Think child, think parent, think family: a guide to parental mental health and child welfare
Introduction: The policy context
In recent years, under both the previous government and the coalition, there has been a notable shift in children's and adult social care policy and guidance, which places greater emphasis on the need to support parents in their parenting role. The main policy drivers in England and Wales are set out here.
No Health Without Mental Health
The coalition government's outcomes strategy for mental health explicitly looks at mental health across the lifespan, and explores how whole-family approaches can benefit the wellbeing of all family members. The strategy has six key aims:
- More people will have good mental health.
- More people with mental health problems will recover.
- More people with mental health problems will have good physical health.
- More people will have a positive experience of care and support.
- Fewer people will suffer avoidable harm.
- Fewer people will experience stigma and discrimination.
The Think Family agenda is relevant to all of these. No Health Without Mental Health:
- stresses the need to intervene early, and tackle stigma, where mental health problems arise in children; to break the intergenerational cycle of them growing up with mental health problems which then affect their own parenting
- focuses on early intervention with adults with mental health problems
- calls explicitly for whole-family assessments and care plans to promote family and individual recovery
- recognises the crucial, detailed information other family members, including children, have about a person's mental ill health, and the importance, therefore, of listening to all family members when planning a person's care and support
- cites the improved outcomes that whole-family approaches can achieve.
Other coalition initiatives are highly relevant to this agenda. Both the government's Vision for adult social care (9) , and Professor Eileen Munro's review of the child protection system (10) call for a wider family focus to safeguarding children, so that all staff are aware of their responsibilities, and recognise that meeting the needs of family members who may put children at risk benefits the child, the adult, and the family as a whole.
Link: No Health Without Mental Health (2011)
Troubled Families initiative and Community Budgets
In December 2010, the Department for Education launched a new national campaign to try to support 'troubled families': those experiencing multiple social, health, and economic problems. The government estimates there are 46,000–120,000 such families, which at times make very high demands on local services but which can still experience poor outcomes. The aim is that each family will be supported by a single key worker, who will help them engage with services such as education and employment. Other local services will be encouraged to invest in, and benefit from, any savings generated by supporting families earlier and more effectively. This new approach builds on the work of Family Intervention Projects (FIPs) which by March 2010 had supported over 1,800 families (DH figures).
It is worth noting here that whilst many of the families targeted by the FIPs and the Troubled Families initiative are experiencing adult or child mental health issues, the majority of families experiencing parental mental health problems will not be eligible for these services. Organisations therefore will still need to consider how to support those families affected by parental mental health who fall outside of these targeted groups.
The government's plans for Community Budgets also aim to support families with multiple problems. Starting in April 2011, 28 local authorities in England are piloting an approach to tackle barriers to shared funding, in an attempt to provide services more holistically and effectively. Both Community Budgets and the Troubled Families initiative are clearly seeking to generate a context in which whole-family approaches can flourish. At the time of writing, it is too early to judge their success in doing so.
Think Local, Act Personal and Putting People First
Think Local, Act Personal9 builds on the landmark protocol Putting People First (11), which sets out governmental commitment to independent living for all adults. Some of the key elements of personalised adult social care are that:
- All people, irrespective of illness or disability, should be supported to sustain a family unit, which avoids children being required to take on inappropriate caring roles.
- Family members and carers should be treated as experts and care partners.
- Carers should be supported by programmes which develop their skills and confidence.
- Systems should support integrated working with children's services, to include transition planning and parent carers, and identifying and addressing concerns about children's welfare.
Adult social care will also take responsibility for championing local action to tackle the stigma faced by people with mental health problems.
Working Together to Safeguard Children
Concerns about risks to children are a strong driver to improve inter-agency communication, collaboration and integration. Updated from the 2006 original, the new version of Working Together reflects the growing importance of inter-agency collaboration and includes strengthened recommendations, such as the recommendation that adult mental health services sit on Local Safeguarding Children's Boards, which have the potential to benefit families affected by parental mental health.
Now superseded by No Health Without Mental Health, New Horizons was a Labour administration strategy to promote good mental health and wellbeing, while improving services for people who have mental health problems. It aimed to build on the National Service Framework for Mental Health – widely acknowledged as the catalyst for improving mental health care – which came to an end in 2009.
New Horizons takes a new approach to whole-population mental health. The focus on prevention and maintaining good mental health, and on promoting recovery, is particularly relevant to parents with mental health problems and their children, as is putting mental health promotion at the centre of public health efforts. Many services, not normally considered as mental health services, can help promote public mental health and wellbeing and prevent future problems, both individually and across generations. It is these types of services that New Horizons and No Health Without Mental Heath try to promote. Examples include:
- mother and toddler groups
- school health initiatives that promote self-respect or better relationships
- reading initiatives which improve literacy, social skills and self-esteem.
Link: New Horizons (2009)
The Sure Start Programme and the development of Children's Centres brought together early education, childcare, health, employment and family support services under one service and by 2010, 3,500 such centres in England were scheduled. Originally targeted at the poorest families in England, (13) this is one of the most substantial social reform initiatives for families embarked upon in recent years. However, successive evaluations have had to acknowledge that greater effort is required to reach the most vulnerable households and in particular parents with mental health difficulties (14).
Link: Sure Start Programme
Care Programme Approach (CPA) Briefing
This briefing summarises why it is important to address the needs of parents with mental health problems and ensure that they and their children receive support. It describes the potential of the CPA to improve outcomes for affected families. The CPA guidance recommends that the needs of the parent, the child and the family are assessed routinely at each stage of the care pathway from referral to review. Service activity data should be recorded, collected and used to inform local commissioning, reviewing eligibility criteria for access to assessment and services, as well as professional training and development. In addition, this briefing also references key related policy, guidelines, practice developments and further reading.
Refocusing the Care Programme Approach (CPA): Policy and Positive Practice Guidance
This report states that the needs of key groups, including parents, should be fully explored to make sure that the range of their needs are examined, understood and addressed when deciding their requirement for support under the new CPA. These were important changes to the CPA process which for the first time explicitly recognised the needs of the adult as a parent and the importance of taking a holistic approach to the assessment and care planning process.
These two reports from the Social Exclusion Unit (SEU) Task Force (SEU 2008a, 2008b) outline the previous government's commitment to ensuring that adult services support whole families, not just individuals.
In order to support and enable local services to put these principles into action, the previous government committed to:
- launching a series of Family Pathfinders to test and develop the Think Family model and to generate and share evidence of what works on the ground
- continuing to invest in projects such as Family Nurse Partnerships and FIPs with the aim of embedding early intervention and prevention within the existing system of support and extending tailored family services to reach a wider range of vulnerable families
- extending cooperation across children's services to include adult social services, so that all services share responsibility for family outcomes. The aim is to encourage and empower frontline staff to innovate and cooperate in response to whole family situations.
Much of this work, and the learning from it, is now feeding into the Troubled Families initiative.
In Wales, the updated 'National service framework for mental health' (19) published in 2005, committed the Welsh Assembly Government and local authorities/local health boards to implement local and national actions to promote social inclusion. Included within this were specific actions to meet the needs of parents who have mental health problems.
Mental Health and Social Exclusion report 2004 (20)
This report addressed the social and economic costs of mental health problems and their impact on family wellbeing and child development. Included in the report was a 27-point action plan to improve access to social participation, employment and services for those affected by mental health problems. Action 16 of the plan focused on enhancing opportunities and outcomes for parents with mental health needs and their children. A review of the implementation of Action 16 can be found here
Every Child Matters: Change for Children
Every Child Matters: Change for Children (21) sets out the national framework to build services around the needs of children and young people so that we maximise opportunity and minimise risk of poor outcomes. The Children Act 2004 (which also covers Wales) provides the legislative foundation for whole-system reform. It outlines new statutory duties and clarifies accountabilities for children's services. It acknowledges that legislation by itself is not enough: it needs to be part of a wider process that can only be delivered through local leaders working together in strong partnership with local communities.
Every Child Matters identifies five outcomes that are key to wellbeing in childhood and later life:
- being healthy
- staying safe
- enjoying and achieving
- making a positive contribution
- achieving economic wellbeing.
The aim is to improve those outcomes for all children and to narrow the gap in outcomes between those who do well and those who do not.