Commissioning: Assessing needs and outcomes

In last month’s issue we established that needs assessments are a significant factor in securing appropriate placements for looked-after children, particularly those with high needs. In this article we explore the need for a reliable and comprehensive assessment strategy to facilitate true outcome monitoring and inform sufficiency strategies.

Placement costs for children in care can reach several thousand pounds a week. This is a significant use of public funds, for which local authorities have a responsibility to demonstrate impact. This naturally is a key driver for outcomes-based commissioning. Yet, how many commissioners are really confident in the data they have to show that impact?

We have plenty of data related to “symptoms” such as frequencies of behaviour (for example reduction in absconding, improved attendance at school, fewer reports of angry outbursts) but how many commissioners receive outcome reports that address other meaningful factors such as emotional wellbeing or social functioning?

True outcomes represent distance travelled between time points. They are relevant to a service and the population it serves. At the individual level, they demonstrate changes over time in needs, strengths and risks and as such provide invaluable insight and learning.

It goes without saying that outcomes-based commissioning is only possible with an effective, consistent and reliable assessment strategy. Assessment must begin from the point when an individual starts to receive a service, and ideally at the point of referral to facilitate consensus. For example, when a therapeutic placement is commissioned, the Placement Referral Form should include a comprehensive assessment for providers to review, not just a summary or “cut and paste” from the latest review or single perspective. The assessment should then be repeated at periodic time points, and ultimately at the point of leaving a service. This is true outcome monitoring.

Assessment tools, some with questionable evidence base and reliability, are sold to local authorities as outcome-monitoring solutions. Caution is needed: we must constantly remind ourselves that using unreliable data could result in children’s needs not being met when our services respond incorrectly based on unreliable conclusions.

A further duty for local authorities is to secure sufficient accommodation within its area – generally referred to as “the sufficiency duty”. A comprehensive and robust sufficiency strategy is not possible without a clear understanding of the needs of children (and families) among the relevant population.

We know there is a shortage of high-quality placements for high-need adolescents, yet, much of the time, when local authorities are asked about the needs of the children for whom they require placements, only symptoms are described (for example risk behaviours, not attending school). The picture is not full enough. Providers need to really understand the underlying needs, factors driving this and circumstances to ensure that their practice is suitable. It is also vital that assessments also capture strengths. Good-quality providers should be using a strengths-based approach; they need to know what they have to work with.

Universal assessment tool

We must do better in assessing and understanding the needs and outcomes of children and young people in care. Based on several years of rigorous review, I have found the Child and Adolescent Needs and Strengths (CANS) assessment is a good solution. The CANS is a universal assessment tool designed to be used across whole agencies and systems of care. It provides a shared language and framework for understanding needs and strengths, one that all services can use to guide decision-making and planning.

It uses a consistent and validated four-level rating system to assess needs and strengths in a structured way within seven comprehensive domains (see graphic). There are versions suitable for all children and young people. Where appropriate the CANS also assesses caregivers, a critical and often missing link.

Established worldwide, the CANS is central to the Transformational Collaborative Outcomes Management (TCOM) approach. I am leading its implementation in England through TCOM England – a not-for-profit assessment-based system to improve decision-making and outcomes.

With comprehensive online training implemention of CANS in a local authority can be achieved in a matter of weeks, has negligible cost and offers a range of benefits (see below).

THE CANS ASSESSMENT BENEFITS

The Child and Adolescent Needs and Strengths (CANS) assessment provides the opportunity to gain individual, service and system-level perspectives of needs, outcomes and trends across groups and populations, through the aggregation and analysis of data. It offers the following benefits:

• Confidence: The tool is established, validated and has been subject to significant peer review.
• Intelligence to inform sufficiency: Provides detailed information about the needs (not symptoms) of children across the local authority.
• Collaborative: It can be used by those who know most about the child/young person, including residential practitioners and foster carers.
• Distance travelled: Reliable baseline information on the child provides a starting point for assessing outcomes consistently and meaningfully.
• Free to use: It can be specified in commissioning frameworks and contracts due to the CANS being free to use (low training and accreditation costs)
  
  

Mark Kerr is chief executive of the Centre for Outcomes of Care