Think child, think parent, think family: a guide to parental mental health and child welfare

Providing care

Problems with current practice

There are gaps between children's and adult services which do not reflect the extent to which children's and adults' needs are interlinked. There are few services that aim to support the whole family.

Parents and young people are not invited to participate in commissioning and service development initiatives in a meaningful way.

Professionals want to be able to work together to better meet the needs of a whole family. Strict entry criteria and service boundaries do not allow practitioners to collaborate or undertake joint working arrangements across service settings. There can also be disagreements as to where responsibilities lie. For example, adult mental health services tend not to arrange home support for children when a parent requires treatment, because children and family services are viewed as being responsible for all forms of child support.

There are also differences between the professionals' and parents' priorities for support. Professionals do not always prioritise more social interventions, but for parents, it may be more important to deal with any financial or housing problems first, as they are then better able to usefully engage with any therapeutic intervention.

When it comes to commissioning services, commissioners tend to focus on meeting the needs of individuals, rather than families. Services for families with a parent with a mental health problem are not being given a high priority because:

• the drivers for improving outcomes for these families are less significant in comparison with others
• there are no specific performance indicators to promote service provision in this area
• the existing Quality and Outcomes Framework standards for mental health are about assessing and treating individuals
• systems for joint commissioning across services exist, but are not yet being used fully.

There are also limitations on the kinds of service that can be developed because of current funding arrangements:

• There is little long-term funding for services, even though families often experience chronic problems and would benefit from longer-term, 'revolving door' support. In many instances this might be less costly than, for example, hospital stays and children being looked after by the local authority. There would also be enormous value in enabling families to re-engage with services they trust.
• There are problems with funding joint care packages. Disagreements between services are often about who will pay for which service component.

In a successful service:

• Parents and children are meaningfully involved in developing, reviewing and evaluating services (e.g. commissioning processes and developing interagency service protocols).
• The specific needs of families with parental mental health problems are met.
• The variety of needs experienced by members of these families are addressed.
• Staff take a greater account of parents' priorities and desired outcomes and their perceptions about the cause of their mental distress. They are more sensitive to the sometimes complicated, chaotic lives some of these families lead.
• Support is provided in the long term through long-term funding for services that have demonstrated continuous positive improvements for families.
• Barriers to access are addressed, including practical barriers (e.g. transport and childcare), as well as acceptability factors (e.g. sensitivity to ethnicity, sensitivity to parents' other needs and priorities).
• The most vulnerable and excluded groups are targeted by services (e.g. young mothers, mothers in the perinatal period, black and minority ethnic families, asylum seeking and refugee families, staff who use services, parents with personality disorder or dual diagnosis and their children, families who are separated temporarily or permanently).
• The emergence of mental health problems in the next generation is prevented by targeting children most at risk of poor outcomes, intervening early and using preventive interventions (e.g. supporting looked-after children to break the cycle of disadvantage that can pass across generations).

Recommendations for change

All staff need to implement interventions that will:

• address immediate concerns about the safety of children
• quickly identify and treat any mental health problems
• help parents with mental health problems to better manage their symptoms
• prevent crises and promote good health and wellbeing
• help manage a crisis quickly and effectively
• prioritise social inclusion
• reflect the priorities of parents and their families
• be flexible enough to take account of issues such as medication side-effects, scheduling of hospital appointments etc.

Organisations need to:

• Develop, implement and regularly review interagency protocols that include clear pathways for decision-making, that are explicit about who makes decisions and in what circumstances, so that decisions are timely and delays in allocating services are avoided.
• Involve parents and young people in the development, review and evaluation of interagency protocols.
• Develop or maintain services that meet the full spectrum of need in these families including:
  • services that tackle social exclusion issues
  • family-focused mental health services
  • services for families whose problems are less severe, but who need help to maintain their health and wellbeing (e.g. including access to psychological therapies (IAPT))
  • interventions that will reduce other stresses on parents (e.g. short breaks for parents and shared care options)
  • services for young carers
  • services that help parents with parenting (e.g. childcare, parenting skills courses)
  • services that support parents through crises (e.g. when a parent goes into hospital).
• Develop commissioning processes to enable:
  • parents and children to be involved
  • joint commissioning across agencies
  • the development of non-traditional and creative ways of delivering services (e.g. delivering therapy services from libraries, community centres and children centres) as a means of targeting families and improving access
  • commissioning based on reliable information about how well services are meeting local needs
  • ongoing monitoring and evaluation to inform future planning and commissioning cycles.
• Change funding mechanisms to:
  • pool budgets so that adult mental health and children's services jointly fund these services, which will require developing new protocols that explicitly define who, how, why and when financial issues will be decided when agreeing multi-agency care packages
  • provide long-term funding (e.g. for voluntary sector services), so that they can continue to support families where a parent has a chronic mental health problem
  • make funds available for evaluating services, separate from the service delivery budget
  • facilitate the use of personal budgets to give more flexibility and choice for parents