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Macpherson, R.J.S. (2013). Evaluating three school-based integrated health centres established by a partnership in Cornwall to inform future provision and practice, International Journal of Educational Management, 27(5), June.
Published: 2013-06-15
Posted: 2013-06-07
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Purpose – The aim of this paper is to report the process, findings and implications of a three-year evaluation of integrated health centres (IHCs) established in three secondary schools in Cornwall by the School-Based Integrated Health Centres (SBIHC) Partnership. Design/methodology/approach –When the partners had completed the capital works, an evaluation strategy was designed for 2009-2012 to identify the extent to which each of the IHCs was meeting the aims set for them, and each IHC and school was contributing to the aims of the SBIHC project. Formative and summative evaluation used annual case studies to apply data progressively regarding (a) the use, users and operations of each IHC, (b) students’ perceptions of the user-friendliness of the IHCs, (c) indicators of the general health and well-being of students and their sexual and mental health, (d) students’ exposure to crime, substance abuse and poverty, and (e) students’ academic achievement, attendances and exclusions. This process culminated in this paper which reports and discusses findings, suggests implications for practice, theory and research and proposes future directions for the partnership. Findings – All three schools engaged students closely in the design and decoration of their IHCs to create attractive reception areas leading into modern clinical and group meeting rooms. Student ownership was extended into the selection of coordinators and into centre management and governance, alongside school, community and provider representatives. Budehaven Community School appointed a National Health Service (NHS)-trained coordinator for their IHC, The Haven. He was a male mental health worker funded for one year by the NHS. When he took a permanent NHS post elsewhere at the end of 2009-2010, his responsibilities were thereafter shared between the NHS-trained receptionist and the manager, an assistant head teacher. The Haven was established in a converted caretaker’s bungalow. During 2011-2012, Year 3, Budehaven added a ‘co-location’ building, Kevren, with hot desks and small meeting rooms to extend the reach of the IHC in order to pioneer a community health support service. The health, welfare and educational professionals hosted have exhibited early forms of interprofessional collaboration (IPC). About 37 professionals are now located in or visit The Haven and Kevren weekly, each either funded by the school, the NHS, charities or Cornwall Council. Student footfall doubled to about 4,000 in the second year of operations, and increased by another 25% in the third year due to additional users from the community. The wide range of general, mental and sexual health services, which focus on prevention and students making informed choices, were found to be highly valued by the students. A solely positive association was found between visits made to The Haven, academic progress, attendance and exclusions and a sharp fall in students’ engagement with the Youth Offending Service (YOS). Students’ exposure to crime, substance abuse and poverty remained constant. Unsatisfactory sample sizes meant there was an imprecise knowledge of the perceived user-friendliness of The Haven and student mental health status. Budehaven plans to move towards a more evidence-based approach to improving professional practices and integrating health services with in-school interventions, curriculum development and community outreach. The Crayon, the IHC in Hayle Community School, achieved a similar footfall over the three years, similarly engaging students in design, management and governance from the outset. It was also housed in a converted caretaker’s bungalow. It started with a Receptionist and the Pupil Welfare Officer, a nurse, with many other health and welfare responsibilities distributed across the school. The Manager, a deputy head teacher, and the head teacher triggered a major turn round at the end of Year 1 by moving most student support services into the IHC. From then on the Crayon had three full-time and highly collaborative professionals serving only school students. By the end of Year 3, with a growing number of visiting professionals funded by the school, the NHS, charities and Cornwall Council, the Crayon had reached the limits of its facilities. Perceptions collected using the User Friendliness Survey (UFS) affirmed that Hayle students strongly appreciated gaining access to the health services they prefer, a welcoming atmosphere, confidential services, caring and supportive staff and health professionals, high quality information and advice, and being able to improve the user-friendliness of their centre. Mental health data collected in two year groups over the three years showed the substantial impact of mental health innovations, pointing to the combined effects of targeted individual and group interventions delivered through the IHC, and the targeted cohort, whole-school and beyond-school interventions, and the customised professional development organised by senior staff. External data indicated effective levels of sexual health self-management by students while their exposure to crime, substance abuse, domestic violence and poverty had remained constant. A solely positive association was found between IHC usage and measured improvements to mental health and academic progress. Hayle students’ attendances also improved, exclusions stabilised and their engagement with YOS fell sharply. Plans focus on housing additional health and welfare professionals from the NHS, charities and Cornwall Council experienced in working with children and young people to extend services into the community. The IHC in Penair School, Bywva, was a fresh build. It developed a wide range of general, sexual and mental health services and attracted a similarly strong footfall. It also reached capacity during Year 3. UFS data confirmed that students regarded the user-friendliness conditions noted above as essential. Students helped select two co-coordinators, one a social worker and the other a person experienced in working with young people, who job shared until a functional review in early Year 3 refreshed expectations and they negotiated separations. Penair refined their IHC’s line management by an assistant head teacher and coordination by a lead practitioner who was transferred from the Learning Support Centre. Two other lead practitioners and three pastoral support workers were also transferred into the IHC for 2012-2013 to help safeguard students and take up family case loads, and to implement Penair’s policy of delivering family-centred community health services through IPC. The presence of the Bywva in Penair was closely associated with major in-school advances in evidence-based practice. They included the ground-breaking Health, Fitness and Wellbeing curriculum and the associated personal weight management programmes, the Fitness Suite and the Trim Trail. The Student Information Management System (SIMS) was re-engineered to embed the analysis of student mental health into academic progress reviews and to provide integrated evidence for planning individual, group, cohort and whole-school interventions, and for targeting professional and curriculum development. External data showed that students’ sexual health self-management had remained effective and that their exposure to crime, drug abuse and violence had remained constant. A solely positive association was found between students using the Bywva, students’ sexual and mental health, academic progress, and a significant fall in youth offending. In September 2012, the Cornwall Foundation Trust decided to convert the caretaker’s bungalow beside Bywva in order to host many more health and welfare professionals from the NHS, voluntary organisations and Cornwall Council. Since this move was driven in part by a need to cut the cost of down-town offices, it is not yet clear if it will result in greater IPC in the Bywva. Nine themes found in the data centred on the key relationship between students and professionals and were used to create a provisional ecological model of school-based and integrated health care. It was concluded that the three IHCs achieved most of the aims set for them by the SBIHC Steering Committee, and that they and their schools made important contributions to the aims of the project. Research limitations – This trial of a school-based integrated health centre model of care was partly limited by the PCT not commissioning the part-time participation of doctors and nurses, although two schools were able to modify and embed the services of their school nurses in their IHCs. To this point, service development has focussed more on the needs of adolescents than on the needs of children in each school area. The provision of data by Cornwall Council personnel encountered difficulties due to the databases used by health, welfare, educational and police services being based on different boundaries; near approximations to school catchments had to be used. The Health and Wellbeing Improvement Tool (HWIT) was withdrawn as unreliable by the Healthy Schools Plus Programme in Year 2 of the trial; the schools each developed unique solutions. Budehaven did not collect adequate samples of UFS and Pupil Attitudes to Self and School (PASS) data but will do so in coming years. The greatest limit was that the research was confined to three sites over three years. Together, these limitations may have slightly impaired the development of each of the three IHCs and understated accumulating effects. They indicate that the findings are to be regarded as provisional, and that only preliminary generalization is warranted prior to further research. Research implications – The practical implications of the findings for the development of IHCs begin with student ownership. Sustaining student engagement in the design, management and governance of IHCs and applying students’ perceptions of their user friendliness were shown to be critical to the effective development and continuous improvement of IHCs. Five practical implications for schools were the importance of (1) using standardised tools annually to screen general health and wellbeing and mental health, (2) eliciting data from Council personnel to understand trends in school catchments regarding sexual health and exposure to crime, drug abuse, violence and poverty, (3) relating progressive health data to the value added by the schools regarding educational progress, (4) enhancing the role of SIMS in providing integrated intelligence for evidence-based practice, planning, interventions and development, and (5) separating the line management and annual evaluation of IHCs. Two immediate implications for the SBIHC partnership are the need to disseminate these findings and to consider follow up. Both imply the need for a fresh coherent strategy for the next phase of the SBIHC Project and the need to revitalise the Steering Group. A programme is recommended with a County-wide remit to facilitate the establishment of more IHCs, expert support for head teachers and schools wanting to develop an IHC in spare space, Council administrative support for the Steering Group, and pound for pound investment in IHC conversions up to a limit of £10,000, on five key conditions. The findings of this project would suggest that such investment should be contingent on schools guaranteeing (1) student engagement in design, management and governance, with staff, governor and provider representation, (2) reporting universal and annual surveys of the user friendliness of IHCs, general health and wellbeing and student mental health to the Steering Group, (3) reporting sexual health data as well as exposure to crime, substance abuse, violence and poverty from Council sources, (4) developing SIMS to integrate health information flows into school reviews, planning, interventions and developments, and (5) hosting NHS, charity and Council health and welfare professionals in a context of IPC to address identified health needs in their catchment area. The need for theory development was identified in three areas; how IHC services impact on student learning, how IHCs affect the pedagogy, curriculum and organisation of schools, and, the role and leadership of IPC in school-based integrated health services. Further research might measure the effect of school-based integrated health services on student health and academic progress, and measure the comparative effectiveness of the SBIHC model of care over time. Originality/value –The first unique feature is that the SBIHC Project and its evaluation was mounted by a partnership comprising charitable, private and public entities; The Duchy Health Charity, The Prince’s Foundation for Integrated Health (PFIH, since replaced by the College of Medicine), the Cornwall and Isles of Scilly Primary Care Trust (PCT) of the NHS, the Directorate of Services for Children, Young People and Families (CYPF) of Cornwall Council, the Peninsular Medical Schools and three schools; Budehaven Community School, Hayle Community School and Penair School. Second, this evaluation is the first to report a formative and summative evaluation of IHCs using case studies with a blend of qualitative and quantitative data. Third, while American and Canadian studies have indicated the benefits of IPC in IHCs, this is the first that has highlighted the need to develop and reconcile IPC with student engagement in the management and governance of IHCs and with the other conditions that students continue to regard as crucial for the success of IHCs. Fourth and finally, this paper offers a new conceptual model of the SBIHC model of health care centred on the reciprocity and integrity of relationships between students and professionals. Keywords–children, adolescents, school-based integrated health centre, model of health care, general health, wellbeing, mental health, sexual health, interprofessional collaboration Paper type–Research report