Jennifer Beecham looks at what we know and don’t know about cost-effectiveness in children’s social care
Lack of evidence
Published UK research into the cost-effectiveness of children’s social care is sparse. Although the number of studies that include a cost component has increased significantly this decade, few meet the criteria for a full cost-effectiveness evaluation – in which case costs are combined with final outcomes (changes in welfare), rather than service-level (intermediate) outcomes. Because there are so few studies, there is no body of evidence for decision-makers to draw on while developing policy or commissioning services to meet specific needs.
Diversity influences costs
Parenting programme staffing costs, for example, might range from less than £100 to more than £10,000. At the low-cost end are the more accessible services – perhaps leaflets or general advice. At the high-cost end are some specialist interventions such as those piloted in the parenting early intervention pathfinders.
It would be difficult to assert that parenting programmes are cost-effective given this 100-fold cost variation. Different outcomes are likely to be generated by the way resources are combined in each programme to meet users’ needs.
Responsive versus specialist services
Responsive services respond to a wide range of needs, including service users’ perceived needs, by providing easily accessible support. Interventions are typically fairly low intensity and likely to be used early in a child’s service career. They rarely use tight selection criteria and workers respond in different ways to the different stresses of each family.
Examples that have been evaluated, although not all with cost-effectiveness analyses, include Home Start, some interventions within family centres and Sure Start, therapeutic family support, adolescent prevention support, and key workers for disabled children.
These are often used in addition to conventional services, but the additional costs will be relatively small. Such services have high user satisfaction and qualitative interviews show positive outcomes. Goal attainment may be a useful and measurable outcome but these goals will cover a range of activities. Cost-effectiveness tends to be unproven in the existing short-term studies; it may be that they are cost-effective, but we lack the appropriate outcome measures to test this properly.
Specialist services are likely to be targeted on particular groups of children and families, commonly serving those at “high risk”. The desirability of the interventions will be professionally determined and the intervention often follows a pre-specified format which helps the potential for replication.
Examples include family functioning therapy, some parenting programmes, intensive health visiting, intensive foster care, and perhaps the original family intervention projects.
Unit costs tend to be relatively high, commonly leading to higher overall costs, so it is important that these services are used by those who will benefit most.
These interventions may affect wider service use but are unlikely to meet all a family’s needs. They tend to be more effective than “services as usual” on pre-specified, but often narrow, outcome domains.
Outcomes specific to social care are rarely measured. A clear cost-effectiveness advantage is difficult to show in these short-term studies of these interventions because they generate both higher costs and improvement on some outcome domains.
Implementing early intervention services
Specialist services require accurate targeting of those who would otherwise have poor outcomes. This is difficult to predict. There is some evidence to suggest the best effects are obtained by focusing on turning points, such as birth of a child, start of school and so on. Responsive services are easily accessible and therefore reach a wider audience.
This implies they may also be used by those not “in need” (eg Sure Start). The lower intensity support may mean smaller effects on families in areas that are difficult to measure.
Early intervention services may identify more children and families with service needs, or more service needs in those they are supporting, thus increasing overall costs. In the short-term, additional funding will be required because until the current cohort of young families go through these early intervention services, and the subsequent benefits begin to appear, it will still be necessary to provide the more intensive (costly) supports for older children.
These double running costs could be required for another 10 years, or until the current cohort of early intervention users leave children’s services through age. Even after that, intensive supports for some older children will still be needed.
This is an extract from a paper by Professor Jennifer Beecham of the Personal Social Services Research Unit at the London School of Economics and the University of Kent, presented to the Public Policy Seminar in November 2009
This article is published in the 3 June issue of Community Care magazine under the heading Measures of success