Health and Wellbeing in Schools Project - Final Report

3. Impact and outcomes - operational level

The Health and Well-being in Schools project offered an opportunity to transform and redesign the school health service by testing out a range of new models of practice. Getting it Right for Every Child principles and practice underpinned multi-agency working, while Curriculum for Excellence provided the flexibility to promote healthy lifestyles through partnership working.

This section briefly sets out examples of new models of practice from the demonstration sites. The examples are presented under the headings of prevention/early interventions, key transitions, health inequalities, and new models of practice; there is, however, considerable overlap of these themes within individual projects.

3.1 Prevention/early interventions

The drive to develop an integrated early intervention approach based on Getting it Right for Every Child principles was a key aspect of the project. It included several linked work programmes:

• providing support for families so that parents/carers could recognise early signs that children or young people had specific health needs;
• improving access to services so that parents/carers and children and young people knew where to seek help and had the confidence to approach services;
• ensuring communication between schools and health services was effective and that referral pathways were well known and easy to use; and
• providing joint training across agencies linked to GIRFEC and Curriculum for Excellence.

Examples

Consultation model - NHS Ayrshire & Arran: Belmont school cluster

Many referrals to children and adolescent mental health services ( CAMHS) arise due to lack of intervention at an early stage. The primary mental health worker within the cluster therefore provided monthly consultation sessions for education staff to raise their awareness of mental health issues in children and young people. Staff embraced the opportunity to develop a better understanding of children in their class who were experiencing emotional difficulties and a number of school staff were upskilled in early identification and intervention options.

School staff now have increased confidence in dealing with young people who have mental health issues and their families and can help prevent inappropriate referrals to CAMHS. There is increased awareness of appropriate strategies that can be used within schools, improved relationships among CAMHS, school staff and external agencies, and clearer pathways for referral to CAMHS.

Whole-school P7 transition - NHS Ayrshire & Arran: Belmont school cluster

A whole-school approach to easing transition from P7 to S1 was developed for all primary schools within the cluster to provide young people with coping methods and skills. The aims of the transition model used by the project team were to:

• improve young people's self esteem, confidence and behaviour; and
• provide young people with links to key personnel and services from which they could access support during and after transition.

Three sessions ^[20] were delivered by the school nurse and primary mental health worker to all P7 pupils within the cluster primaries: the first focused on "emotions", the second on "feelings and what to do", and the third on "how you feel". Each session ended with a short relaxation technique that pupils could use independently.

Health spots - NHS Forth Valley: Clackmannanshire schools

Multi-agency drop-in sessions known locally as "health spots" were introduced in secondary schools in the area. These lunchtime sessions provide a confidential and informal health information service through which young people can access support, advice and health information resources. Each health spot is guided by a partnership steering group that includes school and health service representation, parents and young people. Sessions are open to all pupils. Pupils can also arrange a one-to-one meeting by contacting a specific health spot number or email address or by approaching any member of the school staff to make an appointment on their behalf.

Parenting support - NHS Forth Valley: Clackmannanshire schools

Parenting support became an overarching programme within the project in Clackmannanshire, developing and linking with existing provision and extending this to the development of a suite of programmes that parents/ carers could access.

Healthy minds -NHS Grampian: Moray schools

A central aim of this project was to upskill school staff in the early identification of children and young people who were experiencing mental health and emotional problems. The role of clinical associate in applied psychology ( CAAPs) was introduced to deliver whole-school mental health awareness training for all staff, age-appropriate inputs for pupils, mental health awareness training for parents and cohort training for identified staff in mental health promotion and applied suicide intervention skills training ( ASIST).

"Change 3" - NHS Grampian: Moray schools

" Change 3" is a weight-management programme developed as a whole-school approach. Children are identified either by self referral or through routine screening. Programmes have been developed for two age groups: 5-7 years and 7-16 years.

"Change 3" aims to reduce the number of overweight and obese children and young people by:

• focusing on healthy living;
• using effective, evidence-based obesity prevention and treatment programmes, training and resources;
• making services available as widely as possible at community level;
• training people who come into contact with overweight and obese children so they can provide families with the best possible support; and
• building evidence on childhood obesity prevention and treatment within the area.

TOPP (Transition onto Primary Programme) - NHS Lothian: West Lothian, Armadale school cluster

School staff nurses liaised with the health visiting team early in the year to identify vulnerable children and families who they felt would struggle when starting school in August. The nurses would then work with the families, encouraging them to attend the TOPP course throughout the school summer holidays.

Prevention/early interventions: main learning

Different services define "early interventions" in different ways. Developing a common language proved fundamental to more effective integrated working.

Very vulnerable and disadvantaged families and children, many of whom would benefit from targeted early interventions, may need considerable support to develop the confidence to approach services. The opportunity to build a relationship with one key person who demonstrates a non-judgemental approach, such as a family support worker, is an important first step for some families.

Early intervention with school-age children is most effective when linked to early intervention in the pre-school years. Continuing to support school-age children who need services while simultaneously increasing support through early years is likely to require community capacity building.

3.2 Transitions

Risk increases for children and young people at times of transition, especially for those who are vulnerable due to disability and/or emotional and social circumstances. The task for the project was to map existing support for children and young people and their families at transition times and enhance provision to improve outcomes.

Examples

Pre-school language and literacy groups - NHS Ayrshire & Arran: Belmont school cluster

Questionnaires completed by S&LTs working within the cluster identified a gap in service provision at the pre-school stage. Attention and listening, vocabulary and narratives were highlighted as priority areas to be targeted. Pre-school language and literacy groups were offered to all pre-school children and their parents with the aim of promoting and developing language skills, pre-literacy skills and emotional well-being. Input was also provided within the nursery setting, where language-based activities were carried out as part of free-play activities.

The approach encouraged a higher level of parental involvement, built capacity in parents/carers and educational staff, promoted language skills and helped prevent speech, language and communication difficulties.

Summer holiday "Ready for School" group - NHS Forth Valley: Clackmannanshire schools

The Clackmannanshire Language Intervention Project ( CLIP) team, who were part of the project team in the area, contributed to the nursery-P1 transition processes already in place at three pilot schools by producing a plan for direct contact with children and families and an activity pack for each child. The pack consisted of user-friendly advice sheets and rhyme activities. In partnership with health and education staff, the CLIP team ran sessions before the summer holiday break and introduced the activity pack. Families were invited to attend a summer holiday group for further support. Although uptake of the sessions was not high, the activity pack appeared to be well used at home. Children and parents evaluated the sessions positively and the progress of the children involved has continued to be monitored through P1 and P2.

P7 -S1 transition - NHS Forth Valley: Clackmannanshire schools

Due to the increase in school nursing provision created by the project, school nurses were enabled to become active members of school transition teams. Benefits included children with health needs being identified earlier, extra support being provided for families and improved links being created between health services and the educational psychology department. An introduction and visit to the school "health spot" has become part of the induction programme for P7 children, encouraging them to access the facility for support and information.

Transition team -NHS Grampian: Moray schools

The transition team used a combination of universal, targeted and specialist approaches to support children to prepare for transition from primary to secondary school. Awareness-raising sessions about communication and friendships, experiential sessions, and teaching on back care and schoolbags were offered to P7 pupils. Existing enhanced transition groups for vulnerable children not requiring therapy input were supported and a new multi-agency transition group for vulnerable children known to therapy services was established.

Transition group (P7 -S1) - NHS Lothian: West Lothian, Armadale school cluster

This was a joint initiative targeting specific pupils identified with concerns such as low self esteem and low confidence. The group ran for six weeks, during which two boys were identified as requiring further work from the confidence-building group set up for S1 boys who had experienced bullying and had reduced confidence and self esteem. As part of assisting with this transition stage, early intervention was key to building self confidence and esteem. Some young people needed more than the six weeks on offer, but extra input was available from the school nursing service.

Transitions: main learning

Initial mapping suggested that several agencies and professionals are involved in transition planning, especially at P7-S1 level, but that families can feel anxious and uncertain when children have significant disability and/or learning issues. Early identification of children in need of support enables key workers to ensure that families are kept informed and feel part of the process of ensuring that transitions are smooth.

In Clackmannanshire, health visitors remain in contact with vulnerable children and families throughout the first few years of primary school by working in partnership with the school nursing service. Evidence suggests that this is proving beneficial for children entering school by helping to link school and home and providing continuity of care.

3.3 Health inequalities

Addressing health inequalities was a fundamental element of the project. Many children and young people within the demonstration sites experience significant challenges in terms of health and social disadvantage. All agencies are committed to working together to address the issues that contribute to inequality and lack of opportunity. The project provided an opportunity for partners to work together in a different way, exploring new initiatives to address the challenges.

Many factors associated with health inequalities, such as unemployment and poorer housing, were beyond the direct influence of the project. The project could nevertheless make an impact on health outcomes for children and young people, particularly by its contribution to improving educational attainment through achieving improved health and well-being and by addressing vulnerability and disadvantage through adopting a targeted approach to individual schools based on identified need.

Examples

Community-based targeted intervention girls group - NHS Ayrshire & Arran: Belmont school cluster

This project adopted a different approach from the more traditional whole-school approach to health promotion and prevention work by offering a targeted input delivered outwith school hours at a time and venue that suited the girls. The aim was to work with vulnerable girls in S2 and upwards at Belmont Academy who lived within the Tarbolton area to build their self esteem, improve their body image, increase their confidence, improve their communication skills and support them to deal with emotions, relationships and stress.

One-hour evening sessions were held in the local community centre for a six-week period, led by project staff. Girls were recruited to the group through posters in the school and community and via mailers sent to them by Community Learning Development, a partner in the project. Five girls initially attended, extending to six by the end of the programme.

The project provided the girls with access to health care advice and support that was not available in the community and developed their awareness of the school nurse and project staff within the school. Strong partnership working was a key feature of the project that ensured efforts were targeted on improving the girls' health and well-being.

Supporting families: family support workers - NHS Forth Valley: Clackmannanshire schools

It was recognised that many of the most vulnerable children in schools were members of families that sometimes found it difficult to engage with services. Some families were identified as having a need for specific intensive programmes of support delivered on a one-to-one basis prior to linking to group support. Family support workers were recruited to work under the supervision of the lead public health nurse with families on jointly agreed programmes, with achievable goals set by the families themselves.

Seventy families accessed the service, with the majority fully meeting their care plan goals during the intervention period. Teachers reported better classroom attentiveness from children whose families were receiving support, with school attendance and compliance with homework improving.

Primary mental health worker for children/young people affected by parental mental health issues - NHS Forth Valley: Clackmannanshire schools

The primary mental health worker post was recruited through the project with the aims of raising awareness of the impact of parental mental illness on children and young people, training and supporting staff across agencies and providing a service directly to identified children and young people using a brief therapy and solution-focused approach. The service received positive feedback from the children and young people and from many parents.

Protecting vulnerable young people - NHS Grampian: Moray schools

Vulnerable children and young people who are supported within the looked-after and accommodated process or who are going through child protection issues have had an improved service as a result of redesign within the school nursing skill mix. By being released from routine core activity by the introduction of support workers, school nurses have been able to focus on attending child protection meetings and completing required assessments within agreed timescales.

Community drop-in - NHS Lothian: West Lothian, Armadale school cluster

The community drop-in was launched in October 2010 in response to parents' evaluations of previous parenting groups. The drop-in ran on Wednesday mornings in the local community centre and was co-ordinated by a school staff nurse and/or family support worker.

The drop-in enabled staff to:

• engage with parents/carers outside the school environment and encourage them to discuss any concerns they had regarding their children;
• refer on to other professionals, such as S&LTs and health visitors;
• build trust, enabling parents/carers to have the confidence to approach other agencies for support; and
• explore community needs and organise workshops with speakers from local statutory, non-statutory and voluntary organisations who could support attendees.

The drop-in initiative demonstrated the importance of staff being available to parents/carers outside the school environment and the value of good consultation.

Health inequalities: main learning

Enhanced services for disadvantaged families can demonstrate real benefits for children and young people, as evidenced by improvements for individual children and families and increased community engagement. Families will engage readily if they are fully part of the programme planning and the approach used enables them to be listened to and to identify the issues that are of concern to them.

Staff need to ensure that the child remains at the centre, as many families face a number of interlinked challenges. This is particularly the case with children whose parents experience mental health issues, who are at risk of remaining "invisible".

To date, measurable benefits for disadvantaged children and families as a result of programmes initiated or supported by the project have been seen, but the true extent of the benefit can only be assessed over a longer time frame.

3.4 New models of practice

The project offered opportunities to explore a number of new models of anticipatory care for children and young people, addressing inequalities while providing mainstream universal services. These built on existing anticipatory health improvement initiatives within the demonstration sites. The project also provided opportunities to trial more integrated approaches to service delivery that could ultimately become part of mainstream working practice through the ongoing redesign of community nursing, health promotion and allied health professional services at national and local levels.

Health-focused interventions

Health promotion within Southcraig School for Children with Additional Support Needs - NHS Ayrshire & Arran: Belmont school cluster

The aims of this model were to provide:

• support during transition from primary to secondary school;
• support for young people moving to adult learning disabilities services;
• early intervention work for young people with regards to puberty;
• support for improved self esteem and confidence;
• support to young people with identified issues;
• a consistent message to children and young people from all partner agencies;
• a consistent, whole-school approach for the campus; and
• early intervention programmes.

Individual one-to-one programmes of health promotion input were evaluated after an eight-week session and continued if appropriate. Whole-school programmes were run from term to term, with the school nursing assistant taking the lead role in primary health promotion and supporting with one-to-one work.

Parental input was encouraged and a parent health promotion group was developed. Many of the parents found the information useful and have continued the sessions with their children at home. The group has also developed into a support network and social group, allowing parents to discuss issues with fellow parents in a structured but relaxed atmosphere.

Sexual health - NHS Forth Valley: Clackmannanshire schools

Clackmannanshire experiences high levels of teenage pregnancies. The local sexual health implementation group is working to improve awareness of, and access to, sexual health advice and resources and a number of new initiatives were launched in schools as part of the project. To complement this work, an existing youth drop-in service run by the community learning and development team was extended. This evening facility operates a weekly session that is now run jointly with the public health nurse for schools. Services include health advice, Chlamydia testing, pregnancy testing and condom distribution, alongside smoking cessation advice and more general health support.

The drop-in is well used by young people, with over 100 attending between March 2010 and November 2010. It is open throughout school holiday times and is seen as a "one-stop shop" for young people seeking a confidential and informal advisory service.

School drop-ins - NHS Lothian: West Lothian, Armadale school cluster

Primary and secondary school drop-ins provided opportunities for children and young people to discuss confidentially any health-related problems. The children attended with many worries, ranging from sexual health concerns, to bullying, to worries about families. A "healthy respect" drop-in was also created and has continued to develop.

Physical activity/nutrition

Max in the middle - NHS Forth Valley: Clackmannanshire schools

As part of the NHS Forth Valley child healthy weight programme, interactive events were held within several primary schools over each of the two years of the project. Led by the health promotion department and supported by an interagency group that included dietetics, sport and leisure, community learning and development and school nursing, the week-long events engaged children and families in issues around food and activity. The events were well supported by schools and parents and were popular with children.

Dietetic support/family support workers - NHS Forth Valley: Clackmannanshire schools

Achieving health improvements related to nutritional awareness was an underpinning theme throughout the project programme in Clackmannanshire. The local steering group was supported by a dietician who developed resources for use with families and in school and provided training for family support workers in food hygiene and "eating on a budget". Resources from the health promotion department were distributed to pupils attending drop-in sessions. By making links between good nutrition and good health and behaviour, the project aimed to address the many challenges obesity poses to longer-term health.

Back care - NHS Grampian: Moray schools

The transition back care programme was developed and delivered by the physiotherapist and therapy support worker from the transition team in response to evidence suggesting that 50% of pupils in secondary school will experience backache.

The intervention took the form of a fun and informative interactive presentation on back care to P7 pupils, with advice on use of school bags, carrying and packing. Sessions also highlighted healthy lifestyles, including healthy eating and physical activity.

After-school fun fitness - NHS Lothian: West Lothian, Armadale school cluster

The "after-school fun fitness" programme was initially piloted for P1 children and has now expanded to include those from P1 to P3 within Armadale Primary. This has proved to be a sustainable, joint initiation project that has had a positive impact on the children's health and well-being.

Mental health

Primary mental health worker - NHS Forth Valley: Clackmannanshire schools

Primary mental health workers have been a feature of service provision for some time, but the project enabled the role to be closely linked with other health provision in schools for the first time. The presence of the primary mental health worker at secondary school drop-in sessions was perceived as being very valuable, providing readily accessible support for students and a "sounding board" for staff with concerns about children and young people. Linking closely to CAMHS, the worker offered direct support for lower-level emotional and mental health concerns and signposted appropriately to more specialist help.

Counselling service - NHS Forth Valley: Clackmannanshire schools

A public health nurse who holds a qualification in counselling was seconded to the project. The provision of counselling was seen as an appropriate intervention to help parents address some of their own difficulties and to increase their parenting capacity. It was also recognised that it could be a useful intervention for pupils, especially for those with emotional issues that were outside the remit of the mental health team.

The service was provided one day per week as part of mainstream provision, focusing on issues such as loss, anxiety, family breakdown, bullying, self harm, needle phobia and domestic abuse. Evaluation following each course of sessions was positive, with the majority of participants reporting increased ability to manage their situation and many feeling able to take steps to improve outcomes.

Healthy minds - NHS Grampian: Moray schools

In addition to raising awareness among school staff of mental health and emotional issues affecting children and young people to promote early interventions, the "Healthy minds" project also aimed to promote positive mental health by working directly with children and young people in schools through teaching on mental health promotion, undertaking individual assessments and interventions and facilitating group work.

Seasons for Growth: group work for children and young people who have experienced loss and bereavement - NHS Lothian: West Lothian, Armadale school cluster

Two school nurses trained as Seasons for Growth ^[21] companions and ran, with an experienced family support worker, two primary school-aged groups, a younger group of three children and a slightly older group of four children. The groups enabled children to speak about and share their loss and to help parents to support their children.

Speech and language development

CLIP - NHS Forth Valley: Clackmannanshire schools

The Clackmannanshire Language Intervention Project ( CLIP) comprises a multidisciplinary team of a S&LT, a social inclusion teacher and a supervisory assistant. Direct work with children is focused on three primary schools selected due to the high levels of concern expressed by teachers about communication issues in P1 and P2 classes. There is also ongoing intervention in nursery classes to support children through transition to school.

The programme develops a continuum of language skills from nursery to P2 and includes support for parents/carers and teachers. Elklan training ^[22] was undertaken by the team and by another teacher/therapist team to ensure that the programme was sustainable to some degree after the project completed.

Speech and language development groups - NHS Lothian: West Lothian, Armadale school cluster

One of the huge benefits of working in groups on speech and language development was that more children were able to be seen in a short period of time, resulting in an efficient use of time and resources. The children enjoyed the small group work and it enabled some of the more reticent children to develop their confidence in group settings. Locations were not always ideal for group work, however, due to noise levels and other distractions. The groups will nevertheless continue on a rolling programme in response to the individual needs of the children within each group.

New models of practice: main learning

Workstreams within the project indicate that integrated teamworking is more helpful to families and young people and can be more effective. Young people favour the "one-stop" approach, as in the evening sexual health drop-in sessions in Clackmannanshire, where a number of services are available to offer support and practical help. Parents also appreciate the links between programmes delivered in schools and support in the home, such as the CLIP programme being reinforced by support for children at home provided by family support workers.

Partnership working for the benefit of children and young people would be greatly enhanced by the introduction of increased electronic recording systems that could be shared between agencies as necessary, while protecting confidentiality. In particular, improved links between school nurses and primary care teams would be beneficial, especially for children with disability.

Change management can be challenging, especially when there is a need to bring together a number of disciplines within project teams. There nevertheless seems to be an enthusiasm for joint working among partners in schools. The inclusion of teachers within project teams was especially beneficial in ensuring initiatives complemented and supported education processes and pathways.

Developing a common language has been an important consideration, especially across different organisations and disciplines. Processes linked to Getting it Right for Every Child will be helpful in taking this forward in future.

Conditions of service vary across organisations and between disciplines. This need not be a barrier to increasing integrated working, but needs to be taken into account in relation to building the children's workforce for the future.