investment and impetus to improve the higher level tier 3 services across the county. After the CPFT board agreed these developments new staff began to be appointed during the summer of 2013.

As these new developments were designed to improve the CAMHS services radically across the county, the review team wanted to concentrate on those areas not addressed by other reviews but to examine those Tier 1 and Tier 2 services which support children and young people at an earlier stage. Regular feedback has been given to key organisations therefore about findings as they have emerged to enable those comments to be taken on board without delay.

Tier 1 is part of the remit of all professionals working with children. It is everybody's responsibility and not just primary care workers. Likewise at Tier 2 the Primary Mental Health Workers support colleagues as well as undertaking direct work; again this is everyone's responsibility and it is the universal work in Tiers 1 and 2 that helps children develop emotional resilience.

Independent Review of services supporting children and adolescents with mental ill health

Cumbria’s Whole System Model for the Emotional Wellbeing and Mental Health of CYP

Tier 1: consists of non-specialist primary care workers such as school nurses (now known as school – age nurses) and health visitors working with common problems of childhood such as sleeping difficulties or feeding problems.

A number of organisations and individuals pointed to the importance of good Tier 1 and Tier 2 provision that would allow CAMHS to focus where they can be most effective, i.e. Tier 3. CAMHS should have a role (not just through the Primary Care Workers) to offer consultancy and reassurance to the rest of the system as they try to deliver Tiers 1 and 2.

“Clearly the voluntary sector need resourcing to do such work, but sometimes they also need reassurance and consultancy in doing this kind of work when they encounter self- harm, eating disorders, etc. Sometimes this is just so they can continue to do it and at other times so they know they need to pass it on because it has gone beyond the ken of the voluntary sector or indeed school pastoral services.”

Tier 2: consists of specialised Primary Mental Health Workers (PMHW’s) offering support to other professionals around child development; assessment and treatment in problems in primary care, such as family work, bereavement, parenting groups etc. This also includes Substance Misuse & Counselling Services.

Tier 3: consists of specialist multi disciplinary teams such as Child & Adolescent Mental Health Teams based in a local clinic. Problems dealt with here would be problems too complicated to be dealt with at Tier 2 e.g. assessment of development problems, autism, hyperactivity, depression, early onset psychosis.

Before the CAMHS service received additional investment 91% of young people responding to a CCG instigated review thought that the CAMHS service should also support the wider family; family

Independent Review of services supporting children and adolescents with mental ill health meetings, information for families, workshops and home visits most commonly cited as ways in which this could be achieved.66

Tier 4: consists of specialised day and inpatient units, where patients with more severe mental health problems can be assessed and treated. 67Zarrina Kurtz for the DH’s National CAMHS Support Service Tier 4 Advisory Group produced an Evidence base to guide the development of Tier 4 services (2009). Its foreword states:

‘Until recently the idea of Tier 4 specialist CAMHS was synonymous with psychiatric inpatient provision, sometimes with day hospitals attached. Tier 4 has more recently come to be understood as multi-faceted with multi-agency services that can include in-reach, outreach, intensive and crisis community initiatives, day provision, therapeutic fostering and other services that may be described as 'wrap around'. What we have seen over the past few years are innovative approaches in assessment and treatment of this most complex group of young people and the development of new intensive community focused services.’ 68

Tier 4 services are now commissioned by NHS England, not the CCCG.69 These are highly specialised services with a primary purpose of the assessment and treatment of severe and complex mental health disorders in children. These services are part of a highly specialist pathway and provide for a level of complexity that cannot be provided for by comprehensive secondary, Tier 3 community services. It is generally the complexity and severity rather than the nature of the disorder that determines the need for specialist care. Around 2,500 children access the service each year. Throughout this review it was highlighted that there is huge pressure on Tier 4 services nationally. This was raised in the House of Commons in October 2013. 70

“In-patient Mental Health Services (Children and Adolescents)71

Alan Johnson MP (Kingston upon Hull West and Hessle Lab) raised the issue of In-Patient mental health services in Parliament:

The Royal College of Psychiatrists is among the many expert organisations that have expressed concerns about poor in-patient mental health provision, particularly for children and adolescents.’”

There has been considerable pressure on Tier 4 provision, which is a problem for the whole of the North of England. i. The Junction Tier 4 service, Lancaster and The Platform, Preston.

Child and Adolescent Mental Health Services (CAMHS) Tier 4 services managed by the Lancashire Care NHS Foundation Trust provide inpatient and outreach services to adolescents and families who are resident within Lancashire and South Cumbria and who have acute mental health difficulties.

66 Reform of the Emotional Health and Wellbeing Service for Children and Young People (CAMHS) Research commissioned by NHS Cumbria CCG Research delivered by the Cumbria Children and Young People’s Voluntary Sector Reference Group (CCYPVSRG) and managed by Cumbria Youth Alliance. 67 http://www.england.nhs.uk/wp-content/uploads/2013/06/c07-tier4-ch-ado-mh-serv.pdf 68 http://www.nmhdu.org.uk/silo/files/the-evidence-base-to-guide-dvt-of-tier-4-camhs-apr-09.pdf 69 http://www.england.nhs.uk/resources/spec-comm-resources/npc-crg/group-c/c07/ 70 23 Oct 2013 Column 408 In-patient Mental Health Services (Children and Adolescents) http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm131023/debtext/131023-0004.htm 71 Hansard debate 23 Oct 2013 : Column 408 http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm131023/debtext/131023-0004.htm

Independent Review of services supporting children and adolescents with mental ill health

They provide a specialist clinical service to enable local Tier 2 and 3 CAMHS to meet the needs of children and young people with complex difficulties. The provision is based on an inpatient facility, with services providing assessment and a range of specialist treatment packages and interventions, as well as a consultation service to CAMHS professionals.

The Platform is a 6 bedded unit for 16-18 year olds and is accessed for South Cumbrian young people via the Tier 3 CAMHS team. The Junction and The Platform, although 20 miles apart, are one service, with many staff working across both inpatient wards.

Two members of the review team visited the Inpatient Services provided at The Junction in Lancaster. The Junction is an 8 bedded inpatient service for young people between the ages of 12 and 16 years (end of year 11). It is a planned treatment service (can take same day admissions but not out of hours) which supports young people with severe mental health issues who can no longer be safely and effectively managed in their own home/community setting and need a specialist inpatient service.

The Service provides a wide range of psychological, medical and social interventions from an experienced, multidisciplinary team which includes psychiatrists, psychologists, nurses, occupational therapist, psychodynamic therapist, family therapist, dietician and social worker. The social worker is employed by the Lancashire Care Trust and not by the local authority, and this is seen as an advantage.

Young people and families are actively encouraged to participate in their care planning and work in collaboration with the team, whilst supported by participation workers and an independent advocate. The service also provides on-site education, provided by Lancashire County Council and managed via ACERS (Additional and Complementary Education and Residential Services).72

The CAMHS Tier 4 Outreach Team is a service which is complementary to the inpatient services for young people between the ages of 12 and 18 years. Consultation and joint assessments can be offered to all Community Mental Health Teams and support regarding potential referrals to CAMHS Tier 4 services.

The Team provides a focal point, co-ordinates and provides an assessment for referrals to CAMHS Tier 4 services; attending all reviews and CPA meetings including those for young people placed in other CAMHS Tier 4 services Out of Area. The team can provide additional and essential support to prevent admission, with short term outreach support for young people, in conjunction with the CAMHS Tier 3, EIS and Adult Mental Health teams. The team are also able to provide additional therapeutic support from experienced clinicians within the CAMHS Tier 4 service.

The CAMHS Tier 4 Outreach Team provides an Eating Disorder service to support local CAMHS Tier 3 teams with complex presentations by providing specialist therapeutic input.

The Team play an active role and participate in the discharge process for young people from CAMHS and can offer additional Outreach work on discharge for a time-limited period. It is commendable that the service employs dedicated transition workers.

Staff team members felt there was a general lack of knowledge about what they did and many myths associated with their work. They had prepared a DVD about the centre and tried to spread the word whenever they had chance. Some staff felt it would be useful for Tier 3 services to run family support groups. Some of their young people had no homes suitable to return to and it was

72http://www.lancashirecare.nhs.uk/Services/Children-Families/CAMHS/CAMHS-Tier-4/Junction.php#sthash.uuczT8DS.dpuf

Independent Review of services supporting children and adolescents with mental ill health suggested that higher level professional foster carers with enhanced training and skills should be employed to support them.

“Everything we do has the young person at the centre and we try to find the most effective and supportive way to enhance their emotional resilience.”

The team had seen improvements in the Cumbria CAMHS service over the previous 6 months and applauded the fact that it was offered to young people up to the age of 18 whereas the Platform in Preston offered services only for 16 and 17 year olds. The team had a number of ideas to continue developing their services, including an opportunity to have patients and carers on the management team. They would like to see social care colleagues start discharge planning from the date of admission as some young people wait some months for discharge, preventing new admissions and causing unnecessary stress.

The preparation for admission and discharge was very impressive and the paper work was child- friendly and designed to help the young person settle in quickly. The review team liked in particular the calm atmosphere and enthusiastic presentations by the staff and their obvious commitment to their service users. Of particular note was the plan to have a “Friends of The Junction” scheme, designed for people who have experience of The Junction either as a resident, having had a member of their family use The Junction, or having a professional interest in the work of The Junction.

Website work is undertaken by young people and parents called The Crew. They are an integral part of the Participation Strategy and meet monthly to advise and guide the service development decisions. Members are on all staff interview panels and provide training and conference presentations. The Crew are working on a script and content advisory basis with The Brewery Arts Youth Theatre and Ashton Youth Theatre to develop a resource for schools to improve knowledge and open discussion about mental health.

The Junction facilitated a meeting between parents of Cumbrian children with the review chairman to discuss their experiences. Two parents from different families were interviewed and gave moving accounts of the traumatic experiences they had lived through. Both felt that active case management within Tier 4 was crucial to helping their child make progress and noted much better warmth and empathy compared with the previous Tier 3 support experienced in Cumbria.

They would have appreciated home visits and support from Tier 3 staff, and some continuity as to who to contact. Both remarked that they had problems with social workers in Cumbria going off sick. They flagged up poor experiences when their children had been on home leave and ended up in crisis. On these occasions the local team ‘would not come out to offer support.’

The outreach team from Tier 4 had visited for 2 weeks before admission and were approachable and reliable and always turned up, which had not happened locally. They particularly liked that they could ring the Junction at any time. The team in Lancaster was welcoming to friends and relatives and 11 friends had turned up for a birthday celebration which had greatly helped the service user. One of the issues they raised was that Tier 4 can feel like home if they are not discharged in a timely manner. They both felt strongly that the Cumbria Tier 3 service needed to give support to parents and the family, not just the young person.

“Going to Tier 4 was the first time I felt that someone was actually listening to us. The quality of the information we were given, the way we were greeted was all perfect and helped us feel confident that at last we were going to see our child make progress.”

Independent Review of services supporting children and adolescents with mental ill health

“I am interested to hear that there is a new Tier 3 being developed. It was badly needed. What I hope they change is a better attitude if they get more staff so they are not overworked. They need better communication and to keep appointments. It would have been great if someone just once had asked me how I was doing. I just got so worn out having to be the one ringing them all the time to find out what was happening. I felt useless through all this as though the self-harm was my fault and I didn’t know what to do to stop it. I was always walking on eggshells with my child and the team. CAMHS didn’t help with self-harm and I just sat outside my daughter’s bedroom all night trying to make sure nothing was available to do more cutting. In Lancaster they talk to me by name and treat me as an individual person that they are trying to support.”

“I do find the expense hard of having to visit Lancaster so regularly as I have only benefits to live on and need to look after the family at home as well which puts big pressure on me.”

“Thank you for asking to see me. I feel much better to be able to share how I felt for such a long time and I hope that the new team will be better able to look after children and families going through what we went through. It would have been good to be interviewed by an independent person when we were at our lowest and nothing was happening.”

“I am just so anxious that my child might die. I feel low and it is all I can think about.”

The 2012 external clinical review stated that:

“A local tier 4 unit should not be considered at the present time as it would be a very high risk diversion to the major task of restructuring the service. The development of other enhanced services however is likely to attract high quality applicants as the recruitment is undertaken and should therefore be given serious consideration. In the absence of a local tier 4 unit children placed outside of the county in such facilities should be the focus of ongoing clinical review and plans made for their return to their home community as early as it is deemed safe to do so.” 73

In addition there are some key clinical interdependencies with specialist services including:  The interface with neurology: consideration of neurosciences as a service which could comprehensively cover neuro-developmental disorders  Neuropsychiatric services which people currently access out of county 74

One parent responded about her son and his cluster headaches. After a CT scan in Lancashire he was discharged but did not get to see a neuro-psychiatrist. She understood the nearest one was in Manchester. After weeks of constant headaches and seizures, with increasingly disruptive and regressive behaviour the family paid to see a consultant in Newcastle. She had been advised that CAMHS would be unable to provide an appointment at that time for around 9 months.

“We felt that we had to do all the research ourselves and were given little help to source appropriate care for our son. When we did eventually see a CAMHS worker she had no time for him – just gave him 5 minutes. After finding our own specialist we are hopeful that things have settled down. The difference between secondary and primary care was amazing and our consultant when we found him was a star, he knew just what to do.”

73 Recommendation 25 External Clinical Review 2012. CCG and CPFT. (Note – this refers to an inpatient unit.) 74 Johl & Masson December 2013 Strategic Vision for Mental Health and Learning Disabilities Care Delivery Group

Independent Review of services supporting children and adolescents with mental ill health

During the summer of 2013 the Cumbria NHS Partnership Trust began appointing to the new posts to build a Tier 3 Service fit for purpose. Regular reports were provided on the progress in developing this new team and it was acknowledged that it would take some time to become fully effective.

“The recent senior management restructure within CPFT will strengthen the integration of the CAMHS teams into the wider Children and Families Care Group. This will provide additional professional support for all CAMHS staff and will increase the nursing accountability in particular, with a focus on implementing the ‘Six Cs’ national nursing strategy in all settings.”

At the original review in 2012 the staff complement totalled 45 staff, ‘with an identified poor skill mix to provide a modern Tier 3 service.’ The first phase of staff changes resulting from the Tier 3 CAMHS re-design has, as a result of significant investment from CCG and CPFT, increased the staff team to 63 and on 9th September 2013 Clinical Director (Specialist CAMHS Consultant) Dr Luisa Sanz commenced in post. By the end of the month all staff not required under the new structure and approach were “released from service” and newly recruited clinical staff came into post during October and November. By 2nd December 2013 a Clinical Services Manager and Consultant Clinical Psychologist/non- medical staff lead commenced work.

One of the service priorities was to address Out of Hours Provision. The CAMHS ‘on call’ service for advice continued between 5pm-9am weekdays, weekends and Bank Holidays. An Extended Hours Pilot commenced on the 4th November 2013. The extended hours plan provides access up to 7 pm x 3 days during the week and four hours of appointments on Saturday for Choice and Partnership work. Urgent cases on the paediatric ward were to be assessed during Saturday working.

The usage of the 24 hour Out of Hours helpline findings from 1 January 2013 to 30 September 2013 showed:  A total 78 calls were received  84% of young people were already known to CAMHS  44% (34) of calls were ‘Urgent’  10% (8) of calls were administrative queries  55% of calls were received across weekends (including Bank Holiday Mondays)  The highest volume of calls (64%) were regularly received between 4.30 pm and 8.00 pm  A breakdown of patient age showed that 57% were 16 & 17 year olds.

CPFT has faced significant challenges in restructuring and re-focussing the CAMHS Tier 3 service at a time of substantially increasing demand. Numbers of young people being referred from all sources has been reaching unprecedented levels. For example over 400 referrals were received during July and August (256 of which were in July) which is significantly high for a 2 month period. This is around the number of referrals expected over 3 months. All urgent cases are now triaged within 24 hours, through a consultant-led process, in a consistent way across the area. Any delay in offering an appropriate appointment and support can have stressful repercussions on the young person and the whole family.

CAMHS use CORC (CAMHS Outcome Research Consortium) to monitor outcomes. This includes a service user evaluation and CORC monitoring will be included in the planned work used to monitor performance. CAMHS is participating in work to ensure the service meets ‘You’re Welcome’ Standards.75

75 https://www.gov.uk/government/publications/quality-criteria-for-young-people-friendly-health-services

Independent Review of services supporting children and adolescents with mental ill health

The CAMHS external review indicated “a high proportion of long term psychological interventions with a very reduced medical workforce and strongly advised a more medical approach in the assessment and treatment of children and young people in CAMHS.” ii. Development of Tier 1 and Tier 2 services. As the newly designed Tier 3 CAMHS team develops it should extend its external relationships, outreaching to the many organisations which are involved in offering informal Tier 1 and Tier 2 services. Schools and their inclusion managers together with youth leaders are particularly keen to develop stronger relationships.

A number of anxious parents who have been waiting some time for an appointment have welcomed the development of a new service. Indeed some have contacted the review chairman subsequently to say they had just received an appointment.

“Just to let you know that a parent of two of our young people is absolutely made up now that both of her children have been accepted by CAMHS. The youngest has been before but I think it dropped off and the other has been waiting for ages. The parent said that ALL HER CHRISTMASES HAVE COME AT ONCE.”

“I am really pleased to hear from you that there will be a new service, I hadn’t heard. The previous team were just so overworked. I hope they will come and see us and realise just how much work we do at Tier 1 and then make sure they give us help when we ask. We can’t refer direct to them so they need to come and support us.”

“We have a lack of emergency beds for 15 to 17 year olds for CAMHS and just 1 bed for 16 to 18 year olds at the Dova unit at Danegarth designated for the county. This is just not enough and we need more to be able to deliver a better service.” 76

“We give mental health reports to our school governors. This is one of our highest priorities. We are very aware of how rapidly some children progress from ‘I don’t like my parents’ to something more serious. We have had a couple of serious attempts at cutting in the last 14 months. We have also had 2 girls with eating disorders and we have referred to CAMHS.”

“We are a very athletic school and have no obvious problems with thinness. Our students want to have fit bodies.”

“We have experienced and qualified counsellors and don’t need to clog up CAMHS. When we ask for help though we hope this will be acknowledged and that we have done lots of groundwork with the child. We would appreciate an escalation of Triage because of what we have already done.”

“We have not gone in for private counsellors, we are very positive about CAMHS.”

“Our psychologist was superb. She was aware of the trauma that staff experienced and she came in her own time to support them.”

“We have filters on all our computers, but everyone has smart phones. The only thing we could do would be disable the mast!”

76 Description of the Dova Unit http://www.cumbriapartnership.nhs.uk/dova-unit.htm

Independent Review of services supporting children and adolescents with mental ill health

“Escalation: No-one disputes the contribution of community based services – schools, youth organisations, numerous 3rd sector organisations – in promoting mental health, but the role of more specialist services in supporting people working in the community is seldom clear. Too often, the pattern is of community services referring children and adolescents upwards to more specialist services, rather than of specialist services providing active support and guidance to colleagues in the community. As a result, lip service is paid to prevention and early recognition, but is seldom converted into practical action.”

“I have worked in the area for the last 10 years and had NO contact from CAMHS. I’ve made occasional contact with them but they are not outward facing by nature. It is very different with other parts of the Trust as we get regular referrals and feedback.”

“When the Partnership Trust reconfigured it spread its services but lost its focus.”

“Pressures of education had led to psychosis. I see some people privately.”

“I do think we need at least 1 more Tier 3 bed for Cumbria.”

“I would recommend that we need earlier intervention and not at crisis times. My child has eating disorders and sleeping problems and there are no transition plans for her to go to college.”

Whilst this redeveloped service has been adopted in Cumbria some respondents questioned whether it will offer the best holistic service to children with complex needs.

“Local developments of CAMHS teams have sometimes been informed by national guidance and sometimes in spite of it, particularly given the freedom afforded foundation trusts to pick and choose from the guidance and to interpret selectively their meaning.”

“Despite the NHS Reforms in 2013 ostensibly being a move to greater clinician influence on commissioning, in CAMHS this seems to have been operationally better defined as greater medical influence.”

“The start of any commissioning cycle includes seeking demographic information on population need – yet this is gathered by medical diagnostic category and cannot appreciate co-morbidity and complexity.”

“Tier 3 was supposed to be constituted as a multidisciplinary endeavour to look at a child’s difficulties on a case by case basis, and integrate the best approach to address those needs. The alternative is to categorise every child and follow the manual to treat the category, not to meet the needs of the child.”

“The contribution that psychological therapies have made within Cumbria CAMHS at all tiers has been seriously compromised over the last 4 years, despite clear local need and with a disregard for national recommendations.”

“Much of the expertise that had been assembled in this area has now been lost to the service. This results, perversely, in longer term work with some children (who can’t be discharged because they are demonstrably in need of a service, but can’t receive the NICE recommended expertise as it is no longer available within the service), leading to tier 4

Independent Review of services supporting children and adolescents with mental ill health

services or refusal to accept referrals as they do not meet more restricted / limited referral criteria. This in turn results in unmet need, need met further from home (the opposite of the commissioners’ express intention to provide better services “closer to home”) and overwhelmed comprehensive CAMHS services across all sectors.”

The CCG is also exploring repatriating young people from Tier 4 services where possible and retaining them within Tier 3 to give them appropriate support. During the review period some children are being cared for in paediatric wards in local hospitals, waiting for a Tier 4 bed to become vacant. There are no places of safety available and it can be disruptive for other children in paediatric wards who can be very poorly. The CCG will consider assessing and managing risk prior to admission, managing the placement on a paediatric ward, assessing the skills needed to communicate effectively with teenagers experiencing high levels of anxiety and disturbance and the opportunities to develop a place of safety within the county. This approach is to be applauded. In addition, UMBT has been in touch with the specialist commissioners to negotiate financial support when having to provide additional nursing help to a young person awaiting a Tier 4 placement. iii. Children Looked After. Prior to 2011 Tier 3 CAMHS had a full time B Grade psychologist dedicated to Children Looked After funded by Cumbria County Council. When this post was withdrawn by the Partnership Trust the funding ended and the Council has since commissioned some short term contracts to support Children Looked After and post-adoption mental health support. These are contracted to March 2015 in an interim measure in anticipation of a jointly commissioned approach with the CCG. Whilst Tier 3 in the new service does provide services to Children Looked After there is more work to be done to integrate the complex networks that often surround these children.

This group of children have been shown in a number of studies to present with heightened mental health difficulties in comparison to other children and it is well known that they present with an exceptionally heightened profile of risk with regard to harm to themselves and harm to others. They have been found also to have suffered more harm and neglect, including of their health, than other children. The needs of this group should figure prominently in the assessment of needs.

One particular group which would like more contact with social workers overseeing Children Looked after and CAMHS are youth workers.

“We are asked to take a child into our groups without any background information which would help them settle. Often key information isn’t shared with us and after getting to know them really well we may feel the child needs support from CAMHS but our views don’t seem to count. This is a waste of our experience and skills. We seem to be ignored yet spend valuable time with the child. If they have a CAMHS worker it would be really useful for them to spend time with us to both share what we do and to learn from them, as we feel we should be part of the whole systems approach which needs to be strengthened.” iv. The Children and Young People's (CYP) IAPT Project 77

The 2014/15 offer for new CAMHS partnerships to join the CYP IAPT programme through a learning collaborative was launched on 13th March 2014.

77 http://www.youngminds.org.uk/training_services/vik/children_young_peoples_iapt/about_cyp_iapt

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The Children and Young People's (CYP) IAPT Project is a Service Transformation Project for Child and Adolescent Mental Health Services (CAMHS) working in targeted and specialist settings (Tiers 2 and 3), including both the statutory and 3rd sector. The focus of CYP IAPT is to create change by

. involving children, young people and parents through participation . embedding evidence-based practice across services through training . creating local strategies to improve access . making sure that the whole service, not just the trainee therapists, use session by session outcome monitoring . supporting dynamic service leadership . making use of new technology.

In terms of the involvement of children and young people, the CYP IAPT programme has some clear messages for mental health services:

. Children and young people's participation is critical to the success of CYP IAPT. There need to be clear structures and systems in place to enable children and young people be able to contribute in a meaningful way to how services are designed, delivered and monitored. . Services involved in the IAPT programme must all be committed to hearing the views of children, young people, parents and carers and, crucially, acting on them to make improvements and share good practice. . Services will start using ‘session by session’ monitoring which means they will be asking children and young people using services to feed back about every session they come to. This will help guide the therapy in the right direction – so that it is as useful as it can be. Children and young people are behind this and really value this approach. . It’s important for there to be choice about what therapies are available to children, young people and their families.

In addition the CAMHS service with support from the CCG aims to access the national CYP IAPT programme. To comply with national standards and recommendations it needs to continue its development by establishing a fit-for-purpose CAMHS service in line with standards around the provision of safe, effective psychological therapies. This includes standards of robust supervision support, systems to support use of recommended outcome measures, expertise at psychological therapies and service user involvement. The Trust is working in partnership with the voluntary sector to apply for CYP IAPT.

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11. Triage

The Cumbria Children’s Trust Board introduced revised guidance on the application of multi-agency thresholds for use across the partnership in Cumbria. This guidance has been strengthened through consultation across the partnership and has been endorsed by both the Children’s Trust Board and the Cumbria Local Safeguarding Children’s Board (LSCB). Current figures show that around 30% of referrals to Triage are accepted and the remainder are referred back to implement ‘Team around the Child.’ For every 27 cases referred to Triage only 1 Common Assessment Framework (CAF) was developed.

a. Cumbria’s Local Protocol for Assessment - A child’s journey through assessment and planning January 2014 78

“In 2013 over 14,000 children in Cumbria were referred to our children’s social care services by individuals who had concerns about their welfare. For children who need additional help, every day matters. The actions taken by professionals to meet the needs of these children as early as possible can be critical to their future. Children are best protected when professionals are clear about what is required of them individually, and how they need to work together. Professionals help best when all local agencies have carried out a thorough assessment and drawn up a plan for support. Ultimately, effective safeguarding of children can only be achieved by putting children at the centre of the system, and by every individual and agency playing their full part, working together to meet the needs of our most vulnerable children.”

“In January 2013 Cumbria launched the Multi-agency Thresholds Guidance. The Thresholds Guidance describes the four levels of need and support for children, young people and their families and the type of intervention or help they can expect. The guidance is fundamentally about working better together and intervening earlier with children and young people to provide services at the earliest opportunity to meet their identified needs.”

This statement was welcomed by the review group: “The LSCB has agreed a refreshed wording in respect of the thresholds in response to feedback from professionals across the partnership. This makes it clearer that "early help" is a responsibility of all agencies where the identified needs of a child/young person require input from more than one service. An increased understanding across the partnership of the thresholds guidance will ensure the right services at the right level for children are delivered at the right time. It should also mean that referrals through the Triage service for children's social care do meet that threshold. In May 2014, 48% contacts to Triage were accepted as referrals for children's social care. In the same month 56 Early Help Assessments (CAF) were initiated.”79

“Fragmentation: There is plenty of evidence of good practice within services and between services. Yet the impression is of frequent exhortation to work together rather than of a unifying culture with organisation structures that facilitate working together. As a result it is too easy for services to work in isolation from partners in their own field, (e.g. health, education, social care,) let alone in partnership with colleagues in other fields.”

78 http://www.cumbrialscb.com/elibrary/Content/Internet/537/6683/6687/41687135717.pdf 79 Response to draft report 11th July 2014 from CCC.

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Cumbria ‘Wedge’ thresholds 80

This Local Protocol describes the statutory intervention (help) for children and young people who, when assessed, come under the ‘Targeted Intervention’ level within Cumbria’s ‘Wedge’ Thresholds Model.81

b. Common Assessment Framework (CAF) process.

The Common Assessment Framework (CAF) process was developed for practitioners from a range of backgrounds to use to gather and assess information in relation to a child’s needs in development, parenting, and the family environment.

Work has been on-going to reinvigorate and re-launch the CAF with new multi-agency training, and e-CAF solution and secondment opportunities to drive a CAF Support Structure across the county. The LSCB is committed to ensure the number of CAF increases and impacts on the quality and timeliness of early help for children and families.

“It is really key for our improvement that all Partners share responsibility for this priority. We must all commit to using CAF as our consistent tool for identifying children who would benefit from early help and for recording planning. Unless we can evidence significant improvement we will remain ‘inadequate’. In September we reported only 8 CAF were opened across the whole partnership.” 82

80 The chairman understands that this diagram is being revised but was not yet available for inclusion 11th July 2014. 81 Multi-agency Thresholds Guidance, Cumbria Children’s Trust Board, January 2013, Multi-agency Thresholds Guidance, Cumbria Children’s Trust Board, January 2013, (under revision Feb 2014) http://www.cumbrialscb.com/ 82 Richard Simpson Interim Chair Cumbria LSCB Autumn Newsletter 2013 http://www.cumbrialscb.com/elibrary/Content/Internet/537/6683/6684/415841554.pdf

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The CAF is a four-step process whereby practitioners can identify a child's or young person's needs early, assess those needs holistically, deliver coordinated services and review progress. The CAF is designed to be used when

 a practitioner is worried about how well a child or young person is progressing (e.g. concerns about their health, development, welfare, behaviour, progress in learning or any other aspect of their wellbeing)  a child or young person, or their parent/carer, raises a concern with a practitioner  a child's or young person's needs are unclear, or broader than the practitioner's service can address. “I am very disappointed about my (autistic) son’s CAF as it is not filled in properly. Social workers are assessing against what is available and not what is needed for the child.”

The ‘Love Barrow families’ project will ensure a CAF is in place for every family involved with the project and work to the Multi Agency Threshold following Cumbria County Council’s operational principles for working together.

A number of respondents made comment about the Triage system.

“I am a GP and I don’t use the CAF system, I just phone Triage and ask what to do.”

“GPs say they haven’t got details about what to do and don’t fill in the referral forms. It is all on line for them to use.”

“I haven’t time to be filling in lots of forms.”

“We used to have a CAF support network which helped work out the best way of doing things. I think it fell apart when the posts were removed. I think they are now being reintroduced so hopefully it will work better.”

“Although this approach to Triage was agreed at the top we think the threshold is too high and we don’t get our risks acknowledged properly. We work in a different way to the social workers in the county council.”

“I listened to a CAMHS worker trying to make a referral on a Friday afternoon that seemed to require intervention, but it was not accepted.”

“I am a support worker and I use Triage to ask for advice. They can give some good advice but always put it back on you to find a solution. We don’t have a special named social worker for the work we do but could do with one. Then we could build a relationship. I am not yet trained to deliver CAF but do sit in on the meetings.”

The latest LSCB report updates the progress of the CAF and the Early Help Team: 83

” The Early Help Team has been in place since January 2014 and has concentrated on creating links with frontline staff – at this stage supporting the development of the Common Assessment Framework (CAF) process. There is evidence of an increased use of CAF as month on month there are more CAF’s registered with Triage. In response to feedback changes have been agreed to the system to both streamline and create a common language:

83 http://www.cumbrialscb.com/eLibrary/Content/Internet/537/6683/6684/41761123635.pdf

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• From May 2014 CAF will be renamed Early Help Assessment/CAF. • Other assessments that reflect the CAF process i.e. assessment, plan review and Team Around Child (TAC) – with parental permission can also be registered with Triage. At present this includes Early Support, ASSET (End Stage) and the form that is currently CAF. This can happen with immediate effect. • The form on the LSCB website will be expanded to create a Family CAF – allowing for assessments of all family members. • The term ‘Lead Professional’ will be replaced with the term ‘Coordinator’ – to emphasise the role as one that coordinates the process rather than takes overall responsibility. • At the March 2014 LSCB it was agreed that all Early Help paperwork will carry the LSCB logo. These changes are hoped to ensure that the assessment is more of a shared process – with key partner agencies involved in a family’s Team Around Family (TAF) contributing their own knowledge and experience to the assessment. To further strengthen the process of change the Early Help Strategy has been completed and agreed by the LSCB.84

c. Team Around the Child (TAC)85

A TAC is a multi-disciplinary team of practitioners established on a case-by-case basis to support a child, young person or family.

After gaining consent from the child/family to share information gathered from discussions, the initial task for a practitioner is to advise other relevant service practitioners to come together in a TAC to assess those needs and decide with the child/family a course of action to provide the services needed. TAC supports particular elements of good professional practice in joined-up working, information sharing and early intervention. The TAC is a model of service delivery that involves

 a joined-up assessment, usually a Common Assessment Framework (CAF).  a lead professional (LP) to coordinate the work  the child / young person and family at the centre of the process  a virtual or flexible multi-agency team that will change as needs change  coordination at the point of delivery  a TAC support plan to meet the needs of the child / young person  regular meetings to which the child / young person and families are invited to attend.

d. Children’s Centres – Access to services by young children and families

A number of respondents commented on the valuable work done by the Sure Start Children’s Centres. There are 28 Centres in Cumbria and they received a 4.5% cut in funding in 2013-14. They provide information and access to services and activities for children aged up to 19 and their families. Cumbria County Council aims to offer local access to services to make life better for children and families with Cumbria`s Sure Start Children`s Centres, Extended Services and other available services. Cumbria`s Sure Start Children`s Centres provide support and information for parents and prospective parents on local services for themselves and their children. They aim to help ensure that these services are made available in an integrated manner, so that every child in Cumbria has the

84 www.cumbrialscb.com/professionals/default.asp 85 http://www.cumbrialscb.com/eLibrary/Content/Internet/537/6683/6684/41761123635.pdf Updated:26 April 2012http://webarchive.nationalarchives.gov.uk/20130903161352/http://www.education.gov.uk/childrenandyoungpeople/s trategy/integratedworking/a0068944/team-around-the-child-tac

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best start in life and that parents have better opportunities. They aim to help make communities safer and stronger. Services are tailored to meets local needs and may vary between different centres. All centres are expected to provide access to, or information about how to access, the following services:

 Good quality, integrated early learning and childcare  Child and family services  Family support services, including support for parents and children with additional needs  Links with Jobcentre Plus to support parents and carers who are considering employment or training leading to employment  Drop-in sessions and other activities for children and carers  Support for childminder networks  Effective links with the Children and Families Information Service, local childcare providers, out of school clubs and extended services.

Ofsted inspects all children`s centres. Inspections check whether children`s centres help families with young children to find out about and use the services they need. Ofsted reports are available on line. 86

Inspections check that centres know their community and the types of services, activities and courses that families who live there need

 To deliver the services most needed, to a high standard  To do all they can to help families use the services they need most, especially the families that find it hard to do so, making sure that no groups in the community have been overlooked  To have good partnerships with health services, employment services, adult training, childcare providers and other relevant services, and that they `join up` the support that families need.87

“It is crucial that we have a whole system approach including the voluntary sector and schools, right across the county. We need to be aspirational and lift our standards.”

“We should not be commissioning by issue, young people today are struggling. We need to be doing assertive detached youth work with them and their families.”

12. Suicide

 About 50 people die from suicide each year in Cumbria and the suicide rate is above average (about 10 - 15 more per year) 79% are male.  On average, there is one death per year from suicide in young people under 20.  More than half of suicides registered in 2006 and a third registered in 2008 had a history of self-harm.  23% were in a skilled trade such as agricultural, engineering, construction work.  57% had mental health issues.  40% were unemployed.88

86 http://www.cumbriasurestartchildrenscentres.co.uk/misc/about.asp 87 http://www.ofsted.gov.uk/resources/framework-for-childrens-centre-inspection-april-2013 88 Self-harm and Suicide Prevention in Children and Young People: Awareness, Risks and Resources County Psychological Service 2013

Independent Review of services supporting children and adolescents with mental ill health

a) The first suicide prevention strategy for Cumbria was produced in 2009. Much progress has been made since then, including:

 Training for professionals and community ‘gatekeepers’: Carlisle and Eden MIND was commissioned by Life Matters (adult social care with NHS) to deliver the evidence-based ASIST, safeTALK & suicideTALK courses countywide for 18 months from May 2012. Funding has been secured to continue this training to end March 2015. 2012’  Support for those bereaved through suicide and post-suicide interventions. With the help of the national charity, Survivors of Bereavement through Suicide (SOBs), Cumbria Mental Health Group set up a support group for people bereaved through suicide which has now been running for three years in Keswick and at the end of 2013 a group in Kendal was started. Recent achievements include work with the Cumbria library service to begin stocking a collection of suicide bereavement support books recommended by SOBs.  Samaritans: Samaritans nationally has successfully piloted a ‘Step by Step’ post-suicide intervention service for schools.  Preventing Suicide in England: a cross government outcomes strategy to save lives was published by the Department of Health on 10 September 2012, World Suicide Prevention Day.  The Cumbria Suicide Prevention Strategy has been updated in order to align more closely with these national priorities.89

“As we have learnt in undertaking repeat suicide audits since 2009, the variations in the ways in which coroner verdicts of probable suicide are recorded make it difficult to monitor success of the strategy using National Statistics. In addition it is difficult to know what might have been different had there not been concerted suicide prevention action by many committed individuals and organisations since 2009. Finally, Cumbria has not escaped the impacts of the recession over this time period, and national and international evidence tells us that, in times of recession, suicide rates tend to rise.90

In addition the following initiatives are led by the Multi-agency Suicide Prevention Leadership Group.

• Carlisle and Eden Mind training: see www.livingworks. • Training for Children’s Services Staff and schools. • Samaritans and Network Rail Partnership (training staff and work with police). • Work with media re reporting of suicides. • Support for People Bereaved by Suicide (SOBS). • Samaritans Step by Step for schools. • Development of Pathways and support for service improvement • Audit and intelligence • Task and Finish Groups aligned to key priorities for attention, including media training.

“It is vital that the press respond sensitively after a suicide instead of making it headline news. I was devastated to see what was written after my relative died and his family are still alive and have to live with this memory.”

89 http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/6164/4145915738.pdf 90 A Refreshed Multi-Agency Suicide Prevention Strategy for Cumbria 2013-2015

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Public Health leads will be holding a road-show event for members of the press in 2014 to share best practice and Task and Finish groups will be aligned to key priorities for action, including media and training. The Samaritans have updated their guidance to the press.91

Following the death of a child Public Health lead a cross-agency response to ensure that agencies continue to work together to support the emotional health and wellbeing of those communities affected by a suicide, and specifically to prevent further suicides among local children and young people. This can take the form of a multi-agency response centred on a school and involving the mapping of vulnerable groups and communities, working with the local media, and developing an enhanced surveillance system.

“WHY does Cumbria have a 20% above the national average suicide rate?”

“Suicide prevention is everyone's business. We need to get the message over that the ordinary man in the street is as capable of preventing suicide as the trained professional if his awareness to the problem is raised through education. Professionals who stand behind ‘confidentiality’ is costing lives in this county. Sharing raises awareness and awareness can divert people from the black thoughts there are experiencing. There seems to be a lack of understanding within Human Resource departments about the needs of employees who are survivors of bereavement by suicide.” b) Suicide prevention awareness and training

“Everyone should do the Mental Health 1st Aid Training.” 92

Progress has been made in raising awareness of mental health and suicide, and providing training across Cumbria for ‘gatekeepers’ (frontline workers, specialist staff and community members in direct contact with those who may be at risk of suicide).

Basic awareness training aims to dispel myths, tackle fears and break down the taboos around suicide. Suicide intervention training provides participants with the knowledge and skills to identify signs of suicidal behaviour and to take appropriate action to keep people at risk of suicide safe.

Life Matters (adult social care with the NHS – then public health) commissioned and provide tailored suicide prevention training.93 They commissioned Carlisle Eden Mind to deliver a county-wide programme of suicide prevention training and awareness across all sectors of the community in 2012.

91 http://www.samaritans.org/media-centre/media-guidelines-reporting-suicide/advice-journalists-suicide- reporting-dos-and-donts 92 mhfaengland.org 93 Excellent training overview at http://www.cumbrialscb.com/news.asp

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Courses include:

 SuicideTALK a short basic awareness raising session, addressing core beliefs about suicide and simple interventions, which can be tailored to an individual group’s needs.  SafeTALK a 3.5 hour session that helps participants identify people with suicidal thoughts and connect them to suicide first aid resources  ASIST (Applied Suicide Intervention Skills Training) – a two-day skills-building workshop that prepares participants to provide suicide first aid interventions to help people with thoughts of suicide or at immediate risk of suicide.

Training has been targeted at front-line staff working with vulnerable people and/or higher risk groups, and participants have come from a wide variety of agencies and groups, including:

 Statutory services – Cumbria Police, Cumbria Probation Trust, Cumbria County Council (housing, children’s services, adult and local services), as well as NHS staff in Cumbria (GPs, A&E staff, school nurses).  The 3rd sector – local MIND Associations, carers groups, learning disability support, self- harm support, family support etc.  Young people – local further education colleges, Inspira, Young Cumbria  Community – Church leaders, freelance artists, WIs, SOBS (Survivors of Bereavement by Suicide), peer support volunteers.  In 2013 and 2014 Senior Educational Psychologists within Children’s Services delivered multi- agency half-day plus workshops across the county covering self-harm and suicide prevention.

There has been a significant demand and participants comment on the usefulness of participating alongside workers from other agencies and settings within the children and young people’s workforce.

By the end of August 2013, over 900 people had received some form of training, with a target of 1000 people to be trained by the end of the year. Providing funding is forthcoming, further targets for training include: farmers/agricultural workers, housing associations, Cumbria Advice Network. Community-based ‘open awareness’ sessions are also being piloted and developed in parts of Cumbria.

The majority of people who die through suicide have been in contact with their GP in the year preceding their death. For this reason the Suicide Prevention Leadership Group has also designed and piloted a suicide prevention and self-harm training package specifically for GPs and their staff. A second version of the Cumbria General Practice Learning Pack has now been developed to reflect learning from the pilot and is ready for rollout and distribution across Cumbria.

Staff at Cumbria Partnership NHS Foundation Trust (CPFT) also receive training in suicide prevention tailored to their roles. Training is one of the priorities of CPFT’s suicide prevention action plan launched in 2013.

“CPFT Children’s services are increasingly being delivered in partnership with children’s services within Cumbria County Council, other NHS and 3rd sector organisations in Cumbria. Stated commissioning intentions are that this will continue and increase. Whilst this training strategy is specifically designed for CPFT staff, it can be seen as a foundation, supporting

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quality service delivery in partnership. Delivery of training may often be most effective when done in partnership.” 94

A suicide prevention training strategy group meets regularly and a draft training strategy has been produced.

 Some secondary schools in South Lakeland are looking to set up ‘Cybermentors’, a national initiative established by “BeatBullying” (the UK’s leading bullying prevention charity). Young people aged 11-17 receive two days intensive face-to-face training by “BeatBullying” staff which gives them the skills and confidence to mentor offline (in their school or community) and online (on the “Cybermentors” website). Once graduated, they mentor, guide, and support other young people on issues of bullying, cyber-bullying and wellbeing.95  A ‘Webchat’ hosted by Cumbria Constabulary on 25 June 2013. Responses received on line.96 c) Training to Raise Awareness of Child Sexual Exploitation (CSE) 97

A multi-agency conference took place in March 2014 to raise awareness of CSE among professionals working with children. Some of the issues covered included the signs of CSE that parents and adults can look out for, information about how CSE affects both boys and girls, and how CSE is tackled in Cumbria. People can follow the advice and information, on Twitter, via the hashtag #CSECumbria. The conference was hosted by Cumbria Constabulary, Inspira and the LSCB and provided frontline staff (i.e. practitioners, teachers, and other professionals working directly with children) with the opportunity to hear about the issues of CSE from the perspective of the child, the parent and other practitioners helping to recognise the children who may be vulnerable. A victim of CSE also addressed the conference about her own personal experiences.

E-Safety Briefing Sessions for Professionals 98 Cumbria Police have produced a PowerPoint Presentation as a response to a request from a local school who wanted a presentation they could play, on a loop, at a parents evening. 99

94 “Supporting Best Practice, A recommended Training Strategy for Clinical Staff in Children’s Services CPFT 2012 95 http://archive.beatbullying.org/dox/what-we-do/cybermentors.html. 96 www.cumbria.police.uk/contact-us/web-chats/suicide-awareness-webchat 97 http://www.cumbrialscb.com/news.asp 98 E-Safety Briefing Session for Professionals http://www.swgfl.org.uk/News/E-Safety-Live/Schedule/North-West 99 Presentation from Cumbria Police - Child Sexual Exploitation (PPT)

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13. Self Harm 100 a) Self-harm, as defined in the NICE guideline, is an expression of personal distress, usually made in private, by an individual who hurts him or herself.101

The nature and meaning of self-harm, however, vary greatly from person to person. In addition, the reason a person harms him or herself may be different on each occasion, and should not be presumed to be the same. 102 The most common ways of self harming include cutting (72%), burning (35%), banging or scratching one’s own body (30%), interference with wounds (22%), hair pulling (20%), and breaking bones (8%).

The CQC review of Cumbria referred to self-harm specifically in January 2014.103

2.11 Local health and social care services are very stretched in meeting the diverse needs of adolescents in crisis, some of whom are previously unknown to services. (Recommendation 3.1) This includes young people presenting in a psychotic state, young people who are threatening serious self-harm or who are at high risk of suicide, including those with eating disorders and those misusing substances. Action is being taken to improve access to specialist CAMHs advice and support including out of hours, however, coverage remains limited in some localities. Pathways to manage the care of young people who self- harm require development. (Recommendation 6.4) These issues were highlighted as areas for improvement at the last inspection.

Self-harm is an important health concern in its own right. However, a wide range of psychiatric problems, such as borderline personality disorder, depression, bipolar disorder, schizophrenia, and

100 Images courtesy of YPAS Liverpool http://www.ypas.org.uk/counselling/selfharm.htm 101 http://www.nice.org.uk/nicemedia/live/13619/57179/57179.pdf 102 NICE, 2004, p. 8 http://guidance.nice.org.uk/QS34 103 Review of Health Services for Looked After Children and Safeguarding – The role of health services in Cumbria 16 January 2014 http://www.cqc.org.uk/sites/default/files/media/documents/20140116_clas_cumbria_final_report.pdf

Independent Review of services supporting children and adolescents with mental ill health drug and alcohol use disorders are associated with self-harm. Furthermore, self-harm has been shown to increase the likelihood of suicide by between 50 and 100 fold.

In Cumbria, there were 1,592 accident and emergency department attendances for self-harm in 2010/11, of which 56% were female. The highest rates of self-harm attendances occurred in females aged 10-19 and in males aged 20-29. The 2010/11 directly standardised rate of emergency hospital admissions due to self-harm in Cumbria was 265.6 per 100,000 persons. This was statistically significantly higher than the national rate of 212 per 100,000 persons. Furthermore, rates of self- harm in Allerdale, Barrow, Carlisle and Copeland are statistically significantly higher than the national rate.104

Any organization working with young people who self-harm should have a formal policy to guide their work. They must take care to measure and record how effective their work is. In hospitals in England and Wales, A&E services already have guidelines for how they are supposed to treat young people who self-harm. The NICE guidance about managing self-harm is useful but is not universally adopted. Morecambe Bay Hospitals Trust has already started a review group to address this.

Research suggests that peer support can be helpful but works best when it is used alongside a whole school approach to mental health and reducing social isolation, which includes strategies such as anti-bullying ones. Part of an overall policy in school should be to encourage peers to listen empathically, be aware of signs and to tell a trusted adult if they suspect serious self-harm or that a friend feels suicidal.105 We heard of some good work in this area but it was not universal.

Many young people prefer to turn to other young people for support. The review team heard regularly of young people who had been helping friends to cope with self-harm. We need more information on how ‘peer support’ schemes, where student ‘mentors’ are trained to support other students who are having problems, could be helpful for young people who self-harm.106

“I am really pleased I did the Mental Health First Aid Training Course, it helped me understand self harm so I can work better with young people. We have seen an increase in self harming incidents.” 107

“The young people I work with all feel they have to be thin and beautiful. Some of them do self harm.”

“We have had 4 or 5 young people experimenting with self harm, usually cutting themselves over this last year. They access the internet where there are groups encouraging people to do it.”

“Self harm is on the increase and some youngsters struggle to talk about it. One I know used a pencil sharpener blade and it broke. In summer they struggled as it was too warm to wear large jumpers to cover up their cuts.”

“I have been supporting a friend from my youth club who is cutting herself and I want her to tell her parents. She won’t go to the doctor. I told my mother about her.”

104 http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/6164/4145915738.pdf 105 http://www.mentalhealth.org.uk/content/assets/PDF/publications/truth_about_self_harm.pdf 106 http://www.mentalhealth.org.uk/content/assets/PDF/publications/truth_about_self_harm.pdf 107 www.mhfaengland.org

Independent Review of services supporting children and adolescents with mental ill health b) SAFA received a great deal of positive comment during the review.108 SAFA is a charitable organisation based in South Cumbria offering services county-wide. It provides free information, counselling, workshops, group work, training, and volunteering. It also seeks to eliminate the stigma and discrimination associated with self-harm by creating greater awareness through education and training.

“In my school we just use SAFA as they respond and have good advice to give.”

“I’ve phoned SAFA for help and they were really good and responded with what I needed to know.”

“When we get asked to see children who are self harming, because we deal only with adults, we refer them to SAFA. They do sessions in Kendal which is convenient.”

“I am a GP and I refer my patients first to SAFA, when they are self harming.”

“I took a school friend to SAFA in Kendal for help and they were really good with her.”

SAFA, like the statutory sectors and many 3rd sector organisations, has seen funding reductions over the last 3 years at a time when its referrals and waiting lists are going up. Whilst it received investment to offer services county-wide, its referrals also increased leading to it having a waiting list of over 50 children, most referred by statutory organisations including GPs, social workers, CAMHS and other charities.

The review chairman raised with a number of organisations the clinical risks involved both for the child and the charity in having children on waiting lists referred by statutory organisations which themselves do not have the skills or resources to support the child. Who holds the responsibility if something goes wrong? What happens when a young person self-refers but is placed on a waiting list?

“If I refer to SAFA, as a GP I expect to keep the risk myself. I would expect to be kept up to date with what is happening.”

This then raises the issue of who refers the young person. Do they always ensure the GPs are aware of the referral? What happens when a young person self-refers? This again raises the issue of the length of the waiting lists. At what point does the 3rd sector consider refusing more referrals and closing the waiting list? Does accepting a referral raise an expectation for the young person that they will be seen in a timely manner suitable to address their needs? What priority should be given to developing a CAF for these young people?

A recent development is the award to SAFA of a county council grant for delivery of children’s self- harm therapy intervention for approximately 25 young people over a course of 20 weeks.109 The project will run from January to June 2014. The contract states it will require a clear referral pathway and information-sharing between SAFA and CAMHS with expectations of roles in place. A care plan will be developed for young people that will be shared across the services and schools. A key outcome of the contract will be for protocols to be agreed and school-based counselling developed.

108 www.safa-selfharm.com/ 109 http://www.safa-selfharm.com/

Independent Review of services supporting children and adolescents with mental ill health c) Website links with advice to prevent self harm.

Most young people interviewed said they searched the web initially for information. The National Inquiry into Self-harm among Young People gives good web advice.110 However, locally, there is a wide variety of information given on websites about self harm. Doing a simple ‘Google’ search for self-harm in Cumbria brings up inconsistent information.

 The County Council Website signposts for example the work of SAFA but with no other links on that page. 111  The Local Safeguarding Children Board has an excellent website and resource page together with a Twitter feed.112 It does not however link to other organisations and their services but a document can be downloaded to find out who is on the Board.  The Cumbria Partnership Trust website gives an excellent clinical overview of what self harm includes.113 However it does not link to the key council pages and one link is not working. It also needs updating to reflect the county-wide work for example of SAFA.114 The Trust has been developing an excellent portal for the voluntary sector to populate to help GPs find up to date information about what is available in their patch.  The Cumbria Police & Crime Commissioner’s office is developing a web portal which will also include useful information about the groups receiving grants. This will be accessible in the summer of 2014.115  UK Charity Directory runs a searchable online database of UK charities but currently only CADAS appears on it.116  Young Minds offers a range of training and their website is one of the most comprehensive available. 117  MIND South Lakeland has a good range of documents for people in crisis to download.118 It also gives details of emergency numbers.

It would be useful to agree the self-harm advice and contact details for the whole county and hold this together on a single portal with web links from all other organisations. This could be an important action by a new Self-Harm Working group.

14. Autism, Asperger’s syndrome, ADHD and conduct disorder.119 a) The Cumbria Partnership Trust completed a structured analysis of the significant backlog of diagnosis of suspected autism spectrum patients (200) and the work necessary to complete this work in 2013. A joint funding approach was made to the CCG and CCC, to address the backlog by the end of March 2014. To address the future pressures discussions have taken place with Cumbria CCG and it has been confirmed that a new Autism Diagnostic service will be developed. Funding has been agreed and the service is currently being developed with a planned start date of January 2014.

110 www.selfharmuk.org 111 http://search3.openobjects.com/kb5/cumbria/asch/service.page?record=36NdqwZ5RMM 112 http://www.cumbrialscb.com/ and resource list at http://www.cumbrialscb.com/training/ssh.asp 113 http://www.cumbriapartnership.nhs.uk/api/condition/self-injury 114 http://www.cumbriapartnership.nhs.uk/rollercoaster-selfharm-help.htm 115 http://www.cumbria-pcc.gov.uk/ 116 http://www.charityportal.org.uk/detail.php?id=1019124297 117 http://www.youngminds.org.uk/for_children_young_people/guide_to_mental_health_services 118 http://www.southlakelandmind.org/pages/needhelpnow.aspx 119 http://guidance.nice.org.uk/CG158 Conduct disorder guidance

Independent Review of services supporting children and adolescents with mental ill health

Over 40 parents with children with autism traits have been interviewed for the current review and they will welcome this new approach. They formed the single largest group with children responding to the review. Groups in both Barrow (covering South Lakeland) and Carlisle (‘Bouncers’) responded. The coordinator of the Carlisle group gave the chairman access to their private Facebook pages which revealed the enormous amount of information parents shared and the immediate and ready support available to members after distressing episodes, usually at school.

The review chairman also went to a well attended group meeting in Barrow with parents and adolescents. This is an active group where members shared many examples of delays in assessment, challenged what they felt were inappropriate Statements of Special Education Needs, their legal challenges via Tribunals and lack of integrated care upon transition to adult services.120

The group is a branch of the National Autistic Society with a strong committee and high profile in the area, stretching to Kendal. The group did not feel represented by the Cumbria Autism Partnership Board as it never met in the south of the county and they did not feel it directly impacted productively on their needs. It is noted that the last meeting recorded on the County Council website was 23rd January 2013. 121 Although local focus groups are supposed to take place there is no mention of a meeting after November 2012. 122

A number of parents mentioned their total frustration at trying to get help for their child, the self- harm, suicide attempts and crisis situations they had faced before they got sufficient appropriate help. They all felt that appropriate transition to adult services was not available.

“There is no-one in adult services to meet our needs. My son was 10 before I was listened to. We get a direct payment now to help and I use some to pay for a private therapist as he has no NHS help. We have no case worker. Thank goodness we have had help from Gemma the autism therapist from our charity but she has to cover the whole county.”

“My daughter went to CAMHS 2 years ago with an autistic disorder and was discharged in January and we have had no contact since. She barely attends school and, although she is dyslexic, has no scribe or help with doing exams.”

“My GP asked why my son doesn’t speak. Not helpful. There needs to be more training for GPs on autism.”

“Support for children with autism must be long term and sustained. There is no point in just having a few weeks of help. The independent support worker has been superb.”

120 https://www.gov.uk/children-with-special-educational-needs/statements 121 http://www.cumbria.gov.uk/healthandsocialcare/adultsocialcare/about/partnerships/autism/capbminutes.asp 122 http://www.cumbria.gov.uk/healthandsocialcare/adultsocialcare/about/partnerships/autism/capbfocusgroups.asp

Independent Review of services supporting children and adolescents with mental ill health

“We have a good person helping us, a coordinator who helps with a personal budget for support.”

“Children in year 9 got a letter from Inspira but it didn’t result in any help for my son.”

“I have asked the county strategy group every year for a plan for improving Autism services but we are still waiting.”

“We really need supported housing for our children when they become adults. They find it very hard to live in a noisy community and be alone, but I have more than 1 child like this and can’t manage with them both at home together.”

“I want to complain about the job centre staff. They stopped my son’s benefits for 6 weeks and then for 26 weeks. He missed one appointment by 5 minutes and got stopped. We have no disability advisers we can ask for help. We have been desperate for money.”

“My son was born in the county which has had 18 years to get used to the fact that he has special needs, so how come now he has just become an adult that no-one knows about him? Why is there no co-ordination of day services?”

“In some other areas they have care managers to co-ordinate all the care for their children. Why can’t we have them in Cumbria?”

“I am very disappointed about the CAF as it is not filled in properly. Social workers are assessing against what is available and not what is needed for the child.”

“One of the best things about our meetings is we learn how differently we are being treated by social workers for allowances, even though our children’s needs are the same.”

“We have a very good senior learning disability nurse.”

“We have had senior people from the local authority attend our meeting, to listen to our needs, but we were disappointed the last children’s plan didn’t mention disability.”

“We are having to pay a huge amount in bus fares as we have chosen a child centred friendlier school for our child – the John Ruskin in Coniston – compared to the local one suggested in the Statement.”

“Our statement of educational need was just woolly! The educational psychologist recommended special speech and language therapy and OT and because it didn’t exist we didn’t get it in the statement.”

“I am now a full time 52 week boarder doing my GCSEs. CAMHS was never able to meet my needs. I ended up with full time support at school and had to get to crisis point and everything fell apart before I got the help I needed. Where I am now staff don’t cause issues, they help me with my subjects and with life skills. I hope I don’t get discharged when I have done my exams as this is the most progress I have made. I needed a special environment where everyone is like me, not a range of general disabilities. I ended up damaging my family before I got the help I needed.”

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“No one looks at sensory needs. And there is just no provision in the county appropriate for autism which is why some of us have challenged the statements and taken our case to the Tribunal and won.”

“The first thing a new helper (school teaching assistant) said was ‘I am strict!’ Problems we encountered were bed wetting and his self esteem was really low by the time he was 6. We eventually found a school that is brilliant and wanted him! We did have an educational psychologist who ‘didn’t want to label him’. Eventually after lots of pushing from us we received a statement and we had to challenge it immediately for more hours of support for the school. Since autumn his medication has doubled and things are not going well at school.” b) ADHD

A number of parents responded to the review directly and not via one of the two groups. They referred to long waiting times for their children to be assessed, some had kind and understanding support from their GPs whilst others struggled to find support.

“I just wonder who is supposed to be dealing with ADHD? We need more community paediatricians to respond to GP referrals.”

“My 6 year old son was having serious problems and was very aggressive at school. He was completely out of control. He was referred to a community paediatrician last September. We heard nothing. The educational psychologist spoke to me herself and has agreed to bump our son up the list and see him in a couple of weeks (although this will of course bump somebody else down the list), the wait for the community paediatrician is 10 months or so (that's next summer holidays!) I just find the lack of support to be appalling. This can be for one of two reasons: 1) lack of funding or 2) because nobody will fill vacancies. And I suspect it’s probably the first! I shouldn't have to ring them up to beg/pester for support. Especially when that will mean that another child doesn't receive that support. Interestingly, I spoke to a friend at church on Sunday who teaches secondary school kids with emotional and behavioural difficulties in Lancashire. He commented that the lack of support for such issues is legendary in Cumbria, in contrast to a much greater resource in Lancashire (is this a case of more densely populated area = more funding?)”

“I have lots of dealings with children with ADHD. Their families need a great deal of help and there seems to be little help for them.”

“I have a child with ADHD. When I have had a problem all that has happened is an increase in medication. My GP struggled to help and I lost faith as I was told ‘he will grow out of it.’ The health visitor was sent to talk to me about behaviour techniques and the school punished him and then excluded him regularly when he was under 9 years old. I had to keep him out of school before he was sent to a referral centre. He had a 12 week placement and then stayed a year. They really helped him but there was no great push to get him statemented. His first school just did not ‘get him’ and employed the wrong people to help him.”

5 parents raised an important issue about Statements of Special Educational needs.123

123 https://www.gov.uk/special-educational-needs-disability-tribunal/overview

Independent Review of services supporting children and adolescents with mental ill health

“Why was there no review in the council when I launched an appeal? Do the Councillors know that I challenged the statement and after spending almost £7,000 we won and the Tribunal changed the statement and our son is now in the school he needed all along. We cannot be reimbursed for our costs though and he can’t be reimbursed for the 3 years he lost in his development. They tried to save money throughout and have really done him no good.”

“We waited 3 years and still didn’t get a statement which suited our child’s needs. We couldn’t get a special sensory assessment in the county so paid for one.”

Having been given a copy of a recent Tribunal finding the review chairman gained the permission of the parents to share the report with the chief executive of the Cumbria Partnership Trust as she had not seen it or been aware of Tribunal findings. It was clear that some Statements had been appealed by parents during the last year, and all had been won by them. This is an expensive, stressful and lengthy route for them to take but they felt it was their only option. Defending the original Statements and losing at tribunal is also an expensive route for the County Council. Our main concern on reading this Tribunal finding was the lost opportunity over 3 years for the child involved and the inappropriate education placement in which he had been placed.

15. Foster carers

A small number of experienced and long-standing foster carers responded to the review. They explained their commitment to Children Looked After and the successes they had with individuals. On 31st May 2014 there were 631 looked after children in Cumbria of whom 530 lived with foster carers. As in the rest of the country more children are coming into care, meaning more families are needed to look after them. The children who are looking for foster families come from all backgrounds and are of all ages. For some of these children fostering can be a temporary solution, just overnight or for a few months. But for others they require long-term or permanent solutions, be that in foster families or adoption.

“We used to have a good social worker who worked well with us but she took redundancy.”124

“We had a foster carer support worker who was really helpful but these posts were made redundant. I really miss her help. The social worker we have now is very nice but she is just so busy that she can’t spend much time with us.”

“I am an experienced foster parent and have cared for many children over the years. I recognise the issues which require mental health services input. I have tried to explain to the social workers that the child I cared for needed a referral to CAMHS but they just insist they don’t ‘want a child labelling’. They insist I care for the child’s physical health but won’t let me ask the GP for a CAMHS referral as they insist they are the ones who do this. They don’t do it though.”

124 The following response to the draft report was made by CCC: “The quote refers to a social worker who took redundancy; the last time this option was available was 2011 as the Council has prioritised protecting children and therefore social workers are not able to apply for voluntary redundancy. The fostering and children's workers will make referrals to CAMHS where the criteria for tier 3 and 4 are met; sometimes the criteria are not met and so it is more about supporting the foster carer in their day to day management of a child.”

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“I won’t foster again when my current child leaves. I don’t feel my views are listened to or that I am treated like a professional. Very little history comes with the child.”125

“When I asked for help I was made to feel I couldn’t cope.” “There seems to be no health screening before placing children with families.”126

16. Schools in South Lakeland

The South Lakes Federation (SLF) of schools 127

a) SLF is a vital and important resource in supporting children and young people. With the addition of Appleby Grammar School it now works with 6,500 students, 450 teachers and 250 other staff across South Lakeland. It achieved National Teaching Schools status and is chaired by Stephen Wilkinson.128 It consists of 8 secondary schools, one special school and one further education college. Together they focus on

 Professional development for teachers  Creating subject expertise  Broadening and improving provision  Broadening and enriching experience for pupils  Improving the achievement of specific pupil groups.129

One of the most supportive approaches taken by schools in the Federation is to have inclusion leads who meet regularly and aim to take responsibility for each child and to not exclude them from school. They take collective responsibility for children. Together they have been able to provide for the wide needs of young people who are sometimes struggling with social and personal problems. The inclusion manager is full time with support and can do 1:1 work alongside teachers. There is an inclusion advocate group and a senior representative from each school attends, together with social care, education welfare employed by the Federation and CAMHS. The aim is to encourage a partnership approach to do the best for the young person. Originally the County Council gave

125 CCC made the following comment in response to the draft report “CCC undertook a survey of our foster carers this year and as a result we changed the way payments are made and are putting in place out of hours support.” 126 The following response was made by CCC to the draft report: “When children become looked after they do have an assessment of their health needs within 28 days. Foster carers are also involved in contributing to the Strengths and Difficulties Questionnaire that informs the child's care plan. This particularly informs action to address emotional health needs.”

127 https://www.southlakesfederation.co.uk/SitePages/Home.aspx 128 www.education.gov.uk/nationalcollege/teachingschools 129 Federation partners: The Queen Katherine School, Dallam School, Kirkbie Kendal School, The Lakes School, Settlebeck School, Cartmel Priory Church of England School, John Ruskin School, Sandgate Special School, Kendal College, University of Cumbria, Appleby Grammar

Independent Review of services supporting children and adolescents with mental ill health funding to the Federation for ‘behaviour, inclusion and partnership’ but there is no recurring funding now and the Federation works on a subscription basis.

The Federation has a base in Kendal College. Originally, ensuring a fair distribution of financial resources was a challenge but as the Federation started to perform well local Kendal primary schools wanted to follow this approach and started their own group. In 2013 rural primary schools also developed their own Federation.

Family support is offered in the ‘Red Shed’ at Queen Katherine’s School Kendal, which offers counselling and family support. The whole approach across the Federation is to offer early intervention.

“We have often been working with the young person in some depth and if we feel a referral is needed it is really important and we feel our referral should be escalated by CAMHS on receipt. We should be considered as ‘equal status’ partners. We are not about ditching children.”

“Before SLRP there seemed to be nothing officially in place for families or pupils in sudden crisis. As a school we managed to get bereavement support from Dr Barnado’s who were superb at supporting children and had a very positive outcome for a young year one pupil who had lost their father.” 130

“The community nurse angle is quite limited as they are only really meant to be dealing with medical issues. Once it moves into possible psychological or emotional they are told they need to hand over. I have Dr Barnado’s currently working with a family (as community support has been withdrawn) and they liaise with school and with an SLRP counsellor to create a team around the child. School facilitates meetings and is base for these.”

“Having a SLRP counsellor I have been able to refer 4 children who have needed support, 3 of whom are still receiving help.”

“The needs of these children have arisen out of family situations. I can now be pro-active about supporting a child who has a sudden change in circumstances and is showing signs of not coping, distress or being unable to learn. What a difference this has made to me as a leader in school and what a difference to the parents of the children who are at a loss of how to help their children.”

“We do have some access to services via other routes - SLRP, Barnado’s and voluntary groups - bereavement counsellors, Cancer Care specialists”

“The main LA support comes via education psychologists - we have a very good one but he is incredibly stretched and hard to get.”

“CAMHS. Our experience of CAMHS has been very unsatisfactory. Not a very recent case but they were poor at making and keeping contact and tended not to work with the children. They were also reluctant to give advice or contribute to a child's service management/ plans. Most recent request went via a GP but does not appear to have resulted in any contact.”

130 www.barnardos.org.uk

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“Mental health is a complex area which needs dealing with by experts and needs flexibility of response. Schools therefore need access to responsive, affordable (preferably free) mental health services. At present our only professional support is via the school nurse and then the next step is CAMHS, which isn't always needed, and if they are needed, they are so busy they are rarely able to respond in a timely fashion. It would be better if there were something which acted as a 'half-way' point. There are services for self-harm, but nothing for other mental health issues. The only support I have even been able to access for any children has been through the SLRP counselling service. Without that I don't know what I would have done with a recent girl who has needed help.”

“Most of our dealings are with CAMHS. The majority of the time they are very good at dealing with our young people. It can depend on the worker assigned to the student. We have had some CAMHS workers who fully support students and communicate effectively between student, parent and school.”

“In the past though we have had some cases where communication hasn't been good and cases have been closed when possibly they shouldn't have been!”

“It isn't always a positive picture in terms of lesser support from Children's Services who often drop a case before it has even been fully assessed - not as happy with their support at times.”

“We have struggled to get access on two occasions. The process has been slow and complicated. When we did get access, the assigned counsellor changed frequently and we lost continuity.”

“It takes forever to get a CAMHS referral. When you do, they get cancelled at no notice. When they do have appointments, the quality is very variable. Sometimes very helpful, often no better than experienced pastoral staff can provide at school.” b) Some good work has been done in schools to ensure that sound policies are in place. Many organisations and individuals mentioned the Red Shed at Queen Katherine’s School, Kendal.

“The Red Shed is at Queen Katherine’s Kendal, and is a multi-agency/extended services base providing support to students and their families, but, in reality, it is so much more. The atmosphere is always welcoming, always a warm greeting and a chat, often the offer of a “brew” to students and visitors alike. There is a balance of informality and flexibility with purpose. The eight staff permanently based there are models of collaborative working and strong supportive relationships. The students quickly pick up on this and they welcome visitors warmly, without prompting and offer to make you a drink when you come in from a wet and windy yard duty. All the staff are known on first name terms. Students come in for timetabled appointments, some work in groups addressing all sorts of issues.

One major contributory element in the success of the Big Red Shed and its impact on young people has been the partnerships with other agencies and providers that have been enhanced or established. Traditional partners such as the school nurse not only use the Big Red Shed as the base for her established role. We have a monthly Young Carers’ lunch that is organised by a learning mentor in conjunction with the Young Carers staff.

The local Police Community Support Officers (PCSOs) drop in on a regular basis to hand out

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tickets to the monthly Police disco, meet with students informally, as well as offer help to staff and students when needed. They are very much part of the “team” and this relationship has helped to breakdown some wariness and antipathy to the police.

By making the Big Red Shed the sort of place that you would like to spend time in, we overcame the first barrier of getting some students into school and attending. Once we had them in, we quickly worked on building up relationships. Students were accepted and not judged, we were interested in anything that was going on in their lives and happily spent time with them. The next step was to establish a personalised curriculum for each student. It could be one-to-one work on literacy and numeracy, support for coursework, placements on alternative learning courses, work experience or any combination of these. The focus was very much on the Every Child Matters outcomes. We worked individually with them to ensure a progression plan for when they left us. As part of a Comenius Project a group of students made a short film about the Big Red Shed, entitled “What the Red Shed Means to Me”. 131 It conveys something of what we have tried to do and a feeling of the commitment and passion of the really exceptional staff.”132

CADAS workers visit the Red Shed for 1:1 counselling and student counsellors from Lancashire University work there.

“Peer support if well managed can be seen as peer tutoring and tutors also benefit. Well planned peer support in school will help channel through teacher’s special needs where needed.” c) Having more children without Statements of Special Educational Need but for whom one would be helpful is a key challenge to staff and one they try not to lose sight of. Whilst Cumbria County Council has an inclusive approach it was felt that if some children had been in a different county they would have been assessed and statemented much earlier.

The county also has a number of children taught at home and then when older, register at school. Their needs are sometimes quite high and their curriculum gaps can be a problem to try and help them catch up.

“I think the County Council needs to rethink ‘Inclusive Cumbria’ as this system does not work best for some children, especially those with autism.”

“There are lots of students with low level anxiety and we need to strengthen services at Tier 1 and Tier 2 to support them.”

“I don’t think our experience and skills at working with adolescents for many years are really appreciated by some of the CAMHS team. We have lots of successes they never hear about and if we feel we need help and advice we wish we weren’t patronised as though we know nothing about mental health issues.”

There are some good innovations taking place in the Federation’s secondary schools and they received £25,000 funding from the County’s Children’s department to develop approaches to emotional resilience in late 2013. Young Cumbria offer peer mentoring and there is a good relationship with other local organisations such as the Brathay Trust. 133

131 http://vimeo.com/15947635 132 https://queenkatherine-web.sharepoint.com/Documents/QKSNews_10-07.pdf 133 www.brathay.org.uk

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Having Kendal College as a partner was seen as very positive and helped strengthen the Federation

A comment was raised a number of times about the cost of school uniforms. d) Mental Health Research Group, Queen Elizabeth School / Inspira

This in-school project was initiated by Zoe Butler, a student at Queen Elizabeth School, Kirkby Lonsdale and review group member. Zoe has been involved with Cumbria Young Advisers which is run through Inspira, and has been working with Clair Haynes from Inspira as a young adviser during 2012-13. (Zoe, as already mentioned, formed part of the review team for this report.)

Following initial discussion they decided that an area of focus should be the mental health provision for young adolescents. This was due to the perceived gap between CAMHS and AMHS which leads to young people “falling between” two mental health services at a crucial time when young people are particularly susceptible.

Their aims were

 to survey students from Year 11 to year 13 asking them about their perceptions of mental health and their awareness of services that are available to their age group;  to survey GPs in the QES catchment area to ask similar questions;  to use the research to formulate policy recommendations for QES and other local agencies that might be interested;  to engage with local organisations such as Inspira to consider ways in which to address “well-being” issues;  to use their findings to create materials that can be used in the QES PD programme.

A target population of 354 students at QES were sampled (opportunity sample) with a final sample of 319 completing the questionnaire (90.1% completion rate). The main findings are summarised below:

 Students have a varied view on what “mental health” is.  The main causes of mental health issues in young people are body image, family, relationships, bullying and exams.  39% of students would not know who to contact with a mental health concern.  The majority of students would not speak to their GP about a mental health issue.  The least support in the local area was for relationship, family and friendship issues.  The majority of students did not know of any external mental health organisations.  The overwhelming majority would want to find out about support via websites.

The research has led to two main areas of development:

1. The group has developed a Health & Wellbeing hub on the Queen Elizabeth School website. This is in direct response to students’ concerns that they knew little about outside agencies to support mental health issues. The hub will allow students to access website support from a range of local and national organisations. 2. The group is currently surveying local GPs about their perceptions of mental health issues and support in young people

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This was an admirable and timely piece of research, undertaken painstakingly and with great sensitivity. The group used their findings to make direct developments to support young people who are anxious about their feelings. e) The Cumbria Home and Hospital Tuition Service provides specialist educational provision for those pupils aged 5-16 who, for medical reasons, cannot access mainstream education. The review chairman was invited to visit the Barrow service and met staff and pupils.

Across the county there are differences in pupil numbers:

 South – 2 sites and 40 students currently being supported plus hospital cases both in Barrow and Lancaster due to students placed at the Tier 4 CAMHS service at The Junction  North - 1 site and 20 students approx.  West - 1 site and 20 students approx.

The 2014/15 Budget allocation for HHTS is £190K but although the current budget did allocate more to the South team in recognition of higher numbers the allocation was taken from elsewhere in the overall Pupil Referral Unit (PRU) budget allocation.

“The key concern of the management committee is how they are expected to manage an open ended service with a fixed budget. In addition

 There is an inappropriateness of referrals where ADHD/Autism/Aspergers is being given as a medical condition for which HHTS is appropriate to supplement pupils’ timetables.

 Students receiving HHTS have been taken off the school role NOT in accordance with the statutory guidance. Not challenged by LA when evidence provided and specifically asked to do so.”

The team would welcome stronger links with CAMHS on a regular basis, and have greatly appreciated exceptional support from some individuals, including from the Platform tier 4 CAMHS service. Practical support would also be welcomed, especially when dealing with children with complex needs. Likewise, stronger links with social care would be welcomed and advantageous to their pupils. Transport can be a problem for children especially when they are within the service for some time. The longest one of their pupils had been with them was over 2 years.

“We are not realistically resourced for the ever-increasing need we are facing, and our priority for medical cases is offset by young people not in school for a long time.”

The staff highlighted the Department for Education consultation report ‘Supporting pupils at school with medical conditions’ launched on 3 February 2014 for which responses were due by 14 March 2014. A summary of responses was published in April 2014.134 Responses to the consultation questions were universally favourable. Several overarching themes emerged from the consultation.

These are:

i. general agreement that the guidance reflects the minimum requirements of good practice and will impact positively on pupils with medical conditions; ii. broad welcome for the focus to be on each individual child and the recognition that each child may have different needs;

134 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307228/medical_conditions _consultation_report_-_publication_version.pdf

Independent Review of services supporting children and adolescents with mental ill health

iii. strong support for the clear message about inclusion in school trips etc and for the section on unacceptable practice; iv. a call for all children with medical conditions to have an individual healthcare plan; v. a call for governing bodies to be required to audit the implementation of school policies; vi. concerns about the role and capacity of the school nurse; and the role of other healthcare professionals e.g. specialist nurse, children’s community nurse; vii. a need for greater clarity in terms of roles and responsibilities, especially in respect of the provision of local health services; and viii. greater clarity about the provision of staff training

The draft guidance will be reviewed to take account of comments received.

The review chairman met with 7 pupils of the service across a wide age range. They were happy to talk about their school experiences and what had led to their current arrangements.

“My school nurse was really nice when I knew I had problems. She arranged for me to be seen by CAMHS really quickly.”

“Teachers here are the best as they don’t talk AT you; they listen and hear what my problems are.”

“I’ve had 4 CAMHS workers. I need one who when they say they will do something they do it. I used to have a great one who did what he said he would, and made sure he kept in contact with me.”

“My attendance has been 100% since I came here and my parents and boyfriend have noticed how much better I am.”

“I feel safe here, they think I am normal.”

“Thank goodness my CAMHS doctor knew what was wrong with me and made sure I got the help I needed.”

“I am going on to college and want to work with animals. A year ago I didn’t believe that was possible.”

“I did try going back to school after a year here, but it didn’t work and I came back. I am going to college next.” f) Lakeland Youth Council.

Lakeland Youth Council is a group of young people aged 11-19 who either live, work or study in South Lakeland. They cover the area from Coniston, Ambleside, Windermere, Kendal, Sedbergh, Grange, Arnside to Ulverston and they represent every young person in their area. The Lakeland Youth Council (LYC) meets regularly in South Lakeland District Council and is funded by Cumbria County Council. South Lakeland District Council has a role to help and facilitate the Council’s work. The Youth Council’s priorities for 2014 are about mental health:

 Challenging prejudice  Develop posters and film to raise awareness of prejudice

Independent Review of services supporting children and adolescents with mental ill health

 Improving mental health facilities in school  Making information available to young people  Get the message across that there should not be a stigma about people who use mental health services.  Do intergenerational work to raise understanding.

They have been undertaking surveys in schools about mental health facilities.

“The young people leading on this are very articulate, professional in their approach and committed to the end goal of a sustainable Lakeland Youth Council.” 135

The chairman spent some time with the Lakeland Youth Council members and was impressed by their understanding of the needs of their peer group and their wish to support more effective services. By making mental health their priority to address this year they reflected a sensitive and realistic understanding of the needs of their peer group.

135 http://democracy.southlakeland.gov.uk/documents/s4414/Executive%20Report%20to%20Council%20- %20Environment%20Sustainability.pdf Councillor Clare Feeney-Johnson

Independent Review of services supporting children and adolescents with mental ill health

17. The Brewery Arts Centre Kendal. 136

It was difficult to know where in this report to include the Brewery Arts Centre as it was mentioned so often and was highly regarded. It was described as an education setting, as an organisation offering support and confidence building, working in the area of prevention and development and by one young person as “encouraging a supportive non-threatening environment for me to explore who I am.”

Brewery Youth Arts provides fun, high quality creative experiences for young people and encourages them to aspire to achieve their personal creative best. It is open to all ages from birth to 20 years. It enables young people to participate, create and perform in their chosen art forms at a local, regional and national level. Brewery Youth Arts Outreach Programme currently works in over 10 different schools, bringing the arts to hundreds of children.

The coordinators work with babies as well as adolescents and ‘want young people to make projects their own.’ It gives young people a place to go out of school and many turn up when experiencing stress in their own lives. Whilst trying to be as accessible and cheap as possible the Brewery has to earn 89% of its income, with the remainder coming via grants, charitable given and the KCC catering company. It is supported by the following organisations:

Its vision for the next generation is to provide more education, better access for young people outside school and to extend engagement, participation, develop rounded personalities, provide a safe environment and create a tolerant environment.

Transport is always a huge challenge when taking children out on visits. The review team was impressed to see there were strong links to the Junction Tier 4 service in Lancaster and to a small residential school for children with special needs.

Whilst supporting many children it is clear that many more would benefit from attending if they could afford the fees and if arrangements could be made for rural children to have transport home in the evening. The Brewery also supports vulnerable adults.

It is clear that the Brewery Arts Centre is a key partner in helping to build emotional resilience and should be acknowledged for its in house expertise and the range of children and young people it tries to support.

136www.breweryarts.co.uk/

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18. Special Residential Schools 137

Some children have needs or disabilities that affect their ability to learn. For example:

 behavioural/social (e.g. difficulty making friends)  reading and writing (e.g. dyslexia)  understanding things  concentrating (e.g. Attention Deficit Hyperactivity Disorder)  physical needs or impairments

Parent Partnership Services (PPS) offer information, advice and support for parents/carers of children and young people with special educational needs (SEN). There is a PPS in every local authority. Cumbria Parent Partnership Service offers impartial support, information and advice to parents/carers of children with special educational needs or disabilities.138

Whilst there is no legal definition of an independent 'special' school the DCSF considers that any independent school where at least half of the pupils have SEN and at least 25% having statements it should be considered as a school catering wholly or mainly for children with SEN.139

An independent school is a school which is not dependent upon national or local government for financing its operation and is instead operated by tuition charges, gifts, and perhaps the investment yield of an endowment. a) Non – maintained special schools.

There are over 70 Non-Maintained Special Schools (NMSS) approved by the Secretary of State for Education under Section 342 of the Education Act 1996 as independent special schools. To become approved, NMSS have to be non-profit making, have demonstrated that they operate to a level at least equivalent to state maintained special schools and their day to day running is controlled by a governing body, the articles and instruments of which will be agreed by the Secretary of State.

To keep NMSS status, schools must comply with the Non-Maintained Special School Regulations. Local education authorities are permitted to fund pupils to attend NMSS and, almost without exception, their pupils are funded through the public purse. NMSSs cater for pupils with extreme and/or low incidence difficulties and provide very specialist schooling. Over the last 20 years the number of Special Residential Schools in Cumbria has increased and there are now over a dozen in the county. They cater for children whose homes are within over 90 different local authorities, many in urban areas.

When placing authorities decide to fund an Independent place they have three options when ensuring continued oversight:

1. To retain direct responsibility for assessing and meeting all their health needs 2. To retain direct responsibility for assessing and meeting some of their health needs (other than the universal services to which they are automatically entitled) 3. To remain responsible but to enter an agreement with a local provider to assess and meet their health needs

137 http://www.specialneedsuk.org/ 138 http://www.parentpartnership.org.uk/find-your-pps/north-west/cumbria/ 139 http://www.specialeducationalneeds.co.uk/independent-and-non-maintained-special-schools.html

Independent Review of services supporting children and adolescents with mental ill health

At present the obligations for ensuring that authorities placing children and young people out of district to inform the host CCG are only very rarely honoured. Even having done so it is rarely clear which of the three options above will be taken (and if option 2 which services will be provided directly, and which locally). The NHS Cumbria CCG therefore is implementing a systematic approach to gathering information about children placed in Cumbria and then engaging with placing CCGs to determine how they wish the health needs to be met.

One change that would assist with this is an obligation on Local Authorities to inform both the host and responsible CCG that a child is being placed, or moved from a placement.

“There are systems in place for CLA (albeit that those systems could be improved significantly) but the health needs of children placed out of area for educational purposes are largely overlooked. Guidance on responsibility for payment is clear enough but guidance on a systematic approach to getting these children’s health needs met would be very helpful”

There are currently over 500 children and young people placed in these schools in Cumbria from 92 Local Authorities.

The review team was pleased to receive this response to the draft review recommendation:

“The council has recently agreed with the CCG to share information about other LA looked after children placed in Cumbria and notified as required to the County Council. The regulations have recently changed and providers are now required to inform the host local authority of children placed with them.” b) The Appletree Treatment Centre School. The review chairman visited the school to explore what kind and level of special therapeutic provision it made for its children.140 Appletree opened in 1995 to help support traumatised young children whose lives have been severely disrupted to grow socially and emotionally and learn to cope with school. The centre aims to return the children to families and day schools before they reach their teenage years. In 2008, through their Next Steps initiative, they extended the programme and opened Willow Bank to help the small number of Appletree children who still needed support in their teenage years.

“Appletree helps children with emotional, social and behavioural problems who have struggled in school but are academically able. Fell House helps children with emotional, social, behavioural and learning difficulties who are more vulnerable in a larger group. Willow Bank emulates a family experience that ensures a consistent focus on stability facilitating personalised education and developing life skills for independence with the best possible support.”

The centre provides qualified and experienced psychologists and therapists provide individual therapy for the children, clinical input for the children's individual programmes and clinical consultation and training for care and teaching teams.

Over the first three months of a child's stay at Appletree or Fell House their needs are assessed in the following areas: Physical, Home and Family, Social Skills, Educational, Anti-Social Behaviour, Psychological.

140 http://www.appletreeschool.co.uk/

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The team use this information to compile an individual treatment programme. This identifies the goals which form the core of the child's programme throughout their stay at Appletree. It incorporates their Individual Education Plan and is reviewed with the child and all involved agencies every term. When a child is getting ready to leave Appletree it includes a detailed transition plan to enable them to progress appropriately.

The range of professional help provided is impressive. The school employs Chartered and Educational Psychologists, Play and Art Therapists and a Child and Adolescent Psychiatrist. Usually children remain under the oversight of their local psychiatrist if medication has been prescribed. If this is not practical then support is accessed from the local CAMHS Child and Adolescent Psychiatrist. In addition there is a confidential Counsellor and an Independent Visitor to provide children with 24 hour access to an independent person who will listen to any concern and can be a point of assistance outside of the organisation. There is also support from a speech, language and communication therapist contracted privately. The school employs a school nurse who oversees the health needs of children and ensures regular health, dentist and optician appointments. She is available during the day for minor injuries and ailments and will attend any medical appointments with the children. She provides advice for the teams on minor or common childhood ailments and co-ordinates training. She monitors children’s immunizations and ensures that these are kept up to date. The School Nurse also co-ordinates referrals to the occupational therapists, who also work for the NHS.

The school is embedded in its local village and contributes to many events there. It has strong support from friends and locals and makes good use of other facilities. Its links with the local primary school St. Marks are very strong and children share new opportunities together. Children who are struggling to make relationships visit a local farm regularly and enjoy spending time with animals. Others attend the Brewery Arts Centre in Kendal where they take part in a great many different events. Platform dancing is a favourite and some young people have become very skilled and do performances for the public. The school has made a video of two of their young men dancing and they talk about the huge impact it has made on their lives.

“The school would like to do more work with Cumbrian schools and consider more imaginative approaches for some local children. We aim to be part of the community and not hide away from what is going on around us.”

The school makes good use of its pupil premium, spending it on tailor-made events and experiences for each child, helping them grow in emotional resilience. There was disappointment that having offered to pay another secondary school to employ a teaching assistant to enable a child to try returning to school, the offer was refused. The head teacher was also willing to do workshops for secondary school teachers to help them develop their skills at managing the child.

The head is keen to talk to others about the lessons they had learned after the death of one of their children three years ago.

They invited the police to come and talk about the dangers of running away and managing risk was incorporated in all their work.

It was interesting to hear other respondents recommend their work and they are closely linked in with the Inclusion team at the South Lakeland Federation of schools. One described the top team at Appletree as

“having a moral compass, not just in it for the money.”

Independent Review of services supporting children and adolescents with mental ill health

“They case manage both the children and their family. It really works.” c) Finally, from a different establishment, one respondent who had worked in both the state and independent special school sector as a teacher made many points about his experiences. He has now left the profession. He made the point that in one school where children went to 18 years he had been the only qualified teacher and the whole exam approach was watered down. Although the school advertised that they had a psychologist this was not accurate. There was an independent advocate but he was 80 miles away and the children didn’t like the person so they wouldn’t go.

“The head was never in school as he was always visiting potential students and then they suddenly arrived within 24 hours with no preparation. There were rules about the students having private mobile phones but they never handed them back in. Some days it felt like a complete riot. Transition was likely to be to prison. Nothing was proactive, just responsive, and we had the police in regularly. They must have been really fed up always having to look for adolescents who had absconded.

We did have self harmers and we usually took them to A and E. One had to have glass taken out of the mouth. We also had some who head banged. We did have a CAMHS person came in but that dwindled. It would have been hard to carry out therapy there.

Review meetings were really tight as the kids demanded them. If one got an iPad from a social worker they all wanted one – demanded them, and got them. Reflective practice was just a laugh. If we knew an inspection was likely we had to ship the worst out for the day. They had lots of criminal records and were ready to bully any member of staff who couldn’t cope. I asked my union for advice but then realised I didn’t have a proper contract of employment. I may have had plenty of money to spend on equipment but really it was just unruly.”

19. Inspira

Inspira is a national social enterprise company based in Cumbria. It is a provider of community services, and aims to inspire people, organisations and communities to success. It offers comprehensive solutions to a wide variety of social challenges, including delivery of statutory services to public bodies, strategic support for local and national programmes supporting youth in the community and managing contracts across geographically and socially diverse areas.

Two young people were extremely positive about the help they had received and felt it had been hugely supportive to their development. A third young person felt that his special needs with Asperger’s were not understood and he failed to make progress. Inspira is involved in supporting a number of initiatives including the excellent work done by Zoe Butler and the team at Queen Elizabeth School Kirkby Lonsdale on mental health. 20. Bullying

Bullying of any kind is unpleasant, but cyber-bullying, using the internet or a mobile phone to harass, intimidate or threaten, can be particularly bad since it can be constant and reach a young person wherever they are, even at home.141 It was clear that the young people interviewed were knowledgeable about the risks associated with using social media but were aware of friends having problems. Only one student said he had no mobile phone and that he refused to get involved with the internet.

141 http://www.knowthenet.org.uk/articles/warning-cyberbullying-could-be-holding-youngsters-back#sthash.WHX2IF0C.dpuf

Independent Review of services supporting children and adolescents with mental ill health

Whilst 5 respondents from secondary schools remarked that they had been bullied at school it was not a high profile issue in this review. A further 5 pupils being supported in the Home and Hospital Tuition Service had all experienced bullying to varying degrees.

Two older adolescents reported that when they had been bullied the school had dealt with it properly. One student reported that he had wanted to go to Kendal College as he understood they had a strict no-bullying policy. This was important to him as he was exploring his sexuality and was frightened of being ridiculed. He reported that he was never bullied during his time in the College.

“We have drawn up and analysed a process for bullying and should have a good structure in place to deal with it.”

21. Eating Disorders.

A number of parents responded about their children’s eating disorders and remarked that it was very stressful learning to cope with them. There was a general feeling that everyone had to be thin – slim was not good enough. Youth workers were particularly aware of this and focused their work on supporting the debate about eating disorders when the need arose.

“Boys are just as interested in caring about their bodies and how they look. Everyone has to be thin and look good. They are into their power drinks and energy drinks and some of them become obsessed with gym sessions.”

“One school has gym sessions that are very popular but a lot of the attraction to attending is about being thin not fit.”

“Puppy fat is just not acceptable from about the age of 7 or 8.”

One parent shared his distress at not being able to access urgent Tier 4 specialist services for his daughter, who was then being cared for on a general paediatric ward in a general hospital.

“I fear she is going to die and there is nothing I can do about it. I need support as well and there is just no time to think about anything other than her awful loss of weight.”

Two young men talked about their concerns for female friends who were obsessed about losing weight. One tried to encourage his friend to visit a GP but when he failed, discussed it with his own mother to try and think of other alternatives. The friend was also self-harming and he talked about taking her to hospital for help.

22. Lesbian, gay, bisexual or transgender issues.

A small number of gay adolescents commented on how they felt quite comfortable in Kendal College where there were very strict rules on anti-bullying, and they had never been challenged by peers.

“Our youth leader talked to us about being non-judgemental and we had some good discussions about not making other people feel uncomfortable about who they are.”

“It’s still hard for a young person in a rural village to ‘come out’.”

Likewise, 2 adolescents who attended the Brewery Arts Centre felt comfortable and non-threatened and were able to ‘be themselves’.

Independent Review of services supporting children and adolescents with mental ill health

23. Substance misuse including alcohol.

There is a close relationship between alcohol and drug misuse and mental health problems. People with mental health problems have a higher risk of drug and alcohol problems and vice versa. The alcohol-attributable hospital admissions data for 2010/11 shows that in Cumbria there were 1,924 hospital episodes per 100,000 population due to alcohol-attributable conditions. The estimated rate of drug use (opiates and/or crack cocaine) in Cumbria during 2009/10 was 7.6 per 1,000 persons aged 15-64. This was lower than the national rate although there are some large disparities across Cumbria.

The Cumbria Health and Wellbeing Board received a report in January 2014 on the Cumbria Alcohol Strategy.142 Regarding the health of children and young people it stated:

. “Recent figures are encouraging in terms of the numbers of young people accessing alcohol, however, those that drink underage are drinking more and services are beginning to see earlier and younger presentations for life limiting conditions related to alcohol. Young people’s attitudes to alcohol are shaped by media, society and parental attitudes. Availability of cheap alcohol inevitably means that more young people see alcohol as a social norm. Protecting children and young people from alcohol harm is an essential component of the wider children and young people’s health agenda. . Mental health (including alcohol) The Joint Strategic Needs Assessment tells us that alcohol and poor mental health often co-exist. It is often assumed that it is only in relation to high level/severe dependant drinking. However evidence suggests that as incomes are squeezed and stress levels potentially increase, drinking levels can also rise leading people to self-manage stress or anxiety with often hazardous levels of alcohol.” a) CADAS has been providing drug & alcohol services to individuals, family members & communities to support recovery for over 30 years.143 CADAS used to offer resilience training on a regular basis but this project lost its funding. It was re-commissioned last year to run a 1 day each week programme for 1 year from transitional funding. Currently CADAS is also running a waiting list and it is offering more service users support than ever, but with less funding. Staff are trying to improve relationships with UNITY from Greater Manchester which won the contract for drug and alcohol services 2 years ago.

CADAS runs the STARS (Supporting Teenagers At Risk Service) Project for young people aged 11 to 25 years old. The team deliver alcohol awareness workshops in the community including schools designed to give young people an understanding of how alcohol affects the body, how to stay safe around alcohol and where to go to get further help and support. Free and confidential one to one sessions are offered to young people who want to make changes to the way they use alcohol. This project was funded by Comic Relief, for 3 years and the funding ends in 2014.

In South Lakeland CADAS can offer advice and information over the telephone, by email and in person about services, basic drug and alcohol awareness including harm reduction information and signposting to other organisations. Free and confidential structured one to one support sessions are offered to enable community members aged 18 years and over to address their drug and/or alcohol use, to make positive changes whilst improving health and well-being. Carers and families are often ignored because of the attention given to the person with the problem. Families attempt to keep relationships going and continue to offer support in the most difficult and sometimes distressing circumstances. Cadas provides a free service to help families cope. Its project in South Lakeland

142 Cumbria Health and Wellbeing Board report Cumbria Alcohol Strategy 24th January 2014 143 www.cadas.co.uk

Independent Review of services supporting children and adolescents with mental ill health currently offers support to young carers with parents who have alcohol problems and there is anxiety that this service may be lost in the new contract being tendered for with the County Council. These young people may also be at risk of mental ill health and are exposed to some challenging family relationships.

There are also two county-wide alcohol assertive outreach workers from the youth offending service.144 b) Cumbria Youth Offending Service (YOS) is a partnership created by the Crime and Disorder Act 1998 made up of a range of statutory and other key partners. The County Council is responsible for establishing and maintaining a Youth Offending Service in the county in partnership with core agencies (Police, Probation and Health). As such the YOS Strategic Plan needs to be informed by the priorities of a range of organisations and partnerships, and in particular the County Council, Children’s Trust Board, Cumbria Local Safeguarding Children’s Board and the Safer Cumbria Partnership. There has been increased collaborative working in relation to tackling alcohol misuse, particularly in relation to the county-wide roll out of Assertive Alcohol Outreach project (AAOW), in Children’s Services. c) Legal highs

Most 3rd sector organisations working with young people knew about legal high products and that they were available in South Lakeland and Barrow. In July 2013 shops were issued with a warning by Cumbria Trading Standards and Cumbria Police to crack down on so-called legal highs being supplied in Cumbria.

“The use of novel psychoactive substances or ‘legal highs’ can have devastating consequences for individuals and their families, yet many are sold in shops on our high streets or over the internet. Unfortunately the law does not provide a simple way to tackle the growing phenomenon of ‘legal highs’, but Trading Standards and the Police are working together to share intelligence, confront local businesses and raise awareness of the risks of legal highs.

This action is being taken after concerns have been raised about the supply of 'legal highs' to young people in our communities and the increasing popularity of these substances at summer music festivals. The people who make and sell legal highs try to get around the law by labelling them as research chemicals, bath salts or pond cleaner and they are often marked 'not for human consumption'. Where Trading Standards has evidence that the products have been mis-described or mislabelled they have power to take action under consumer protection and product safety legislation.” 145

144 Cumbria Youth Offending service strategic plan 2013-14 http://councilportal.cumbria.gov.uk/documents/s21057/Cumbria%20YOS%20Strategic%20Plan%202013- 14%20V2%20110613%202.pdf 145 http://www.cumbria.gov.uk/news/2013/July/03_07_2013-140443.asp

Independent Review of services supporting children and adolescents with mental ill health

24. The Internet and Mobile Technology

The internet is an integral part of children's lives in 2014. It opens up many educational and social opportunities, giving them access to a world of information and experiences. Whether on a computer at school, a laptop at home, a games console or mobile phone, children and young people are increasingly accessing the internet whenever they can and wherever they are. More than a quarter of 11 -16 year olds have given up an activity they enjoy because of bullying according to research carried out to mark Anti-Bullying Week. The figure highlights how serious the problem can be in holding youngsters back from achieving their full potential.

According to new figures, more children could be members of the social networking Facebook than previously thought. The statistics suggest a million youngsters have signed up to the site, despite restrictions aimed at preventing under 13s from becoming members.

The Office of the Children's Commissioner has completed a two-year Inquiry into Child Sexual Exploitation in Gangs and Groups (CSEGG).146

The Child Exploitation and Online Protection (CEOP) Centre is dedicated to eradicating the sexual abuse of children. CEOP is part of UK policing and very much about tracking and bringing offenders to account either directly or in partnership with local and international forces.147 A CEOP representative spoke recently at a training session for professionals including GPs in Kendal and this was found to be very useful. CEOP has an excellent section on its website for parents. 148

Continued vigilance needs to be taken by all those supporting children and young people and initiatives such as the launch of the child sexual exploitation (CSE) campaign in December 2013, by Cumbria Constabulary and partners, needs to be applauded. It focused on how everyone has a role to play in reporting any signs of child sexual exploitation; with the focus being on how parents/guardians can keep their children safe. The use of webchat allowed anyone to ask questions around CSE.

Cllr Anne Burns, Cumbria County Council Cabinet Member for Children’s Services, said of the launch: “People who exploit children are experts at grooming young people into believing they are in a special relationship when really they are being abused. If we are to protect them, parents as well as professionals need to be equipped with the knowledge and understanding to spot the signs that could indicate a child is being sexually exploited and what they can do to stop it.”

New figures shed light on the extent of the issue known as ‘sexting’ where young people share explicit images or videos of themselves online. 60 per cent of the 13 to 18 year olds surveyed by ChildLine said they had been asked for a sexual image or video, showing the true extent of the problem and the immense pressure young people can be faced with. More worryingly, a third of the youngsters surveyed said they sent a sexual image or video to someone they met online but didn’t know in real life and 15 per cent said they had sent it to a total stranger.149

“I have counselled some young people about being careful what they have on their phones and what they share. It is all just so easy for them to do without realising the legal

146 http://www.childrenscommissioner.gov.uk/info/csegg1 147 http://www.ceop.police.uk/ 148 https://www.thinkuknow.co.uk/Parentsold/ 149 http://www.knowthenet.org.uk/articles/help-teenagers-halt-spread-explicit-images-themselves-online#sthash.YUtNjvIC.dpuf

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implications.”

A number of organisations expressed concern about this area of work.

25. Sexual Health

The Cumbria Public Health Report in 2013 made the following statement:

“Whilst free condoms are widely available and distributed across a number of community settings, there is still work to be done – sexual health services do not seem to adequately cater for young men, particularly in areas of higher deprivation. Given the enormous cultural shift towards social media, local NHS services and resources need to play ‘catch up’ if they are to effectively engage with service users. This is particularly important when it comes to sexual health for young people. The provision of access to and uptake of effective contraception for young people, particularly those most at risk of teenage pregnancy, is a priority in addressing health inequalities. Increasing effective contraception use results in better outcomes for women and a reduced cost to the health service. Adults should be encouraged to access contraceptive services through primary care to allow more provision of young people’s sexual and reproductive health services through multi-agency young people’s providers, across all six Cumbrian localities.” 150

As part of the health reforms taking effect from April 2013, the commissioning responsibilities for sexual health will be transferred from NHS Cumbria. Cumbria County Council will commission comprehensive sexual health services, including Sexual health specialist services, young people's sexual health and teenage pregnancy services, outreach, HIV prevention and sexual health promotion work, services in schools, colleges and pharmacies.

Youth workers commented that they had previously had access to free condoms from Inspira to distribute appropriately to young people but the arrangement had ceased. The Cumbria Partnership Trust agreed to investigate this at the request of the review chairman.

26. The Voluntary and Charitable sector (referred to as the 3rd Sector in this paper).

The county has a rich and enthusiastic group of voluntary and charitable organisations playing a huge part in the life of residents.

These organisations, often called the 3rd sector, also include community organisations, social enterprises, co-operatives and mutual societies. They cover a huge range of issues and services including social care, health, the arts, training and skills, the environment, rural life, sports, the economy and many more. Faith organisations and housing associations that are involved in community work are also considered to be part of the sector.

“These organisations are invaluable to Cumbria County Council and our residents because they are hugely important in innovation, designing, developing and delivering services, advocacy and campaigning for change on many issues. Cumbria County Council works with and supports these organisations in five main ways:

150 http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/6164/4145915738.pdf Public Health Report 2013

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 We work directly with some organisations, commissioning them to deliver specialist services to our residents  Our procurement practices include social clauses – contracts which make sure something is put back into the community as a result of work we commission  We have signed up to the Cumbria Compact which details how the council will work with voluntary and charity organisations to improve relationships and work better together  We offer neighbourhood forum grants which support small scale community organisations and activities and are part of our pledge to buying from, investing in and giving to 3rd sector organisations  We promote and encourage volunteering amongst residents and staff” 151 a. Cumbria Compact - 2011 The County Council has signed up to the Cumbria Compact. This means it has pledged to develop better and stronger relationships with the voluntary, community and charity organisations it works with.

The Compact is an agreement which lists a number of principles on how a statutory sector organisation (such as the Council or the NHS) should do business with the 3rd sector.

The commitments of the Compact include:

 Sharing financial risk fairly  Sharing information  Giving a minimum consultation period of 12 weeks when a major service change is proposed  Supporting the principle of full cost recovery, and working towards achieving this  Funding 3rd sector organisations in advance of spend (or in line with any specific contractual arrangements as may be agreed). b. Grants & Funding for Community Groups

The County Council’s Area Support Teams manage a range of grant funds that are used to invest in communities to bring about a positive and lasting change for the benefit of the whole community. Applications for funding are welcomed from locally based voluntary and not for profit groups who are involved in community projects or initiatives. To receive funding groups must be constituted and hold a bank account in the name of the group. Grants are available for projects that demonstrate lasting community benefit. Funded through the County Council’s six Local Committees, grant funding is currently available from three separate funds:

 Community Grants – Small grants of usually around £1,000 to £1,500 or less to contribute towards the set up of new community initiatives or the purchase of new equipment or refurbishment costs for existing groups  0 – 19 Youth Grants – To support projects and initiatives that have a child or youth focus  Local Member Scheme (LMS) Grants – Funding at the discretion of a local county councillor for community based initiatives or improvement works within the

151 http://www.cumbria.gov.uk/community/third_sector/default.asp

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councillor’s electoral division. Each county councillor has £10,000 to award on one or a number of projects.

Applications for funding are judged on their ability to demonstrate wide-ranging and lasting community benefit. Applications are also assessed on their ability to contribute to locally agreed community priorities and the council’s priorities as listed in the council plan and local area plans. c. Cumbria CVS offers help, advice, training and support to 3rd sector groups throughout Cumbria. It brings organisations together to form a powerful voice for the sector. It seeks to:

 take a leadership role with the 3rd sector in Cumbria  develop, encourage and support leadership skills  provide high quality infrastructure support services that will support and develop 3rd sector organisations throughout Cumbria  offer fully accessible services equitably across Cumbria  develop and share good practice  promote voluntarism in the broadest sense  support individual volunteers as well as voluntary and community groups  support grass-roots inclusion in local planning and decision-making  work in partnership with other agencies to the benefit of member organisations and the communities they serve  ensure an effective workforce and governance structure.

It offers funding advice and support and can help with specially tailored searches for appropriate funding, planning and writing funding applications, business and financial planning and developing a funding strategy. The group runs Funding Fairs around the county to enable groups to meet local and national funders face to face and pick up tips for raising money.

It hosts the Cumbria Action for Health Network, a network of 3rd sector organisations with a health, wellbeing and social care focus. The Network gives 3rd sector organisations the opportunity to:

 promote their work  find out about support, training, key contacts and good practice  keep up to date on health and wellbeing issues  find out about local, regional and national policies and access information which may affect groups and their beneficiaries  influence decisions made in Cumbria regarding health and wellbeing through consultations, and by representing the network at strategic meetings. d. The Voluntary Sector reference group for children and young people. 152

The 3rd sector in Cumbria recognises that it needs to be proactively engaged with the public authorities to ensure the best outcomes for all, especially children and young people. It aims

 to involve the children’s voluntary and community sector in the development and implementation of children’s services in Cumbria at a strategic level  to facilitate information sharing  to equip the voluntary and community to deliver services that children, young people and families need  to provide a balanced voluntary and community services perspective

152 http://www.cypvsrg.org.uk/

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 to demonstrate and articulate the diversity of the sector  to ensure prevention is embedded in all planning, commissioning and delivery  to contribute to positive change for children in Cumbria  to ensure all children, young people, and families, are included

It provides a good overview of its work and the wide range of county-wide groups its members attend.153 It offers a comprehensive website which gives an excellent insight into the District Delivery Groups and the work they are involved in.154

155

Respondents commented:

“Since New Labour's administration, the 3rd sector had been expected to play an increasingly large role in supplementing and delivering care and support to children, young people and their families. The key issue here for the sector in being truly effective for

153 http://www.cypvsrg.org.uk/index.php/about-us/members 154 http://www.cypvsrg.org.uk/index.php/ddg/south-lakes-borders 155 http://cumbriacvs.org.uk/giving-you-a-voice/cumbria-third-sector-network/

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children and young people, is the extent to which they are encouraged (and permitted) to work with the major front line agencies.”

“Piece-meal development. The enthusiasm and energy of individuals running both statutory and 3rd sector services is impressive. Most areas can point to examples of successful innovation. The problem is that they remain examples. Success is attributed to an exceptional individual or group, with little attempt to analyse how success has been achieved and diffuse the lessons learned throughout the county.”

“I am disillusioned about the tendering process feeling that only 1 large provider is wanted for each contract, so the commissioners go with cheapest not the best.”

“I wonder how this project for the development of support for recovery in the community in Furness was advertised as we never saw it and would have bid. It went to a firm from Liverpool.”

“The statutory organisations in the county need a sustainable approach to working with the 3rd Sector.”

“In straightened times like these the role of the 3rd Sector could play a crucial part in an asset-based community development.”

“It was really helpful that South Lakes District Council switched to 3 year funding in 2013.”

“They can’t just turn project funding off as clients are still coming to us. Our core services are vital to supporting the statutory services and if we go under there is no one else left to help our service users.”

“ We have seen some groups fold over the last 2 years and if we don’t get contracts in 2014 when our Lottery funding comes to an end we will have to turn our attention away from seeing clients to fundraising.”

“We are now finding the financial situation very challenging. Every group is struggling. It is impossible for us to cover our core costs and sadly we are not able to do some of the befriending we want to do as we can’t afford to run that service.”

“We try to encourage service users to use mental health Apps on their phones. We also have a friend’s social media site with ‘Hear what you say’ buttons and ‘Thumbs up’ and ‘Like’ or ‘Thinking of You’ buttons.”

“We have had the Police phone us asking for help as a place of last resort.”

“We must all work together to help people with signposting them to the right service.”

“The voluntary sector will just collapse if the financial situation does not change.”

“We have a real problem recruiting good people to run charities when we can’t pay a huge amount and there is so little security of tenure. If they are inheriting a service that is lacking funding they spend all their time doing fundraising instead of managing the service and developing strategies to help their client group.”

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“The 3rd Sector really needs to do things differently by engaging and working with each other as a single team. We need to consider what roles we can share and stop being so competitive.”

Every group interviewed was experiencing funding pressures. The 3rd sector in modern Britain is a major force for social and economic change. With an expenditure of over £33bn and a paid workforce of 634,000, the voluntary sector is also a key player in the modernisation and delivery of public services.

This is in no small part due to a significant expansion in the scale and scope of collaboration with government over the last decade, an expansion underpinned by statutory funding. At a time when public expenditure is under pressure, policy makers and voluntary sector leaders need the latest intelligence on the statutory funding relationship.

There are thousands of voluntary sector organisations in the UK with millions of volunteers. Every day, across the county, people give their time, energy and money. They solve problems, address root causes, and inspire each other. The power of the voluntary sector and volunteering is vital and in Cumbria should be harnessed.

“No one organisation can solve society's challenges alone, but collectively we're all vital for sustaining society in times of challenge and change.”156 “Within Cumbria we should support and celebrate the 3rd sector and volunteering in all its diversity, and champion and strengthen the voluntary sector – by making sure commissioners know its true value, and making sure it can continue to do what it does best”. “A vibrant and thriving voluntary sector improves the world around it.”

“Mindfulness training is increasingly recognised as highly effective in improving the wellbeing that is essential to effective performance and productivity in the workplace. Some of the world’s leading companies, recognising the need for a fresh approach to organisational development, are investing in mindfulness training for their employees, including Google, Barclays, Deutsche Bank, London Transport, Apple Computers & Yahoo. We need to consider this as part of an integrated approach to support our staff.” 157

One of the recurring themes throughout this main review was the precarious financial situation of the voluntary and charitable sector which provides crucial services to support statutory organisations. Their contribution and worth is felt to be unacknowledged and unappreciated and the majority have experienced cuts to their funding and many have had to shed staff or restrict their activities.

The review chairman interviewed or met with many of these groups. One example is that of South Lakeland Mind which has lost over 40% of its funding from various organisations in 2013- 2014. It has a full complement of qualified and experienced voluntary counsellors, all receiving paid external supervision. Whilst carrying a full caseload, they have as many adults again on the waiting list, with little prospect of seeing them in a timely fashion.

156 http://www.ncvo.org.uk/ 157 Ondy Willson http://www.wellseeingconsultancy.co.uk/

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MIND faces issues of referrals coming in off the street, from GPs or social workers or after First Step support which has not worked and the service user has been added to a long NHS waiting list. MIND does not at present accept referrals from children or young people and when they receive enquiries they try to signpost them to appropriate services. This has often been to the self-harm support group SAFA, about which more is included in the main report.

“Given the risk factors across the locality and increasing demand we need to adopt a preventative approach.” 158

An experienced highly qualified counsellor described the issues he was dealing with as including:

“Economic difficulties being experienced by client; the medical model of care still predominates; in episodes of extreme distress powerful drugs are still prescribed although clients want to ‘be themselves’ again without the drugs.

We need to do more co-working. I see the client regularly but never meet the psychiatrist. We also need to meet with the First Step team.”

When charities are struggling to meet core costs they report they are focusing on their own priorities, signposting to other organisations, if appropriate, and additional important support such as befriending has to be reduced. They feel they cannot turn service users away but having them on waiting lists does not help in the short term.

One raised a pertinent question – does anyone know the total length of the waiting list across the county of all service users in all mental health services, statutory or voluntary?

This raises an important governance issue as to who carries responsibility for the service user’s risky situation, when they end up not only on a statutory waiting list but also on a voluntary sector waiting list. Charities are loath to turn service users away in case they lose more funding and are perceived as failing.

“There has been a significant reduction in county council support for mental health services but this is short sighted. The 3rd sector makes good use of each £ and adds value to each contract.”

“It should be recognised that for each £ we receive in funding from the county council we attract four times that from alternative funding sources. Where there is no evidence of statutory funding other sources refuse to match fund.”

“I have seen valuable charities falter because they cannot provide statutory match funding.”

“This is a real challenge now for adult mental health services. Funding for charities has traditionally been from the County Council and not health commissioners. We need to demonstrate the £s we are saving to health. There also needs to be a realisation that if we demonstrate a reduction in mental ill health this does not equate to a cost saving.”

“I hope the Health and Well Being Board will use top sliced CCG funding to address funding to the 3rd sector where it is so badly needed.”

158 http://www.southlakelandmind.org/assets/Development_Objectives.pdf

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“I want the CCG to start contracting the 3rd sector for non medical therapeutic provision. We can do it effectively with positive outcomes.”

“We need the preventative and rehabilitative aspects of our work to be recognised.”

“There is a real opportunity if the CCG met regularly with providers to discuss care pathways. Lines of communication should go both ways.”

“The paper work when applying for grants is so demanding. We are overburdened with it as it takes 3 hours to complete a funding form, when we don’t have the kind of admin support to do this. Every application takes a therapist away from a client.”

“There needs to be a joint audit between the County Council and the CCG of the contribution of the 3rd sector.”

“Just who is taking control of this situation? We are left holding the massive referrals, not the statutory sector.”

“People must realise that the 3rd sector can’t continue without funding.”

There is also a case however for charities running similar kinds of organisation across the county to consider their financial situation and discuss merging their core services, whilst keeping a local presence in their districts.

It was appreciated that this year some local councils have switched to 3 year funding which helps the 3rd sector plan for the future, albeit with reduced budgets. All groups wanted to do more preventive work, seeing that as the crucial element which will save lives and money in the future.

Another key organisation CADAS has been providing drug & alcohol services to individuals, family members & communities to support recovery for over 30 years.159 Currently CADAS is also running a waiting list and it is offering more service users support than ever, but with less funding. Staff are trying to improve relationships with UNITY from Greater Manchester which won the contract for drug and alcohol services two years ago. CADAS has submitted a tender for the carer service to the county council and a decision is due in March 2014. More is said in the main body of the report about the work CADAS does with adolescents in its STAR project. This is a pivotal moment for the voluntary sector, with pressures on all kinds of funding, at a time of growing demand for services. Statutory funding, and the way that public services are commissioned, is the source of much current concern as so many 3rd sector organisations say they are delivering public services and have waiting lists.

A highly pertinent comment comes from Dame Anne Owers, chair of the Panel on the independence of the voluntary sector in January 2012. 160

“We found that there are real and present risks in all of those areas which need to be addressed by all concerned – government, private sector, regulators and voluntary organisations themselves:

159 www.cadas.co.uk 160http://www.independencepanel.org.uk/wp-content/uploads/2012/01/Protecting-Independence-final.pdf

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 An inability for the sector to influence design, delivery and funding models;  the increasing blurring of boundaries between private, public and voluntary sectors;  the risk of self-censorship and challenges to the sector’s independence of voice;  the pressures on independent governance; and  the need for regulations and safeguards that protect, and do not hinder, independence.

These challenges are particularly acute at a time of reduced public sector funding and individual giving: the result of which is that organisations can be faced with accepting sub- optimal delivery arrangements or diversion from core purpose as the price of survival. The greatest effect is likely to be on smaller organisations and those that deliver services to vulnerable and marginalised individuals, which currently rely heavily on state funding and are unlikely to replace it through donations.

If the voluntary sector is perceived to be simply the delivery arm of the statutory or private sector, or appears indistinguishable from either, it will lose the public trust on which it depends for volunteers, donations and tax benefits.”

27. The Needs of the GP

After the draft report was circulated the following response was received from Dr. Peter Weeks, GP, Chairman of Cumbria Local Medical Committee, which raises the needs of doctors in general practice. It is included here as it reflects the pressures on GPs as individuals and resonated with comments made by other professionals. GPs are often the first line of enquiry for assistance and to be effective need personally to be in good mental and physical health.

“The need for specialist mental health services for doctors is vital, the following paper put together by Dr Duggan gives a clear clinical need, gives information how this service is already provided in London and funded by the CCGs (for every pound spent it saves the NHS £60-£100) and gives costings, which to cover the whole of the north of England is frankly not a vast amount when you look at the savings. At a time when morale is at its lowest, and all other prevailing factors, now is when we need this most. “Who cares for the carers?”

Clinical Need

The proposal is to develop a clinical service in the North East of England and Cumbria to target the needs of a population group (patients who work as doctors and dentists) with evidenced poorer than average mental health and addictions outcomes. The proposal is for a clinical service to meet the significant mental health and addiction problems of a cohort with poor health outcomes; it is not a proposal for occupational health provision.

Doctors and dentists have poor mental health and addictions outcomes than the wider population because of three factors:

1. They are a hard to reach group. They do not seek help, or present late, with mental health and addiction problems due to fear of stigma, and concerns about potential breaches of confidentiality through organisational grapevines. A survey of 2,500 doctors in Birmingham, found only 13% would seek help if they developed a mental health or addictions problem (Hassan, 2009.)

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2. They are a high risk group. Partly as a result of not accessing appropriate help, doctors are at higher risk of depression, alcohol dependence, drug misuse and death by suicide. The relative risk of suicide is raised for all doctors, and for female doctors is 2.7 – 5.7 that of the general population (Lindeman, 1996.)

3. Assessment and treatment requires specialist competencies. Practitioner-patients tend to be treated as colleagues, and do not receive appropriate follow-up care (Harvey, 2009; Strang 1998). The Chief Medical Officers report, Good Doctors, Safer Patients (2006) and the Invisible Patients report (DOH, 2010) define the need for specific competencies and training in clinicians and services providing mental health and addiction treatment to practitioners. The Royal Colleges of Psychiatrists and General Practitioners have recently published clear competency frameworks.

Clinical Evidence Base

International evidence demonstrates that services with a focus on practitioner health achieve good engagement and excellent outcomes. The Chief Medical Officer’s report, Good Doctors, Safer Patients (2006) proposed the setting up of a prototype London-based specialist health programme for doctors. This lead to the Department of Health’s Working Group for Health of Health Professionals launching the London Practitioner Health Programme (PHP) in 2008 (DOH, 2010). The intention was services outside London would be created when the PHP prototype demonstrated its success.

The CCGs within London now provide the full recurrent funding for the London PHP following the proven success (in terms of access, engagement and excellent outcomes) of the prototype stage. It meets the needs of 35,000 doctors in inner and outer London, and continues to demonstrate excellent engagement and clinical outcomes. It receives 4.5 new referrals per week, and has a case load of 350 – 380 doctors and dentists, i.e. approximately 1% of this population group.

PHP reduces barriers to care for practitioners in London by offering self-referral, and rapid, flexible access. Practitioners outside London can access it, but the barriers are significantly different: practitioners outside London are required to gain agreement for a written referral from their GP to support referral, and their GP needs then to approach the CCG to seek specific funding. As a result 3 out of 4 inquiries from outside London are not taken forward; suggesting a significant unmet need outside London. In practical terms, however, a geographically distant service in London could not provide the effective, integrated and safe mental health or addictions ongoing care needed by a patient living in the North East of England or Cumbria.

Clinical outcomes, related to mental health symptoms show remarkable and rapid recovery in the PHP. For addictions, the PHP achieves an 82% recovery rate for doctors treated for alcohol addiction (compared to 10% for those treated for alcohol addiction in the general community), and an 88% recovery rate for doctors treated for drug use (compared to a 10-20% abstinence rate in the general population.) Looking at wider health indicators, 80% of doctors accessing the PHP are able to return to work, or remain in work during treatment (NHS London SCG, 2010).

The evidenced clinical outcomes of the London PHP led to the launch in 2013 of Health for Health Professionals Wales for doctors and dentists in Wales.

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Although, the drive for developing a service focussing on this population group is the inverting of poorer than average clinical outcomes, there are a number of additional rewards to the wider health population, in terms of health economics and patient safety, in treating this cohort. The London Specialised Commissioning Group (SCG) has estimated that sickness in doctors and dentists costs over £23.2 million per annum to the NHS in London. This comprises three figures; sickness absence of at least £16.8 million very year, backfill for GP’s sick leave of £900,000 per annum, and doctors suspended from duties as a result of health concerns at the cost of £5.5 million per year. For the 7,500 doctors in the North East and Cumbria, the estimated total sickness cost to the NHS is £6.25 million per year.

In addition, there are the significant costs of the risks of presenteeism (attending work but underperforming due to ill health), which is estimated at 1.5 times the cost of sickness absence. (DOH, 2009) Presenteeism in practitioners poses significant risks to patients through medical errors, underperformance, and team dysfunction.

Professor Clare Gerada, Medical Director of PHP, estimates, based on London SCG data, that every £1 invested in practitioner health returns £60-£100 to the UK economy. Dr Doug Russell, Medical Director of Tower Hamlets PCT, believes his organisation was able to invest an additional 0.5 million in patient care over 2 years because of savings delivered by the London PHP as a direct result of preventing sick-leave and suspensions (London SCG, 2012).

Services focussed on practitioner health are supported by health professionals and the public; in a survey, three quarters of health professionals, and 7 out of 10 of the public backed services targeted on the health needs of health professionals (Ipsos MORI, 2009).

Service Specification

The Practitioner Health service proposed for the North East would closely follow the evidence-based model of the PHP. It would be a clinical service treating the significant mental health and addiction problems of a population with poor health outcomes, by providing a focussed mental health and addiction treatment for the 7,500 patients who are doctors and dentists in the North East. It would be a clinical service that is separate and distinct service from any occupational health provision.

International and UK evidence demonstrates 1% (75-100 patients) of practitioners will access the service for the first time each year. The service, like the PHP, would reduce barriers to care by offering self-referral and timely, flexible assessment and treatment. It would link closely with primary care, occupational health, the Deaneries, 24 hour crisis services, and inpatient care, and would develop efficient pathways and further enhance competencies within these services. It would also work closely with expertise in the third sector, such as the British Doctors and Dentist Group and Doctors Support Network.

The service would be provided by the Specialist Care Group within Northumberland, Tyne and Wear NHS Foundation Trust. It would be multidisciplinary, and offer accessible and timely integrated specialist psychiatric, addictions and psychotherapy assessment and treatment. It would deliver direct clinical care and supervision by Consultant Psychiatrists (Professor Eilish Gilvarry in Addictions, Dr Richard Duggins in Medical Psychotherapy, and Dr Hamish McAllister Williams in Specialist Psychiatry), working alongside a

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multidisciplinary team including a specialist psychiatric nurse, an addictions nurse, an adult psychotherapist and a CBT therapist. The Consultant Psychiatrists in the service all possess established experience and national expertise in assessing and treating GPs, Consultants, doctors-in-training and dentists. They have led the national practitioner health competency trainings for the RCGP and RCPsych, have close links with the PHP (including providing supervision), extensive experience in working with the GMC, and are members of the UK Association of Physician Health and National Advisory Group on Doctors Health. These consultants already informally work together to offer assessment and treatment to a number of doctors and dentists, but this is currently limited, ad hoc, not easily accessed, and very dependent on postcode. The local wealth of senior experience and specialist competencies ensure a high quality service could rapidly be established and delivered.

Costs

The London PHP’s budget, funded by the London CCGs is £900k per annum. This meets the needs of a client base of 35,000 doctors (inner and outer London) leading to a case load of 350-380 doctors and dentists (i.e. about 1% of the population.) The Practitioner Health service in the North East and Cumbria would need to meet the needs of approximately 7,500 doctors and dentists, and therefore would be deliverable at a cost of less than £250k per annum.

NHS England DDT Area Team have agreed £50,000 pump-priming money to reduce the required funding from 250k to 200k in the first year. We would wish to follow the established model of the London PHP in looking for CCG funding for the service, which would be 200k in the first year. The model in London is that each CCG contributes an equal amount, which if followed for the North East would be approximately 15k per CCG for the first year. As the service embeds there will be information regarding the number of patients from each CCG treated by the service, allowing opportunity to modify the share of funding.

Procurement Process

The procurement process would need to be agreed with CCGs.

Timescales

The established local expertise and experience means key aspects of the Practitioner Health service are deliverable immediately from the date of agreed funding. The full integrated multidisciplinary service would be ensured within 6 months.”

Dr Richard Duggins Professor Eilish Gilvarry 7 February 2014

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APPENDIX i

Key Statutory organisations and committees within the county.

It was clear that many respondents, both statutory and voluntary, and parents did not fully understand the current structure within the county and often referred to either ‘health’ or social services’. This review has included therefore the following information to add clarity to how business is conducted. a. Cumbria County Council. Cumbria County Council is a directly elected body providing a wide range of important public services for the people of Cumbria. The Council also champions the interests of Cumbria at regional, national and European levels. The Council has 84 elected members, each representing a single electoral division. For the purposes of this review the County Council is responsible for the following:

1. Child and Family Support Services 2. Fostering and Adoption 3. Young Carers 4. Outreach and respite for young people 5. Public Health

The council is both a commissioner and a provider of services.

In 2014 the Council is planning to publish its Anti-Poverty Strategy (2014-17). This will describe how the council plans to promote health and wellbeing and tackle poverty by supporting people facing financial challenges through a range of services. Consultation was open from 7/2/2014 to 17/3/2014.

i) Equality Impact Assessment - Commissioning of continuation of services for young people with caring responsibilities

Cumbria County Council has a statutory duty under Carers Legislation to provide a Carers Assessment and inform Carers of their right to an assessment.161

Young Carers are recognised as a vulnerable group in need of specialised support. However it must be remembered that there is no single profile of a carer: carers are as diverse and varied as the general population in terms of their own needs and characteristics.

There are an estimated 175,000 young carers in the UK and there is a clear relationship between poor mental health and caring. 2011 census data shows 3,378 carers in Cumbria aged under-24, though this figure may not include those looking after family members with mental health or substance misuse problems. 162

161 The Carers (Recognition and Services) Act 1995, The Carers (Equal Opportunities) Act 2004 162 Children and young people Emotional health and wellbeing in Cumbria: Joint strategic needs assessment [refresh] Version 1 February 2014 http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/6164/41696135154.pdf

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ii) Focus Family 163

"Focus Family" is the Council's response to the government's Troubled Families programme. CCC Children’s Services and its partners are improving the way they work with families who need extra help. They will do this by jointly tackling all the different needs that are faced by the family as a whole. This way of working is being termed the “Focus Family” approach. For the initial phase of this work families have to meet a set of criteria (below). This is so resources can be directed to the families with the most entrenched difficulties.

A “family” is defined as a household and must meet at least 2 out of 3 of the criteria:

 Crime/anti-social behaviour - an under 18 year old with a proven offence and /or an adult with anti-social behaviour order / injunction / contract, including for housing related anti- social behaviour.  Education - Over the last 3 terms: unauthorised absence above 15%, attendance at the Pupil Referral unit or alternative provision due to previous exclusion, more than 3 fixed term exclusions (or equivalent) or a permanent exclusion.  Worklessness - Out of work benefits in the household.

For families who meet 2 of these criteria there is a 4th category “Local Discretionary”, covering households who are high cost to the public purse and those with health problems. The fact that a family has an issue which has raised a professional’s concern may be enough to secure support from the Focus Family work. Focus Family is about supporting service change so that Cumbrian families receive co-ordinated holistic support.

iii) The Troubled Families Programme

The Government has committed to identify, and turn around the lives of, 120,000 troubled families in England by 2015 through the Troubled Families Programme. 1,050 of those troubled families are in Cumbria. Cumbria County Council will work with Cumbria Partnership NHS Foundation Trust to profile both the number of families and funding over the life of the Programme to reflect peaks in demand.164

The national criteria that the Government would like to address through this programme are:

 getting children back into school  reducing youth crime and anti-social behaviour  putting adults on a path back to work  other criteria deemed appropriate and introduced by the Government throughout the life of the Programme.

The Troubled Families Programme is one strand of Cumbria County Council’s Focus Family agenda. “Love Barrow Families” is a programme locally initiated and jointly funded and led by Cumbria Partnership NHS Foundation Trust to deliver improved outcomes for families which face complex problems in Barrow-in-Furness and Walney Island. In order to identify and work with the Troubled Families engaged in “Love Barrow Families” this specification provides, through an effective partnership between Cumbria Partnership NHS Foundation Trust and Cumbria County Council, for the additional specialist and skilled direct service delivery and capacity.

163 http://www.cumbria.gov.uk/childrensservices/strategyandcommissioning/focusfamily.asp 164 https://www.gov.uk/search?q=Working+with+Troubled+Families&tab=government-results

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“Love Barrow Families is a catalyst for the future integration of services; it will focus its service delivery specifically on the most complex families with mental health issues that meet the Troubled Families criteria.”

There are Local Authority Discretionary Criteria for the Troubled Families Programme. The local discretionary criteria that Cumbria would like to address through this programme are:

 mental health  domestic violence  children in need  substance misuse  parents’ uptake of the 2 year old funding offer  other criteria deemed by the Local Authority, as being ‘high cost to the public purse’.

Cumbria County Council has to identify and work with 1,050 families that meet the criteria of a Troubled Family. Love Barrow Families will ensure that 60 families are identified that meet the criteria. A Troubled Family is one who meets all three of the national criteria or two of the national criteria plus at least one of the Local Authority discretionary criteria.

Cumbria Partnership NHS Foundation Trust can expect to have the opportunity to:

 take an innovative approach to the delivery of services  set outcome based performance targets  share their learning through the evaluation of this programme;  work in an integrated way with Cumbria County Council and other agencies and partners which includes Children’s Centres  remove the barriers that prevent families from engaging positively in society. b. Cumbria Health Scrutiny Committee

The Cumbria Health Scrutiny Committee is responsible for:  Reviewing provision and operation of healthcare services in Cumbria  Reviewing any relevant issues concerning health care

The membership of the Committee includes County Council and District/Borough Council members and it is chaired by Cllr Rod Wilson.165 c. The Cumbria Health and Wellbeing Board

The Board is chaired by Cllr Bell and exists to provide a mechanism for partners to work better together so that everyone in Cumbria is able to benefit from improvements in health and wellbeing. Its Draft Strategic Plan Executive Summary 2014/15 – 2018/19 can be downloaded. 166 The plan outlines the challenge in Cumbria:

“Delivering our aims and objectives will be difficult. We will need to achieve radical change on a scale previously unseen. In part, this is because of the major challenges the NHS, and the interconnected social care services, are already facing in Cumbria.

165 http://cumbria.gov.uk/scrutiny/healthandwellbeing/healthscrutinycommittee.asp 166 http://councilportal.cumbria.gov.uk/documents/s27834/Appenidx%201%20Draft%20Executive%20Summary.pdf

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Collectively, we need to acknowledge the scale of the problem:

The system causes more harm than is acceptable. A wide range of core standards, including NHS Constitution Commitments, are not reliably delivered in Cumbria. This inevitably compromises patient outcomes. There has been significant regulatory intervention from the Care Quality Commission (CQC) regarding the quality of a wide range of services. Both North Cumbria University Hospitals NHS Trust (currently in special measures, the highest level of escalation in the NHS) and University Hospitals of Morecambe Bay NHS FT are within the first Chief Inspector of Hospitals Reviews.

Our system currently spends more money than it is allocated. Collectively, we need to get the best possible value from our resources, and deliver a credible programme of cost reduction that removes our current over spend (in the order of £40M in 2013/14) and meets the efficiency challenges of the future (in the order of £30M in the next five years), in a period of austerity for the NHS.

There has been a loss of public confidence. Inevitably, the continuous media reporting of the challenges in Cumbria has led to significant public anxiety. Additionally, communities are worried that valued local services will be lost, and that the NHS system will make bad choices just to balance the books.

We can’t always attract the right staff. Across Cumbria it continues to be very difficult to attract the right clinical staff, particularly in some specialist areas.

Our previous plans weren’t successful enough.”

Joint Strategic Needs Assessment (JSNA) for Cumbria. The board develops Cumbria’s JSNA which aims to provide a comprehensive analysis of the current and future health and wellbeing needs of the county’s population to inform commissioning and guide the future planning and delivery of health services.

The JSNA is a statutory duty for upper tier local authorities and the local NHS in recognition that strategic planning for health and wellbeing is best done in partnership. The Health and Social Care Act, 2012, reaffirmed the government’s commitment to the planning and commissioning of health services at a local level, giving the JSNA a nationally enhanced role. Health and Wellbeing Boards have to produce a JSNA and Joint Health and Wellbeing Strategy for a local area and to commission with regard to them.

The JSNA draws together a wide range of information about the health and wellbeing of the people of Cumbria. The evidence base provided in Cumbria’s JSNA will be used as a driver for local health improvement, enabling local decision makers to set priorities and target resources to meet the county’s health challenges, tackle health inequalities and fulfil the health and wellbeing needs of the people of Cumbria, including those of vulnerable and seldom heard groups.

The Cumbria’s Joint Strategic Needs Assessment (JSNA) online resource includes a wide range of information about the health and wellbeing of people living in Cumbria. 167

167 http://www.cumbriaobservatory.org.uk/health/JSNA/2012.asp

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“Improve population health outcomes, based on a major impact on reducing social isolation, smoking and alcohol misuse, and increasing activity and healthy eating.” d. The Local Safeguarding Children Board (LSCB) The Local Safeguarding Children Board (LSCB) is an independent body. Membership complies with statutory guidance ("Working Together 2013) and as such has representation from all the key statutory agencies in the county as well as third sector representation and two lay members.

It cannot be absorbed by any of the organisations which are represented on it. Nor can it instruct them about what they should do. However, the LSCB should properly monitor and challenge the safeguarding arrangements of agencies. Its key roles are:  Co-ordinating the work of organisations which are responsible for safeguarding and promoting the welfare of children.  Overseeing and challenging them in carrying out their safeguarding responsibilities, to make sure that they are doing that work effectively.

The way in which safeguarding work is carried out is changing significantly. In 2010 the Government asked Professor Eileen Munro to review safeguarding arrangements for children. She produced a wide ranging review of safeguarding services, and the key changes which she proposed can be summarised as:

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 Focussing child protection on the needs and experiences of children and young people.  Enabling staff to develop, and use, their skills and judgement, instead of being dependent on procedures.

The LSCB business plan 2013-14 states:

“Emotional and Mental Wellbeing

Half of those with lifetime mental health problems first experience symptoms by the age of 14, and three quarters before their mid 20s. Around 19,000 children and young people in Cumbria are at risk of poor mental health due to life events such as bullying, bereavement, divorce or serious illness. Some children are at greater risk of developing problems with rurality identified as one of the contributors to poor mental health and well being. 28% of Cumbria’s young people live in rural communities. Cumbria has a higher rate of suicide and self harm amongst the 1-17 year age range than nationally, with 1-2 suicides per year and 220 Accident and Emergency attendances for self harm. The number of referrals to the Child and Adolescent Mental Health Services (CAMHS) continues to rise which presents a challenge to accessing intervention programmes.” 168

Cumbria Local Safeguarding Children Board structure 169 e. The Cumbria Children’s Trust

The Trust Board is chaired by Councillor Anne Burns and is a strategic partnership which brings together the organisations responsible for services for Children, young people and their families in Cumbria. These key partners come together with a shared commitment to “making Cumbria a great place to be a child and grow up in.” The Board has the objective of identifying key shared priorities on which to work in order to achieve maximum collaborative advantages.

168 http://www.cumbrialscb.com/aboutus.asp 169 http://www.cumbrialscb.com/

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The Board promotes  a vision for children and young people which is inclusive and outcome focused  joint planning and commissioning strategies  integrated processes  integrated front line delivery  robust performance management and impact evaluation  locality based delivery models which are tailored to need.

Each partner agency retains its own responsibilities whilst working collaboratively together to strengthen the impact of front-line delivery. The Children’s Trust has a commitment to improve outcomes for all children. These are:  No avoidable child deaths  No children living in poverty  All children are to be ready for school by the age of 5  All young people are to be pro-active and productive citizens by age 16.  Children and young people to respect and value themselves and each other. f) Cumbria Autism Partnership Board (CAPB)170

The CAPB “brings together people from different departments and services and others that have a say in how services are delivered. The Board's primary purpose is to develop an action plan to deliver the National Autism Strategy in Cumbria.” This will include:  Reviewing and considering current guidance and policy relating to autism at both a national and local level  Mapping local needs, resources and identify gaps to inform the Joint Strategic Needs Assessment and commissioning of future services  Identifying local commissioning priorities and develop a local commissioning plan  Overseeing the development of a clear pathway to diagnosis, assessment and support following assessment  Improving multi-agency working with particular attention to boundary management issues  Overseeing the development of a multi-tier training framework  Overseeing the development of a long term strategy to improve local support services for adults on the autism spectrum  Linking with and feeding into regional plans for strategy implementation g) Cumbria Clinical Commissioning Group (CCG).

NHS Cumbria Clinical Commissioning Group is the main commissioner of local NHS services in the county. The CCG receives an annual NHS budget for Cumbria from the Department of Health and uses this to plan and deliver NHS services including: acute hospitals, community hospitals, community based health services and mental health services. It does not commission Primary Care in Cumbria (GPs, Opticians, Dentists and Pharmacies). This is commissioned by NHS England.

170 Terms of Reference CAPB http://www.cumbria.gov.uk/eLibrary/Content/Internet/327/946/4139015434.pdf

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When operating in shadow form in 2012 NHS Cumbria CCG included in its priorities “improving the health of children and young people and the quality and integration of care services” and “improving mental wellbeing and reducing alcohol misuse.” Whilst these continue to be commissioning priorities the CCG Governing Body agreed the main focus in 2014-15 needs to be on

 “Reducing the harms caused by sub-optimal services  Improving the financial stability of the economy  Continue a discussion with the public which provides reassurance and invites participation.”

As part of the CCG commissioning priorities it is intended to implement the current Children’s programme including the continued improvement in CAMHS and safeguarding.171 h) Cumbria Partnership NHS Foundation Trust

Community health services in Cumbria run by the trust are supported by hospital beds and rehabilitation services from nine community hospitals, community beds in acute hospitals, and mental health and learning disability inpatient units. 172 i) University of Morecambe Bay Hospitals Foundation Trust

The Trust operates from three main hospital sites - Furness General Hospital in Barrow, the Royal Lancaster Infirmary and Westmorland General Hospital in Kendal and two centres - Queen Victoria Hospital in Morecambe and Ulverston Community Health Centre.

Furness General Hospital and the Royal Lancaster Infirmary have a range of 'General Hospital' services, with full Emergency Departments, Critical/Coronary Care units and Consultant led beds. Westmorland General Hospital provides a range of General Hospital services, together with a Primary Care Assessment Service (PCAS) and GP led inpatient beds, operated by Cumbria Partnership NHS Foundation Trust. j) North Cumbria University Hospitals NHS Trust

The Trust was created in April 2001 by the merging of Carlisle Hospitals NHS Trust and West Cumbria Healthcare NHS Trust. It is the managing Trust of two hospitals - the Cumberland Infirmary in Carlisle and the West Cumberland Hospital in Whitehaven. It provides a midwifery-led service at Penrith Community Hospital. It serves a population of 340,000 people and provides secondary health care services.173 k) The Cumbria Health and Care Alliance

The Alliance comprises Cumbria County Council, Cumbria Partnership NHS Foundation Trust, NHS Cumbria CCG, NHS England Cumbria, Northumbria, Tyne and Wear, North Cumbria University Hospitals NHS Trust and University Hospitals of Morecambe Bay Foundation Trust. The Alliance members have given a commitment to work together and not form a new organisation; nor does it have any formally constituted arrangements.

171NHS Cumbria CCG Governing Body 19 December 2013 Agenda Item 9 172 http://www.cumbriapartnership.nhs.uk/about-the-trust.htm 173 http://www.ncuh.nhs.uk/about-us/index.aspx

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CCG board papers on 19th December 2013 outlined that Cumbria’s health and social care network agreed to work towards a “fully integrated, patient-centred service over the next five years. This collegiate and comprehensive approach has the support of all providers, the CCG and County Council.” 174

Members have agreed to work towards “radical reform of services to provide more care closer to people’s homes and release acute care to focus on patient needs. The programme of action will demand higher quality of care from increased efficiency and collaborative working. While some progress has been made in combining resources around primary health and social care, this initiative intends to deliver modern, community-based services around sound acute hospital care.”

The Cumbria Health and Care Alliance members have been discussing how to develop short to medium term ‘stabilisation’ plans, and longer term ‘transformation’ plans, to enable a higher quality service within a context of lower resources.

In November 2013 the Local Government Association, NHS England, Monitor and the NHS Trust Development Authority set out a joint planning framework. This requires NHS Trusts, NHS Foundation Trusts, and Clinical Commissioning Groups, to submit two year plans in early April and five year plans in June. The CCG is required to submit a two year operational plan to NHS England in April 2014, and a five year strategic in June 2014. Each NHS Trust is required to submit plans to the relevant regulator to the same time period. Collectively, the organisations have agreed to take this planning process forward through the Cumbria Health and Care Alliance. l). Healthwatch Cumbria 175

Healthwatch Cumbria is an independent organisation set up to champion the views of patients and social care users in Cumbria, with the goal of making services better and improving health and wellbeing.

Its main roles are to:

a) provide free information to help people navigate health and social care services and understand the choices available b) gather and provide information on the quality of services in Cumbria – holding those services to account and bringing issues that need a national response to the attention of Healthwatch England c) promote better and more joined-up services for patients and social care users in Cumbria d) help people to find ways to improve their personal health and wellbeing

174 http://www.cumbriaccg.nhs.uk/about-us/how-we-make-decisions/governing-body-meetings/2013/2013- 12-19/Papers/9-cumbria-health-and-care-alliance-developing-the-two-and-five-year-plan.pdf 175 http://healthwatchcumbria.co.uk/

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Appendix ii Adult mental health service themes

This appendix concerning adult mental health care was provided in March 2014, in advance of the main report to enable it to be used by external reviewers commissioned by the County Council Scrutiny Committee and Cumbria CCG. No recommendations have been considered about these issues which did not also apply to young people.

As the main review was focused on the needs of children the chairman met with Cllr Rod Wilson, Chairman of the County Council Health Scrutiny Committee to agree a strategy for dealing with adult issues.176 It was subsequently agreed that the Scrutiny Committee would make adult mental health a priority for review in 2014-15. She met also with Dr. Jim Hacking, mental health GP commissioning lead for South Lakeland and CCG directors who also had plans to review adult services.

This appendix merely records the themes arising out of the main review and makes no recommendations about future services. The items are not in any priority order.

A. First Step Service. The Cumbria Partnership Foundation Trust (CPFT) manages a First Step service which is a free NHS service that provides talking therapies for all common mental health problems (such as anxiety or depression) for adults across Cumbria.177

It can support people to make changes that will increase confidence and the ability to cope. It offers a range of options including: a. Stress Control courses delivered by NHS experts over 6 weeks b. support using self-help workbooks c. Cognitive Behaviour Therapy (CBT). d. one-to-one CBT e. EMDR for trauma memories 178

When reviewed by the Cumbria Partnership NHS Foundation Trust the First Step service respondents reported that if this service was appropriate for them it was very successful.179 They found the referral system sometimes laborious but on the whole felt the support had been useful. One respondent suggested the following about the referral system:

“It took 7 days to respond from First Step – could they not use email or text? There is only a telephone assessment.”

However, where longer term or more expert support was identified as necessary all respondents complained of long waiting lists of between a year and 18 months. One patient had felt obliged to contract privately for psychotherapy in the interim period. Many complained that they had their hopes raised during First Step support and their mental health deteriorated when waiting for further support.

The summary report in the first year review of this service reported “Co-morbidity of depression and anxiety with Long Term Conditions (LTCs) results in increased physical healthcare costs. Patients also present with physical symptoms, when in

176 http://cumbria.gov.uk/scrutiny/healthandwellbeing/healthscrutinycommittee.asp 177 http://www.cumbriapartnership.nhs.uk/uploads/First%20Step/11-15871%20Cumbria%20First%20Step%20Review.pdf Review of the first year of First Step Summer 2011 178 Eye Movement Desensitisation and Reprocessing 179 http://www.cumbriapartnership.nhs.uk/first-step.htm First Step service

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fact they are suffering from a common mental health condition, for example 69% of depression in primary care presents with physical symptoms. 20% of people with acute chest pain actually have panic disorder as a cause for their symptoms.”

The First Step team has entered into a three-way working arrangement with Cruse and SOBS demonstrating that the 3rd sector and statutory organisations can work together. It enables a service user to receive dual support and appropriate signposting.

B. Absence of psychotherapy support.

A number of respondents raised this as an important issue as it impacted upon long term conditions. The service currently provides for a 0.5 whole time equivalent (w.t.e.) post in North Cumbria but there is no service in South Cumbria. A personality disorder clinical reference group within the CCG was felt by two respondents to have failed to consult users and carers of the service and the present lack of service could lead to high risk clinical situations. The absence or further loss of medical psychotherapy also threatened the training of future clinicians.

Another respondent was previously an NHS Senior Psychotherapist working with groups and individuals in Lancashire. She trained and supervised health professionals and doctors. She sent a copy of her research on the benefits of psychodynamic psychotherapy. Her paper shows the advantages of year long therapy in a group and its cost effectiveness as an approach. Her conclusions showed:

“Group therapy offers something different from individual work.... It allows people to normalise and be less extreme, to think by ‘stepping back’, and to change their perspectives on life and others. They begin to cope better and differently with themselves.

The results show therapeutic movement: clients are viewing themselves as being in a different place than when they started. Using quotes from the Positive emotional change code. ‘More confidence, not as regressed, out of bubble more, feel more normal, less anxiety, ruminate less, cope more, less in head, depression has lifted, want to come off medication, exactly the same but on the inside it is different, feeling warmer is huge, stopped worrying, not as wobbly, calmer, not as angry, still fragile but don’t shatter.’”

“I saw more people for less time. Everything had to be done by paperwork – I couldn’t just contact a patient direct or ring them. It could take 3 weeks to make contact. More time needs to be allocated to long term work.”

C. Community Based Mental Health Services

A number of complaints were received about the reduction in community based mental health services over the last 3 years. People expressed concern that the Assertive Outreach Team had been heavily reduced. Original levels of service had enabled meaningful support, the development of external interests and a re-introduction to life for service users. In the past the staff took great interest as to the preferences of the service user as far as possible which had a marked improvement on their daily lives and mental well being.

In 2010/11 respondents felt all this changed with the introduction of ‘Care Pathways’ and the perception is that since then the service had gradually reduced.

“For lives without much colour or perspective, it has become a severe reduction in what should be a high level duty of care”.

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“Strain on staff has become intolerable, a long standing irreplaceable social worker has moved to another department, leaving just two workers. Their dedication to clients is quite remarkable...”

“Targets are ill conceived and unachievable.”

“How did we manage to lose such good staff?”

“Managers used to be able to concentrate their efforts more on patient care and delivering frontline services”

“Current team of experienced clinicians are overstretched.”

“Support offered at Garburn House had been removed without consultation.”

D. Experienced mental health social work cover

Many respondents complained that over the last 3 years the experienced social workers supporting them had left the service, either through early retirement, or from accepting redundancy. Some had just chosen to go elsewhere to work which was less stressful. This loss has been severely felt and had impacted directed upon respondents’ care.

They felt that they now received less time and support, social workers are carrying much higher case loads, often have to cancel meetings at short notice, and have to cover for illness or resignation of other colleagues at an unacceptable level. In addition newly qualified social workers have little experience of the complexity of mental health conditions and there is a perception that their managers are also not expert in this field of work.180

“With the decline in the numbers of experienced mental health social workers comes the decline in training places for trainee social workers.”

E. Carers

A number of carers responded to the review. They too echoed their distress at losing experienced social workers. They were depressed about the lack of respite for both them and their adult relation with a mental health condition. They were also anxious that their monthly support group may have to close if the contract were removed. Their group meetings were not expensive in the investment of time and support but included taking a group walk, meeting afterwards for lunch and then social support.

The review chairman met with a number of these carers, some of whom were well into retirement and not in robust health. They expressed concern as to what would happen to their relative on their death, their personal lack of a carer assessment or plans for the future and the prejudice and isolation some faced locally from neighbours because of the behaviour or reclusiveness of the service user. Many were finding finances difficult to manage and had many years without an overnight break away from home. One described with great sadness how she felt when a new neighbour wouldn’t place her baby in the garden in his pram because of her concern living next to someone with mental illness.

180 Note – during this review the County Council advertised for experienced social workers offering a financial premium to attract them.

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An 80 year old carer described the impact on his family of having cared for his son for 51 years and having a daughter with bipolar affective disorder. His wife had taken the brunt of the work and stress whilst he was at work but they had both needed support. He felt their whole lives had been “lived in a mental health wilderness, wondering what crisis was going to hit them next.”

Research has shown that 85% of carers reported that their caring role had a negative impact on their own health and 90% of those felt that caring affected their own mental well being (e.g. anxiety, depression or poor sleep patterns).181

“The last time I had a break was in 2012, 3 days after the death of my husband. I am just so tired caring for my adult son.”

“We really need to have a plan for my son, for when I die. Otherwise he will end up being very distressed and back in hospital.”

“I feel so sorry for the 2 remaining STAR workers; they have too many people on their case load, and can’t give us enough time to do anything meaningful.”

“Our GP can offer no support, other than a monthly blood test.”

“My son really could do with a befriender and although we are at the top of the waiting list for that, there is no money to provide it.”

“It needs to be emphasised that there is a statutory responsibility to undertake carer assessments. Also funding for carer respite has been dramatically reduced.”

F. The needs of grandparents caring for their grandchildren.

Three sets of grandparents wrote to describe how they were lacking support after they agreed to care for their grandchildren. These all occurred after the mental health of their adult daughters deteriorated. Their complaints included failing to receive support, their lack of legal rights to safely hold on to their grandchild when approached by the child’s mother who wanted to remove the child, and the financial hardship they faced, often for many years. This had resulted in one set of grandparents caring for a child for many years, into her older adolescence, but feeling they could not take on another young child to their daughter, without such help. This child went for adoption.

All three complimented the police on their experience, sensitivity, immediate help when faced with the parent arriving unannounced and their continued contact over many years. They alerted grandparents if they heard of possible problems and were seen as staunch reliable supporters.

“We have been frustrated and very concerned parents for over 18 years. Our daughter has a high level of Asperger's traits. We have had a grandchild living with us but the social work support is just so inadequate. The social worker left the child with us as a baby and our daughter therefore thinks we kidnapped the child.”

“Our daughter started at 15 with bad moods, self harm, depression and this got worse by the time she had a second child. Although she has never been sectioned we had to fight for a diagnosis and were told the professionals didn’t want to label her. We had no support from our GP.”

181 http://www.cumbriapartnership.nhs.uk/uploads/First%20Step/11-15871%20Cumbria%20First%20Step%20Review.pdf Review of First year of First Step in Cumbria 2011 page 31

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“The only people to help have been the police, unfailingly helpful. Family liaison has even phoned to ask if we are ok.”

“My support bringing up such a difficult child with Asperger’s? I have been prescribed 2 courses of anti-depressants. That is all. I got no other help. Talking therapies was just a laugh. I developed insomnia during those years. We used to have a very good social worker but she left and then it just got to crisis situations. My daughter is very bright but has totally inappropriate actions and behaviours.”

“I am very worried about the legal status of my grandchild. I just have a residence order. This caused problems when hospital treatment was needed. Parental rights rest with the child’s mother. Because we agreed to take the child in a crisis we receive no foster payments. In another county the child was on the child protection register but on coming to us was discharged. We still receive threats that the child will be abducted by our daughter.”

G. Suicide Prevention Strategy – see main report page 44

A number of organisations reported that the prevalence of self-harm has increased over the last 3 years and there is not yet a consistent approach to dealing with it.

H. Transition from children’s services to adult mental health services

The previous external clinical review recommended a review of “all cases where the patient is aged over 18 years and develop a clear transition policy that begins all transition planning no later than at 17 years 9 months and completes it no later than at 18 years 3 months.”

There is still evidence that this work needs extending.

 There appears to be a number of young adults under the age of 25 who still have mental health needs who have not received a satisfactory transfer to both health and social care services.  This is also an issue for students enrolled at the University of Cumbria where they are living independently and away from home and have not had a robust transfer of their care. Not all of these students came to the University from Cumbria.

 Another area of concern is that of eating disorders where there is a lack of specialist adult and children’s services. These services are patchy and transition can be a lengthy process to arrange.  ADHD. The lack of an adult service means that the short term solution is to keep hold of cases for an extra six months. This poses a risk to existing cases and new referrals. There is the potential for long waits and higher clinical risk for any cases waiting for transfer.

A number of young adults on the autism spectrum or with Asperger’s Syndrome complained about the lack of a planned transition or of a robust supportive transfer to adult services. This included health and social care support. In addition they found employment extremely hard to secure together with a lack of understanding about their condition and inappropriate responses to their inability to work in certain environments. They had lost benefits or felt anxious that benefits would be removed. Some were living in inappropriate housing, unsuited to their needs. If they did have social worker support they felt that it was of insufficient time, appointments

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were often cancelled, and the support did not enhance the daily living training and skills they needed to make a positive difference to their lives.

One respondent outlined the inappropriate placements he received when a County Council apprentice. This included one in the education department where his statement of education needs was held.

Many parents responded and one described her son who is leading a lonely and reclusive life in a noisy environment which only enhances his stress. Comments included:

“My son is just so unhappy in his flat that he saves up to spend a night in a Premier Inn to get a night’s sleep”

“He was moved from supported housing and just can’t stand the noise, partying, and hostility. Mediation (with neighbours) didn’t work and he has to live with his head phones on. The Council just does not want to move him back to supported housing because of the money.”

“My son had good help with floating support, on budgeting, creative support through assessment, and they bonded with him, but they can’t take him shopping or do practical things.”

“My son survived schooling and did get an early statement but has mental health problems now and has been depressed since puberty. Noise is a trigger for him and he loses his temper. He self harms with head banging or punching himself. He has had two black eyes, and kicks the radiator. The autism development worker helped but she is only 1 person in Cumbria trying to help so many parents.”

“My son’s transition from CAMHS was awful, everything was crisis led, and there was no day centre for him to go to.”

“My second son has just been diagnosed at 26. He can’t concentrate, services have nothing to offer him and his anxiety is off the scale. He lives with us, but that is really stressful and he could not live with his brother.”

“We have a daughter with a schizo-affective disorder and have been through the whole thing.182 It has affected me so badly. I had to go for anger management support at one time. I have found it just so difficult to be told by professionals that we as her parents could not have information, when we were the ones living with her and trying to help her. We have spent thousands of pounds trying to get her the right support but we are told by the social worker to just leave our daughter alone and let her make a mess of her life if she wants to. Her social worker is leaving and told us there won’t be a replacement for at least 3 months. She has no practical support other than us and she is not talking to us at present. Her fridge is filthy, the kitchen is dirty and she doesn’t wash her clothes. When she is in hospital her treatment is excellent. Are there not any group therapies she could go to? The social worker was very aggressive and shouted at my wife when we raised these issues.”

“Our daughter needs structured support and a daily regime. She does not need social worker support but a social carer. Our daughter can’t fill a form in and was promised help

182 http://www.mind.org.uk/information-support/types-of-mental-health-problems/schizoaffective-disorder/#.UytcYah_uSo

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with filling in her DLA premium application and the social worker said she would sort it but never did. I was surprised my daughter was given a prescription without the doctor seeing her. She needs more support from Making Space but there is no more available.”

Cumbrian parents have made good use of the internet to gain support via two closed Facebook groups. In addition there is a support group for people with Asperger’s which meets twice monthly in Kendal.

One young man reported that when he was at school although he had a Statement of Special Educational Need it was not really useful for him as the attached support was mainly used for other children in his classes who were not statemented. He has creative writing and acting skills and wants to move to Kendal as he currently lives in a remote area with no buses in the evening. Although he gets the lower rate mobility allowance of £21 per week to enable him to have guidance or supervision outdoors, this is hard to achieve where he lives. He is keen to move and get a job as he feels depressed and hemmed in. He has had to see his GP recently as his depression has deepened.

Another young man described his regular ‘melt-downs’ and emotional shut-downs. He had only two friends both on the autistic spectrum. He passed his GCSEs but at a poorer level than he was capable of. He quite enjoyed his time at Kendal College although the course he did was not right for him. His main current issues were with the Job Centre staff.

“who seem to have little experience or understanding of my disabilities. I can’t cope with large numbers of people or noise and my placements did not take this into account and I had more shut-downs. I have had lots of mixed messages and wrong advice re. my entitlement to Job Seekers allowance. After this advice I was so bad that I was diagnosed with depression and couldn’t get out of bed. My GP was brilliant but cannot help me with benefits or getting a job”.

“I recommend more general understanding from teachers, job centre staff and bus drivers. I have offered to give a talk to bus drivers at Stagecoach but they didn’t accept my offer. They don’t understand I am different and just treat me as though I am difficult. I am very worried about the DLA rebranding and how it will assess me.”

I. University of Cumbria

The review chairman interviewed Dave Wilson the lead for Cumbria University who authored its ‘Counselling, Health and Wellbeing Annual Report 2012-13’. The Counselling, Health and Wellbeing Team saw a significant increase in the number of referrals to the service in the last academic year, from 171 students in 2011-12, to 241 in 2012-13 (an increase of 41%).

It is important to consider the needs of students in colleges across the county and the University, and also the positive role that these organisations can play strategically. One respondent said

“The University has the potential to raise the aspiration of young people across the County and there are opportunities to be more integrated into all strategic groups.”

“The health care faculty could be a direct contributor to local research, a real part of the solution. We could have more joint appointments between health and the university and there could be a dramatic impact on delivering community services.”

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“The University has the skills to lead best national practice and development of services, leading it across the county. We are too introverted in Cumbria and should make more use of the research staff at the University.”

In so far as students are concerned, it is relatively easy to capture the experiences of those who are registered at the University as mentioned in G above. The University Counselling, Health and Wellbeing Team publish an annual report. There are 10,000 students, representing 5,500 whole time equivalent places and around 1,000 of these live in halls of residence. Students live across three CCG areas, in Cumbria, Lancashire and London.

The team saw a significant increase in the number of referrals to the service from 171 students in 2011-12, to 241 in 2012-13 (an increase of 41%). This increase shows that they saw 2.64% of the students who were registered with the University of Cumbria (9114), which brings the service in line with the national trend, (on average, between 2 and 4% of students nationally access in-house counselling services whilst they are in higher education.) Altogether 700 appointments were delivered to students (with a total 936 offered) which equates to an average of 3 sessions per student. The number of average sessions is slightly down compared to previous years, but this was projected to be the case when the new system of working was introduced (more in-depth referral and a longer assessment session aimed to reduce the total number of sessions a student would require). A third of referrals to the service are for depression followed by academic stress, relationships and self esteem.

For 2012-13, The University introduced a new Stepped Care Model including a new online referral route for students to access the service. The aim was to free up more time for the counsellors to see more students. The team however is very small, comprising three part time counsellors equal to 1.003 w.t.e., together with a voluntary counsellor and three trainees. All receive clinical and peer supervision.

Some students with a history of mental ill health arrive in their first year having not had a planned transfer of their care, resulting in them not having a GP, repeat prescriptions or a referral to an adult mental health service. Some GPs have had many years of experience working with the University and offer a good service but that is not always the case. Over the last year there has been an increase in the number of students who have approached their GP for help but as mental health waiting lists are long they access the University team to try to expedite a referral.

Currently around 800 students are in receipt of Disabled Students’ Allowances. 183 Two thirds of these have specific learning disabilities. The University Mental Health Advisers Network is a national UK Charity working for people in Higher Education institutions who experience mental health difficulties and the team belong to this network.184

The team would like to have better communications with statutory services and more sharing of information. Shorter waiting lists and better transfer from CAMHS and other mental health services are essential if students are to gain the most from their courses.

The University has a student code of conduct covering incidents of bullying and a social media policy.

183 https://www.gov.uk/disabled-students-allowances-dsas/how-to-claim 184 http://www.umhan.com/about-umhan.html

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J. Lack of emergency beds in crisis

A number of respondents reported their concerns about the lack of emergency beds in crisis situations. Carers reported their distress when relatives were sent as far as Newcastle where they could not visit them as they had no private or public transport. This was also reported as a problem when patients were held in police custody.

“We need an increase in mental health beds locally. Triage for adults needs appropriate signposting and crisis intervention needs more staff.”

One respondent acknowledged that

“for some patients, placement in an out of area bed which is more specialised in delivering the care required may lead to better outcomes. In fact, in the face of generic provision that does not meet the need vs. more specialist provision at a distance, families will sometimes be relieved that the right provision is available, regardless of distance. However this all needs to be balanced with the benefits of being close to family support and easier discharge with the out of area provider.

Robust case management of patients out of area is the key here but it necessitates having staff who are skilled and deployed to do this. If it doesn’t happen, families can form stronger alliances with the out of area provider and lose confidence in local provision which makes discharge home and linking into local provision much more difficult.”

“We had discussions about more beds in Carlisle in 2012 and there were plans to rebuild the psychiatric unit. We developed a strategy but it never got build and now we can see the impact with lack of beds.”

“What happened to the agreement we had to have mental health trained nurses in our A and E departments? I thought that had all been agreed and funded but it hasn’t happened.”

“There is still a huge lack of understanding between health and social care as to how each department works.”

K. Police Custody setting – waiting for a mental health assessment.

The Mental Health Act 1983 requires that in those cases where two medical recommendations for the compulsory admission of a mentally disordered person to hospital are required one of the two must be made by a practitioner approved for that purpose under Section12 (2) of the Mental Health Act 1983.

A qualified mental health nurse responded to the review to complain about the length of time she had to wait for a S12 (2) approved doctor to arrive to undertake a mental health assessment on a person held in the police cells. On 2 occasions she has had to ring the crisis team when a person was about to be bailed but was self harming and in her opinion was at risk if released. She is an experienced mental health nurse and felt that her assessment of a person at risk should be acknowledged and acted upon quickly. She also commented upon the numbers of service users having to be transferred out of area.

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Other respondents commented that

“Use of police custody overnight could never be considered acceptable – and would certainly come with unacceptable risk. This needs much more consideration and planning needs to regard this as a ‘never event’.”

“We need to simplify this to protect life. Sometimes it feels as though the police are the first port of call but services don’t want to respond when we ask for help. Crisis intervention is not sufficiently well staffed and we get a poor GP response when we need help.”

“We have a real problem when a patient goes missing from hospital and would like to see more done to prevent that happening. Hospital staff don’t think they can stop them leaving. It is an ‘Urban Myth’ that they can’t ‘put hands on’. There is a simple mechanism for managing risk – a section 136, but health staff don’t like using it.”

“Are hospitals going to consider having their own security staff who are mentally aware? At present they are just relying on the police to respond.”

“When young people go missing from residential schools we do a high priority job to find them. Recently we have done some work with such a school where children were going missing regularly and the local sergeant has managed to resolve the issue with the staff.

“We need to educate primary care, A and E and GPs about mental health law”

“We could do with less defensiveness from other services when they get things wrong.”

There have been some excellent developments recently between the Partnership Trust and the police in South Lakeland.185

“The Partnership Trust will be changing their staffing structure in May to the extent that the minimum number of staff on duty will double from 1 to 2 overnight (and at weekends etc). Another change is the merging of the Crisis Team, Mental Health Liaison Team and the AMHP teams with a Cumbria wide single access point eventually which will be available 24/7 which should mean that telephone advice should be available more often.

 The local mental health sub group meetings need to be re-started.  There will be joint Section 136 mental health training to involve police, ambulance, mental health team – Andy Shaddock will deliver this as a 1 day training input. 1 Sgt from each unit will attend and 1 community Sgt.  There will be the creation of mental health champions on each shift.  Contact will be made with the heads of Dova Unit and Kentmere ward to hold informal sub-group meetings whilst Jan Greasley will re-form the formal sub-group.  Police will consider ideas to reduce the number of S.136 cases. Police in the South currently detain a far greater number of people under S.136 than the other 2 areas.  Better recording of issues with the crisis team providing information about delays, etc.”

L. The 3rd Sector see section 26

185 Response after meeting with Mark Pannone Superintendent South Cumbria Territorial Policing Area

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M. The use of technology, telehealth, telecare and the development of Apps

A number of respondents raised the issue of better universal use of telecare and the development of integrated IT systems across the statutory and 3rd Sector. This could be particularly productive if statutory services started to make more use of text and Skype with service users, the majority of whom have SMART phones.

A number of voluntary groups use closed Facebook sites to support members, give feedback and flag important courses, meetings or changes in legislation. One also reported that it did this so members could speak confidentially as there was some anxiety about speaking out about their circumstances.

Cumbria University introduced Skype and Microsoft Office Communicator as an alternative option as an interface this academic year, aimed primarily at students who were distance learners or on placements and would struggle to access counselling on campus.

The Cumbria Rural Network chaired by Professor Alison Marshall, Professor of Health Technology and Innovation at the University of Cumbria, reported on 6th March that the group has been successful in securing funding from the Academic Health Science Network North East of £80k. This will fund development of the Cumbria Strategy for Digital Technologies in Health and Social Care, as well as development of a web based portal. This will have a members’ area and a repository of best practice in rural health.

N. Training and development (There is more on this topic in the main report.)

A great deal of training takes place across the county, some formally run by and targeted at professionals, and some more informal like the training sessions run by South Lakeland MIND in Windermere Library. Eden MIND has a county-wide contract to provide a range of training on mental health awareness. They run Mental Health First Aid (MHFA) and the LivingWorks suite of suicide prevention training alongside bespoke courses. Recently organisations receiving training have included the Cumbria Constabulary, East Cumbria Family Support, Employer’s Bridge Project, Cumbria CABs, People First Advocacy and a range of local community groups.

A number of parents responded however that they had become ‘expert carers’ over the years with no training or educational support to help them address the needs of their relative. Neither are they are asked to contribute to such training yet they feel they could tell the story more accurately than professionals as they are ‘living’ it.

The review chairman has introduced one of the young male respondents to a number of organisations as he delivers a talk on his experiences living with Asperger’s.

O. Preferred provider commissioning

A number of organisations commented that there was a perception that both health and social care commissioners only wanted to contract for services with large organisations. The general feeling is that if this continues smaller local organisations will close, removing local fundraising opportunities and community accountability.

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In particular comments were made about the drug and alcohol service contracted to Unity.186

“Large organisations can get contracts by being the cheapest by bidding for the service as a loss leader to shore up their core funding, to continue their other services outside of Cumbria; we can’t do that.”

“I would like to know how the outcomes of these large out of county organisations compare to previous providers.”

“What impact does a contract have when it goes out of county, on our own internal infrastructure? Isn’t this just money lost to the whole economy? Their management team probably don’t live in the county either so they are not reinvesting in the county.”

This was raised with Cllr Anne Burns who is already having discussions with the Cumbria County Council procurement officer to consider future contracts.

P. PARADES Psycho-education Trial. 187

Currently, the Spectrum Centre is running a new research project into two group treatment for bipolar disorder called psycho-education and peer support. Psycho-education aims to enhance people’s understanding of their disorder. This study is part of a major research programme grant which has been awarded by the National Institute for Health Research and is based at Lancaster University.

Main research questions include: o To demonstrate that such group therapy is feasible and sustainable across different NHS sites o To determine that group therapy is clinically and cost effective compared to group support o To identify barriers and potential solutions to barriers to the implementation of effective group therapy

If the study is successful this will strengthen the case to make these interventions more widely available in the NHS. Recruitment is active in Cumbria with the first groups scheduled to start in Barrow during March. Once the groups in Barrow are up and running, recruitment will start in Carlisle for the second set of groups, due to start this September.

186 Unity http://www.gmw.nhs.uk/search/venue/unity-penrith-61 187 http://www.lancaster.ac.uk/shm/research/spectrum/research/parades/psychoeducation.php Natasha Lyon [email protected]

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Appendix iii The Big Lottery Fund’s Fulfilling Lives: HeadStart 188

This national initiative designed to build the emotional resilience of children and young people aged 10 -14 years involves considerable investment on the part of BLF, aiming to equip young people to cope better with difficult circumstances and help prevent common mental health problems.

Cumbria was invited as one of 12 areas nationally to bid for £500k to deliver an ‘initial project’ between July 2014 and December 2015. Five or six of the areas will go on to succeed in attracting a further £10m of funding each to roll-out the project and transform services between 2016 and 2020. BLF require the project to be delivered by a Partnership which includes children, young people and their families/carers.

Dr Jane Mathieson, Public Health Consultant and Anne Sheppard Strategic Manager, Emotional Wellbeing and Mental Health Services are the current leads for the project on behalf of the Cumbria HeadStart Partnership.

A new survey has revealed that 45 per cent of children aged 10-14 have reported being unable to sleep because of stress or worry, with fifty nine per cent saying they feel worried or sad at least once a week. The findings come as the Big Lottery Fund, the largest distributor of National Lottery Good Causes money, launches its £75m HeadStart programme aimed at helping children in this key age group to cope with the pressures of modern life. The Fund has worked closely with its own panel of young people to identify how their age group would like good causes money from the National Lottery to help them. Having carried out their own research and discovered mental health was one of the top concerns of their peers they helped to develop HeadStart, which has received the support of the Chief Medical Officer.

The YouGov survey of over 700 children aged 10-14 also discovered that:

• More than one-in-five (21 per cent) have avoided socialising with friends because they were stressed or worried. • 75 per cent of children aged 10-14 think that a healthy mind is just as important as a healthy body. • A quarter are already worrying about choosing a future career.

Only around 25 per cent of young people needing treatment for mental health problems actually receive it and usually only once they reach 18, meaning younger children are missing out on vital support. HeadStart targets the key 10-14 age in a child’s life and will help improve young people’s resilience by giving them the support and skills to cope with adversity.

The Big Lottery Fund is investing £75m to enable children to have a better chance of dealing with the knocks and setbacks in life which many adults take for granted. For many young people, how they feel about themselves; their self-esteem, confidence or negative peer pressure can become deep troubling, take root and lead to crime, self-harm or even suicide. But with the right support and access to help at this key transition stage of our lives we aim to show that young people can be given a HeadStart to lead happier, more fulfilling lives. 189

188 http://www.biglotteryfund.org.uk/global-content/press-releases/england/211113_eng_hs_so-stressed-they-cant-sleep 189 http://www.biglotteryfund.org.uk/global-content/programmes/england/fulfilling-lives-headstart

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Appendix iv Asset-Based Community Development (ABCD)

Asset-Based Community Development (ABCD) is an approach to community based development founded on the principles of appreciating and mobilising individuals and community talent, skills and assets (rather than focusing on problems and needs) and is community driven development rather than development driven by external agencies (Cunningham and Mathie, 2002). ABCD draws on:

 Appreciative inquiry which identifies and analyses past successes, strengthening confidence and inspiring action  The recognition of social capital (the connections within and between social networks) and its importance as an asset  Participatory approaches to development based on the principles of empowerment and ownership of the development process  Collaborative community development models that place priority on making the best use of the community’s resource base  Efforts to strengthen civil society by engaging people as citizens in community development, making local services more effective and responsive (Mathie and Cunningham, 2002).

The ABCD process involves the community in making an inventory of assets and capacity, building relationships, developing a vision for the future, and leveraging internal and external resources to support actions to achieve it. Building on the skills of local people, the power of local associations and the supportive functions of local institutions and services, asset-based community development draws upon existing strengths to build stronger, more sustainable communities for the future. By encouraging pride in achievements and a realisation of what they have to contribute, communities create confidence in their ability to be producers not recipients of development (Foot and Hopkins, 2010).

This approach was recommended in the Public Health Report ‘Living Well in Cumbria’ in 2011 and has gradually been gaining credence locally and nationally. 190 It was also highlighted in the extensive work done by Dr John Howarth, a GP in Cockermouth and Director of Integration with the Cumbria Partnership Trust. 191

190 Living Well in Cumbria 2011 A report for the Director of Public Health and the Cumbria Intelligence Observatory Supporting Cumbria’s Joint Strategic Needs Assessment http://www.nwpho.org.uk/cumbria/LIVING%20WELL%20IN%20CUMBRIA%20REPORT.pdf 191 http://www.cumbriapartnership.nhs.uk/uploads/WorkingTogether/John%20Howarth.pdf

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Appendix v

Key statistics

Key statistics about children and young people in Cumbria can be seen at “Children and young people Emotional health and wellbeing in Cumbria: Joint strategic needs assessment [refresh] Version 1 February 2014” 192

Details of the South Lakeland Health and Wellbeing Profile 2013 can be downloaded in full from http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/6164/417251517 58.pdf Some key statistics from this report are included here:

Statistics about Suicide

“The likelihood of a person committing suicide depends on several factors. These include physically disabling or painful illnesses and mental illness, alcohol and drug misuse and level of support. Stressful life events such as the loss of a job, imprisonment, a death or divorce can also play a part. For many people it is the combination of factors which is important rather than any single factor.”

“Figure 24 shows the latest data for suicides in the general population. Currently South Lakeland experiences a suicide rate of 16 deaths for every 100,000 population. This is above the county rate of 14 deaths per 100,000 populations and national rate of 10.4 deaths per 100,000. During 2012 16 people were recorded as committing suicide.

The report also considers alcohol use and looks at the trend for under 18s admitted to hospital with an alcohol specific condition. There has been an increase in the number of young people admitted to hospital with an alcohol specific condition. The latest South Lakeland crude admission rate of 67.75/100,000 is below the county rate of 96.4/100,000 and above the national average of 55.8/100,000.”

Self-Harm “There are many reasons why people self-harm, but the causes usually stem from unhappy emotions. Self-harming has been described as a “physical expression of emotional distress”. If somebody is

192 Children and young people Emotional health and wellbeing in Cumbria: Joint strategic needs assessment [refresh] Version 1 February 2014 http://www.cumbria.gov.uk/eLibrary/Content/Internet//536/671/4674/6164/41696135154.pdf

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“Figure 42 and table 8 look at local hospital data for relation to hospital spells for self-harm. Levels of self-harm within South Lakeland are below the county average. There appears to be a slight increase in the number of hospital spells for self-harm with rates estimated to increase by 7% when comparing rates for 2008/09 with the estimated rate for 2012/13.”

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Andrew House Stainton Nr Penrith Cumbria CA11 0ES [email protected] [email protected] www.uk-sobs.org.uk

National Helpline 0844 5616855

Appendix vi

Thursday 13 March 2014

Submission to the review of C&YP Mental Health Services in South Lakes

Thank you for inviting the Cumbria group, survivors of Bereavement by Suicide to respond to your consultation and please accept my apologies for leaving it late in the day.

By way of context as a result of work undertaken by the Cumbria Suicide Prevention Strategy Group established in 2009 a need was identified to establish a self-help support group for people who lose a loved one to suicide in Cumbria. It is a tragic fact that we lose, on average a Cumbrian every week to suicide, I know you will agree this is a wholly unacceptable statistic and it is vital that we as Cumbrians leave no stone unturned in reducing this figure.

Having said that the purpose of this brief letter is to ask you to consider suicide prevention and support for young people affected by suicide as part of your work. In the three and a half years that we have been operating:  Young people have died by their own hand and  Many young people have lost a parent or a sibling to suicide

Be in no doubt the damage resulting from the loss of a child or sibling to suicide is massive and forever. Survivors of Bereavement by Suicide is constituted and insured to work with people over 18 years of age, i.e. adults but through our work we have inevitably seen and been involved in trying to support young people. Consequently we know there are a number of issues that we would ask you to consider:

 In South Lakeland Tina Sudlow who works for Child Bereavement UK, provides counselling to young people, a significant number of whom have lost siblings to suicide. We have seen first- hand how effective this can be in helping young people deal with the loss of a brother or sister, mother or father. There is a pressing need to strengthen and develop this service in South Cumbria.  Throughout the rest of Cumbria there is NO comparable service and we would urge you to consider recommending that this service is strengthened and extended.  Every school should have a meaningful policy to address the sudden unexpected loss of a child or parent which recognises the role that voluntary organisations can play, including

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Papyrus, the Samaritans, SOBs etc. This should not be seen as the sole province of ‘paid professionals’ though clearly they have an important role.

In our experience parents who are survivors are not always treated in a way which is sensitive to their situations, for instance addressing absence from school with threats of legal action.

We have a perception that support services for schools including access to educational psychology has been reduced and this gives us cause for real concern.

We believe that the risk of self-harm and suicide amongst young people could be reduced if resilience training were to be included in the school curriculum.

The media have a crucial role to play in suicide prevention; they can and do however on occasions cause terrible harm to adults and young people through insensitive reporting. The Cumbria Suicide prevention leadership group has established a small working group to find a way of harness the good the media can do and minimising the harm.

We believe that when the media report in a way which is insensitive it could be considered a safeguarding issue in some cases and we would urge you to give this some thought.

Another issue we are concerned about is when inquests are delayed this has various consequences one of which can be the inability to access money as accounts may be frozen – for instance one of our members was taken to court and threatened with eviction as she was unable to pay the mortgage – fortunately in this case the court was sympathetic.

John M Brown Group Facilitator On behalf of SOB’s Cumbria

Submission 2

Survivors of Bereavement by Suicide (SOBS) is a national charity founded in 1990 by Alice Middleton MBE, a Salvation Army Captain living in Hull. She lost her brother to suicide and found there was no support for survivors. Currently there are 50 groups operating throughout the UK. Each group is facilitated by a survivor following approved training.

In compiling this County’s Suicide Prevention Strategy in 2009 the County Suicide Prevention Leadership Group recognised the need for support to those bereaved by suicide. Such a need was confirmed by a public meeting when 15 survivors indicated they would like to meet on a regular basis to support each other. A facilitator was identified and the first County monthly meeting was held in November 2010 at Keswick. There have been over 100 enquiries and recently a second group was started in South Cumbria. Referrals to Cumbria Facilitators are via a 24/7 mobile phone service. Groups are self funding and so far have received generous donations which have enabled the work to expand. The Cumbria groups are organised by a small steering group of four volunteers.

Suicide recognises no social, ethnic or cultural boundaries-neither does SOBS. Consequently the groups are open to anyone affected by suicide aged 18 and over. The scale of the problem is enormous with the World Health Organisation identifying one death every 40 seconds in the world; whilst in Cumbria 50 people take their own lives each year. The number in Cumbria is 20% above the national average.

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Unlike normal bereavement survivors of suicide have to endure a number of additional experiences such as stigma, Inquests, media reporting and self searching why loved ones took their own lives. Suicide still attracts stigma generated by societal attitudes and is felt deeply by family members left behind.

Inquests are public examinations of what are often private family events. They are extremely anxiety provoking for survivors, and add additional trauma when conducted months and sometimes years after the death.

Graphic and sensational media reporting further compounds the problem for survivors and often results in them becoming isolated and withdrawn.

SOBS exists to help in these situations. The Groups provide a safe, confidential environment, in which bereaved people can share their experiences and feelings thus giving and gaining support from each other. There is no agenda at group meetings, rather an emphasis on self-help where an individual's situation can be explored and perhaps explained, as they start on what is a new normal journey in life. Unlike counselling self-help allow survivors to work at their own pace, reflecting on feedback whilst both giving and gaining support regularly over the years.

In addition to group meetings throughout the UK, SOBS operate a National Telephone Helpline between 9 AM to 9 PM daily, support days and residential events. Representatives serve on a number of influential government committees where they are able to negotiate improved services for the bereaved and influence practice towards prevention, training and awareness raising.

Within the Cumbria group there is a Facebook page, e-mail exchange and supportive friendships have developed outside group meetings. A three-way signposting and referral system has been developed with Cruse and First Step (Talking Therapies). Child Bereavement UK operates in the Kendal area and close links have been forged enabling support for both adults and children. There is a need for this to expand throughout the County.

Raising awareness of suicide prevention has become another key aspect which the Cumbria group concerns itself with. It made a contribution to the national consultation on the latest National Prevention Strategy for England and Wales. For the first time this strategy recognised the need for bereavement support. A submission was also made to the Ministry of Justice consultation on Coroners Courts which has brought about improvements for those attending Inquests. Other aspects which impact on our members lives currently being investigated include inappropriate media reporting, the need for supportive family therapy and HR arrangements for those returning to work after the death. The Cumbria groups are now part of a European Union project which is researching a number of aspects to improve Suicide prevention and support to Survivors across the nations.

As part of this submission SOBS provided the following - a family's account of how suicide impacted on their lives. The non-indented numbered comments by SOBS reflect many common themes which have emerged from the Cumbria branch of Survivors of Bereavement by Suicide over a 3 1/2 year period. (NOTE ALL NAMES HAVE BEEN CHANGED):

“William died when he was 47 years old by hanging himself. We had been separated for 2 years prior to this following him deliberately hurting our youngest child when drunk. The children were: Richard 18, Alison16, Michael 15 and Joanna 14 when their father died on 16th December. Richard was living with him but had started University. Richard found his father and tried to resuscitate him.

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Police and Coroners – although contact was limited they were very kind. The young officer first on the scene made a point of saying Richard had done everything right, including attempting resuscitation. The coroner’s office, unfortunately, changed the date of the inquest just when I had arranged to take the youngest 3 children to Gran Canaria. As my presence was not essential Richard went with my friends as support, but I regret not being there.”

1. Inquests which often take months and sometimes years before the hearing takes place are very anxiety provoking experiences for families. The public examination of family events is an additional trauma survivors have to endure. Media reporting very often compounds the stress and adds to the stigma of death by suicide. Families retreat into isolation in many instances. 2. Until recently families were not given advice on where to seek help and support from immediately after the death. The specific publication “Help is at Hand” which sets out the processes and support services available, together with a Guide to the Coroners Court will be made available via the coroner’s officer.

“Health – our GP promised me that I, or any of the children, could turn up any time without an appointment and she would always see us. I don’t think anyone took her up on it but I do know Alison and Michael ‘held it in reserve’ that if all else failed they would see her.”

“Richard went back to University and was seen by the nurse there who, I believe, left it for him to make an appointment “if he needed it”. He also asked to see someone before he went back to university, and the GP (at home) referred him to mental health services but they had the wrong address so cancelled the appointment and it never happened.”

3. There needs to be a failsafe system put in place to follow up referrals. Young people are particularly vulnerable when they have suffered the tragedy of suicide and it can be a trigger for them to take their own lives if not appropriately responded to when seeking help.

4. At the present time there is no pro active Family Therapy Service in the County which offers support at an early stage following the death. Consequently interfamily relationships become distorted, behaviour irrational and support for each other difficult to maintain.

“I think it took about a month for him to go into ‘melt down’. He came home and I rented him a little house as he didn’t want to stay with us. He was very angry that I’d let William die and had severe flash backs (PTSD?) of finding his dad that made him physically ill. He didn’t want to accept professional help. One day in late summer he was in such a mess he said that he kept thinking he heard his dad kick the chair away as he’d left the house, although he knew if wasn’t true. He said that he had worked out how to kill himself (under a moving lorry on the main road). I rang CHOC hoping I would get a Dr. I knew but the Dr. on duty said that I would have to go through proper channels (I had cheated and rung the direct line as a senior nurse who worked with them all regularly) so that they could “make a case out of him” and I couldn’t stand it. So instead I asked Richard to tell me exactly what had happened, in detail, the evening and next morning when he found his dad. (He had spent the night at his girlfriend’s house). He did and was much calmer and got past the fantasy of hearing him kick the chair (Richard had left his dad in bed and thought he was a bit “fluey”). What he told me was so terrible, and I hurt so much for him, but it was the right thing to do.

Education – Richard re-started at University to be near to me. My sister worked there, and knew the head of his department and got him a little clerical job from the Easter onward before the term started. Although formally, there was no special pastoral care, the key people in the department

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Alison was doing A levels. The teachers greatly admired her and there was a special mention of her at the A level prize giving, even though she was abroad. She was giving English help to 3 Polish children and insisted on going to school the day after her father’s death to give them mince pies she had promised them. When, a few months after William had died, she was really struggling with course work and I went to see the head of Sixth Form College to discuss, his reply was “what do you want me to do?” He wasn’t being unkind he just didn’t have a clue, which was a bit unhelpful. Again I supported her at home. I conclude that when it comes to it, my love and support was probably better than anything they’d have offered anyway, but it was quite hard on me, and I got ill later, but also it’s lucky at the time I was strong enough. Alison went on to get 5 A’s at A level. She just missed a place at Oxford University, the interview was just before her dad’s death and there was a second round just after. The school offered to put in mitigation but Alison refused.

Michael and Joanna were at the same school that our children had attended since infants. The headmistress later told me that when her mum had died and she was a teenager she had felt excluded. She therefore immediately told both sets of class mates that Joanna and Michael ’s father had died by hanging himself, which shocked some teachers but the classmates were 100% supportive. The children went back to school on the Friday, following their father’s death on the Tuesday. The children asked 2 teachers who knew William from his volunteering at school Duke of Edinburgh camps to come to the funeral. A master helped Richard re-apply to university. The most special thing was that Michael’s classmates decided to buy him a new bike as his had been stolen 12 days before his dad died. This had been a Christmas present from his father. The classmates collected £500 from both staff and children, and the form prefect came around with it on the first Saturday following William’s death. Michael tells me that he still thinks of it often as the most special act of kindness. Although it was arranged by the classmates (genuinely) and not the teachers, I think it was lucky that they were at such a friendly caring school.”

5. Many schools and universities do not have a Bereavement Policy and if they do it rarely includes how to respond to suicide. Within the University of Cumbria there is a very limited counselling service for an age group of vulnerable young people.

“Joanna started “acting out” badly the autumn following William’s death. She had an art teacher who criticized her art work, which Joanna used very much as a way of putting her emotions ‘out there’ and I think that the teacher criticized in a similar way to her dad, who was very critical of some of Joanna’s dyslexic tendencies. She ‘flipped’ and called the teacher an “f-ing bitch”. We all met, Joanna, form teacher, house mistress and art teacher and talked through why she struggled so much with the teacher. There were lots of tears and it was made clear that swearing at teachers was not acceptable, but fully acknowledged how tough Joanna was finding it. She achieved her art GCSE!”

6. Ideally there needs to be ongoing communication between parents and school to monitor children's behaviour. Triggers such as anniversaries or insensitive responses may produce uncharacteristic behaviour. There is also a need for ongoing liaison when the School Psychological Service or Child and Adolescent Mental Health Services are involved.

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“Things we did to help ourselves

I tried to be open with the children, for it always to be ok to tell me things and for me not to justify myself to them or be defensive. Richard and Joanna both blamed me for not stopping William from killing himself when I knew that it was a strong possibility (it had been his ‘plan B’ for 10 years). It took Richard a couple of months to say what was in his head, and as soon as he said it he started to understand how confused his thoughts were. He quite openly talks about that time now, and the difficulty getting a clearer understanding of it. I think that he needed to work it out himself and if I had been defensive we might never have got there.

I always made it very clear I would walk out of work any time if they needed me, which I think was important to them. In fact we still joke now as if we have a missed call from ‘family’ it always gets a priority call back, but is usually because of something silly It took Joanna 11 months before she screamed at me in a hotel in Mexico about how I’d just lost an ex boyfriend but her dad had died. It was awful but again I think she needed to say it and things have improved since. Joanna found it very difficult and was very conflicted as her father had behaved very badly to her (he had) which she was angry about, but then it was awful that he had died. Joanna had a repetitive dream that she was sat on his lap having a cuddle, she cried for days. When I asked her what was so awful about the dream she said it was because she always woke up. When that happened I took a day off work and we went up the Lakes for a walk and chat. I requested the day as carer’s leave because she was so distressed (it was 10 month after William died) and ended up in a huge row with my line manager, who said I shouldn’t take compassionate leave because my teenage daughter was having the usual teenage temper tantrums. I ended up ‘OK’ with my manager, but when she changed jobs her parting words were I did my job very well apart from ‘that blip’. That certainly felt like an understatement, and ironically we had been neighbours for years and she knew William and all my children. Surprising as I work in the NHS.”

7. Self-help is a very important aspect in the recovery to living a new normal life. It allows individuals to work at their own pace and share their thoughts and feelings with people they trust in surroundings they are comfortable in. As is noted above it is not unusual for families to live with a member who has enduring mental health problems over a long period.

8. Honesty and detailed explanations are vital for people in the grieving process. They are likely to remember these details for the remainder of their lives.

9. Within this family the children have reacted differently to their father's death and this is somewhat predetermined by the relationship they had with him. Helping children explore and understand the feelings at times like this is a mammoth task for a parent who is also grief stricken. A natural phenomenon is to put their children's needs first and in doing so they often have to do delay dealing with their own grief.

10. Very few Human Resource Departments or Occupational Health have bereavement policies which include responding to the aftermath of suicide. This issue needs addressing at a national level. Returning to work after a tragedy is often a major step in returning to the new normal life and it requires sensitive handling both for the individual and colleagues. It needs to be understood that people will have days when they are very low.

“We wrote up in the kitchen “it is not the events themselves that cause us to suffer but our interpretation of them”. At the funeral we asked everyone to write on a card a happy memory of William and have kept them. We announced at the funeral it was a celebration of his life. I have made a point of trying to talk about the good things he did. At one point I guess I over-did it as I was

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I tried to keep life as it would have been, so I bought the boys cars, Alison went abroad on her gap year, we had the same holidays even though it was financially challenging. I didn’t want them to feel everything was ruined by their father’s death. Now, 5 years later, I tell them when we are ‘financially challenged’ but I didn’t then. I also tried to maintain the same standards e.g. you still go to work/school, you don’t wallow in self pity, you are polite (we sent thank you letters to the young policeman, the coroner’s officer and our friends). I didn’t think it should be an excuse for anything if we could avoid it. But having said that, we did various ‘out of character’ things, so it was more an aspiration than achievement.”

11. Managing family finances following a death can present real problems. In some instances bank accounts frozen until a death certificate is issued at the Inquest, which can be months later. Suicide can plunge families into poverty if the main breadwinner is the person taking their own life.

“Richard behaviour changed significantly. He went from being a bolshie teenager wanting to live as far away as possible, to meeting weekly to do his shopping etc. It seemed he would ‘test me’ to see if he could push me away or I would stop loving him. Maybe he was thinking if I left his father when he needed me I would leave him, I don’t know. There hasn’t been ‘a moment’ but he has got stronger and hasn’t had a flash back for a while. He graduated and moved to Germany to do a Masters and to a large extent has re-invented himself, leaving the anxious person behind. He is now the person he can be.

Managing the blues We all have bad patches and we talk about what you should do to help – so a gym membership for Richard was a priority , we tried vitamin supplements, scented candles, massage, being creative and eating lots of fish! I don’t know what worked especially – singing to pop songs at breakfast? But we tried! We still compare notes and strategies - when I got ‘blue’ this year I went to see Alison, now studying in Paris, and we splashed out and went to see a show at the Moulin Rouge, as it was on my wish list of things to do. Sometimes I send the kids chocolate bars, £20 for a meal out or a stupid card. I think everyone does it with kids away from home, maybe I just do it a little more deliberately. Christmas is tough. Year 2 we booked a spa hotel in Preston for the worst time (just before the anniversary) and played pool and sat in the Jacuzzi. It wasn’t exactly posh- we were still ‘financially challenged’ but it did the job.

Terrible jokes – when the children went back to school 3 days after their father dies, Joanna came home and said someone had said that her hair looked funny, but then added “that’s the worst thing that happened today”, as if on a Tuesday mum comes to school at lunchtime to say your dad’s dead and on Friday someone criticizes your hair and the two were being compared. We absolutely cracked up laughing – black humour but we used a lot of it!

The stuff ups. I got exhausted the 2nd Christmas (12 months) after William died and waited until Alison came home from abroad and collapsed for 9 weeks. The children say they didn’t go to school as much as they should have and we ate a lot of take away meals. Overall I think I held it together until they were stronger and coped and no-one bears a grudge. At work I was referred to Occupational Health, who said I should be managed under the capability policy, as I had no relevant health issues. With the support of my (very angry) GP I got an apology, but it is the time when if I hadn’t had children I would seriously have considered joining William. Subsequently, Survivors of Bereavement by Suicide (SOBS) and an appropriate referral within the NHS for support has been of great value to me.”

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12. When there is no early intervention or support, People's health invariably deteriorates and they can become isolated and depressed to a point where they become a danger to themselves.

13. Survivors of Bereavement by Suicide offer self-help monthly group meeting support, the national telephone helpline, online support and a local group Facebook page. The group is facilitated by a survivor and only those affected by suicide are eligible to attend. There is no set agenda and participants share their experiences and support each other.

“Friends. Richard became good friends with a boy whose girlfriend had died in an accident when they were backpacking abroad. Michael has a friend whose father died of a stroke at the same time as William and Joanna has “fallen in love” with someone whose sister died of a drug overdose. The first two have definitely been positives, jury out on the third!!”

14. Throughout this family story we have seen how important friends are in supporting their peers and this is especially vital for young people who often see friendship groups more of a reference point than family.

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Appendix vii Useful Information around Mental Health and Emotional Wellbeing

All schools in Cumbria and all Children and Family Centres in the county were sent a pack of factsheets titled ‘Mental Health and Growing Up’ from the Royal College of Psychiatrists in the summer term 2011. These packs were purchased for schools through TaMHS. The following information is taken from The National Strategies, Inclusion Development Programme Primary and Secondary: Supporting pupils with Behavioural, Emotional and Social Difficulties (2010). Each school in Cumbria should have this CD Rom.

There are over 50 documents available in the library section of the resource that offers information around the inclusion of students with behavioural, social and emotional difficulties. The following documents are included in Appendix 1.

 Definition of Attachment  1.4. National CAMHS review diagram showing risk and resilience factors  1.7 Helping children with anxiety and depression  2.2 Key characteristics that promote pupils’ mental health  2.9 Developing a positive mindset  2.11 The importance of the physical environment  Active listening  Anger Management Resources  What is a nurture group?  Checklist of arrangements for out of class  Peer mentoring  The Common Assessment Framework  5.1 Self evaluation resource for the learner  1.2. List of Publications, References and Websites

In addition to links given in the body of the report some leaflets or useful websites were collected during the review:

1. Self Harm and Suicide Prevention in Children and Young People: Awareness, Risks and Resources County Psychological Service 2013 Sue Sanderson [email protected] 2. South Lakeland Sure Start Children’s Centres Newsletters February and March 2014 Tel 01228 888320 3. Thinking about Fostering – Cumbria County Council www.cumbria.gov.uk/fostering 4. Ways to welfare in Cumbria plus directory of services at www.cumbria.gov.uk/welfare 5. Supporting teenagers at risk service CADAS STAR project www.cadas.co.uk 6. Cumbria parent/carer/family support service CADAS [email protected] 7. Is your life affected by someone else’s alcohol or drug Use CADAS [email protected] 8. Cumbria Domestic and sexual violence partnership – Help and support for victims www.cumbria.gov.uk/communitysafety/domestic/violence 9. Introducing Healthwatch in Cumbria Peoplefirst www.healthwatchcumbria.co.uk 10. The Learning Network The Cumbria Partnership NHS Foundation Trust journal of research, practice and learning. Spring 2011 11. Cumbria and Lancashire NHS End of Life Care Network ‘When someone has died’ Wendy Lewis-Cordwell www.cancerlancashire.org.uk www.endoflifecumbriaandlancashire.org.uk 12. Child Bereavement UK Bereavement support in South Lakeland [email protected] www.childbereavementuk.org a. Bereavement support and information – ditto-

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b. Publications and resources –ditto- c. Rebuilding lives together –ditto d. Regional development project –ditto- e. Elearning: supporting bereaved pupils –ditto- f. Training and consultancy service –ditto- 13. Finding the Way – a parent’s guide to autistic spectrum disorders in South Lakeland and beyond South Lakeland Autism and Aspergers Support Group Sally Percival Mob 07808813622 14. South Lakeland Young Carers [email protected] 15. Cumbria Youth Alliance Annual Report 2012-13 www.cya.org.uk 16. Adult social care tell us what you think about services via www.bestlife.org.uk 17. Shelter advice services in Cumbria Barrow in Furness www.shelter.org.uk/getadvice 18. Your voice Young person’s advocacy www.yourvoicecumbria.org 19. Bestlife independent advocacy Complaints about the NHS Service in Cumbria [email protected] 20. BestLife wellbeing network Your voice in shaping mental health services in Cumbria www.bestlife.org.uk 21. Bestlife independent advocacy Peoplefirst www.bestlife.org.uk 22. Survivors of Bereavement by Suicide Support after a suicide www.uk-sobs.org.uk 23. Gateway Centre information advice and practical support Kendal 24. Appletree Treatment Centre Natland Kendal www.appletreeschool.co.uk 25. Samaritans (2014) Media guidelines for reporting suicide and self-harm. Available: 26. Care Quality Commission How we protect the rights and interests of people who are detained in hospital [email protected] 27. Sedbergh International Summer School www.sedberghschool.org 28. The Inquest handbook [email protected] 29. Lancashire Care NHS Foundation Trust CAMHS service at The Junction Lancaster a. ACERS - alternative and complementary education residential service part of CAMHS Lancashire County Council Email [email protected] b. Children’s commissioner’s Take over day 2013 c. The Junction Staff induction d. Headspace toolkit – your right to know and your right to be heard e. Family support framework ‘Statement of Purpose’ f. Family Support Strategy 2011 g. Visitor’s information pack 27 items of information 30. Time to Talk Parentline Plus www.parentlineplus.org.uk 31. Connecting with People Training in emotional resilience and suicide prevention Dr Alys Cole-King www.connectingwithpeople.org email [email protected] 32. Cumbria Observatory and Atlas information http://www.cumbriaobservatory.org.uk 33. Joint Strategic Needs Assessment a. http://www.cumbriaobservatory.org.uk/health/JSNA/2012.asp 34. Multi-agency Thresholds Guidance a. http://www.cumbria.gov.uk/childrensservices/ctb/threshold.asp 35. The Matthew Elvidge Trust http://thematthewelvidgetrust.com/ 36. Department of Health Mental Health First Aid Course http://www.mhfaengland.org/news/ 37. Department of Health Help is at hand 2008 http://www.nhs.uk/Livewell/Suicide/Documents/Help%20is%20at%20Hand.pdf 38. the place for young people to find information advice and support. http://www.cumbriapartnership.nhs.uk/rollercoaster 39. PAPYRUS (Prevention of Young Suicide) provide a helpline (HOPElineUK - 0800068 41 41). www.papyrus-uk.org

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40. National Self Harm Network www.nshn.co.uk/downloads/UsefulResources.pdf 41. Self-Injury - Text and Email Support Service (TESS) http://fsd.liverpool.gov.uk/kb5/liverpool/fsd/service.page?record=HQ9chATMCHA 42. A chronological list of the executive summaries or full overview reports of serious case reviews, significant case reviews or multi-agency child practice reviews published in 2013 is available from the NSPCC website.193 43. The Academies Act (2010) and consequently the increase in the number of schools moving to academy status. 44. The Education Act (2011).194 45. Developments in relation to youth policy reflected in the “Positive for Youth” discussion papers (2011) and an impending cross government policy statement on services for young people.195 The summary to these papers confirms that Positive for Youth was developed through an extensive collaborative process. a. “The government cannot create a society that is positive for youth on its own. It is only right that young people, councils, charities and businesses have all contributed significantly to developing the Positive for Youth vision”. 46. Ongoing reform of the welfare system (Welfare Reform Bill, 2011).196 47. Financial consequences of the Spending Review 2010; including, in Cumbria, funding cuts of 35.4 million by 2013/14. 48. The Munro review of Child Protection 197and the work of the Social Work Reform Board (2010 -11). 198 49. Development of Health and Wellbeing Boards (Health and Social Care Bill 2011).199 50. Wide ranging implications of the Localism Act (2011).200 51. Childcare Act 2006. 52. The Child Poverty Act 2010. 53. The United Nations Convention on the Rights of the Child. 54. Equality Act 2010. 55. Apprenticeships, Skills, Children and Learning Act (ASCL) 2009. 56. Health and Social Care Act 2012. 57. Welfare Reform Act 2012. 58. Sure Start Children’s Centre Statutory Guidance (April 2013). 59. Children and Families Act 2014. The Children and Families Act 2014 is an important piece of legislation with many significant measures that will impact on the lives of thousands of children in England including improving the adoption system and provision for children with special education needs. 60. An excellent bibliography is available in the Cumbria Suicide Prevention Strategy document at http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/671/4674/5359/5360/4101911752.pdf 61. Mental Health Crisis Care Concordat Improving outcomes for people experiencing mental 201 health crisis Published February 2014 by the Department of Health

193 http://www.nspcc.org.uk/Inform/resourcesforprofessionals/scrs/serious_case_reviews_2013_wda94557.html 194 https://www.gov.uk/government/policies/increasing-the-number-of-academies-and-free-schools-to-create-a-better- and-more-diverse-school-system 195 https://www.gov.uk/government/publications/positive-for-youth-the-collaborative-process 196 https://www.gov.uk/government/news/welfare-reform-bill-restoring-the-welfare-system-to-make-work-pay 197 https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system 198 https://www.gov.uk/government/publications/building-a-safe-and-confident-future-progress-report-from-the-social- work-reform-board 199 https://www.gov.uk/government/publications/health-and-social-care-act-2012-fact-sheets 200 https://www.gov.uk/government/publications/localism-act-2011-overview 201 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281242/36353_Mental_Health_Crisis_ac cessible.pdf

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GLOSSARY OF TERMS

ABCD Asset-Based Community Development ACERS Additional and complementary education services Lancashire County Council ADHD Attention Deficit Hyperactivity Disorder ASD Autism Spectrum Disorders BCF Better Care Fund CADAS Cumbria Alcohol and Drug Advisory Service CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CAN Cumbria Advice Network CAPA Choice and Partnership CAPB Cumbria Autism Partnership Board CBT Cognitive Behavioural Therapy CCC Cumbria County Council CCG Clinical Commissioning Group CEOP Child Exploitation and Online protection Chi-Mat Child and maternal health observatory CLA Children Looked After CLASS Children Looked After Support Service CORC CAMHS outcome research consortium CPFT Cumbria Partnership NHS Foundation Trust CQC Care Quality Commission CSEGG Child Sexual Exploitation in Gangs and Groups CYP Children and young people DASH Drug, Alcohol and Sexual Health [team] DH Department of Health EMDR Eye movement desensitization and reprocessing EUREGHA European Regional and Local Health Authorities GPs General Practitioners GRiST Galatean Risk Screening Tool HoNSCA Health of the Nation Outcome Scales for Children & Adolescents JSNA Joint Strategic Needs Assessment KF King’s Fund LSCB Local Safeguarding Children Board NICE National Institute for Clinical Excellence NMSS Non-maintained special schools PMHWS Primary mental health workers SAFA Self-Harm Awareness for the Furness Area – now county wide SEAL Social and emotional aspects of learning programme SEN Statement of Education Needs SLF South Lakes Federation of Schools SLRP South Lakes Federation of Rural Primary Schools SOBS Survivors of Bereavement by Suicide STARS Supporting Teenagers at Risk Service TAC Team Around the Child TaMHS Targeted mental health in schools programme WHO World Health Organisation w.t.e Whole time equivalent employees

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Appendix viii Schedule of consultees / respondents

*Note – To protect their identities this list does not include details of any parents or service users who were interviewed or responded to the review. Neither does it include some professionals who chose to remain anonymous.

John Asher Review member and SOBS Zoe Butler Review member and Young adviser South Lakeland Inspira QE School Louise Furness Campaigns Assistant and Youth Project Officer Tim Farron’s office

CQC Beverley Cole Complaints Manager CQC – contacted to notify her of the review

Cumbria County Council Cllr Rod Wilson Chairman CCC Chair Health Scrutiny Committee Cllr Patricia A. Bell Cumbria CC Cabinet Member for Public Health and Community Services Cllr Anne Burns Cumbria CC Cabinet Member for Children's Services Cllr Clare Feeney-Johnson Cumbria CC Cabinet Member for Environment John MacIlwraith Acting Corporate Director Children's services Dr Jane Mathieson Consultant in Public Health, chair suicide prevention reference group Richard Simpson Asst Director (Children’s) Barnardos acting chair Cumbria LSCB Anne Sheppard Strategic Manager, Emotional Wellbeing and Mental Health Services. Nick Waterfield Cumbria County Council County Manager Health and Wellbeing Graham Bassett Locality Officer Barrow and South Lakeland Access and Engagement Team

South Lakeland District Council Cllr Graham Vincent South Lakeland District Council Health and Wellbeing Portfolio Cllr Anne Hall Overview and Scrutiny Committee Cllr Janet Willis Deputy Leader Innovation and Improvement Portfolio Holder Lawrence Conway Chief Executive

Cumbria Clinical Commissioning Group Nigel Maguire Chief Officer Dr Neela Shabde Clinical Director Children and Families Eleanor Hodgson Commissioning Director Children and Families Dr Jim Hacking GP GP Lead mental health Dr Amy Lee GP GP safeguarding lead South Lakeland Greg Everatt Senior Commissioning Manager

Cumbria Partnership NHS Foundation Trust Mike Taylor Chairman Claire Molloy CEO Heike Horsburgh MBE NED Dr Wendy Rankin Children’s services Clinical Director Russell Norman Children's services general manager Teresa Waleboer Interim CAMHS manager Dr Louisa Sanz Clinical director CAMHS Dr. Sara Munro Director of Quality and Nursing Mary Kiddy Consultant Nurse for Public Health Jim Bradley Public Governor Chair SIG Mental health Prof David Galloway Public Governor Chairs SIG children’s service Elissa Robinson Public Governor Zoe Lenaghan Voice of the Child Tom Bell Facilitated introductions Lesley Houfe Interim HR

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Morecambe Bay NHS Foundation Trust Jackie Daniel Sue Smith Director of Nursing ditto Dr Paul Grout MBE Clinical Director Acute Medicine ditto

Lancashire Care NHS Foundation Trust Lindy Simpson and 7 team members CAMHS Tier 4 Services Lancashire and Preston

Cumbria Constabulary Peter Johnston Head of Commissioning Manager Police & Crime Commissioner’s office Supt Mark Pannone Cumbria Constabulary South Cumbria

Education Links Arthur Capstick Retired - South Lakes Federation of schools Marian Kearney South Lakes Federation of schools together with 7 school pastoral leads Linda Potts Barrow consortium of schools Lorraine Thompson Inclusion team manager Furness via Linda Potts Pete Rushton Deputy Director 6th Form QES Kirkby Lonsdale David Wilson Cumbria University head of counselling Bill Sang Cumbria University Board of Directors Prof Diane Cox Cumbria University Director of Research & Head of Graduate School Rob Davies Appletree Special School Lisa Balderstone Head South Cumbria Pupil Referral Service Peter Ely Centre Teacher Home and Hospital Tuition Service Caroline Faulkner Higher Level Teaching Assistant ditto Chris Hough Academic PhD custodial sentences on inmates and families Andrew Fleck Headmaster Sedbergh School Sarah Coleman Headteacher Lindale CE Primary School

Voluntary Sector John Brown SOBS Anne Armstrong Surestart Kendal West Children's Centre Angie Fordham Barnardos Christina Sudlow Child Bereavement UK Jonny Gios Community worker Sandilands Methodist Church Sonia Mangan South Lakeland Age UK Lindsay Graham People First Best Life Advocacy Operations Manager Cath Clarke Cumbria Youth Alliance Liz Cornford Young Cumbria Ian Parr Young Cumbria Youth Worker lead Kendal Lad and Girls Club Davinia Jones Turner Young Cumbria Youth Worker Paulyne Hartley ditto Sarah Cutts ditto Cindy Daltioni Chief Officer SAFA Peter Davies South Lakeland MIND Colin Reynolds South Lakeland MIND Peter Ovens ditto Counsellor Phil Robinson Carlisle Eden MIND Beren Aldridge Growing Well Sizergh Alix Jagger Growing Well Sizergh Alison Quigley Growing Well Sizergh Helen Davies Service Manager CADAS Julie Oram Family support worker CADA Tricia Gordon Brewery Youth Arts Ondy Wilson Wellbeing practitioner Anka Green Compassionate Friends

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Sai Thomas Winston’s Wish Richard Crake Autism partnership board member Malcolm McNicholas Making Space Wendy Lewis-Cordwell Director Bereavement Care Services Jennie Davies UKCP Group Analyst BACP Accredited Counsellor Jackie Bell Furness and Kendal Autism group Debbie Barnes Independent social worker Graham Bassett Birchall Trust Lynne Murray Brathay Trust Maddy Lackey Chair South Lakeland Youth Council members Abby Editor of the South Lakeland Youth Council magazine Blink Jo, Alice, Max, Karen and Chim Members of the South Lakeland Youth Council Faye Waites Young Carers Dr. Elaine Church Independent public health consultant Dr Alys Cole-King Clinical Director Connecting With People Tara Quinn Advocacy Manager Your voice Gill Puncher People First

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