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A key objective of the Labour government's health strategy is the provision of patient choice. A separate but equally significant objective is that of achieving cost-effectiveness: that is, of getting value for money from spending on health and social care services.

Between these two goals there is potential for considerable conflict. Increasingly, the Department of Health is looking to "evidence-based" research to provide support in determining what policies and practices should prevail. This approach brings its own problems as can be seen from one of the DoH's own research studies.


The DoH is sponsoring a series of cost-effectiveness studies co-ordinated by the University of York's social work research and development unit. In its second briefing paper it presents the outline of a study into the costs and outcomes of different interventions for sexually abused children.¹

A full account of the study has yet to be published, but details are provided in the briefing paper. A group of sexually abused girls were "randomly allocated to either individual or group therapy". The outcomes of the therapeutic interventions were measured and it was found that both groups improved significantly over time in terms of "psychiatric psychopathology and functioning".

However, the cost of individual therapy was calculated as being on average £1,246 more expensive per person than that for group therapy. The study concludes that, in cost terms, group therapy is the more effective option - the only caveat being that there may be logistical problems in setting up groups which can cause delays in starting therapy for children who may have pressing treatment needs.

The most logical outcome of this study is that the health service, despite its commitment to choice, will not in future provide individual therapy for sexually abused children. A decision along these lines would force those requiring such a service to seek it outside the statutory framework of provision. After all, if the DoH is commissioning this type of research, why not act upon its findings?

Of course, to do so would be totally unacceptable. And, in fact, most studies into the sexual abuse of children have pointed to the considerable shortage of any type of therapeutic facilities.²

Another key finding of studies of sexually abused children (and their carers), is that there is a range of responses to being abused and that each child has their own particular needs that must be addressed to ensure the best outcomes.³

This study indicates the need for the provision of more accessible services offering greater flexibility and based on the expressed wishes of the children themselves, which is in direct contrast to the one-size-fits-all solution offered by the DoH's cost-effectiveness study.

But which studies are likely to have the most influence? The fact that the cost-benefit analysis considered here has been sponsored by the DoH ensures that it will be given serious consideration when policy is being developed, and there is no guarantee that it will be counterbalanced with independent research. The fact that this study is concerned with evaluating the effectiveness of two types of treatment to which subjects are randomly allocated gives it an aura of being scientific and of carrying greater weight than other studies not conducted in this way. Unfortunately, the synopsis of this study suggests there are some major pitfalls.

The first of these is an ethical one. The fact that the sexually abused girls were randomly allocated to either individual or group therapy is of concern in itself. How this was done? Presumably, they were not given a choice. At least one could be thankful that, in the pursuit of scientific exactitude, a control group was not left untreated.


A second issue relates to the evaluation of the outcomes that, as has been noted, are said to have been positive ones. It is not clear whether these judgements include the views of the children or their carers. If, as I suspect, they do not, this raises even more concerns about the issue of choice and who decides what is best for whom.

It is clear that the parameters a piece of research sets for itself and the way in which it is conducted have a major influence on the findings and conclusions. Research that confines itself to collecting data from the professionals and from documentation in order to evaluate the outcomes of a project misses out on the key participants in the process - the children and their carers - who are best able to comment on whether the therapy has worked for them.

Similarly, the focus on cost to determine what form of therapy to apply to children who have been sexually abused seems insensitive and, given what we know about the variation and complexity of their reactions in these situations, misguided.

Although cost-benefit research can undoubtedly help in deciding between the cheapest equally effective way to mend a broken finger, it does not work as well with helping to "heal" sexually abused children. If the government is truly committed to choice in health care provision, then this seems to be an area where there should be no question about providing it - almost regardless of cost.

On the other hand , if we are really forced to consider the costs of providing treatment for sexually abused children and their families, we must take into account research showing the longer-term consequences of being sexually abused. Apart from the human cost to every individual who has been abused, we could be more hard-headed about calculating the financial cost associated with the over-representation of women who have been sexually abused in the psychiatric hospital population.⁴

In the light of this knowledge, penny-pinching on the provision of therapeutic services for sexually abused children seems to be a short-sighted and potentially expensive policy. 

Brian Corby is professor of social work studies, University of Central Lancashire.

References

¹ Department of Health, Costs and Outcomes of Different Interventions for Sexually Abused Children in Costs and Effectiveness of Services for Children in Need, Briefing Paper 2, 2003

² R Calam, L Horn, D Glasgow, A Cox, "Psychological Disturbance and Child Sexual abuse: a follow-up study", Child Abuse & Neglect 22, 901-13, 1998

³ S Richardson, H Bacon, Creative Responses to Child Sexual Abuse: Challenges and Dilemmas, Jessica Kingsley, 2001

⁴ C Wurr, I Partridge, "The Prevalence of a History of Childhood Sexual Abuse in an Acute Adult Inpatient Population", Child Abuse & Neglect 20, 867-72