Evolution of Jigsaw ‐ a National Youth Mental Health Service

There has been a global movement towards transformation of youth mental health services, but limited information on the core principles and characteristics of these new services is available. Jigsaw is one such service, established in Ireland in 2006, with the intent of creating change in Ireland's system of mental healthcare for 12–25 year olds. The aim of this paper is to describe the evolution of Jigsaw services, which are now firmly embedded in the Irish system of care for young people, and recognized internationally as an established service network.


| INTRODUCTION
It is well established that adolescence and early adulthood are peak times for the onset of mental health difficulties. There is also a growing body of evidence indicating that the prevalence of mental health difficulties is increasing amongst 12-25 year olds (Bor et al., 2014;Collishaw, 2015). Paradoxically, mental health difficulties often remain undetected until later in life and many young people do not get adequate support (Patel et al., 2007). In recent years there has been an international movement to transform youth mental health services, so that access to and engagement with services for young people is improved. A global framework for youth mental health was recently developed by Orygen and the World Economic Forum (Killackey et al., 2020), articulating eight principles that underpin an approach to youth mental health. Recent reviews have also described the key attributes of and emerging evidence from existing services, described as integrated youth mental health services (IYMHs) and integrated community-based youth service hubs (Hetrick et al., 2017;Settipani The O'Reilly, Aileen and O'Brien, Gillian contributed equally to this paper 3 | SERVICES AND INTERVENTIONS

| Therapeutic service
The Jigsaw model of therapeutic support is brief and evidenceinformed. Following initial intake and assessment young people may attend for a therapeutic intervention of up to eight sessions (referred to in Jigsaw as a brief intervention); the average is 5.9. Prior to March 2020, and the official declaration of COVID-19 as a pandemic, a brief intervention was delivered in-person by a clinician in a Jigsaw hub.
However, clinicians are now delivering a combination of in-person (57%), video (28%) and phone (15%) support, with phone/video support set to continue beyond the current pandemic. Typically, Jigsaw clinicians draw on a range of therapeutic approaches, such as cognitive behavioural, compassion focused, acceptance and commitment, or solution focused, depending on the needs and developmental level of each young person. Uniquely in the Irish system, Jigsaw provides a consultation service (which accounts for just under 30% of engagements) advising parents, teachers and other concerned adults about how to support youth mental health and/or how to navigate the complexities of the mental health system. To ensure rapid, easy and affordable access, services are provided at no cost at the point of delivery in youth-friendly service settings, and no professional referral is required. As Table 1 shows, most young people engaging with Jigsaw are female (61%), aged 15-17 years (39%), while self-referrals, parents and General Practitioners (GPs) account for about 87% of referrals. Similar to other services, anxiety, low mood and stress are top presenting issues, a pattern that has been consistent for many years. Other common difficulties reported by young people include sleep changes (10%), anger (8%), family problems (8%), isolation (7%) and thoughts of hurting self (7%); these are reported in detail  et al., 2015). Encouragingly, the majority of young people report significant reductions in this distress and improvements in wellbeing following a brief intervention (Donnelly et al., 2019;O'Keeffe et al., 2015). Additionally, young people and parents report high levels of satisfaction (O'Reilly et al., 2021).
A recent independent evaluation of Jigsaw commissioned by the Irish Health Service Executive (HSE, 2018, p.47) concluded that "the Jigsaw youth mental health service model is focused and robust, delivering evidence-informed approaches." Recently, Jigsaw has extended its opening hours to include evening appointments (up to 8 PM) at least one day a week, to accommodate young people with commitments during the day. Although the goal is to offer additional appointments at evening and weekends, staffing services out of traditional working hours is challenging. In counties characterized by a large rural population with poor transport links, services are provided in outreach locations to ease accessibility.
Close collaboration with organizations that support vulnerable groups has been essential in helping to ensure accessibility, and Jigsaw intends to improve its method of collecting demographic information so that efforts in this regard can be more accurately captured. In 2020, Jigsaw developed a suite of digital supports for young people, including a synchronous chat service (www.jigsaw.ie). These more recent developments go even further in ensuring that Jigsaw is providing accessible, responsive and youth specific mental health supports.

| Scope of practice
Prior to the establishment of Jigsaw, there were very limited primary care mental health supports for young people in Ireland, leaving little option but to refer to secondary care services. The Jigsaw service model was designed to address this gap by occupying a position "upstream" on the mental health service continuum, providing early access to care for young people with mild to moderate mental health difficulties. Jigsaw has developed a set of referral guidelines to support consistent, good quality decision-making but fundamentally, the critical consideration when faced with every referral is whether a brief intervention of up to eight sessions would be helpful and appropriate given the young person's needs. Given Jigsaw's accessibility, some young people with moderate to severe mental health needs present to Jigsaw (e.g., eating disorders, psychosis). In such circumstances, assessment and intervention with multidisciplinary secondary care services is required.
The success of this service model relies on the functioning of "downstream" services (secondary and tertiary care) as well as good communication and integration between services. Unfortunately, many of the systemic factors in the statutory system, which existed when Jigsaw was established are still present and impact on the feasibility of operating within this scope of practice. These include chronic under-resourcing of statutory mental health services, disjointed services especially at transition points between child and adolescent and adult services, differing inclusion and exclusion criteria, lengthy waiting lists, and limited service provision for those in suicidal crisis. If, following psychosocial assessment using the HEADSS framework (Cohen et al., 1991), Jigsaw identifies that a young person requires input from secondary care, they are supported to access these services, but there can be challenges in facilitating an onward referral as some secondary mental health services only accept GP referrals.
Young people who are referred onwards can access a range of online supports whilst awaiting their appointment with secondary care services. Given the potential for these young people to "fall between the  has also developed a new online learning platform to deliver live webinars, eLearning courses and workshops, and is now reaching wider audiences within and beyond Jigsaw service areas. This has been particularly successful with teaching staff, and over 10 000 teachers have registered to date (Jigsaw, 2020). Youth participation is also embedded in Jigsaw's therapeutic services, which are developmentally appropriate and fundamentally person-centred in their orientation; for example, young people are centrally involved in their assessment and intervention plans, and satisfaction data are routinely gathered from young people to inform service delivery. An online service user forum is planned to ensure that the views of young people who have used Jigsaw services are informing future developments. A youth research council, which involves young people actively contributing to Jigsaw's research programme, has also recently been established to ensure that this work is relevant, meaningful and impactful.

| Youth participation
Ongoing quality reviews and research show high levels of youth involvement in the development of new initiatives, staff recruitment and governance (Barry, 2014). However, a recent mapping of youth participation practice has highlighted that participation does not always equate to youth voice in decision-making. Therefore To support the transition to a single governance model, Jigsaw invested in the development of centralized functions including finance, human resources, and IT/facilities. Figure 1 outlines Jigsaw's organizational structure and details the operational and clinical governance model for services. Under the terms of service level agreements with the HSE, Jigsaw is responsible for delivering safe, high quality services in line with agreed targets and KPIs. Jigsaw has adopted a quality assurance system and has a Quality and Safety Board subcommittee to oversee this.

| Service providers
Early experimentation in the Jigsaw model meant that each service looked very different, comprised of mental health professionals with a range of skills. Over time, as the critical components of the model emerged, the skillset and competency mix required became apparent.
Today, each service is jointly managed by a clinical manager and service manager who are responsible for clinical and operational elements of the service respectively (see Figure 1). Members of the clinical team are drawn from a range of disciplines including psychologists, social workers, occupational therapists, mental health nurses and psychotherapists. The clinical team is transdisciplinary in that each member draws on their experience and training, whilst working in a brief therapeutic model. There is a strong emphasis on shared competencies and cross-disciplinary learning, and the discipline-based hierarchies that exist in traditional mental health services in Ireland are absent. In addition to clinical work, clinicians have protected time to engage in mental health promotion. Teams have youth and community roles focused on health promotion and youth participation, and support is provided by service administrators. The public health model in Ireland, in which Jigsaw is a contracted provider, does not allow for incentive or individual fee payments. Jigsaw staff are paid on salary ranges, which take due regard to public sector pay scales. Whilst mainstream funding provided staff with the security that comes with permanent contracts, Jigsaw is a relatively small organization in competition for staff with the HSE, which is the largest employer of healthcare professionals in Ireland. Developing innovative ways to attract and retain staff has impacted on service provision, so this is a priority for Jigsaw alongside influencing training of the future workforce and further enhancing organizational culture.

| CONCLUSION
This paper provides an up-to-date description of the Jigsaw service model, and describes historical and ongoing challenges that have shaped the evolution of this model. This addresses a key recommendation from systematic reviews of youth mental health services, and we hope that our contribution will be useful to those interested in creating similar service models. However, it is important to note that while Jigsaw's service model aligns too many of the principles set out in the recently launched global framework for youth mental health, local contextual factors heavily influence implementation of youth mental health services (Killackey et al., 2020). Further evolution of the model is also required to ensure Jigsaw continues to be responsive to the needs of young people, and particularly in light of the current COVID-19 pandemic.