Are children’s services cost effective?

THE RESEARCH

Title: Costs and Outcomes in Children’s Social Care.
Authors: Jennifer Beecham and Ian Sinclair.
Institutions: Jennifer Beecham is reader in social policy at the PSSRU, University of Kent, and senior lecturer at the Centre for the Economics of Mental Health, Institute of Psychiatry, London. Ian Sinclair is a research professor in the Social work Research and Development Unit, University of York. The research was originally  commissioned by the Department of Health but transferred to the DfES.
Available: The research is published by Jessica Kingsley Publishers, 2007.

OBJECTIVES

This overview draws together the findings of 14 studies commissioned by the government to explore the relationship between costs and outcomes in children’s social care.

In undertaking the studies, all the teams were asked to build on previous knowledge and add an economic component to the existing data. The studies sought, therefore, to provide data-based feedback for service commissioners to help them use public money effectively and facilitate change for vulnerable families.

The studies fall into two broad groups. A starting point was that a large proportion of the funding for children’s social care goes into providing high levels of services for a relatively small group of children who have very complex needs and are often on the cusp of or already being looked after. Therefore, most of the studies looked at interventions related to the care system while a smaller group looked at services provided at an “earlier” point or were accessible to a wider population of families. The studies examined individual services and asked:

● What was the money was being spent on?
● What makes a service more effective?
● How far is one service more effective than another?

FINDINGS

The overview is essential reading for those with the responsibility for the strategic management and commissioning of children services. But social care practitioners may be uncomfortable with a research culture which appears to be financially oriented. Such reluctance would be misplaced.

Beecham and Sinclair argue that one of the aims of this overview is to provide “ammunition” for practitioners in making a case for the allocation of resources to individual families. They seek to show that there is a “business” case for some services in terms of the relationship between costs and effectiveness. For example, specialist adolescent teams that sought to divert children from the care system were found to be both popular and cost effective.

However, the findings highlighted in the overview raise a more profound question about the relationship between the business and moral case for services for children. While Beecham and Sinclair focused on the financial dimension of services and practice, they argued that financial costs could not be seen as the sole determinant when planning services. Services must be analysed within the context of the wider social and emotional costs of difficulties faced by individual children and their families which, of course, pose implications for society. Policymakers need to consider the responsibility that the state has toward vulnerable families in deciding what the nature of state intervention should be in such situations. This argument is timely as the government has placed an emphasis on the link between child welfare, social exclusion and the long-term health of the UK economy.

Beecham and Sinclair show there is no simple link between early intervention and cost-effectiveness and draw out some of the complexities that emerge across the cohort of studies. Some of the initiatives highlighted, such as the Home Start scheme, could not be justified in terms of saving money in the longer term. But many parents praised the support provided by Home Start. Such views, as Quinton argues in a later research overview, raise the question of the relationship between “effectiveness” and “entitlement”. In other words to what extent should services be justified on the basis of them being popular with families or whether they meet prescribed outcomes?Likewise, a study that looked at therapeutic family support services found “no significant change” for many children when narrowly measuring such change in terms of defined outcomes but a high level of service satisfaction on the part of the users.

The studies also highlight the fact that a substantial proportion of funding for children’s social care is spent on a relatively small group of children with acute needs. Beecham and Sinclair argue that this raises a question for directors of children’s services as to whether this is a desirable allocation of resources. Certainly there was nothing to suggest that services should be withdrawn from the children in acute need but the overall strategic aim of Every Child Matters is to improve outcomes for all children. The overview, therefore, poses questions as to what level of resources should be allocated to targeting services at the proportionally  wider group of children “at risk” whether or not they are likely to achieve improvement against those outcomes.

One complicating factor is that the delivery of children’s services continues to be frequently fragmented and unco-ordinated. Services have for the most part been delivered by the erstwhile generic social services departments. There has always been a tension between the needs of children already in the care system and the “earlier” needs of a significantly wider population of children in the community. Services for these wider groups have often been sited in the education, health and voluntary sectors and the costs of family support not formally part of social care are hidden.

It is perhaps a paradox that, in adult services, social care is regarded as a lower cost, lower threshold service that has attempted to preserve resources for the NHS and  maintain individuals in their communities for longer. In children’s services, on the other hand, social care is often offered only to families which meet the highest thresholds of need. As the integration agenda moves forward, it highlights the question of whether social care should work only with acute need or whether its input should be made across the spectrum of need.

The other major cross-cutting theme to emerge was the poor quality of recordkeeping in children’s social care. Important information was often missing both in relation to the family’s social histories and their history of service provision. These deficits made the task of assessing the effectiveness of a specific service difficult, although being implored to spend more time on recordkeeping will fill many practitioners with gloom given their dislike of bureaucracy.

Responsibility must rest with managers to devise systems that are both rigorous and effective in terms of time and free practitioners from repetitive recording systems. Beecham and Sinclair emphasise, however,  that core assessments are cost-effective when undertaken to a high standard. A well-argued assessment more than justifies the time spent on it in terms of gaining a full picture of the needs of a family and how resources can best be allocated. The overview showed how often a lack of cost  effectiveness in children’s social care was associated with a poorly formulated link between families’ needs and services offered.

RESOURCES

● Summaries of each study and of the overview itself can be found at www.everychildmatters.gov.uk/resources-and-practice/RS0002
● June Statham from the Thomas Coram Research Unit has produced a research overview
● Quinton, D (edit) (2004) Supporting Parents, Jessica Kingsley Publishers.

PRACTICE IMPLICATIONS

Responsive Family Support Services

Several studies looked at what the authors described as “responsive” family support services such as Home Start. These were positively evaluated by service users but the impact was difficult to measure in terms of change. Therefore, practitioners need to be realistic about the way that they refer to such projects and recognise that, although they can play an important role in supporting many families, they are in themselves unlikely to resolve complex difficulties facing every family.

Early Intervention
Several studies reported very positive views expressed by families about their social workers. However, there was a feeling among many families that social workers were preoccupied by “risk” and did not address their children’s wider needs adequately. Too often this meant support was offered “too little too late”.

Holistic assessments of needs

A relatively small number of children received a core assessment. Some studies found that cases of children who had high levels of need were closed without being fully assessed; or, where need was identified, it was defined only very narrowly. Giving practitioners time and means to produce rigorous core assessment can be justified in both costs and good practice.

Work with adolescents

Accommodating adolescents in need was often resisted at all costs and viewed as a last resort. One study found that the creative use of respite, short-term care could be very effective. When young people were accommodated, all too often they drifted in care until they “aged out of the system”. Specialist adolescent support teams, often staffed by former residential workers are well received and cost effective.

Care planning

Good care planning is based on good assessment. Looked-after children are four times as expensive as other children in need and so there is a sound economic as well as moral argument for maintaining as many children in the community as possible.

Foster care

The studies reinforce the findings of other studies that support is pivotal in maintain high quality placements. At present foster carers in the private sector reported higher satisfaction rates from their support services and therefore it may well prove cost effective for local authorities to invest in this area of services.

Better research for better outcomes

Beecham and Sinclair argue that there needs to be far more robust research into outcomes in children’s social care. Although this overview provides some helpful insights, they argue that costs vary significantly between areas and, at present, the full causes of this discrepancy are not known.

This article appeared in the 31 May issue under the headline “Can outcomes justify the cost?”