The austerity challenge
Richard Selwyn
Thursday, May 4, 2017
Richard Selwyn assesses the long-term and hidden costs of public-sector austerity, and asks what can we do about it.
Last month's feature talked about how innovative models of commissioning are helping children's services deliver more with less. This month, we look at the impact austerity is having on services and the ability to intervene early.
Between 2010 and 2020 there will be a 50 per cent cut to local government funding; some parts of the country have already lost half. These changes alone might be considered tricky, but are actually part of a bigger national challenge. Factors to consider include:
- Local government is not the only sector being cut.
Children's lives are also affected by funding reductions to policing, the benefits system and increasing demand pressures in the NHS. Schools and nurseries are now facing real-term reductions. The cumulative impact of these cuts are not well understood, as each organisation plans for their own reduction - not the aggregate impact. - Early help is the first category of services to be hit.
If you're facing the choice between statutory services that you're legally required to deliver, or early help that you know reduces children's needs, which will you choose? And when demand starts increasing, services that were once early help raise their thresholds and gravitate towards statutory provision. - How long does it take before a family's resilience is eroded?
Does austerity cast its shadow over one year, two or 10? When we cut services, do we feel the impact much later? I suspect austerity is creating a bow-wave of demand that will hit us in the future, and may explain the alarming rise in children now coming into care with complex needs.
Has anyone added up all the cuts to early help in their local area? It would be a telling exercise. My guess is that some places will see their early help reduce by £0.5bn by 2020. Half a billion pounds of local outcomes that will have to be supported through other routes such as self-help, families helping each other, and community resilience.
Nationally, once we add up early help cuts to the NHS, benefits, local government, policing and increasing demand, this is perhaps £50bn. Commissioners have a job on their hands of superhero proportions to redesign services and local resources to tackle austerity.
Hidden need
The twist in this story is the hidden need in our communities and families. Around 20 per cent of families have a combination of needs that makes them less resilient. But public services tend to deal with only the presenting tip-of-the-iceberg need, not what is hidden.
For example, in children's services we know that one in 10 children has a diagnosable mental health condition, and one in seven has an additional mental health need. Combining these means 24 per cent of a classroom has a need - but we have a service capacity for around one per cent (see graphic). Other studies based on anecdotal local experiences show similar hidden needs for young carers and children's social care.
Not only is hidden need difficult to support, but it also undermines the return on investment for early intervention case studies. This is because it might be the hidden need that leads to late intervention cost, rather than the presenting need that we are supporting. So return on investment must be divided by the volume of hidden need. Therefore, for mental health, divide by 24.
The sucker punch for commissioning is that most types of early help are too expensive to give a good return on investment. Services with a case-holding professional are only cost effective in limited circumstances such as edge-of-care support. So is this game over for children's services?
Real Early Help
If case holding models of early help are too expensive, are there other ways to help families that cost less? Can we scale up this early help to support more families? Could we predict or target people who will benefit from early help? And the biggest question: would real early help be better and cheaper than the traditional approach of only delivering services required by law? These are some of the questions we will be exploring next time.
EXAMPLE OF REAL EARLY HELP FROM PUBLIC HEALTH
- Making Every Contact Count is a practical public health programme that asks professionals visiting residents to look out for small issues, such as a cold house, lifestyle choices and diet.
- The programme can be adapted to identify whether an individual is resilient, for example asking: "If something happened to you today, where would you go for help?"
- Some areas are asking local businesses - gas engineers, hairdressers and taxi drivers - to participate, multiplying our ability to identify and give early help to vulnerable families.
Richard Selwyn is a member of the Association of Directors of Children's Services resources and sustainability policy committee @rjselwyn