Theme 6: External Partnerships and Pathways
What does it cover?
- Relationships with primary and secondary health care
- Relationships with social care
- Relationships with 3rd sector providers
- Relationships with Disabled Students Allowances (DSAs) funded private suppliers
Principles of good practice
6.1 Universities take proactive steps to build relationships with local NHS, Social Care and third sector agencies, creating a shared understanding of each other’s roles and responsibilities and demonstrating a commitment to principles of effective collaboration.
6.2 Universities are able and willing to work collaboratively with NHS/Social Care to support individual students
6.3 Universities support NHS/Social Care and other relevant agencies to understand the context of student life and the implications of treatment options and other decisions.
6.4 Universities have arrangements in place to assess risk and effectively communicate this to NHS/Social Care.
6.5 Universities work with NHS/Social Care to support students to return to study when appropriate.
6.6 Universities work collaboratively with DSA funded private providers, ensuring they are aware of providers provide support to their students that those providers understand the mechanisms for reporting concerns.
Why is this theme important and what matters?
Sector debates, media coverage and recent reports have all raised concerns about the way care is managed between universities and NHS/ Social Care (1–4).
A number of voices have called for universities and local NHS/Social Care providers to form collaborative partnerships and effective working relationships, to better improve the support students with mental illness receive (1, 4, 5). Collaboration across organisations is generally recognised as being necessary to ensure that individuals receive consistent, safe, effective, integrated and cohesive care and support (6, 7).
In the Charter consultation focus groups, support services staff highlighted a number of challenges to creating effective working relationships with external services. This evidence indicates that relationships are variable across both primary and secondary care.
Where GPs are based on a university campus, this can result in much better relationships and closer working between universities and GPs to support individual students, although this is not guaranteed. Building effective relationships between universities and GPs off campus appears to be much more difficult and variable. This becomes more problematic when GPs are based out of the area, are not used to working with universities and are less likely to understand the nature of the support universities provide. University staff identified that it has become increasingly difficult for students to access secondary care, even when in crisis or seriously mentally ill. This increases risk and places additional strain on university support systems. Gaps in care between universities and statutory services means that the responses and support an individual receives may become fragmented and even contradictory, leading to harm.
There appear to be common misunderstandings between universities and the local NHS or Social Care agencies. For instance, there were multiple accounts, from support staff in focus groups, of students being discharged to ‘University support services’ without consultation with the university. Others reported instances of ill and distressed students being returned to halls of residence late at night, as a place of safety, when no staff are available. It should be noted however, that university staff in general did not believe any blame was attributable to NHS staff. Many of the staff in the focus groups were or had been NHS clinicians and fully understood why external agencies would make such decisions, given the current availability of resources and demand.
University staff did highlight that it was easier to build relationships with NHS teams, when university staff were also mental health professionals who understood the context, language and systems of the NHS.
In response to this, a number of initiatives have been established to try to improve collaboration. These vary from creating NHS roles within university services, building formal partnerships and seeking to create specific care pathways that recognise the unique needs of students (8, 9). Some universities have created working relationships with third sector providers to help address gaps and provide a wider offer to students.
Building effective working relationships is clearly desirable for all (1, 6). However, how this can be done will inevitably vary from place to place. Some participants identified that a number of the current initiatives being developed are in large cities with multiple universities, resulting in very large student populations. It was felt that such solutions are unlikely to work for small providers or those based in rural locations. Colleagues in London universities highlighted the problems of having a population spread across a number of health boroughs.
Much of the dialogue in the sector revolves around the need to properly define the ‘hand–off’ point, at which universities should step back and statutory services take over (3). However, some participants felt this may be a problematic approach.
Good practice, particularly in the case of serious mental illness, is to mobilise all of the support available to an individual, to come together and work on a shared plan of care. The idea of a hand off point runs contrary to this. Mental health is also subject to fluctuation, sometimes rapidly, which may mean an individual passing back and forth between university and NHS as their health fluctuates, fragmenting care.
Instead, it is more appropriate to speak of thresholds of responsibility and collaboration between services and the student, to deliver a complete support package, centred on the needs of the individual. Where university services and statutory services can work together, alongside the individual, each with an understanding of their own appropriate threshold of responsibility, a better outcome for a student is more likely. However, this requires a better understanding of where those thresholds lie, what responsibilities each partner has and how collaborative working should be described on either side. A recent paper in the Lancet (2) attempts to bring some definition to these principles and there are significant echoes between this paper and the views of participants in the consultations.
Effective collaboration, of course, requires willingness on both sides and a recognition that students don’t stop being students when they become ill, or immediately cease to be patients when they are able to re–engage with studies.
While universities cannot control the responses of local NHS services, they can commit to principles of collaboration and, through better collaboration, make every effort to close the gap between Higher Education and healthcare.
In addition to these relationships, support services staff participants in Charter focus groups highlighted potential risks in arrangements between universities and private providers of DSA funded support to students who experience mental illness. These concerns suggested that providers may be supporting students who are seriously ill and potentially at risk but may be unaware of what support is available within the university and how to contact or access this support. Confidentiality arrangements or understanding may also act as a barrier to this information being passed to the university. As a result, support services may be unaware that a student is significantly ill, despite them receiving support for their illness on university premises. This indicates an area of potential risk that requires concerted action.
Universities UK – Minding our Future: Starting a conversation about the support of student mental health
|1. Universities UK. (2018) Minding our Future: Starting a conversation about the support of student mental health (Rep). London: UUK.. https://www.universitiesuk.ac.uk/minding–our–future|
|2. Duffy, A., Saunders, K.E.A., Malhi, G.S., Patten, S., Cipriani, A., McNevin, S.H., MacDonald, E. Geddes, J. (2019). Mental health care for university students: a way forward? The Lancet Psychiatry. https://doi.org/10.1016/S2215–0366(19)30275–5|
|3. Lewis, B. (2019) University View. The Western Mail. 3rd October.|
|4. Raddi, G. (2019). Universities and the NHS must join forces to boost student mental health. The Guardian. 15 Feb.. https://www.theguardian.com/education/2019/feb/15/universities–and–the–nhs–must–join–forces–to–boost–student–mental–health|
|5. Royal College of Psychiatrists, (2011). Mental health of students in higher education London: RCPSych.. https://www.rcpsych.ac.uk/docs/default–source/improving–care/better–mh–policy/college–reports/college–report–cr166.pdf?sfvrsn=d5fa2c24_2. [Accessed: 9/11/19]|
|6. British Medical Association (2017) Breaking down barriers – the challenge of improving mental health outcomes. London: BMA|
|7. South East Clinical Senate (2017) Improving clinical communications between primary and secondary care clinicians. East Surrey: SECS|
|8. Office for Students (2019). Improving mental health outcomes – Office for Students. [online] Officeforstudents.org.uk.. https://www.officeforstudents.org.uk/advice–and–guidance/student–wellbeing–and–protection/improving–mental–health–outcomes/. [Accessed: 7/10/19]|
|9. Waller, R., Mahmood, T., Gandhi, R., Delves, S., Humphries, N. & Smith, D. (2005). Student mental health: how can psychiatrists better support the work of university medical centres and university counselling services? British Journal of Guidance & Counselling, 33(1). Pp117–128. DOI: 10.1080/03069880412331335876|