Children’s services across the UK have demonstrated immense resilience while under incredible pressure during the pandemic. We should congratulate and thank the frontline professionals who are weathering this storm. Sadly, 2021 looks to be shaping up much like 2020, yet we must still focus on service improvement.
While the sector overall has been resilient, in my work with commissioners and providers I have heard anecdotally that serious challenges exist in securing care placements for children with high/complex needs and risk profiles. These challenges include acute mental health needs, particularly step down from Tier 4 mental health placements, and offending, including step down from secure accommodation, alongside the long-standing shortage of secure placements.
This “market failure” has created bottlenecks in the system, with severe consequences for commissioners and, most importantly, children and families, with cases being highlighted by the family courts on several occasions in recent years. Unfortunately, there are no easy solutions or “quick wins” to produce new placements for these groups of children and young people. However, there are opportunities to improve the chances of securing placements within existing provision.
Assessment tools
Critical to securing placements for these cases is the inclusion of reliable and detailed information in a Placement Referral Form (PRF) based on the use of a reliable and valid assessment tool. However, despite such assessment tools being available for children and, where appropriate, caregivers, they are not routinely used. Assessment tools used by local authorities often have no reliable evidence base or validity and as such, should be rejected by providers.
Considerable focus is given to assessment to explain why a child has been taken into care, for example, risk assessment, parent capacity to change and level of unmet need. However, there is far less use of assessment to develop care plans and identify the most appropriate placement(s) for the care journey to permanency, as illustrated in the example below (see below).
Poor referrals
The consequence of poor-quality referrals is severe. At best, it results in placement fees being higher than necessary because providers must factor in unexpected costs. At worst, no placement is found. This problem can be addressed by ensuring that referrals routinely include an appropriate, evidence-based assessment tool, one that is suitable for the population and captures the strengths of the child as well as risks and needs.
While increasing the potential to secure an appropriate placement, the introduction of a reliable assessment tool will also improve the ability of local authorities to map the level of needs of a child and identify appropriate outcomes to agree with the provider. For providers, appropriately trained professionals can review the results of the assessment to inform decisions on their ability to meet the needs and risks.
We need a shared understanding and “universal language” in our assessment of children and families, especially with complex cases that can span multiple services. Commissioners and social workers need a clear understanding of needs to inform decisions about referrals and services. Providers need confidence in the information contained in referrals.
To identify a solution, The Centre for Outcomes of Care undertook a review of available assessment tools. The review was informed by various criteria including reliability, validity, usability and economic viability. The decision on the most appropriate assessment required an element of pragmatism due to the need for it to be completed by frontline practitioners – particularly residential and foster carers – and for the tool to be free to use, which is important to maximise take-up. The review concluded that the most appropriate tool is the Child and Adolescent Needs and Strengths (CANS) assessment, the details of which will be discussed in the March edition.
IMPROVING REFERRAL QUALITY
The Centre for Outcomes of Care facilitated a workshop with more than 100 local authority commissioners and providers to identify how to improve their ability to find placements for challenging cases. We found there was a clear need to improve the quality and reliability of referrals. Providers stated a lack of overall confidence in Placement Referral Forms due to:
- Significant variability in quality of referral
- Insufficient or out-of-date information
- Absence of risk assessments
- Absence of comprehensive chronology to map important events in the child’s history.
In terms of the shortage of placements for some adolescents, control lies with the providers, who stated they generally accept placements when they are confident in the referral information, can meet the needs, can mitigate the risks and improve outcomes. Examples of problems with referrals included:
- Incomplete or missing information to maximise chance of a placement being offered
- Giving a sense of emergency, when in fact time pressure is internal
- Not enough help given to providers to assess young people in an emergency
- There is an element of guesswork about the child’s story which is unfair to them; you have to think “what am I not being told”
- No voice of the child in referral processes.
- Overall, significant problems with trust and relationships between commissioners and providers were found.
Mark Kerr is chief executive of the Centre for Outcomes of Care
