Child Protection for the Autistic Child - A Resource
'The American Model
I’m approaching this subject ( just in case you were wondering what it is - 'How our health and welfare service provision is changing so it more closely matches the American model of provision and delivery by private providers' or possibly 'Are we watching the welfare state being dismantled without questioning why?') with trepidation but a few things got me thinking about this recently and I’m going to give it a go. Apologies to any Americans who do not agree with anything I've written. I'm writing in and about a UK context and I hope you keep reading.
First a bit about markets. I understand a little about the marketplace and how markets work. I think we all need to if we are to understand how services are delivered these days - services that 15 years ago would have been delivered by agencies and local authorities are now delivered by 'private providers'.
There is a place for markets obviously. I’m just not sure where markets that need to be robustly competitive when working effectively, fit with services that need to be delivered in a collaborative way to be effective. I've also been on the 'Troubled Families Programme' that had 'payment by results' financial model that exposed woefully alarming financial naivety on the part of the Department that put the programme together. In addition I've read evaluative reports on Local Authority 'spin-offs' that read like the writers of 'The Office' stepped up a gear in quietly pointing out the at best un self-conscious, un reflective absurdity of much practice and policy resulting from 'group-think' around what the benefits of contracted-out services are and to whom. You can make anything work, if you put your mind to it. The questions are 'Is something worth the effort? Is it a good use of resources? What problems are you solving and what might the risks be? Are there easier ways, better ways, cheaper ways?' and so on.
I know to understand markets you have to understand risk, including the risks of failure. I also know that trust between all the parties underpins successful delivery of contracted-out services as does good working relationships, stability, and a framework which is understood by and fair to all the parties. What I've been describing so far are the elements of a successful relationship between service commissioners and suppliers. The third piece of the puzzle is the impact a service has on people who use it - their idea of what a good quality service is and how reliably the service commissioner and provider get this right or indeed if they share the same aims. (Commissioners might want cost savings, the service user might have beensold a vision of flexible service delivery that is unachievable alongside cost savings) Most service users however are not that concerned about the 'nuts and bolts' of who delivers their service, they just want a good service. They notice when things go wrong even if they do'nt have a view on how the service is delivered.
There are many though who dismiss perspectives such as these. They usually share an approach to service delivery that is championed by right-wing think tanks including the The Institute of Economic Affairs , registered as a UK charity. The IEA describe their mission and purpose as: “to promote the intellectual case for a free economy, low taxes, freedom in education, health and welfare, and lower levels of regulation.” All involved in the IEA’s work “believe that society’s problems and challenges are best dealt with by individuals, companies and voluntary associations inter-acting with each other freely without interference from politicians and the state. This means that Government action, whether through taxes, regulation or the legal system should be kept to a minimum.”
It is also worth pointing out that the IEA have a page on theirwebsite to allow American nationals to donate to them in dollars. That’s why I’ve titled this piece ‘The American Model’ even though that is a gross simplification of the cultural cross-fertilisation that formed and is sustaining what is essentially a belief in small government, not confined to the IEA or the UK or America.
Coherence in Service Delivery I think that, fragmentation in the name of competition has brought incoherence to service delivery and is in itself wasteful of scarce resources. Focus has been on the market (a variety of types of schools, hospital trusts etc. all in competition with each other) rather than making sure the needs of vulnerable children, that many of these services are shamelessly excluding in ways that would not have been acceptable a decade ago, are met. Somehow policymakers have to bring coherence to the ‘market chaos’ if many of these children are not to be left behind.
Dame Christine Lenehan ( Council for Disabled Children) highlights problems that arise when the focus becomes about the market rather service users ( people, citizens?) left to the mercy of the market. She has this to say in a recent review titled "These are our Children"that looked at ways to make the system better able to co-ordinate care, support and treatment for children and young people with complex needs (and behaviour that challenges) involving mental health problems and learning disabilities and/ or autism.
"Developing coherence within the system Within the system there is money, activity and intent which impacts on this group of children. (children with autism/learning disabilities) However, it fails to come together in a single coherent strategy.
Delivering improvements in a time of austerity The evidence shows us that our group of children tend to be in poorer families and live in challenging circumstances. Even for more affluent and settled families the cuts in local authority support services are biting hard. The loss of local authority early intervention and short breaks services affects our group of children disproportionately. The concurrent pressures on early intervention and particularly prevention services in community health and CYPMHS adds a layer that leads inevitably to higher financial costs and crisis services. This leads to a process where our group of children are escalated through tiers of service as gaps occur and the result is significant pressure on inpatient facilities and a lack of community services for children to return to. Over the course of this Review I have taken repeated evidence of inpatient costs for individual children averaging at £1million per child every three years. Throughout the development of this report I asked each interviewee “What does a post-ATU (Assessment and Treatment Unit) placement look like?“ The answer that I got was that they rarely exist and are not being developed, which is one of the reasons that our children can get “stuck” in ATUs. We have created a one way street for children which will mean a lifetime at substantial cost to the taxpayer for some very poor outcomes.''
Secure residential units are also only one part of a wider support system. Secure units that only see the person as their responsibility when within the unit walls, rather than also having say local community outreach support teams, are unlikely to be as successful for patients, as those that also support the person as they are re-intergrated into the ( ideally local?) community. This takes a genuine engagement with the local context and may not work with a business model that relies solely on full bed occupancy. New market mechanisms or new delivery models need to be developed to incentive community support models and other innovative ways of working not allowed for within service contracts.
Regulation ‘Low levels of regulation’ sounds very persuasive but is not good for those groups, often relatively powerless, who need robust regulation to protect their health for example. There will always be a need for regulation – surely getting it right should be more important than keeping it low? There are other issues about 'widening the supplier base' - there needs to be checks around the history of suppliers, often from different countries and operating in other often unrelated sectors.
As an example someone who worked in a privately run secure mental health unit once explained to me that the management team flew in from America and seemed to have little appreciation that there are different legislative frameworks here, around detention under the Mental Health Act and different approaches re medication regimes or restraint for example. Obviously not all UK ways are better but it should be essential to take the time to understand what is not discretionary in their UK treatment models, before 'setting up shop'.
This does not necessarily fit with a 'minimum regulation' model.
'Small Government' and Austerity -The perfect storm? This 'small government ' agenda fully aligns with the Austerity agenda of cutting back on state spending. The cuts as part of the Austerity Programme are, I believe, highlighting how there are and always will be ‘loss-making’ activities that are essential in the interests of social justice and social cohesion. It is also difficult to know where ideology begins and Austerity ends - the two are so intertwined. I'm not sure policymakers have really got the message about how damaging cuts under this programme are or indeed whether they have any answers other than 'dismantle the old redundant welfare state faster'. ( Was it really so bad?)
What does it mean to have 'Rights'? This is a website about all things related to child protection for autistic children so why am I ‘going-on’ about small government? Well I just cannot square ‘low taxes, freedom in education, health and welfare’ with an environment where autistic people and/or people with learning disabilities, particularly if they have high needs, have good rights to inclusion in a world where all have a decent quality of education, health and welfare support, if the focus is only on small government, competition and low costs.
So are policymakers ready for a change? Frankly rather than focusing on making dysfunctional markets less dysfunctional using complex mechanisms, I’d like that focus to turn to the best way to meet needs. I know if you want to meet these needs then the simplest way to deliver services ( directly commissioned rather than brokered in many cases?) is likely to be the best. These may need to be collaborative value-led initiatives including comprehensive workforce development (more regulation, collaborative working around training , sorry..), ensuring joined-up delivery of good services (cooperation not competition?).
There are few signs that policymakers share my views.
When things go very wrong in safeguarding of children currently, a serious case review might be carried out to see if there are system-wide lessons that need to be learned. One of these The Fenesta Case Reviewhad this to say on the subject of private providers involvement with the review process:-
"The practice of some primary care medical services (as advised by medical indemnity insurers) is contrary to statutory requirements in relation to their involvement in serious case reviews; this risks undermining the ability to learn lessons and improve safeguarding of children in the future. (Finding 8)"
"It is possible that with the increasing involvement of private providers in social care provision (e.g. prisons, care and children's homes), there may be increasing obstacles in the provision of full information to serious case reviews, due to potential conflicts with commercial interests or with advice from insurance companies."
So what is the plan to address this? See Discredited serious case review model scrapped...“Despite guidance to the contrary, the model of serious case reviews has not been able to overcome the suspicion that its main purpose is to find someone to blame. Although there has been some improvement in the quality of some reviews the general picture is not good enough and the lessons to be learned tend to be predictable, banal and repetitive,' ...' The new system should provide a more proportionate response focused on learning, Wood said. He estimated national serious case inquiries would apply to around 20 cases a year, compared to the 101 serious case reviews that were carried out in 2014-15'.
Maybe this is a win-win plan for reasons I do'nt fully understand ( 'predictable' and 'repetitive' mistakes that involve loss of life by children should challenge policymakers to think about whether there might be problems with their policies? ) but I'm just not sure who the winners will be and how this will address the problems that providers may not feel the need to cooperate with reviews for their own reasons.
Maybe turning a blind eye to this is a 'price worth paying' for policymakers whose policy focus is ensuring minimal regulation and encouraging private providers to enter the market? If so that would be very bad for vulnerable children and families.
Jones, R. (2015) The marketisation and privatisation of children’s social work and child protection: Integration or fragmentation?, Journal of Integrated Care, 23, 6, 364-375, http://emeraldinsight.com/doi/abs/10.1108/JICA-10-2015-0040 and Ownership Mattershttps://www.bsa.org.uk/BSA/files/bd/bd39f9dd-6c8a-4564-8e74-1020ee79f448.pdf LaingBuisson, Cobic and Cicada (2016) The Potential for Developing the Capacity and Diversity of Children’s Social Care Services in England. Independent research report. Department for Education and Lepper, J. (2015) Concern as Ofsted ceases regulation of outsourced social work. Children and Young people Now, 29 May https://www.cypnow.co.uk/cyp/news/1151699/concern-as-ofsted-ceases-regulation-of-outsourced-social-work and Mooney, G. (2011) Stigmatising Poverty? The ‘broken society’ and reflections on anti-welfarism in the UK today. Milton Keynes: Open University oro.open.ac.uk and Poole, S. (2017) ‘Deadlier than terrorism’: The right’s fatal obsession with red tape. Guardian, 20 June, https://www.theguardian.com/politics/2017/jun/20/deadlier-than-terrorism-right-fatal-obsession-red-tape-deregulation-grenfell-tower