The National i-THRIVE Programme team caught up with Anne Sheppard, Strategic Manager of Emotional Wellbeing and Mental Health Services in Cumbria, and Joyce Hawthorn, Early Help Service Manager for Cumbria, about how they are implementing the THRIVE Framework for system change (Wolpert et al., 2019) in services for children and young people.
Background to Cumbria
Cumbria has approximately 104,900 children and young people (CYP) aged 0-19, equating to 21.1% of the total population. A high number of young people leave the county to find education and employment, and although CYP growing up here benefit from living in one of the most beautiful parts of England, parts of the county have experienced long term economic decline and have high rates of child poverty.
Developments in CAMHS
Cumbria has an integrated single point of access for specialist CAMHS support alongside targeted support (the ‘My Time’ service delivered by Barnardos). As across the country, demand for mental health support is high, and there are issues with capacity and equitable access. New service developments in response to ‘Future in Mind’ are creating increasing areas of specialism within CAMHS in relation to Crisis Support, Eating Disorder Services and other priorities.
What has been your role in the THRIVE Framework and how long have you been working on it?
Anne: I have spoken about the THRIVE Framework at our multi-agency Emotional Wellbeing and Mental Health Partnership over the last couple of years to raise awareness. To support the implementation of the THRIVE Framework, last year we carefully put together a guide for professionals to help them to recognise early signs and symptoms of mental health difficulties. i-THRIVE terminology was included in the guide to help raise awareness in the communities of practitioners who work face-to-face with children and young people. We delivered this presentation last summer to the 6 Local Practitioner Forums in Cumbria that meet monthly. The forums are multi-agency and include representatives from schools, social care, health and the third sector.
Joyce: From an Early Help perspective, we see the THRIVE Framework as an important aspect of the holistic approach that we want to achieve. What really helped me to understand the THRIVE Framework was developing the Guide for Professionals and seeing that the framework supports taking a holistic, early intervention approach which fits with Early Help. The Early Help Officers have helped deliver the training of the Guide for Professionals and the THRIVE Framework. The THRIVE Framework language is now built into day-to-day conversations we have about Early Help.
How is Cumbria’s implementation of the THRIVE Framework structured?
Anne: We are taking a whole system approach to supporting emotional wellbeing and mental health in Cumbria and my role includes being the Whole System Lead. We have now developed a clear action and implementation plan to support the adoption and roll out of the THRIVE Framework across Cumbria. This was identified as a priority area under our ‘Improving Access’ workstream in our recently refreshed Cumbria Local Transformation Plan, and is fully supported by our Emotional Wellbeing and Mental Health Partnership Board, chaired by our Director of Public Health. Therefore, the implementation of the THRIVE Framework is in our strategic governance and the roll out involves collaborative working across different multi-agency teams and services. We have recognised that this a major piece of work that could take years!
Joyce: We want to have as wide a range of people involved as possible to promote and lead on the adoption of the THRIVE Framework. What is great about presenting at the Practitioner Forums is it creates an opportunity for the practitioners to take the learning and share it with their teams. The THRIVE Framework is mentioned in many of our strategies and is embedded in a number of different processes. For example, Early Help is aligned with the THRIVE Framework through front-loading where we provide support.
Where are you at locally with the implementation of the THRIVE Framework?
Anne: We are at the beginning stage. We’ve done some engagement and awareness raising and are now building more capacity around implementation. It is interesting to see that people are now asking about what the THRIVE Framework is and that it is on their radar. There is more to be done to support the understanding of the principles across the workforce but what is promising is the curiosity to find out more. I think the next phase of our plan will be how to get the THRIVE Framework out to all the different parts of the system.
To support this we have presented the THRIVE Framework to large audiences at the Primary Heads Association and at the Cumbria Association of Secondary Heads.
Joyce: We are really working on getting it into people’s consciousness and helping people to understand the concepts. This takes time to embed.
Which aspects of the THRIVE Framework did you feel were already in place?
Anne: There has been a general move towards having a more needs based assessment in Cumbria that has been hugely helped through the development of the Early Help process. We are moving away from ‘this is what this service can offer’.
Joyce: Early Help was developed over the last three years, this began to introduce the idea that we have the same assessment for a wide range of needs at an early stage and then look at what needs are emerging and what we can do to meet the needs of the young person in the least intrusive way. The development of Early Help has been quite timely in terms of introducing the THRIVE Framework which fits with it well.
Anne: We are now having those strategic conversations about what we should emphasise in the future once people understand the principles of the THRIVE Framework and how we want people to use them to improve service delivery. There has been a focus on pathways for children and young people with complex needs and recognising the responsibility of different agencies in managing risk, which the THRIVE Framework supports. For this we have the Early Help Panel and the Complex Needs Panel.
Joyce: We are developing groups for different areas of risk, e.g. for domestic abuse, to strengthen our response at an early stage. The Early Help Panel brings together different agencies to discuss families so that collectively we can support and strengthen the family at an earlier stage and before the situation needs to be escalated to safeguarding.
Anne: This work highlights the THRIVE Framework stance of having a shared, multiagency responsibility, for a young person’s wellbeing and also supporting Thriving.
Joyce: Recently we have been discussing children, young people and family involvement in developing strategies. In Early Help the involvement of the child is central and not only do we promote children in the assessment, we question if they are not involved, then why not? We audit this on a regular basis. Recently, children and young people helped co-develop the assessment tool as it was felt that their voice wasn’t being heard sufficiently. In addition, the young people who came to the Emotional Health and Wellbeing Partnership Group were helpful at keeping us on target with the development of new services in emotional health. It was as simple as the CYP’s asking ‘you delivered a lot of material at schools, do you deliver this to staff or to young people?’ This made us look at how we roll out this information.
Anne: One thing that arose from our transformation plan refresh was ‘how do you get information about getting advice, signposting and self-management into young people’s hands?’ That is a question that has been raised by CYP and their families so we did some work on this last year by improving one of our websites. We need to do more on this with young people driving this work rather than adults. Our work with Head Start a few years ago has had lasting effects on services such as Kooth.
We consulted young people to find out their views on how they wanted support to be provided and young people said ‘we need to talk to somebody’. We trialled online support and feedback from young people was positive from the start. Kooth is now commissioned for 11-18 year olds until 2019 with funds from Public Health. This has helped to support Getting Advice and Signposting and self-management. It is great that young people who are waiting for face-to-face targeted interventions can be supported by Kooth in the interim.
Which aspects of the THRIVE Framework did you feel would be the biggest challenge to achieve for your service?
Joyce: A lot of people at the early stage of intervention are managing a level of risk. Lots of agencies, such as schools, are having to manage risk and know when to seek a higher level of support. That is why we originally created the Guidance for Professionals to be targeted at schools, to talk them through what to do and who to call on for support. We recognised the challenges and concerns people were having with risk support. We need to make sure we have the pathways in place and know how they fit together e.g. how does the mental health pathway fit with the safeguarding pathway, and look at how they work together. We are in the process of re-writing pathways that will include CAMHS and Social Care safeguarding and how they can work more effectively together. So our question to everyone is, how do we collectively need to change how we work to implement the THRIVE Framework going forward?
What changes have you made towards becoming more THRIVE-like?
Anne: Out of necessity the changes have taken a drip, drip, drip approach and we are now driving that forward through the transformation plan. In Morecambe Bay there is a review underway of NHS commissioned CAMHS services in the south of Cumbria. This review is being approached by utilising the THRIVE Framework to assist the process and proposals will come out in May. This should help support the dissemination of the THRIVE Framework across the whole of Cumbria.
What are some of the barriers you have faced in implementing the THRIVE Framework so far?
Joyce: I think people have been open. When we gave the guidance in schools on the THRIVE Framework the feedback was positive. However, there are external pressures on schools such as budget cuts to support staff and a restructuring of school nurses.
Anne: Originally we wanted to go out and teach people about the THRIVE Framework but that probably wasn’t the best way of implementing the framework so we have used it in an applied way through people’s practice which we now understand will be more effective.
Joyce: The THRIVE Framework has become the backdrop for lots of changes we are making and provides a structure that justifies what we are focusing on.
What are some of the facilitators you have faced so far in implementing the THRIVE Framework?
Anne: We have trained up a team of people who can spread the message of the THRIVE Framework across agencies so that we can think about delivering services in this way and not just refer straight to ‘CAMHS’.
What are you focusing on in the next six months?
Joyce: Ofsted was a big focus for us up until recently so now that has happened we are going to revisit promoting the THRIVE Framework. We are going to redevelop and push the message forward having had to prioritise other things for a while. Cumbria Children’s Trust Board are supporting us and adding capacity through their business team.
Anne: We need to look at how the THRIVE Framework fits with our other key priority areas such as workforce development. We have a comprehensive emotional wellbeing and mental health multi-agency, targeted, universal offer now which includes youth mental health first aid but the THRIVE Framework isn’t part of the core curriculum.
If you would like to take part in a Q&A to share your experiences in relation to implementing the THRIVE Framework and using the i-THRIVE Approach to Implementation, please get in touch with Bethan Morris at firstname.lastname@example.org.