ProposalJigsaw

Tipperary

April 2018

Contact: Lisa Kavanagh, Youth Officer, Tipperary ETB

052 – 6134347 lkavanagh@tipperaryetb.ie Ruairi O’Caisleain, Coordinator, Tippperary CYPSC052 – 6176687 Ruairi.OCaisleain@tusla.ie

Table of Contents

Page Introduction 3

Background 3

Development Work Undertaken 4

Establishing the Need 5

- Mental Health Status of Young People in the County 6

- Contributory Factors to Poor Mental Health 7

- Social Disadvantage 8

Statutory and Voluntary Service Provision 9- Prevention and Early Intervention 9

Jigsaw as a Model 11

- The Goals of Jigsaw 11

- The Policy Context 11

- How Jigsaw Operates 14

- Governance and Risk Management 15

- Jigsaw Hub and Premises 15

- Evaluation of the Jigsaw Model

Funding Jigsaw as a Model of Delivery in Tipperary 17

Conclusion 18

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Introduction

This paper briefly outlines the background to the proposed development of Jigsaw Tipperary, demonstrates evidence of need and the rationale for establishing a Jigsaw project in Tipperary and articulates the broader policy context within which Jigsaw operates as a youth mental health service.

County Tipperary is a rural county based in the heartland of Ireland. Youth Mental Health is a key priority for the county, and agencies have been struggling for the past number of years to address this issue. Jigsaw, as a youth mental health model of delivery, has been identified as being an appropriate response to support youth mental health and address mental health difficulties among young people and to this end the key agencies in Tipperary are working towards securing the resources to bring Jigsaw to Tipperary. These agencies are working together as a direct response to the identification of mental health as a key priority for young people, both by young people themselves and the agencies who work with and support them. The Jigsaw Tipperary working group 1 actively liaise with the Health Service Executive to identify and secure resources for Jigsaw in the North Tipperary (HSE Mid-West) and South Tipperary (Carlow, Kilkenny, South Tipperary) areas as it is imperative the HSE actively support the establishment of Jigsaw in order to ensure an integrated and sustainable model of delivery.

Background

Mental Health has long been identified as a key county priority for all agencies working with young people in the County. In 2011, interagency collaboration culminated with an application being submitted by the inter-agency group from the South County, led by the HSE, to the Department of Health. These agencies have been consistently working to secure a Jigsaw project and since the amalgamation of local structures and the development of the all-county Children and Young People’s Services Committee, the establishment of a Jigsaw project has been a key priority. Furthermore, stakeholders in the Tipperary Local Economic and Community Plan (LECP) and the various structures operating under this Plan are progressing actions around same. Tipperary Children and Young People’s Services Committee (CYPSC) has likewise identified youth mental health as a key priority.

Since 2015, meetings have taken place with managers in HSE Mental Health Services and Primary Care to demonstrate the need for a Jigsaw project in Tipperary and to request that funding to establish and maintain the project is included in the Service Plans. These meetings have been progressed by a steering group of agency representatives made up of Tusla (Mid-West), Tusla (Carlow, Kilkenny, South Tipperary) Tipperary County Council, Tipperary ETB and Youth Work Ireland

1 Tipperary ETB, Tipperary County Council, Tusla, Youth Work Ireland Tipperary. Representatives from these agencies have formed a working group to progress the application for a Jigsaw site to be based in Tipperary. The group is supported by a wide range of other statutory and voluntary agencies and by the Tipperary Children & Young People’s Services Committee (CYPSC)

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Tipperary which is now working with Headstrong2 and local community agencies to progress the establishment of the project in the county. In addition, the agencies have been working with young people throughout the county on youth mental health initiatives and consultations in order to ensure that all stakeholders are involved in the development of the initiative. The genesis of a Youth Advisory Panel is also in place to continue to progress the work. The steering group has engaged with 30 community groups and agencies and also through the PPN (public participation network) which has links to over 900 local groups. Meetings have also taken place with a broad range of agencies in addition to the HSE and Túsla to garner support for a Jigsaw project and it is clear there is substantial support for Jigsaw in the county. Presentations have also been made to Tipperary County Council, who are engaging with the steering group around potential premises for the project. The Director of Community and Economic Development, Tipperary County Council is the Chairperson of CYPSC, and is fully supportive of the process. To complement this work, meetings have also taken place with local political representatives in order to discuss the need for Jigsaw for the county, all of whom have been very supportive. In fact, these latter have assisted in securing meetings with the relevant Ministers: with Minister of Health, Simon Harris, on 24 th October 2016, and with Junior Minister for Mental Health and the Elderly, Helen McEntee, on 24 th January 2017.

Development Work Undertaken

A range of initiatives and activities have taken place over the past number of years throughout Tipperary to raise awareness of youth mental health, to deliver training to professionals and volunteers working with young people and to support young people to be active in identifying, responding to and delivering on youth mental health programmes and projects. Both single agency and multi-agency approaches have been undertaken. Examples include;

- Work supported by the Community Foundation of Ireland through the Tony Ryan fund, as well as the HSE through the Suicide Prevention office to train practitioners in WRAP, as well as ‘Be Well’ Events throughout the county in 2015

- Tipperary County Council funded activities in Tipperary in 2015 including a ‘Be Well Event’ in Tipperary Town

- A large-scale community awareness event in Fethard in May 2016 which saw 700 community members attending an event on mental health and substance misuse. The coordination of the event was led by Coolmore Stud and supported by local second level school Principals, local statutory agencies including Tipperary ETB and Tusla, community councils in Fethard and Killenaule and other locally based community, voluntary and sporting clubs and groups

- A peer led youth mental health initiative rolled out by Youth Work Ireland Tipperary which has seen over 400 young people reached around positive youth mental health in the past 3 years

- Youth Mental Health is an ongoing theme of Comhairle na nÓg who work on different initiatives every year

- Tipperary was chosen as one of eight initiatives in the country to roll out the Connected Communities (National Youth Council of Ireland (NYCI) Initiative around youth mental health) in both 2014 and 2016

2 Headstrong, The National Centre for Youth Mental Health

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- Youth Work Ireland Tipperary is currently working with NCYI to review Mindout

- From 2012 – 2015, the South Tipperary CYPSC Mental Health Sub-Group, with membership drawn from the primary and second level school sector, the County Council, youth services, HSE CAMHS, Tipperary ETB, Comhairle na nÓg and other stakeholders, highlighted the need to build capacity among agencies working with young people to address Mental Health issues and included actions in its Work Plan for the delivery of training to front-line staff and the delivery of such programmes as WRAP and Mindout. The Work Plan also included actions to promote delivery of personal and social development programmes at primary school level and to expand the ‘Rainbow’ Bereavement programme in the south county as measures to promote positive mental health.

- The extent to which issues of Mental Health are of major concerns to schools was very evident in an Education Forum organized by South Tipperary CYPSC for Principals of primary and second level schools in January 2013. The lack of support services for troubled children and young people was a major concern and the views expressed on this and on other issues fed into the consultation process relating to the South Tipperary CYPSC Work Plan.

- The theme of Mental Health also featured at an Education Forum in February 2015, held under the auspices of South Tipperary CYPSC, at which various personal and social development programmes and one promoting positive mental health and wellbeing, all targeting primary school children, were advertised and schools invited to consider availing of them.

The interagency committee3 and CYPSC now consider it an urgent priority for Jigsaw to be established and mainstreamed in Tipperary and for the ongoing funding for this service to be managed through the HSE. Additional funds and a new structural approach to this youth mental health initiative ought to be accommodated and supported centrally and the HSE facilitated to roll out same.

Establishing the Need

Tipperary is the sixth largest county, in geographical terms, in the Republic of Ireland, with an overall population of 159,553.4 There are 24,778 young people, aged 12 – 24 years.

Tipperary has a vibrant youth population, as reflected by the demographics above. A range of consultations with both the general community and in particular young people has been completed over the past two years:

- Consultation around Connecting for Life Strategy (2016)

- Consultations for the Children and Youth People’s Service Committee (2016)

- Comhairle na nÓg consultation (2014 and 2015)

- Focus groups with specific vulnerable groups of young people (2015 and 2016)

- Consultation for the LECP (2015)

3 Tipperary County Council, Tipperary Education and Training Board, Tusla, Youth Work Services 4 According to the latest CSO data

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In all of these consultations youth mental health has arisen consistently as the top priority, and indeed the Jigsaw model has been referenced on numerous occasions as being the most appropriate response to meet the identified mental health needs of young people in the county.

Mental Health Status of Young People in the County

In evaluating the mental health status of young people in Tipperary, it is useful to consider mental health in terms of a continuum from relative mental well-being to acute psychiatric conditions and the various states of mental health that lie in-between. A range of risk factors and protective factors prevalent in a young person’s life can have a major impact on his state of mental health. Such risk factors as high levels of anxiety, low socio-economic status and difficult family circumstances can increase the possibility of a young person developing a mental health difficulty or disorder. On the other hand, protective factors such as good self-esteem, support of friends, parental approval and other such assets in a young person’s life can improve the likelihood that s/he can respond successfully to challenges.

As indicated in the Headstrong ‘My World’ survey on Mental Health (2012), young people in the age group, 12 - 24 years, can be particularly vulnerable over the course of their adolescence and emergence into adulthood. Depending on the mix of protective and risk factors in their lives, they can experience rising levels of anxiety and stress from the age of 12 or 13 years which tend to peak at 19 /20 years, with attendant impact on their mental health.

At the acute end of the continuum of mental health, there are a number of indicators that highlight Mental Health in the youth population as a major concern:

CHO3 recorded the second highest rate and CHO5 the third highest rate of children and young people referred to CAMHS in the State and both were higher than the State average of 155.1.

Relative to the other CHOs, CHO5 had the highest number of children referred that did not meet the service criteria and CHO3 had the lowest. This is particularly significant in illustrating the need for Primary Care intervention.

In 2011, the rate of child admissions into psychiatric hospital for the whole county, North and South, was the highest in the country, at 71.1 per 100,000, compared to a national average rate of 37.9 per 100,000. In 2013, the rate of admissions in County Tipperary was still one of the highest around the country, at 68.7 per 100,000, compared to a national average rate of 36.1 per 100,000. In 2015, the comparable county rate was 63.8 per 100,000, and the national rate, 43.8. The age range of the children concerned is 10 – 17 years, of whom, 4 out of 5 are aged 15 - 17 years (SNC, 2014, 2016).

In 2016, there were 123 hospital discharges of young people aged 13 to 24 years with a diagnosis of mental or behavioural disorders in Tipperary. This is a rate of 5.3 per 1,000 population aged 13 to 24 years and was above the averages for the State (5), the Mid-West (4.3) and the rates for Co.s Kilkenny (4.3) and Waterford (3.6). Relative to other counties, Tipperary had the eleventh highest rate of young people being discharged with a diagnosis of mental or behavioural disorders (AIRO, 2017).

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Suicide rates in Tipperary are above the national 3-year average rate (2012-14) of 11.0 per 100,000, the comparable rates being 12.6 per 100,000 in North Tipperary and c.13 per 100,000 in South Tipperary (Connecting for Life Strategies, South Tipperary & Mid-West, 2017).

In 2015, the Tipperary South LHO recorded a rate of 228 females aged < 24 years per 100,000 recorded as presenting to hospital following self-harm. The rate in the North Tipperary /East Limerick LHO was lower at 135.5. In comparison to other LHO areas, the Tipperary South LHO recorded the sixteenth highest rate and the North Tipperary/ East Limerick LHO recorded the third lowest rate. Both rates were below the State average of 253.18.

In recent years (2010 to 2015), there have been some fluctuations in the rate of females < 24 years presenting to hospital as a result of self-harm in the two LHOs. Between 2013 and 2015 the rate in North Tipperary/East Limerick has decreased from 227.7 to 135.5. However, between 2014 to 2015 the rate in South Tipperary increased from 117.2 to 228. Until 2015, the rate in South Tipperary was consistently below the rate in North Tipperary/East Limerick (AIRO, 2017).

However among young women, aged 20 – 24 years, in the North of the county, the rate of Self-Harm was higher than the national 3-year average rate for the years, 2012 – 14. The rate was 680 per 100,000, compared to a national rate for this age group and sex of 534 per 100,000 (National Suicide Research Foundation).

In 2015, Tipperary South LHO recorded a rate of 198.9 males aged < 24 years per 100,000 presenting to hospital following self-harm. The rate in the North Tipperary/ East Limerick LHO was significantly lower at 105.5. In comparison to other LHO areas, the Tipperary South LHO recorded the sixth highest rate in 2015 and the North Tipperary / East Limerick LHO recorded the sixth lowest rate.

In recent years (2010 to 2015) there have been fluctuations in the rate of males < 24 years presenting to hospital as a result of self-harm in the North Tipperary / East Limerick and Tipperary South LHOs. In 2010, the rates in both LHOs were similar, however since then the rate in North Tipperary/ East Limerick has decreased from 125.6 in 2010 to 105.5 in 2015. In the same time period the rate in Tipperary South has increased from 130.5 in 2010 to 198.9 in 2015 (AIRO, 2017).

For a broader picture of the mental health of young people, the Headstrong ‘My World’ national survey on Youth Mental Health in Ireland (2012) found that many young people experience a lot of anxiety, stress and depression, depending on the mix of protective factors and risk factors in their lives. A sample of 347 young people, aged 12 – 19 years, were surveyed in Tipperary with the following findings:

o 10.4% of the young people experienced moderate levels of depression, while 7.3% experienced severe levels of depression

o 6.1% experienced moderate levels of stress, while 6.1% experienced severe levels of depression

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o 14.7% experienced moderate levels of anxiety, while 10.5 % experienced severe levels of anxiety.

These rates were similar to national rates.

The CYPSC on-line survey of parents in the county found that Mental Illness and Anxiety & Stress were their main health concerns in relation to the age groups, 13 – 17 years, and 18 – 24 years, respectively. The need for education around Mental Health and Suicide in school as well as access to more and better-resourced services, providing information, Early Intervention/counselling and clinical interventions, were suggested as measures to address this issue. There was also a big demand for an easy way to access information on service provision, though this was not necessarily limited to Mental Health services/in general.

The CYPSC on-line survey of 3rd-level students at LIT found that Mental Illness was the highest-rated main health concern. The biggest sources of Mental Health difficulties were identified as Stress, Anxiety, and Low Self-Esteem. For two out of five of the respondents, Family Problems were also a source of Mental Health difficulties. Only less than one in four of the respondents were aware of services in their respective areas to address mental health concerns. Suggestions to address Mental Health issues included education on Mental Health in schools, public awareness-raising campaigns on Mental Health and information on relevant services through social media and other channels, as well as easily accessible, free counselling and other supports.

Contributory Factors to Poor Mental Health As noted above, a range of risk factors and protective factors prevalent in young person’s life can have a major impact on his/her mental health. A survey of agencies in South Tipperary in 2011 identified the following mental health related issues arising for young people aged 12 – 18 years:

Anxiety & panic attacks

Social isolation and lack of social skills

Substance misuse and its exacerbation of negative behaviour

Suicide and Self-Harm

Inability to look for help

Impact of exam pressure, stress and bullying.

Depression, low self-esteem and oppositional behaviour

A survey of 474 young people carried out by Comhairle na nÓg in South Tipperary on behalf of South Tipperary Children and Young People’s Services Committee (CYPSC) in 2012, identified that ‘Body Image’ was the biggest concern for almost half of the female respondents and for over a quarter of the male respondents, followed by relationships and then by financial worries. Bullying was an issue for one in four of the male respondents, while Peer Pressure was an issue for the same proportion of female respondents.

Social Disadvantage & Social Exclusion

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In view of the impact of the socio-economic context on mental health and well-being, it is important to bear in mind the proportion of the age cohort, aged 12 – 24 years who reside around the county in 135 Small Areas designated respectively as ‘Disadvantaged’ and ‘Very Disadvantaged’, in other words, having a Relative Deprivation score of <-10 and <-20, respectively*. These are residential areas with a combination of indicators of social disadvantage such as high levels of unemployment and low levels of educational attainment in the population, as well as a proportion of Lone Parent households significantly higher than the national rate.

The ‘Disadvantaged’ and ‘Very Disadvantaged’ Small Areas (SAs) are largely concentrated in the larger towns around the county which include Clonmel, Tipperary, Carrick-on-Siúr, Thurles, Nenagh and Roscrea. Significant indicators of social deprivation are also to be found in some 27 of the smaller towns and rural settlements around the county. There were 2,349 young people aged 12 – 17 years, and 2,408 young adults aged 18 – 24 years living in these areas, accounting for 17.7% and 20.8%, respectively, of the 2016 figures of all young people and young adults in the two age groups (CSO, 2016: Pobal; AIRO, 2017). Of the overall cohort of young adults aged 18 – 24 years in the county, there are currently 1,172 (10.1% of this age cohort) who are registered as unemployed (DSP, May 2017).

Other categories of young people whose particular circumstances can constitute a risk factor are young Travellers, LGBTI young people and young people with disabilities;

According to census 2011 figures, there were 159 young Travellers in Tipperary in the 10 – 14 year age group, 129 in the 15 – 19 year age group, and 75 in the 20 – 24 years, constituting a total of 363 young Travellers in the 10 – 24 years age cohort. (TETB Youth profile)

There were 1,582 young people, aged 15 – 24 years with disabilities in the county (CSO, 2011 / County Data Hub). More recent figures show that there are 257 children and young people in the county aged 10 – 19 years who are registered with an intellectual disability and 376 in the same age group who are registered with a physical disability (AIRO, 2017)

On the basis of the national estimate of 7.5% (BeLonGTo) for the proportion of young people who identify as LGBT, the figure for LGBT young people, aged 15 – 24 years in Tipperary has been calculated as approximately 1,400.

The unemployment rate among those under 25 years in the Travelling community in Tipperary is 85.47%. The rate for young people with disabilities is 60.7% (Local Economic Community Plan)

These categories of young people have been identified by the National Suicide Prevention Strategy, data from the registry of self-harm and other research findings as being some of the particular groups of the population nationally with an increased risk of suicidal behaviour.

A consultation undertaken in 2016 on behalf of Tipperary CYPSC with 293 young people aged 13 – 18 years, highlighted a number of issues affecting the mental health and well-being of these young

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* These scores are arrived at as composite measures of levels of advantage or disadvantage among a DED population across a set of variables which include Age Dependency rate, Educational attainment, Employment status and Household type.

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people. A high proportion of these young people come from backgrounds and social circumstances which expose them to risk of social exclusion, and includes young people who are variously from areas of social disadvantage, from the Traveller community, who have disabilities, who are involvedin the justice system, as well as LGBT youth. Among the priority issues identified were:

Substance misuse and excessive alcohol consumption

Anxiety and stress relating to life circumstances and school pressures

Bullying, particularly in the school setting

For Travellers, a sense of social exclusion and discrimination against them in school and in local community settings

For LGBT youth, also a sense of social exclusion as well as exposure to taunts and harassment in school

For young people with disabilities, lack of opportunities for social interaction with peers outside school, particularly for those in rural settings.

A sample of young people in the Justice system were asked as part of a consultation undertaken under the auspices of Tipperary CYPSC to identify the 3 main stressors in their lives. Their responses were varied, including having no money, looking for work & accommodation, owing money for drugs, family, Mental Health and addiction. The responses of a sample of young people in After-care services to this question identified school, pressures of academic performance & exams, peer pressure and bullying. They also expressed worries about the future as well as a sense of insecurity about lack of dependable family support.

Statutory and Voluntary Service Provision

The formally organized Mental Health Services for young people aged 15 – 24 years are primarily clinical services for those with acute conditions requiring clinical support and intervention at Levels 2 and 3 on the Hardiker scale.

- In both the North and South of the county, there are HSE Psychology services providing an assessment and therapeutic service for children and adolescents, 0 – 17 years, exhibiting emotional and behavioural problems. The service in the South also works with children and young people with mild learning difficulties and with ASD. There is a major issue of long waiting lists for these services.

- There are 3 HSE Child and Adolescent Mental Health Service (CAMHS) teams in the county, one in the North of the county and two in the South, each comprising clinical nurse specialists, a child care worker, a social worker, a psychologist, a speech and language therapist, an occupational therapist and a CAMHS psychiatrist. They provide psychiatric assessment services and related interventions with psychology and nursing. The target group for this service are children and young people, aged 0 – 17 years, with a suspected psychiatric condition. Again, as with the psychology service, there is a major issue of long waiting lists for the CAMHS services.

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- For people aged 16 years upwards, who are seeking help for self-harming behaviour, there is access to the Self-Harm Intervention Programme (SHIP), a counselling service through the G.P. service.

- The need for primary care intervention in the area of Mental Health is being catered for by the HSE through the inclusion of community mental health nurses on some Primary Care Teams. There is also provision of the Counselling in Primary Care (CIPC) Service for people experiencing difficulties, such as depression, anxiety or loss. These services are available to young people aged 16 upwards, if they are medical card holders through the G.P. service.

- The HSE Mental Health service provides a service to people, aged 18 years upwards, who experience acute mental health symptoms requiring clinical intervention. Services can be provided in the community setting unless hospitalisation is required. With the closure of St. Michael’s Unit in St. Luke’s Hospital, Clonmel, in recent years, there are now no ‘acute beds’ available within the county.

- In the non-statutory sector, Knockanrawley Resource Centre, Tipperary town, provides a Family Therapy service which has some capacity to cover the south of the county.

Prevention and Early Intervention

In the area of Prevention and Early Intervention, there are no comparable service structures or resources to respond to the needs of the young people who are affected by the Mental Health issues described above. This area has tended to be left to ad hoc local initiatives undertaken by youth services, schools, non-statutory family support services, and other agencies.

Prevention;

- Individual second level schools have made their own arrangements to draft in a variety of programmes to supplement the SPHE programme

- The youth services periodically address issues of mental health with their young people, and one particular service delivers a programme to Transition Year students in the schools

- Tipperary Comhairle na nÓg is to the fore in organizing activities to promote awareness of Youth Mental Health around the county

Early Intervention;

There are a number of agencies with some capacity to engage with young people experiencing difficulties, for example;

- Second level schools with Guidance Counsellors and Pastoral Care resources. It is clear anecdotally that schools play a vital role in supporting many vulnerable young people who could not access an appropriate service elsewhere.

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- Youth services have consistently undertaken work with young people in relation to their mental health and wellbeing, and this is the case with the three youth work organisations in the area, namely, Youth Work Ireland Tipperary, Waterford and South Tipperary Community Youth Service and Foróige.

- The three Family Resource Centres, respectively in Cashel, Tipperary town and in the Slieveardagh area have counselling resources for adults.

- Áras Folláin, based in Nenagh, is a voluntary Positive Well-being Centre which supports and facilitates peer group engagement around issues of mental health and wellbeing, and also seeks to build capacity for improved mental health through the provision of WRAP training and other appropriate training. Young adults, aged >18 years, can engage in its activities.

There is currently no coordinated county-wide approach to Mental Health for young people in the area of Early Intervention. There is a need for a service like the Jigsaw structure to bridge the gap to;

- Ensure easy access to mental health supports for young people in need

- Link with all other agencies providing support to young people in order to develop a joined-up, cooperative approach to addressing the mental health needs of young people

- Promote community awareness and understanding of the risk and protective factors that contribute to the mental health and well-being of young people

- Involve young people in consultations and decisions regarding how the service can best meet their needs

Jigsaw as a Model

Jigsaw was developed by Headstrong, the National Centre for Youth Mental Health, in response to the unmet mental health needs of young people in Ireland. Jigsaw is an evidence-informed, innovative, community-based service which supports young people, aged 12-25, to achieve better mental health and wellbeing. Jigsaw provides responsive, youth focused mental health interventions to young people in accessible, non-stigmatising locations. Young people and their parents can avail of a free, confidential brief intervention service of up to six sessions of support.

Direct participation by a Youth Advisory Panel is central to Jigsaw. Young people are involved at all levels, from staff recruitment to service design. Since 2015, Jigsaw is funded primarily by the HSE

Mental Health Division.

The Goals of Jigsaw

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In addition to providing one to one direct supports for young people, Jigsaw delivers mental health capacity building and community awareness workshops to parents, young people and those who work and volunteer with young people.

The Policy Context

A Vision for Change, 2006; Jigsaw operationalises many of the core elements as set out in this comprehensive policy;

“The mental health system should deliver a range of activities to promote positive mental health in the community; it should intervene early when problems develop; and it should enhance the inclusion and optimal functioning of people who have severe mental health problems. Service providers should work in partnership with service users and their families, and facilitate recovery and reintegration through the provision of accessible, comprehensive and community-based mental health services.” (P.14)

Better Outcomes, Brighter Futures, 2014 – 2020

Jigsaw is aligned with Better Outcomes, Brighter Futures, the overarching national policy framework for children and young people aged 0-24 years. In this document, the Government sets out it’s key commitments to children and young people and articulates key transformational goals including a commitment to;

“Establish integrated services or ‘hubs’ for children and young people at community level (examples include Primary Care Clinics, Family Support/Resource Centres and Jigsaw Youth Mental Health Centres) and, where appropriate, bring health and therapeutic services into schools.” (p. 40).

The policy again references the work of Jigsaw whereby “The Government recognises the importance of having ‘One Good Adult’ in a young person’s life and that children and young people need positive role models and positive relationships with older adults” (p. 54).

In BOBF, the Government also commits to the implementation of a Vision for Change as it relates to children and young people, in particular “to improve access to early intervention youth mental health services and coordination of service supports, with a focus on improving mental health literacy and reducing incidents of self-harm and suicide” (p. 57).

Healthy Ireland, 2013 – 2025

The objectives of Jigsaw are very much aligned with those of Healthy Ireland; the HSE’s framework for improving health and wellbeing. The implementation of the Jigsaw model, particularly the capacity building and community awareness programmes, can help to progress the Healthy Ireland

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agenda through a focus on well-being by educating and upskilling volunteers, professionals and families to act as One Good Adults in the lives of young people.

Connecting for Life: Ireland’s National Suicide Strategy to Reduce Suicide, 2015 – 2020

Many of the objectives of Jigsaw map onto the goals outlined in Connecting for Life, for example;

Goal 1: To improve the nation’s understanding of and attitudes to suicidal behaviour, mental health and wellbeing.

Goal 1.3: Reduce stigmatising attitudes to mental health and suicidal behaviour at population level and within priority groups.

Goal 2: To support local communities’ capacity to prevent and respond to suicidal behaviour.

Goal 3.3: Enhance the supports for young people with mental health problems or vulnerable to suicide.

Goal 4: To enhance accessibility, consistency and care pathways of services for people vulnerable to suicidal behaviour.

The overall vision of the ‘Connecting for Life’ strategy also ties in to the work and vision of Jigsaw, as it seeks to promote “An Ireland where fewer lives are lost through suicide, and where communities and individuals are empowered to improve their mental health and wellbeing”.

Connecting for Life formulated 7 Strategic Goals:

1. To improve the nation’s understanding of, and attitudes to, suicidal behavior

2. To support local communities’ capacity to prevent and respond to suicidal behavior

3. To target approaches to reduce suicidal behaviour and improve mental health among priority groups

4. To enhance accessibility, consistency and care pathways of services for people vulnerable to suicidal behaviour

5. To ensure safe and high quality services for people vulnerable to suicide

6. To reduce and restrict access to means of suicidal behaviour

7. To improve surveillance, evaluation and high quality research relating to suicidal behaviour

Suicide Prevention Strategies at county level:

These Strategic Goals frame the Suicide Prevention Strategies for the Northern and Southern parts of County Tipperary, namely:

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- ‘Connecting for Life South Tipperary: South Tipperary Action Plan to Prevent Suicide 2017 – 2020’

- ‘Connecting for Life Mid West: Suicide Prevention Action Plan 2017 – 2020’

The objectives of Jigsaw will support and complement the goals and associated actions in the Action Plans.

Local Economic and Community Plan, Tipperary

Tipperary Local Community Development Committee’s ‘Local Community and Social Inclusion Plan’ was published in November 2015. It identifies a range of groups in the population in the county which are at particular risk of social exclusion, such as the long-term unemployed, lone parent households, young people with disabilities, Travellers, and those living in socially deprived areas around the county. It has developed a set of priorities and measures to address issues of marginalisation, chronic unemployment, gaps in child and family support service provision, substance misuse, mental health and well-being, and others. The Priorities and Strategic Actions are also included in the ‘Local Economic and Community Plan’.

While all the priorities have a bearing on supporting Mental Health and Well-being in the community, some have a particular relevance for Youth Mental Health:

- High Level Community and Social Inclusion Priority 4 with a focus on chronic unemployment, has actions targeting areas of high youth unemployment, as well as young Travellers and young people with disabilities.

- High Level Community and Social Inclusion Priority 5 is ‘to maximise life opportunity and potential for young people and to support and facilitate their contribution to the sustainable development of the county.’ Actions under this priority address the issues of gaps in youth service provision, of facilitating access to services for youth in rural areas, and also target Traveller youth, young people in the justice system, young people with disabilities and young people in after-care.

- Under High Level Community and Social Inclusion Priority 6 in relation to the reduction of marginalization of certain social categories, there are measures outlined addressing this issue for LGBTI people, the Traveller community and the homeless.

- Under High Level Community and Social Inclusion Priority 7, targeting the needs of vulnerable families, children / young people in areas of greatest risk, the HSE is the designated coordinating lead for an action to support initiatives that address the needs of children and young people in relation to Mental Health.

- High Level Community and Social Inclusion Priority 10 refers to supporting access for people with disabilities to opportunities in education, work, etc. and to promote social integration.

- High Level Community and Social Inclusion Priority 11 is to develop an integrated response in relation to health and well-being of the community in relation to marginalised groups and

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areas. One Strategic Action outlined is the development of a Suicide Prevention Strategy for the county.

How Jigsaw Operates

A Jigsaw project is staffed as follows;

Project Manager

Clinical Coordinator

Senior/Clinical Support Workers

Youth and Community Engagement Worker

Administrator

Clinical workers are sourced from a mental health nursing, psychology (clinical / counselling / educational), social work or occupational therapy background

Governance and Risk Management

Jigsaw assures the HSE Mental Health Division that the governance structure for each Jigsaw Service is robust, that the clinical governance process is clear, accountable and clinically appropriate and meets the standards and the needs of young people. Local stakeholder groups, Jigsaw Advisory Group and the Clinical Governance Advisory Group support, guide and advise the work of the Jigsaw Services, within the context of Principles, Guidelines, Policies, Procedures and Quality Standards developed by Jigsaw.

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Policies and procedures within which Jigsaw services are provided are also in line with HSE policies and relevant legislation.

Jigsaw Hub and Premises

A Jigsaw Hub is a neutral, accessible and youth friendly space which operates according to the principles of prevention and early intervention in offering both selective and indicated prevention strategies to young people presenting with a wide range of issues, from common concerns to emerging mental health difficulties.

Depending on their needs, a young person can access information, a brief goal-focused intervention or support in accessing more specialist mental health services, if required. Given the emphasis on creating accessible mental health supports, the Jigsaw Hub is also a space where other mental health professionals can provide a service to young people.

Jigsaw Hub Office Space Requirements

(Based on the occupancy of 7 staff + 2 for growth)

Quantity Area Staff Size (sq ft)1 Large & Open Reception 1 x Administrator 5003 Consulting Rooms General 5402 Offices 1 x Project Manager

1 x Clinical Coordinator110110

1 Open Plan Area (1) 3 x Clinical Staff 2201 Open Plan Area (2) 1 x Youth Engagement

2 x Hot-desks220

1 Large Meeting Room YAP Space/Training/Meetings

470

1 Canteen/Kitchen General 2201 Storage area General 1101 Stationery photocopying

areaGeneral 80

1 Toilets (including disabled access)

General 120

TOTAL SPACE REQUIRED 2,700 sq. ft. (250 sq. m)

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Evaluation of the Jigsaw Model

In order to gather information about service delivery within Jigsaw, a comprehensive information system with both clinical and research functions has been designed by Headstrong in collaboration with Rackspace for data storage and protection (UK) and REACH of Louisville for data mining, site development and improvement (USA); the Jigsaw Data System (JDS). The JDS gathers detailed information about ‘direct work’ with young people in Jigsaw such as case demographics, referral pathways, presenting issues, developmental assets, support provided, intervention approaches employed, and outcome data concerning psychological distress and goal attainment.

In addition, there is an ‘indirect work’ section of the software which provides staff with the opportunity to document other activities that are carried out in Jigsaw such as YAP meetings, fundraising activities, promotional events and training. The primary tool for collation, synthesis and graphic portrayal of these data is termed Jigsaw Analytics. Developed by REACH of Louisville in fulfilment of its data management role, the Jigsaw Analytics tool accesses raw data in a fully anonymised fashion and provides graphic portrayals of programme processes and outcomes.

There are two components to the JDS; data gathered for the purposes of clinical case management (for the exclusive use of the specific Jigsaw Service staff) and data gathered for the purposes of evaluation and shared with Jigsaw in an anonymised way. The intent is for Jigsaw to process the data in such a way as to enable project managers/clinical coordinators, the community, government and other audiences (e.g., the research community) to have available statistical or aggregated data that supports the evaluation of the Jigsaw initiative.

Accruing this data allows for continuous surveillance of Jigsaw’s activities and outputs such as who is served and what services are delivered. In addition, key performance indicators are put in place to establish and monitor the ongoing progress of the Jigsaw model, for example, target numbers of young people to be served are set by each individual site.

Jigsaw occasionally audits the JDS to ensure that the system is being used according to policy and the system is under continuous development and improvement through work by REACH of Louisville and the Research and Evaluation Team (Research Coordinator, Research and Evaluation Officers) in conjunction with Jigsaw staff.

Funding Jigsaw as a Model of Delivery in Tipperary

A Jigsaw site costs approximately € 650,000 to run each year. This cost, which the HSE contribution covers, funds recruitment and salary costs of 7 WTE5 core staff and the regional support costs which include a Clinical Governance Manager and a Jigsaw Regional Manager. The HSE contribution also funds the Jigsaw Data System (JDS) and clinical and operational governance from the Jigsaw National Office. The local interagency working group collaborate with Local Authorities to identify and secure suitable premises as these costs and additional running costs are not included in the HSE contribution and are required to be sourced through fundraising and local community support.

5 Whole time equivalents

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Action Plan and Timeframe to Establish a Jigsaw Hub

Actions Responsibility Timeframe

Identify suitable premises for the Jigsaw Hub

Include Young People in the selection and development of

the Jigsaw Hub space

Recruit staff for Jigsaw Hub

Induct and train staff in Jigsaw model

Train Jigsaw Hub staff on the Online Data Management

System

Open door to the Jigsaw Hub

Develop and implement a communication, marketing and

PR strategy.

Develop relationships and links and networks with relevant

local agencies and services

Executive/Planning Group

Jigsaw National Office

Qtr. 1 2017

Qtr. 2 2017

Qtr 3 2017

Conclusion

This paper, developed by the interagency working group and supported by Headstrong, has aimed to demonstrate the urgent need for prevention and early intervention mental health services in Tipperary for young people aged 12 – 25 years.

There is currently no coordinated county-wide approach to Mental Health support for young people, thus there is a need for a Jigsaw project which will ensure easy access to mental health supports for young people in need, develop a joined-up, cooperative approach to addressing the mental health needs of young people and promote community awareness and understanding of the risk and protective factors that contribute to the mental health and well-being of young people whilst involving young people in consultations and decisions regarding how the service can best meet their needs.

As demonstrated, Mental Health has been identified as a key priority for all agencies working with young people in the county. Development work has been ongoing since 2011, wherein key statutory and voluntary agencies have been collaborating to raise awareness and establish the structures in preparation for a Jigsaw project. Since the amalgamation of local structures and the development of the all-county Children and Young People’s Services Committee, the establishment of a Jigsaw project has been a key priority and youth mental health has been a key priority in the Tipperary Local Economic and Community Plan (LECP) and the Tipperary Children and Young People’s Services Committee (CYPSC) among others.

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The interagency working group are now seeking support to establish a Jigsaw project in Tipperary and consider the following as critical success factors;

- The central involvement of young people in the planning, delivery and evaluation of Jigsaw

- Building and maintaining a strong partnership network, both locally and nationally

- Engaging with all aspects of the community to promote a sense of community ownership relative to the needs of young people

- Building and maintaining strong support for the project within the HSE Mental Health and Primary Care Services

- Building and maintaining strong links with key partner organisations like Mental Health Ireland

- Building and maintaining strong linkages with the local community

- Recruiting and developing a highly skilled staff team with expertise in youth mental health, partnership development and community engagement

- Creating a supportive environment that is achieving real and positive change for young people in Tipperary

Consultations, with young people in particular, but also with all relevant agencies over a number of years, has consistently identified the lack of youth mental health support services as an urgent issue requiring an immediate response. The interagency working group are now seeking support to establish a Jigsaw project in Tipperary.

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