Katie is 15 years old and she’s struggling. For the past year, she’s been living with an eating disorder that has resulted in her being hospitalised more than once, and she’s missed significant periods of school. She has previously been identified as requiring special educational needs and disabilities support, and there have been issues with her family, including a spell when she was homeless.

Her particular combination of needs means that she is in regular contact with a doctor, a clinical psychologist, a social worker, a counsellor and a speech and language therapist, who all need to work with the teachers and leaders at her school.

In theory, all these different services should weave their work together to form the safety net that Katie needs. But the reality is that for Katie, and the thousands of others like her, that’s not happening.

Each separate team around young people who need multi-agency help, alongside the help of their school, are doing the best they can for those who need support. However, those efforts never quite join up in a secure safety net: strands run awry, stitches burst open, knots come loose - and young people fall through the gaps.

It’s often the school that picks up the pieces and has to try to find a way through. But is it realistic to think that schools can bring those teams together for the benefit of the child? How far should school leaders mediate in the provision of multi-agency support? How much power do schools really have to make that difference? The answers to those questions are far from easy.

It’s not surprising that having several separate agencies trying to coordinate their work brings issues. But these are not new issues: the complexity of multi-agency work, using the school as a conduit, has been well-known for decades.

Team Around The Child meetings were supposed to be the answer. This is where a representative of each service required to support a young person comes together to discuss a joined-up approach: the idea is that this avoids communication black holes and enables the coordination of responses.

The trouble is, it rarely works out that way.

One paediatric specialist physiotherapist in the South of England, speaking anonymously, says that there are usually representatives from teams missing owing to the huge workload issues in each of the public services, which makes scheduling incredibly difficult. “The reality is that with the caseloads involved and the various diary backlogs of all the services - including the representatives of the school - you rarely get a full house of people there,” she says.

And even when teams do come together, things rarely work as they should, according to a clinical psychologist working in Camhs in the East of England, who also asked to remain anonymous.

“At worst, the different agencies’ cultures, expectations and targets can mean that it feels like you’re not always all speaking the same language,” she says. “Social care will have their own specific understanding and formulation of the risks and needs, and what thresholds may or may not have been met in order to access support to meet these.

“Camhs has become notoriously difficult to access, the police have their own thresholds, and so on. In overwhelmed services fighting to meet their targets to retain funding, all parties working creatively and collaboratively can be a real challenge.”

Because of the stresses on each service, the physiotherapist and the clinical psychologist both admit that under-resourced and desperate practitioners will work to frame the problems as issues with which only other agencies can work. However, with more than one agency doing this, it becomes easy to lose sight of the real needs of the family, who are likely to be left feeling confused, worried and unsupported.

Missing school, for example, might be approached from a mental health, social care or police perspective. The ideal scenario would be these services collaborating, but more often responsibility will be bounced between agencies until the problem changes, disappears or becomes significantly worse.

The pressure on these services is clear in the statistics. In 2017, a freedom of information request revealed that young people in some parts of the country were waiting up to 800 days for an autism assessment. Meanwhile, a recent Education Policy Institute report on Camhs found that 25 per cent of young people referred for specialist treatment were rejected, amid an average national wait time for starting treatment of two months (double the government recommendation of four weeks). In some areas, this average is as high as six months.

And the pandemic has meant putting many appointments on hold, which is having a knock-on effect on waiting times, as seen in the recently released NHS figures on eating disorders. The number of urgent cases has tripled across the country this year, while eating disorder charity Beat reported a 78 per cent increase in the number of people asking for help in September 2020 compared with February.

Meanwhile, with young people having been out of school for months over lockdown, many problems are only just coming to light. Camhs referrals dropped by 47 per cent in April and May compared with the year before, but in a survey for mental health charity YoungMinds, 80 per cent of respondents said they found that lockdown had made their mental health worse (with 41 per cent saying “much worse”).

With so many children in need of help, waiting lists are huge and there is significant political and moral pressure to reduce them. As such, agencies tend to try to buy time: young people are offered a few sessions after a long wait, enough to manage serious risk, but often not enough to improve long-term mental health. This leads to a “revolving door” of children repeatedly returning to the waiting list, perpetuating the problems of long waiting times, insufficient provision and ongoing distress for young people and their families.

Mixed into this already chaotic situation are two further issues: budget cuts and burnout.

“Burnout and mental health problems among caring professionals are well documented to be steeply increasing under these budget cuts,” says the psychologist. “Staff and managers have to be extremely pragmatic about how to spend resources - ie, practitioner time - so that their service and workers survive and meet their targets.”

We know that these emotionally taxing jobs take a heavy toll on staff. A 2017 study found that 68.6 per cent of Improving Access to Psychological Therapies (IAPT) practitioners were experiencing burnout, along with 50 per cent of high-intensity therapists; and a 2018 study of social workers found that 91 per cent were suffering from “emotional exhaustion”.

At the centre of these storms is always a child in desperate need of support. And because it is usually the school that is trying to make the referral, it becomes the focal point for picking up the pieces.

Marijke Miles is chair of the NAHT school leaders’ union’s SEND sector council and headteacher at Baycroft School in Fareham, Hampshire, a secondary special school that is home to 180 students experiencing learning difficulties; physical, sensory and language challenges; and autism. This means working with a wide variety of external agencies, and Miles has seen the problems and their impact first hand.

“From the day you refer, you know it’s going to be a fight,” she says. “You know you’re going to have to be really dogged about pressing and advocating for a service your students are absolutely entitled to but won’t have access to unless they can get ahead of others in the queue. Chronic underfunding of services means that you’re always asking for something that they don’t really have.”

And so, she says, she and her staff have had to work out their own ways of dealing with each agency to get the most effective results.

“Everybody’s referral systems are different, everybody’s escalation systems are different, and it’s very interesting how escalation culture differs from one system to another. It’s exhausting,” Miles says.

Ed Vainker is executive headteacher of Reach Academy Feltham in West London and co-founder of the Reach Children’s Hub, which offers its community a “cradle-to-career” provision, from antenatal classes through to young adulthood, drawing together a variety of services. He, too, has witnessed the pressures faced by external services first hand.

“I do think, fundamentally, services are at capacity,” he says. “I also think that they’re not particularly rewarded for proactive integration and collaboration. My sense is that sometimes there’s a feeling that if these agencies collaborate with schools, it might lead to them getting more referrals and having more to do. And there isn’t necessarily a clear vision a lot of the time, because of the role that different agencies play - there isn’t that clarity of joint and shared objectives.”

However, members of the agencies supporting young people say that the pressures on schools can sometimes be part of the problem, too. The workload stresses and the huge number of non-education issues that schools now deal with mean that external services often find it difficult to get hold of the right member of staff.

“I can ring up to speak to a head of year, leave a message because they are unavailable (for very good reasons usually), and not get a call back for two weeks because that teacher is so busy,” says the physiotherapist.

“When they do call, I am in clinic and so have to try and find time to call back. That can take a week, because there will be several other situations exactly the same on my caseload. And when I do talk to them, it’s often not the right person I need to speak to, or they are unsure who the right person is, and suddenly it is months before you have actually got the right person and you can actually talk to them.”

She says that no one is to blame here: it’s just the reality of the stresses that teachers are under, which are the same as the stresses hitting the staff of support services, too.

Lack of funding is clearly a major cause of all these problems. There isn’t a big enough budget to recruit enough staff to make this system work properly for the increasing numbers of children who require services. With the huge economic toll of the pandemic and a government not seeming keen on extra funding for public services, resolving that funding gap seems unlikely.

So, in lieu of the major policy changes that would address funding issues, what can be done? Well, organisations are attempting to find workarounds.

Vainker believes schools can be central to those workarounds - if they are allowed to be. He is a “big advocate” of co-location, where external services work from inside schools, saving time and money.

This approach can vary from a nursery being located on the school site (as is often the case) up to multiple family services, such as occupational health, counselling and GPs - all sharing the same space.

The proposed benefits are myriad, with practical elements including reduced travel time for staff (and for families who are using more than one service) and better coordination for meetings, alongside less tangible elements, such as creating a shared sense of identity and vision.

“It can be very, very cheap,” says Vainker. “And it can build those more informal relationships and personal relationships between staff, which can really help provide that integration.”

This thought process was a driver for a project to embed social workers in schools, which took place in Southampton, Stockport and the London borough of Lambeth from 2019. The small scale of the initial pilot - which ran in 18, 11 and eight schools respectively - meant that researchers were cautious in their conclusions, but after 10 months, the evaluation report found that the programme “may have reduced the number of children thought to be suffering or likely to suffer from serious harm”.

The Department for Education announced in May that it was spending £6.5 million to extend the project into 150 schools across the country, with the express aim of helping to “spot the signs of abuse and neglect more quickly and work with teachers to support children at risk”.

So, how does the project differ from normal services? One of the major contrasts is that these school-based staff work exclusively with children from that school (and siblings in other schools) and hold on to cases from beginning to end, rather than referring to others, explains Cathy Henchion, team manager of the Lambeth Schools Social Workers Project.

“Schools are very good at identifying vulnerable children,” she says. “The referrals are mainly coming from designated safeguarding leads and pastoral care teams, and we work very closely with them. Being based in schools has meant that we’re also able to do a lot of preventative, early intervention work to try to prevent cases getting to a level that requires more involvement.

“One really good example was a 14-year-old girl, who was suddenly having lots of difficulties in the relationship with her mother; she didn’t want to go home and wanted to stay elsewhere. The social worker was able to meet with her mum and complete three sessions of mediation over one week. The mother has written to us since and has taken on board what was said and things have improved. That could have ended up with us having to accommodate a child, but instead it never reached that threshold.”

The stronger relationships with staff in schools has enabled them to “identify local issues and deal with them”, she continues, such as developing healthy-relationship courses with the school nurse, and liaising with school officers to take work on issues around gangs and knife crime, both with positive results.

Mental health services can work in a similar way. Counselling service Place2Be worked with 700 schools across the UK last year and, according to Becky Wilkinson-Quinn, the organisation’s clinical lead for Scotland, being based in schools and seen by staff and families as part of the school service is key to being as effective as possible.

“Being embedded in the school is like gold dust,” she says. “It allows for conversations with the teachers, like at the photocopier, that you just wouldn’t have the opportunity to have otherwise. And for the children and parents to have somebody on site who can be responsive in that way is great, rather than somebody parachuting in and out.”

How extensive could these integrations be? A utopian vision would be that every school site functioned as a true community hub, with the full spectrum of physical and mental health services, social services and other community-benefiting organisations (from cooking classes to legal advice) housed together to share space, goals and even budgets.

The practical difficulties of this are immediately clear, however. Shared funding would require a ground-up overhaul of the entire system. Few schools have the space to welcome numerous teams to their sites. And such a move could mean that these staff have less effective relationships with non-school-based users.

A workable compromise could be for schools in most need of services to combine with the services they use most, as with the pilot project above.

Vainker says a more proactive approach to partnership could be key. He recalls the “interesting experience” of looking into being involved in the running of a local GP practice when it came up for tender a couple of years ago. He and his colleagues met with several possible GPs and ended up “getting quite far down the road” before deciding not to bid.

“What was interesting was how much we could have added to the bid,” he says. “It made me feel that there is opportunity, particularly between primary care and education, to run places together, but there really aren’t models of that happening at the moment. That’s something that I’m trying to crack.”

But is the current system so unworkable that it can’t be simply tweaked?

Wilkinson-Quinn says effective joined-up working is possible - but rare. She remembers one instance that included Camhs, GPs, third sector, voluntary sector organisations and the schools themselves creating a joined-up “working together to best support children” approach. The result was a reduction in the Camhs’ waiting list from six months to two weeks. “That was the result of the right referrals going to the right places,” she says. “And the quality of those referrals really improved as a result of that joined-up piece of working. It would be fantastic if we could all be working in that way all the time, but it’s not very common.

“Having worked in Scotland in mental health for 14 years, that one example is the only one I know of that was so succinct and well held and joined up. It’s the absolute gold standard for me of what we should all aspire to be working towards. But it takes somebody to be coordinating it, and for people to be on board with that.”

It also takes a culture shift, says the anonymous clinical psychologist; if agencies could be honest - rather than defensive - about their limitations, the effect could be transformative, she explains.

“The best meetings are the ones in which workers are able to be upfront about their assessment of the problem and their, or their agencies’, capacity to offer support in various ways,” she says. “When everyone’s cards are on the table, it’s easier for the team around the child to work more collaboratively towards the common goal of supporting the child and family.

“Time can sometimes even be saved by combining efforts, but this requires everyone to take a risk in acknowledging their limits. The capacity for this is typically a result of good management, training, supervision, experienced practitioners and feeling supported at work - all things which cost a service money which could be used to, say, reduce waiting lists.”

The fact that this type of collaboration is possible has been proven by US-based community organisation StriveTogether, which began in Cincinnati in 2006. A group of local leaders came together to discuss a new college readiness programme for young people in the area, and hit upon the issue that they were “programme-rich and systems-poor”.

Jennifer Blatz is president and CEO of the organisation and says that it was clear a change was needed to take place in order for outcomes for the most vulnerable to improve.

“We, like many communities, had an abundance of services and programmes but were always looking for the next thing, the silver bullet,” she says. “The lack of coordination, duplication of services and small scale would never have led to a population-level impact. We all had to take a step back and ask ourselves, ‘What would it look like for us to be systems-rich?’”

The result, she continues, was to engage with the community, involving the people most affected by issues in developing solutions to those issues. Rather than adding new services, they looked at what was working well already and brought “business, political, education and cross-sector leaders together” to create a “community vision”.

While the specifics are different in each community (there are now 68 StriveTogether networks across the US), they begin with “aggregating cradle-to-career data that’s typically held by different community agencies” before creating “a shared accountability and differentiated responsibility to get results”.

The key, Blatz says, is to share a vision and goals, allowing each agency to “leverage its unique skills and services to get better outcomes for young people”.

The Milwaukee Succeeds programme, for example, was established in 2011 and brings together more than 300 partners to work towards clearly defined targets: the percentage of immunised two-year-olds, the percentage of children in high-quality childcare, third-grade reading proficiency, eighth-grade maths proficiency, high school completion, and college enrolment and completion. Since 2015, it has seen increases in all areas except college completion and third-grade reading (and immunisation levels have remained static), including a 5 per cent rise in high-quality childcare, and 7 per cent increase in high school graduation.

Whether it is more integration like this, ambitious co-locations or more simple tweaks to the existing system that is needed, what is clear is that this is not something schools can sort out alone. The problems in the external services are too complex and the problems within schools are too limiting for teachers to have the time to do the job of coordination. And they should not have to; no matter how much they wish they could, no matter how much pressure they are under to pick up the pieces, the capacity just isn’t there.

Not that this will stop them. As Vainker’s work shows, schools will try to seek out solutions because their priority is always the child in front of them.

And Blatz says they should let themselves be optimistic in that aim, but understand that they can’t do it alone.

“You need to bring people together around outcomes, not a programme,” she says. “Create a diverse leadership table that includes those most impacted by the inequities in the system as well as leaders from every sector that touches the lives of youth and their families. Think beyond education to include health, housing, public transportation, justice and more. Invite business and government leaders, philanthropy and non-profit leaders.

“Build a coalition of the willing, those ready and willing to get results.”

Zofia Niemtus is editorial projects and content manager (maternity leave) at Tes

This article originally appeared in the 4 December 2020 issue under the headline “Can we fix our safety net?”