‘We can respect rights while finding out what works in social care’

While there is a debate about using randomised controlled trials in social care, recent examples show they can be done ethically and are valuable for informing policy, argues David Westlake

Image depicting randomised controlled trial
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By David Westlake, Cardiff University

Two of the largest randomised controlled trials (RCTs) ever conducted in social work have been published recently by Foundations*.

Last month, Sarah Taylor and her team from Coram reported that children whose families were referred for family group conferences (FGCs) were significantly less likely to be in care 12 months after entering pre-proceedings than those whose families were not so referred.

Earlier this year, my colleagues and I found that a scheme placing social workers in schools did not make any difference to the child protection and care outcomes we assessed, such as the likelihood of a section 47 investigation.

Policy impact of research

Whereas policymakers are not investing in social workers in schools, there is now a stronger case for rolling out FGCs for families in pre-proceedings.

If nothing else, these studies put to bed the idea that RCTs are practically, financially, or ethically impossible in children’s services.

Both these studies weathered the storm of the pandemic, stuck closely to their original plans and collected enough data to present strong conclusions. Neither cost more than one would anticipate for studies of their size, and both were well within the standard rule of thumb for evaluation costing (5-10% of the budget for the intervention).

Ethical objections to randomised controlled trial

Ethics building blocks

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In relation to ethics, some academics opposed the FGC project’s design, raising  objections that have been mounted throughout the history of social work RCTs.

The central critique against randomising families to receive either an FGC or a normal case conference was that proponents believed families had a right to an FGC.

Realising that right was an end in itself, and withholding it from some families through randomisation, in order to test effectiveness, was wrong.

The study has received a broadly positive reception since its findings were published, and it is now likely FGCs will be offered to more families than ever before in a wider roll-out.

That said, some commentators are still concerned about the idea of basing access to this service on the grounds of efficacy and cost-effectiveness rather than rights.

An alternative viewpoint on FGC trial

Robin Sen, lecturer in social work at the University of Edinburgh, has argued that FGCs should be introduced on the basis of families’ rights to devise a plan in response to child protection concerns, not on the basis that they save money.

He has also been critical of the fact that the FGC study did not report any significant difference in outcomes between families referred for a conference, and those who were not, after 18 months, the longest data point examined. The positive impact of FGCs was reported after six or 12 months.

To read his critique of the research, see his comment posted on Community Care’s news story on the study.

I’d like to think part of the reason for the generally positive reception is that Taylor and colleagues showed it is possible to conduct such a trial ethically. The study meant more families, not fewer, had access to an FGC as a result of the project, and many spoke to the researchers about their views and experiences.

Indeed, both these recent RCTs used qualitative methods to give a rounded picture not just of whether it was a success but also how and why. Those who participated in interviews and focus groups would not have had the same opportunity to give their views and shape our understanding of the interventions had the studies not taken place.

Of course, evidence about how effective something is should never be the only thing that determines whether or not we do it.

The inclusion of qualitative and theory-based analysis is important because some interventions – such as problem solving courts, and indeed FGCs – are as much about being procedurally fair as they are about outcomes.

Need to test outcomes

Research results post-it note on mouse

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But even these approaches make claims about outcomes that we should test.

Sometimes these claims are extraordinary – such as the suggestion of effect sizes for FGCs that are several times greater than what Taylor and colleagues found.

Their RCT gives us more precision about effects that can be weighed up against any moral justifications for using that approach.

And, if – contrary to expectations – these interventions are detrimental, or detrimental to some groups, then that also needs to be part of the equation.

Earlier research on FGCs, for instance, found some (albeit limited) evidence that minoritised groups may have worse outcomes as a result of the intervention.

Even the strongest proponents of FGCs would surely accept that a large enough effect in that direction would make it unjustifiable. And without studies like the recent trial, we would be blind to it.

Rights versus outcomes ‘a false choice’

False choices between rights and outcomes create an unhelpful parody of what an RCT in social work can be.

Outcomes are complex but so are rights, especially when the rights of parents and those of children are in tension. On its own, a rights perspective is not usually enough of a basis for overhauling services.

Rather than relegating outcomes in the name of rights, we need a more balanced and well-informed appreciation of the evidence to make decisions about how to help children and families. RCTs like these can make a valuable contribution.

David Westlake is senior research fellow at the Cardiff University’s Children’s Social Care Research and Development Centre (CASCADE) 

*Formerly What Works for Children’s Social Care

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