Coronavirus (COVID-19) Children and Families Collective Leadership Group - holistic family support: vision and blueprint for change

Covid-19 Children and Families Collective Leadership Group Holistic Family Support – Vision and Blueprint for Change

Footnote ^[1]

1) The shared ambition of the Leadership Group and those organisations we represent is as follows:

“The National Performance Framework sets out our collective ambitions that families are supported to give their children the best start in life; that Scotland is the best place for children and young people to grow up and a great place to have a family.

We want all families with children to lead safe, happy and healthy lives, free from poverty; we believe that families are generally the best source of care and nurture for their children and that it is the collective role of those supporting them to build capacity and confidence.

We recognise that all families need support sometimes and we want families across Scotland to be able to access the support they need where they need it, when they need it and for as long as they need it, to protect and promote children and young people’s wellbeing, enable children and young people to achieve their potential, and keep families together wherever possible; and connected and supported in the exceptional circumstances where this is not.

We want that support to be holistic and empowering, based on trusted relationships, rooted in GIRFEC and our existing universal services, and grounded in the conclusions of the Independent Care Review and the broader evidence about the needs of children and families. We want the support to be based on early help and support and preventative action, at whatever level is required – on the spectrum from universally accessible support to more targeted or intensive support. We want asking for and accessing family support - at any point on a family’s life-course - to be normalised, and as free from stigma as it is to consult your midwife or GP, or to take your child to nursery.

We want support structures to be sustainable, responsive and flexible - able to adapt to the changing needs of families. We want supports to fit around families, and get alongside them in their communities - rather than families needing to fit around services or structures. We want the supports offered to be creative and to encompass play, sports and arts-based approaches where appropriate. We want families to know what is on offer, and feel empowered to access the support they need – reaching in to it, rather than being referred on to something.

We must listen to children, young people, pregnant women and families and ensure that meaningful engagement is embedded within the system and that families are partners in the design and continuous improvement of support. We want that improvement to be informed by data which reflects our ambitions for family support and what families tell us is important to them. We want to develop family supports to enable rights-based and informed approaches that are embedded in a commitment to deliver UNCRC Article 12.

We want professionals in all sectors to be able to exercise their judgement, in discussion with families, working together to help determine what is needed and develop targeted, trauma-informed and developmental offers to meet this need. We want our adult support services to work in synergy with children’s support services so that by getting it right for every family, we get it right for every child.”

2) To achieve this ambition, things need to be different. Our ambition is set out below, and is the blueprint for the future on which the proposed actions are based. It is noted that many of these features are in place in many localities and that many families have their needs met early and effectively; our ambition is that this is what we will see consistently all across Scotland.

Family Support should be based on nationally-agreed principles, free from stigma and driven by the views and rights of families (including pregnant women)

What will this look like?

• The views of families will be central to our response to addressing arising needs - drawing on both what they have already told us matters to them, and their views on how the COVID-19 response has met their new and existing needs. Planners and providers will continue to engage with children, young people and families to hear their experiences and seek their opinions.
• There will be an ethos, of “doing with” and getting alongside families and a culture of mutual respect.
• It will be clear that it is healthy to ask for support.
• A wide variety of families will present for support including first time users.
• The views of families will be integral to the continued design and delivery of support at a local and national level. Seeking these should not be ‘outsourced’ but embedded in all our work.
• Families will have continued contact with the person providing their support, until an agreed and managed “warm” handover to a new relationship.
• Families from all walks of life will ask for family support at an appropriate point or points in their life courses; they will access what they need and find it useful – and will tell us so.
• Civic Scotland will recognise that collectively we need healthy and happy families in which children can grow and thrive. Children and families will feel better supported and valued in a Scotland that recognises their contribution.
• Scotland will recognise that strong, safe and supported families will be at the heart of a strong economy in a compassionate country

Families should know what is available to them and how to access it.

What will this look like?

• Families will be clear that they have a right to support;
• All families will be able to find information about what support is available nationally and locally, how to access it, how escalation to more intensive support works, and the principles on which that support will be given;
• The criteria for accessing support must be reduced, and open up access for families to a range of support, including speech language and communication, nutrition and feeding support.
• We will be clearer about different sorts of need, from universal to additional, multiple, specialist and intensive needs.
• All contributing to family support, in whatever sector (health/ELC/schools/third sector/mental health etc.) will feel part of the ambition to improve family wellbeing/ outcomes for families in Scotland, will understand how their

roles contribute to the wider whole, and will know when and how to seek additional support and share information in consultation with families.

• All working with families will recognise that any engagement with families is an opportunity to be supportive and will recognise that kindness, warmth and curiosity in relationships will offer the best opportunity to destigmatise asking for help.
• The workforce will be trauma-informed and grounded in attachment theory, and the importance of a restorative approach; they will understand the impact on parents of unresolved adverse childhood experiences and be sensitive to the fragility of some of those with whom they are working.
• Workers will understand the impact of gender inequality, poverty, racism and discrimination and will consider the impact of these on the ability of parents to cope. Support systems and services will actively identify inequalities in any assessment about children’s wellbeing and safety.

Support should be available to all families across Scotland when they need it, where they need it and for as long as they need it; enhancement of provision should be based on scaling up of local best practice and embed multi-agency working.

What will this look like?

• Principle of equal partnership will be the new norm amongst statutory and third sector services providing family support, acknowledging individual areas of expertise and accountability.
• Arrangements will be made and promulgated within partnerships to ensure that families can access holistic support in community settings such as schools, nurseries and GP practices as lockdown is lifted, to include:
  • emotional support that may be needed by many families “decompressing” as we move out of lockdown;
  • advice, information, financial and practical support, provided through the relationships that work best for families by support staff who have a good understanding of trauma and unresolved adversity in childhood;
  • integration of play within support structures, particularly for younger children;
  • access to developmental supports where concerns have emerged during lockdown such as behaviour, communication issues, and other developmental concerns;
  • intensive (targeted) support for those presenting with more immediate or severe concerns.

• Enhanced and extended support for families will be coordinated locally across services (children’s/adult/health/acute), as part of a whole systems approach building on existing local strengths, partnerships and universal services;
• Flexible whole team supports will include whole range of services where possible, 7 days and out of hours, and will be developed to be responsive and delivered where and when families need this most, building on shifts already made in practice in response to COVID-19 and with a focus on local community settings and continuity of support across age and stage;
• Service planning and design will reflect the fact that the need for support or protection is on a continuum from light-touch to intensive; that effective early support can help obviate or mitigate a future need for protection; and families may move back and forward along the continuum over time;
• Support will be consistently available, including in the longer-term, where this is right for a family;
• Options to address poverty and issues arising from income inadequacy will form part of the discussion with families including where this is not a presenting issue;
• Existing good practice (including team around the child, low-footfall multi-disciplinary working and successful digital support models) will be shared nationally and scaled up within each locality; Family Group Decision Making could be scaled up nationally;
• Support relationships will be streamlined with the most effective relationship being identified by the family.
• Supports anticipated will include financial and practical, emotional information and advice and will take account of the different levels and types of needs anticipated as well as the specific views of the individual family; structures will be varied to meet local need; these will include sustainable and informal community-run and owned supports/self-help/information /drop- in/community café and advice incorporating peer support to tackle isolation and encourage connection and avoid families being pulled into systems unnecessarily.
• Support will be child-centred and family-minded, recognising that direct holistic support to parents is essential in keeping children safe. Support will recognise that parents’ behaviour is often determined by the experiences they had as children. This perspective will inform all parts of the system that supports families.
• For complex and intensive support, more trained staff will be available.
• In line with Community Empowerment Act, community assets, skills and knowledge will be strengthened to support and empower parents, address child need, and promote child wellbeing, learning and development.
• Commissioning (planning, design and procurement) of services will adhere to a set of nationally agreed principles, including being non-competitive, long term and fully reflective of the objectives in Children’s Service Plans and Health and Social Care Plans.
• Adult services will be a clear part of holistic family approach, and practitioners to see one of their roles as supporting adults to improve outcomes for families.
• Systems will be reviewed to reflect our learning from COVID-19, especially where outcomes have surprised us – e.g. some learners doing better away from the stresses and structures of school.

Prevention and Early Engagement should remain long-term investment priorities; the approach to funding and planning must be joined up across Government portfolios, partners and providers.

• Effective holistic support recognises complexity and that each family member may require individual support before whole family support systemic work begins. The value of systemic support will be recognised and the time it takes acknowledged as that is the best way to achieve a long term and sustained change and improvement to family wellbeing.

• There will be a continuation and embedding of the culture of trust and partnership that has been demonstrated so successfully during COVID-19, during which funding organisations empower third-sector providers to act on the basis of their informed judgment.
• Investment and funding will not feel compartmentalised, but will clearly connect with the wider GIRFEC approach and our aspirations for family support, including support from pregnancy through to childhood, continuity across boundaries, local areas being empowered to develop support in response to need, and that funding follows the family to deliver on the NPF.
• The scale of investment will acknowledge the scale of issues. Funding timescales need to be longer-term and sustainable, to enable support to be consistent, high-quality and provided by highly-skilled staff who are secure in their contracts. (NB This may require cross-party political consensus if it is to transcend electoral cycles).
• At national level there will be a clear and coherent picture about how policies supporting families fit together.

Progress must be reviewed; delivery decisions should be based on evidence including learning from families

• Collectively, Scotland will hold the data we need to allow us to understand need, assess progress and drive improvement.
• This will be collected with care and due regard to burden.
• Good practice examples are promulgated widely; we access and share learning from many sources.
• Evidence must include narrative and experience of families and be heard directly from them. Evaluation and impact gathering needs to be funded from the outset with outcomes being determined in partnership

Holistic Family Support – Summary Context

1) There has been renewed discussion of the important role of holistic family support in promoting family wellbeing and averting family breakdown and recognition that provision of such services across Scotland has become very variable. The 2012 Parenting Strategy presented Scotland’s most recent articulation of family support structures and commitments. Since that time the range and complexity of issues facing families and those supporting them has continued to increase, poverty has not lessened, and the current COVID-19 pandemic has brought further or new challenges. There has also been an increased awareness and understanding of the negative impact that adverse or traumatic experiences in childhood can have on children’s development which without the right support, can lead to poorer health and social outcomes in adulthood.

2) The business case for increasing and improving family support - articulated most recently in the conclusions of the Independent Care Review and evidenced by data available across partners including from the Care Inspectorate - is compelling: effective and high-quality family support, explicitly embedded in the UNCRC and the principles of early intervention and prevention, within the wider context of the national delivery of GIRFEC, universal service provision and commitment to the prevention of childhood trauma is critical to helping families to remain together^[2] and develop the resilience to withstand times of pressure. Reframing family challenges using systemic family support approaches can help move from inappropriate diagnostic, clinical responses to more relational ones. This builds family and community strengths and prevents unnecessary long term involvement with services.

3) Family support is of course already integrated into public and third sector systems across Scotland and there is much that works well, including a strong commitment from those working with families to Getting It Right for Every Child and to engage early. Notwithstanding this commitment, we know that many families are not getting what they need at an early stage of difficulties and that this leads to later, more complex or entrenched problems and presentation. The current COVID-19 context shines a light on both the strengths and weaknesses of our current support systems. However, COVID-19 has placed unprecedented pressure on families. Some will have been considered to be in need of support prior to the COVID-19 outbreak, and should have been known to services, and had a child’s plan. Where relationships with families were already in place, we have heard many positive stories. However, the difficulties they are facing may have increased, or changed in nature. Other families, who were not in receipt of services but were sitting just below the thresholds for services at the time of the outbreak are likely to be amongst those who are experiencing increased need. In addition, many children and young people will have new support needs because they have experienced adversity - for example, loss of family income or experiencing social isolation - as a consequence of COVID-19, and the necessary measures to limit its transmission. Ministers and Leaders have seen the more detailed data compiled about what is currently known about vulnerable families.

4) Broadly speaking, services from all sectors have responded well to the new demands arising from COVID-19, adapting their means of delivery, increasing their availability, and doing whatever they can to give families what they need to support themselves during this difficult time. The response has often modelled a more family-led holistic and practical approach, and it is important that we capture the learning about what has enabled this, and use it to build and scale up so the principles underpin national and local responses across the country, and that this continues beyond the immediate COVID-19 crisis.

5) In some areas, there have been excellent examples of crisis-driven innovations that will be sustained beyond the current pandemic, for example, the roll-out of the digital “Near Me” service for pregnant women. However, to a large extent, the response has pushed services to operate in emergency mode, and using emergency funding or reserves. We know this is not sustainable and that despite the innovation, creativity and commitment, some demand remains unmet and that other aspects are hidden. We also anticipate that demand for further immediate and intensive support is likely to increase as the impact of COVID-19 on society and the economy continues to have an effect, and as current lockdown measures are gradually lifted.

6) There is therefore a need to take stock, swiftly, and to take action to move collectively to a more sustainable and consistent approach to supporting families. As well as working with those who plan and provide support and services (NHS and Local Authorities, third sector) to children and families, this work must draw explicitly on the feedback from families themselves - both the learning that they have already shared with us (including via the Independent Care Review), but also by ensuring their views and voices are heard as we improve the design and delivery of support. We must also ensure that the principle of engagement with families is embedded for the long term, and at a local and national level, the views of families are built in to delivery systems and structures. Additionally, the work must make critical links across the systems and sectors supporting families, and the government portfolios which provide the funding and direction for these, most notably across health (including mental health), communities, and children’s services policies, recognising the interplay amongst these and the recurring scourge of poverty that forms a constant backdrop to much of this work.

7) It is envisaged, that the early results of this work must take effect soon, and that there must be available support, clearly signposted, as the lockdown lifts and the phased reopening of schools, nurseries and other systems begin. However, our response to the immediate and severe pressures of COVID-19 must be rooted in our longer term aspirations to re-embed more firmly our collective commitment to prevention and early intervention, ensuring that support is available to all families, from the earliest possible stage and for access to such support to be as routine and non-stigmatising as seeking support from a midwife or nursery practitioner.

Summary of the key challenges faced

1) In considering how to build a more consistent picture of quality support, we have heard and discussed that:

(i) we need to ensure that high-quality^[3] support is available consistently across Scotland building on the entitlement to universal services;

(ii) support should be for pregnant women and all members of families^[4] with children, including the child from pre-birth; support should encompass addressing complex issues including loneliness and isolation, abuse, recovery from trauma, addiction and mental and emotional distress and should continue should families experience the removal of a child or children (in line with the recommendations of the Care Review);

(iii) parents should be asked what support they need and have a say in how and by whom it is delivered. Personalised approaches recognising the individual characteristics of families and communities; families should be able to access support without having to ask repeatedly; we need to take a broad definition of what constitutes asking for support, including requests that may initially appear to be more generic or unrelated (e.g. request to help with child’s learning);

(iv) parents should be empowered to reach for support as early as possible and services should be ready and enabled to respond with appropriate and proportionate support in partnership with parents and carers and include extended family and friends.

(v) support should be non-stigmatising and its use (and provision) “normalised”, to ensure that family support is fully aligned and integrated with the GIRFEC approach with children and young people in the family: nurseries, schools, GP surgeries should be places where support needs are routinely discussed with families to help “normalise“ this;

(vi) families can fear that in reaching out for help, or accepting offers of support, they are risking losing their children. We need to reframe the narrative about support and ensure that families come to value the support and become increasingly confident to ask for help (and variation of the help on offer) without fear of adverse consequence or judgement;

(vii) in areas where support is not working well or consistently, existing services are not joined-up and are insufficiently multi-disciplinary; they involve multiple professionals not all of whom are known to one another or are invested in the relationships with the family; support is not tailored to the needs of the family and can be difficult to get to (time and geography);

(viii) the Children’s Planning Partnership and Children’s Services Plan should remain the key vehicles for the planning of family support provision across localities, integrating with universal and targeted health care support whether in the community or acute. These plans should better reflect community and family views on the type of support required to tackle the needs of families in local areas. Models should evidence partnership so that the right people and services respond to local need;

(ix) there is commitment from every sector to early support, team around the child and improving support for families but despite this it remains difficult to drive change in culture and this will require longer-term collaborative effort, and, many argue, more investment;

(x) we need to move to a culture of “holding” to ensure that we are meeting the needs of families rather than passing these along;

(xi) we need more of what is good, which is most often rooted in the community and in the strong relationships families have developed with those they trust.

(xii) we need to recognise and address the underpinning context of poverty and structural inequality;

(xiii) we need to ensure there is continuity of support from pregnancy through to infancy, early childhood and beyond with increased recognition of equity of access;

(xiv) we need to ensure that in getting alongside families to discuss and deliver appropriately-tailored support, we are embodying the ethos of The Promise and approaching risk assessment in this context;

(xv) there is a need for attitude and culture shift in all agencies and workers to understand the value of relationships as the key evidence based approach to improving children’s health, wellbeing and safety. Many families say they feel judged and or shamed by parts of the support / child protection system we need to move to much more restorative approaches which recognise the load families are carrying in terms of poverty, intergenerational ACEs and fractured relationships.

Definitions and Principles

What do we mean by Family?

• We take a holistic view of the term family – adoptive, biological, foster, kinship, extended, composite and others i.e. settings and homes that have felt like family and that some children and young people may belong to more than one family.
• Our approach is for all families, whether or not they have had any prior involvement with any services, statutory or otherwise.
• For the purposes of family support, family is defined in the context of including a young person of 18 years or younger, or up to 25 years if care experienced, who may or may not be resident with the family; it may include families seeking to conceive; and it includes pregnant women who may need support pre-birth. It does not include families whose children have exceeded the age of 18, 25 if care experienced, although it is acknowledged that families of adults may also continue to need different forms of support.

What do we understand by Family Support?

• There is no single definition of family support; based on Gardener (1998), we understand this to encompass a broad continuum of preventative and early intervention approaches to help families to meet their individual needs to improve their wellbeing including advice, support, and specialist help, starting in the community and signposting families, even those experiencing significant issues, towards support to enable them to avoid crisis.
• The term is in widespread use across Scotland and is broadly understood to refer to support provided by a range of organisations (agencies, professionals, the third sector, trusted partners) to families to build their capacity and resource. It is indeed embedded in both public and third sector roles and service and is a right under the UNCRC (article 18).
• It is offered across a wide spectrum of family situations ranging from very early universal intervention (e.g. pre-birth) to intensive/acute requirements which still play a preventative role.
• At the least intensive end of the spectrum support includes information, advice and practical support (universal interventions, emotional support, financial support and in kind support such as Baby Box). These can include artistic approaches as well as more traditional services.
• At the more intensive end of the spectrum this means support for families (including adult to adult) that may sit alongside statutory interventions, to enable them to live together positively, obviating negative experiences for the child and providing support for families when they are not able to be together.
• The term is used in this paper to cover interventions that may be offered to a broad range of families including families seeking to have children and families with children are not currently living with them, which may be of short duration or which may be envisaged for the years until a young person reaches 18, or (where they are care-experienced) 25. It can also be used to describe support for families where a child or children have been removed and where ongoing, relationship based, holistic support is vital to address the trauma of that separation.
• Family support is thus a mechanism or an enabler which, where effective, will support us in achieving our intended outcome of improved child and family wellbeing.

Principles of Good Family Support

We are hearing that good family support:

• is holistic;
• is assets/strength-based;
• is collaborative;
• builds on trusted relationships, focused on building trust and mutual respect
• is evidenced;
• is multi-agency/ multi-partner;
• crosses organisational and sector boundaries to provide continuity for families;
• is community empowering;
• is agreed with families (consent-based) and tailored to their needs as part of a universal service that reflects the diversity of families ;
• is flexible;
• is swift and responsive to need;
• is proportionate;

• in the right place at the right time; families should be able to “reach in”, not be “referred to” – this is about empowerment
• gets alongside the family
• holds on until a family is ready to let go or move on

• is child and human rights-based;
• offered to the family with the intention of enabling them to meet the needs and improve the outcomes they have identified, for as long as they need it
• is consistent, of high quality and is provided by highly-skilled staff secure in their contracts

• must be genuinely non-stigmatising and non-judgemental, something that all families in Scotland will be comfortable to turn to when they need it
• is informed by understanding of attachment, trauma, domestic abuse, inequality and poverty.

Independent Care Review – The Promise

Ten Principles of Intensive Family Support

Community Based: Intensive family support must be geographically located in local communities, with the explicit intention of maximising the assets of the community and community-based relationships. Support must be explicitly connected to, or even housed in, locations that work for local families and the community, such as schools, health centres, village halls and sports centres. Scotland knows where this support is most needed. Communities must have a say in where support is located.

Responsive and Timely: Intensive family support services must operate outwith a Monday-Friday, 9am-5pm approach. There must be no concept of an ‘out of hours’ service. Families do not operate on those timescales and support must be responsive to family need.

Work with Family Assets: When working with families, the orientation of support must look at what is working well for the family taking a strengths based approach rather than a deficit-based approach that operates from a premise of what is going wrong. The starting point must be listening to what children and their families say they need in order to flourish, not what the system dictates they need.

Empowerment and Agency: Children and their families must have a say about the people who provide them with support. Intensive family support requires relationships built on trust and honesty. If support services are going to succeed, the families receiving support must be able to choose those people with whom they have a natural connection. The quality of relationships between families and the workforce is a key factor in the likelihood of interventions being successful. Peer support has been proven to work in other parts of the world and must be tested during the Implementation of the Care Review. Budgets must be responsive to families’ choices. There should be no barriers to families’ wishes being carried out, with members of various services and organisations available as a support team.

Flexible: The needs of each family are different and Scotland must recognise the agency and unique needs of families to ensure that support is tailored and specific. Scotland must think creatively in terms of the support families might need and ensure the workforce is responsive. For some families there may be a need for partial foster care (a couple of nights a week). For other families there may be a need for live in support to raise the capacity of parents. There is not a ‘one size fits all’ approach. The crux of success lies in the family-workforce relationships. Chapter 3: Family 57 58

Holistic and Relational: Children live within families and support must be family based. Interventions must be focused on the wider family context so that there are not a multitude of services addressing specific, isolated and individual issues within families. The likelihood of success is not based on the specific intervention but on a relationship of trust between families and workers. Support must look across the width of the family and not simply the variety of issues that the family may present with. Family plans must incorporate the child’s plan (and the needs of all other children who may be impacted by changes in the family setting) and these must always be actively considered as part of decision making.

Therapeutic: It is likely that families requiring long-term intensive support have experienced trauma in their lives. Scotland must ensure that support to families recognises trauma and works with families to heal. There must be no barrier, be it referral or category, that limits parents and children from having access to mental health support when and if required.

Non-Stigmatising: The way in which support is delivered must not stigmatise the family. That means there must be no uniforms, lanyards or branded vehicles appearing outside houses or schools to provide support. The basis of all support must be the quality of relationships, not the professionalisation of the workforce. The language of family support must reflect normal discourse, and not be hidden behind professional language such as ‘looked after child’ (“LAC”), reviews and risk assessment. Overly professionalised language stigmatises families and acts as a barrier to engaging and supportive work.

Patient and Persistent: Scotland must accept that human change takes time and effort. Intervention has to be based on need. Scotland must move away from limiting intervention to set periods of time. Long term change and intensive support take time and Scotland must be patient in working with families where there are complex, challenging circumstances.

Underpinned by Children’s Rights: Whilst the family must be viewed collectively and not as isolated individuals, support services must be underpinned by the rights of the children they are working with. That means ensuring that all the rights of children are upheld in all decisions and support for the family. It will mean that children’s rights are the funnel through which every decision and support service is viewed.