Is early intervention under threat from spending cuts?
Addressing families’ difficulties before they grow unmanageable can save money in the long term. But will this approach survive as council budgets are slashed?
Some dysfunctional families cost society a king’s ransom to support. Finding ways to reduce their drain on the public purse is exercising politicians and managers of services across the country and it’s clear that great store is being set by “early intervention”. Among the few positives in the government’s spending review a fortnight ago was the introduction of an early intervention grant and the pooling of departmental budgets for families with complex needs, starting in 16 local areas and being extended throughout England over the next four years.
The concept of early intervention – addressing families’ difficulties before they escalate to create lifetimes of misery and ruinously costly social problems – seems to make such obvious sense that discussing whether these measures are cost-effective, rather than just effective, may appear unreasonable.
But when local authorities must make ruthless budget cuts the issue is not only how well a particular preventive programme works, but also how any future benefits are weighed in terms of hard cash when there are expensive “acute” emergencies (such as child protection) to pay for. No one is going to direct limited funds to prevent a potentially costly – but notional – future problem at the expense of helping a child that is being abused or neglected right now.
“At times of retrenchment, it’s much more likely that people focus on things that you have to deal with today,” says Helen Dent, chief executive of Family Action, which places support workers into family homes to offer struggling parents intensive support in a bid to prevent difficult situations spiralling out of control. “That’s the problem with the cuts programme: it will take us back to crisis management.”
Because money is so tight, and services that help a range of other vulnerable groups are facing deep cuts, the longer-term cost-effectiveness of individual early interventions is being closely scrutinised. Several sessions at this week’s National Children and Adult Services Conference in Manchester will discuss studies from the UK and abroad that assess the ratio of money spent to money saved. Local authorities, charities and research bodies contributing to the conference will be among those sending their findings to a new, independent commission on early intervention being chaired by the Labour MP for Nottingham North, Graham Allen, who sounds an advance warning on how submissions will be considered. “One thing that has to be cleared up is the definition,” he says. “There are lots of people who are now finding that what they’ve done in the past and do now can be squeezed into the term ‘early intervention’ and I am extremely wary of that. Putting rubber pimples on slippers for elderly people is not an early intervention, even though it may well be a useful preventative measure.”
For the commission’s purposes, Allen says, early intervention programmes are those that “build on the social and educational bedrock for babies and children”. He is focused on those under three years old and the mothers who (primarily) look after them. An emphasis on building children’s capacity ultimately to raise successful families of their own extends the commission’s remit, he says, to young people up to 18 years old.
One of the difficulties of assessing value for money in early intervention is that there is no method for tracking the total sums spent by agencies on services used by individual families as their children are born and grow to adulthood. Work to collate this information is essential to making accurate comparisons of money spent and money that might be saved, although collating such information is laborious and time-consuming.
Recent efforts have been made, however, by Croydon council in south London to estimate the current cost of families known to be heavy users of multiple services, so this can be compared with future savings that might be made by implementing seven specific early interventions. “The scary figures are that for the group of two- to three-year olds, calculated up to age 18, [they will end up] costing us £62m,” says Dave Hill, Croydon’s director of children’s services, who is in the process of switching to the equivalent role for Essex.
If the seven early interventions identified by Hill’s department were successful, he says, analysis suggests the first three years would save £5m. After five years, savings would have reached around £11m.
“We don’t claim that the work on the savings is absolutely scientific, plus it’s not just council money: it includes NHS money, benefits agency money and so on,” says Hill. “But the ratios of savings are potentially huge: for every £1 spent, we’d get £15-£20 back.”
The research led to what became Croydon’s project under the Labour government’s Total Place pilots, by which different public service agencies combined their efforts on themes of mutual concern. Hill will speak at the Manchester conference about Croydon’s experience and the conclusions that may be drawn. But he acknowledges that no matter how convinced one might be of the ultimate efficacy of a programme, “you can’t just come in on a Monday morning and switch other services off”.
Clearly there’s a dilemma for councillors in authorising the kind of spend that’s required to implement early interventions. Hill says that where there is a good evidence base – Croydon’s project looks to studies from the US and Sweden – it is vital to persuade councils to take a leap of faith. On the basis of its calculations, Croydon’s elected members have agreed to invest £300,000 on implementing Hill’s seven interventions and the programmes began in February.
More accurate assessments and better targeting of early interventions would minimise the risk of money being spent supporting people who would in any case have ended up suffering no major problems. Agencies are still not skilled enough at making this kind of prediction, says Dent at Family Action. She argues that it is crucial that such expertise is developed.
The Common Assessment Framework (CAF) process, through which all agencies dealing with a family share their professional opinions and create plans of action to address identified need, is potentially a good method of systematically evaluating risk from the earliest stages of contact. However, the Local Authorities Research Consortium’s second year of research into the CAF has concluded that “more needs to be done to embed the CAF as a tool to support early intervention”. And it is only now, in the third year of the consortium’s study, that the focus has shifted to how the cost-effectiveness of the CAF process might be improved.
Though methods of predicting who will benefit most from early interventions remain unsatisfactory, the overwhelming consensus that such interventions are effective means local authorities will come under considerable pressure to fund them.
One approach is for councils not to be given much choice. The Association of Directors of Children’s Services is lobbying for early intervention funds to be ringfenced. And Christine Davies, chief executive of research body C4EO, which promotes excellence in early-years practice and which has validated more than 100 early interventions, is in no doubt central government needs to give local authorities “a very strong steer” that a set proportion of funding must be dedicated to early intervention.
“We will have to do much more relentlessly what we know to work, and stop doing other things,” Davies says. “What we can’t go on doing is leaving these things to chance: if you have a very proactive and thoughtful PCT [NHS primary care trust] or local authority, then fine, but what if you don’t? It is too easy to dissipate focus; we have too many services that pursue what they genuinely think is doing good. But funding needs to be much more weighted towards the early years and that is the role of central government.”
A shake-up in how local authorities commission and pay for services will be critical to success in implementing early interventions, suggests Paul Diamond, director of research and consulting company Impower.
Payment by result
“For instance, an awful lot of out-of-county residential placements [for looked-after children] are provided by the private sector, and my question is, how much incentive is there for private companies to fund innovative solutions that would involve a child moving back home, out of their care?” Diamond says. “It’s about thinking creatively, and payment by results can incentivise people to do that.”
“Payment by results is a brilliant, pioneering method,” agrees Graham Allen. But what about the distaste felt about private companies making even more profit out of social misery? “I frankly don’t care what mechanism is used as long as it delivers and has good results. In this line of work, you don’t get anywhere if people aren’t motivated.”
If early intervention is in fact cost-effective, the argument goes, paying private providers more for good results should still cost less in the long term than paying them less – though still an awful lot – for poor ones. By January next year, Allen’s commission will report on what it considers to be the 12 best early interventions; by May, the MP wants a City-facing institution to be ready to roll with new financial instruments that make investing upfront in early interventions an attractive option for potential investors.
“It’s about a new way of structuring the money,” Allen says. “We’re not asking for government money, but we do want government backing to do this.”