funding

At the top of the hill

I have posted in the past about the feeling of running a small entrepreneurial venture, and how it can feel like pushing a giant boulder up a hill without much help, and how every time I think I’ve reached the summit a new peak appears. Well, for the first time, it feels like that feeling has changed. Suddenly it feels like I’m at the top of the hill, and I have a team of people to help me think about how to make the boulder roll. It is still a daunting task to get the thing to roll in the right direction, and there is still no guarantee it will start to gain momentum and size, let alone reach a good destination. But it does feel like possibilities are opening up that weren’t in my line of sight before. In fact, I now have the task of trying to scale up my ambitions – which is a really strange thing, after trying to keep my focus very much in the present and not falling backwards for so long!

So what has actually been going on? Well, in 2019 we secured a local small business grant to allow us to prepare to scale up. That gave us £50,000 to cover half the costs of getting some basic equipment and taking on an operations manager. We replaced some very dated laptops, and got some new desks and cupboards for our offices, only for the start of the pandemic to lead us to need to move to working from home.

That was particularly pressing, because the office we rented shared a stairway with three other units, which had just changed from very low risk, low traffic businesses (a geological survey company and a quantity surveyor) to a domicillary care company with over a hundred staff that were coming and going from the office in and out of elderly and vulnerable people’s homes. As an employer with staff who had various pandemic-related challenges (eg an employee with asthma who had to travel on public transport that included a lot of children on the school run; an employee in a multi-generational household; a vaccine-hesitant employee) and as a person with increased vulnerability myself due to preexisting medical conditions, we were quite proactive in that decision. I closed the office the week before the government officially locked down, and made the decision four months later to give up renting the office and go to a fully home-based working pattern until the pandemic risks resolved. Whilst that was a big adjustment, and I miss physically getting together with my team, having that social element and bouncing ideas off each other, in a lot of ways it has worked to our advantage. I’ve personally appreciated not having to travel as much, and reducing my carbon footprint, and it has allowed us to deliver projects all over the UK as everyone has become familiar with working remotely over Zoom.

We then secured a £220,000 Innovate Smart Grant to work with local authorities and complete our data set for BERRI. That allowed us to recruit a research team in the Anna Freud National Centre for Children and Families/UCL, where I also have my Senior Research Fellowships, to help us make sense of the data we collect and publish the validation, factor structure and early findings from BERRI. We have then set up partnership projects with eight local authorities (six in London and two in the north east). We added an Operations Manager and two Assistant Psychologist/Fieldworkers to our team to deliver the project. Working remotely meant we could also provide some light-touch input to placement providers across the UK, so we’ve continued to grow the number of organisations with BERRI subscriptions, and our ability to deliver training and consultancy online. We then secured a £96,000 Resilience grant to mitigate some pandemic related delays in the project, add some clinical staffing, commission an independent social and economic impact evaluation of our work, and use some sessional input from psychology graduates for a project in which we plan to build a wider “ecosystem” of resources around BERRI. Coupled with using the government Kickstart scheme (which subsidised businesses taking on young employees who were claiming Universal Credit) to take on three new members of staff, our team has grown rapidly. We now have input from two other qualified clinical psychologists, a small in-house data analytics team, a post to look at identifying and securing further grant opportunities, and a digital training administrator.

There have been other positive side-effects of the move to remote working. We’ve been able to recruit from a national pool of applicants and become more disability friendly – so our team now includes members from Kent, Cardiff, Somerset, Bradford, London, Buckinghamshire, Birmingham, Essex, Suffolk, Liverpool and the north east, rather than just local colleagues around Derbyshire. So I think we will probably work towards a hybrid model in which we have a small office space we use for meetings and training events, that local staff can choose to use when they want to spend more time with colleagues, which should be ready by the time the latest Omicron wave subsides. As well as continued court expert witness work, training and consultancy, and two new projects with additional local authorities, on the clinical side we are also setting up a second base in north Birmingham, where we plan to run a small neurodevelopmental assessment service. So we have recruited another AP to support that location, bringing our team up from me plus six employees in 2019 to me plus 19 today. We also have a network of placement students, researchers, contractors and sessional workers that mean we have over 40 colleagues in our wider network.

That’s a huge shift, and the rapid growth looks set to continue. We’ve secured two more small grants to develop a digital training platform and a demonstration app version of BERRI, and we’ve just submitted a large grant application to build on our work with with local authorities. The independent social and economic impact evaluation has generated some amazing stories of how BERRI has changed the way that services are able to deliver psychological support to young people in care, and their lives have been positively impacted as a result. Whether it is a young person who was stuck in an inpatient secure bed with a negative prognosis who is now living in the community with aspirations of employment, a carer who is able to be more empathic to a child’s trauma history rather than seeing them as naughty, or a professional who feels more able to do their job effectively, it is amazing and rewarding to hear that my little project to develop an outcome measure for children in care is helping to create these increasing ripples of positive impact. It has also shown a remarkable level of economic impact, with over £108 return to the economy for every £1 invested in our service! My goal to change children’s social care and to find a better way to identify and support children’s psychological needs is no longer just a wild fantasy, but might be something we can actually achieve.

The other positive side-effect for me personally, is that I’m finally paying myself the salary I would be on in the NHS. After having started the company by investing my redundancy pay, a decade of subsidising the project through my court expert witness work, and some months where I drew down money from my own mortgage to pay staff, that is no small milestone! It means we are secure enough financially to firm up the social purpose embedded in the business into a formal social enterprise structure, where the majority of profits are pledged to delivering the social impact goals (which isn’t a hard task, given the vast majority of our turnover has always been spent on research and delivery of clinical psychology services).

So, what are the next steps? We have lots of new developments in the pipeline. The BERRI system itself is constantly being improved in various ways, so the next steps are adding third party reporting (eg if a social worker wants to get a questionnaire filled in by a foster carer, or a psychologist wants to get the school to complete a BERRI about a child they are assessing), putting percentile ranks into the reports for greater granularity, and improving our reporting of data to organisation by adding a dashboard with new data visualisations. We are exploring the potential of a Personal Edition of BERRI for concerned parents to fill in to know how best to support their child. And we are building an “ecosystem” of information sheets and videos to advise parents and carers about common issues.

We have several current research studies:

  1. Meryl, our PhD student, is collecting the community norms for BERRI. So if you are a parent of an adolescent in the UK, or know anyone that is, please use this link: https://uclpsych.eu.qualtrics.com/jfe/form/SV_9um9UfYGd2HX9gW (ethics granted by UCL). We really want as many participants as possible, and you don’t need to be concerned about your child or have any involvement with social care – we just want to hear from as many parents as possible (and if your child has no difficulties it should only take 5-10 minutes to compete). If you don’t have kids yourself, please share the link with others, and post the link to our research facebook page on your social media: https://www.facebook.com/BERRIResearch/
  2. If you live outside of the UK or your child is not aged 11-18 to qualify via the UCL research link, and you want a link to the questionnaire to rate a child or young person aged 5-21, just email earlyaccess@BERRI.org.uk, as I can offer free early access to the system to anyone willing to give us some feedback about your experience.
  3. We wanted a few people to complete a BERRI about their child (of any age) and then to complete a short interview about their experience, an MSc student at NTU undertook this as a research project. Another MSc student on the same course interviewed foster carers about how different life experiences impacted upon children in their care.
  4. We are also going to look at how we incorporate the young person’s voice into BERRI, and recognise signs of progress, strengths and post-traumatic growth.

I’m going to apply for some larger grants to look at scaling up our impact, and we are busy expanding the clinical side of our services to deliver more assessments and consultancy. BERRI has been used to review the use of residential care in some authorities, and to idenfity when children are able to return to family based care (either a foster placement, or to a member of their birth family) and what support is required to make this successful. This has generated significant cost savings for some authorities, so we have been commissioned to provide a similar review for a new authority. We are also supporting the growth of in-house residential provision in a couple of authorities, and expanding our clinical services to support fostering and edge of care consultancy in others.

So the future seems full of opportunity to make impact and – provided I can keep up with demand and keep all the plates spinning – maybe that boulder I’ve been pushing up the hill will start to roll. I just need to work out where we want it to get to!

Grand ideas

I recently filled in an application to speak at an event about children in Care. The form asked me to summarise in a limited number of characters what I would bring to the table as a speaker. I wrote:

We have collected BERRI data on the psychological needs of over a thousand children in residential children’s homes over the last five years, and surveyed and trained over a thousand residential care staff to provide care that is tailored to those needs. We can present what this data shows us, and how we have used it to improve the services that are offered, and commissioning decisions made about children. For example, we have learnt that the level of challenge presented varies remarkably little by age or gender, though the types of needs are slightly different. Some types of needs (eg behaviour, risk) are affected much more by proximal stressors (eg exclusions from school, gang involvement, substance misuse, sexual exploitation) whilst others (eg relationships) are affected more by historic adversity and the nature of early attachment experiences. We can present how staff variables (demographic factors, burnout, empathy, ability to formulate) affect the care they deliver, and how the price and types of services commissioned relate to the needs of the child and the impact they make on the life of the child – if at all!

The government spend a billion pounds a year on these 7000 children, and we have good evidence that by better targeting the psychological needs of individual children they can improve outcomes whilst saving costs.

It struck me when I looked at that paragraph that this was simultaneously a grandiose claim and underselling the potential of the systems we have developed*. I think that tension between over and under-selling what we can do reflects one of the big challenges of being an entrepreneur – seeing the potential, whilst being realistic about the frustratingly slow steps it takes to achieve it. I can see so much that we can achieve, and the way that collecting the right data can help put children’s needs in the heart of commissioning decisions, improving outcomes whilst saving substantial amounts of money but it is very hard to get this information in front of the right people. I’ve tried to speak to politicians, policy makers, experts in the field, commissioners, clinicians, funders and the media. I’ve spoken at conferences, written a book, contributed to policy documents, delivered service improvement programmes in major providers in the sector, I’ve even given evidence before a select committee. But because I try to answer the questions that are asked, I don’t always get the chance to promote the products and services that we provide. And it isn’t my personality to aggressively sell what we do.

Looking back, I think that I believed that if you work out a better way to do something, a technique that saves time or money or improves outcomes for people, then once people knew about it then it would start to gain traction until it became the established way of doing things. I figured that was how we had progressed from horse-drawn carts to steam engines, cars and now electric vehicles, or from papyrus to paper to typewriters to computers to the plethora of voice-activated, photo-capturing, text and graphic app laden smartphones – finding iteratively better ways to solve problems. I knew that sometimes there were two simultaneous steps forward that competed (like VHS and Betamax) and that variables like marketing, networks and budget could influence the choice, but I generally thought that the best solutions would win through. Maybe it is my left-leaning political bias or my hippy upbringing, but I think in my heart I have held onto a naive idea of fairness in which everyone should be motivated to solve social problems, and people should be rewarded for their effort and insight.

I suppose the concept that we live in something of a meritocracy is quite a widespread belief, and entrenched in western cultures, that good ideas will surface and the best people will rise to positions of power. That’s taken a bit of a crushing for me over recent years, as I’ve seen the covert influence of the super-rich and we’ve had several prominent examples of terrible people rising to the top of systems that have failed to keep up with social and technological change, but somehow I am still hoping for the system to right itself, because it feels like society should be a functional meritocracy.

I think it is particularly well articulated in the USA, because they started as a nation of immigrants who created their own society. To quote the American Declaration of Independence, “all men are created equal”, are entitled to “the pursuit of happiness” and will rise to their natural position in society. That sounds like a fair way to run a country, but of course the reality has never quite matched the headlines, given the theft of land and resources from native peoples, the decimation of the natural environment and the evils of the slave trade. But somehow the myth of the American Dream has persisted. First described by James Truslow Adams in 1931, it describes a culture where anyone, regardless of where they were born or what class they were born into, can attain their own version of success in a society where upward mobility is possible for everyone. The American Dream is achieved through sacrifice, risk-taking, and hard work, rather than by chance or the privilege of your pre-existing connections. In Adams’ words it is:

a dream of social order in which each man and each woman shall be able to attain to the fullest stature of which they are innately capable, and be recognized by others for what they are, regardless of the fortuitous circumstances of birth or position

Whilst I can see so many places where people are not starting the race from the same starting line, because of geography, race, gender, religion, socio-economic adversity, sexuality, age, or so many other variables I have clung on to my optimism that if you can work out a solution to a big social problem, or have an idea that can really work to make life easier (and/or make lots of money), then it should be possible to gain traction with it, get key people to support you, and get it to happen. The reality is that so many people who think of themselves as examples of a working meritocracy have in fact been handed a huge head start by their privilege. As we joked the other day on Twitter, all the wrong people have imposter syndrome because it is mutually exclusive with entitlement. It seems that private schools in particular train people to expect to be leaders and wielders of power, as we see in the preponderance of Prime Ministers educated in Eton (and in the irritating arrogance of Lottie Lion and Ryan-Mark in the recent series of the Apprentice). Having attended an ordinary comprehensive, and never having been aware of any negative repercussions of my gender or heritage, it has been quite eye-opening to see that maybe the playing field isn’t as level as it appears, even for someone ostensibly white and middle class**.

One figure that has stayed with me is that of all the money invested into fledgling businesses in the UK, 89% is given to all male founder groups, 10% to founder groups containing men and women, and just 1% to all female founders. I couldn’t find any UK numbers, but the figures look even worse if we consider race, with black women only receiving 0.0006% of the of the $424.7 billion that has been invested into startups globally between 2009 and 2017 by venture capitalists. Those white men probably think they simply have better ideas, but the evidence doesn’t support that, whilst the statistics say they are 89 times more likely to be funded than all female groups, whilst a white male entrepreneur is thousands of times more likely to be funded than a black woman, and will have the confidence to ask for much larger sums of money. Only 34 black women have raised more than a million dollars of investment in the last decade. This doesn’t reflect the quality of the idea or the work ethic of the individuals involved (as meaningfully empowered women on boards increase corporate social responsibility and may have a positive impact on the profitability of the business, and diversity increases profitability). It reflects the stereotype of what the (predominantly white male) funders think successful entrepreneurs look like – and they imagine young geeks from silicon valley who are predominantly white and almost always male. And that sucks.

It might also explain why men in suits with glossy patter are able to sell systems they have pulled out of the air for eight times what we charge for properly evidenced tools that do the same job better. Or maybe that’s just a coincidence. But whether or not the playing field is flat isn’t something I can solve alone, and it is unlikely to be resolved within the timescale that is critical for me to make a success of my business and to maximise the impact I can make on the lives of vulnerable children. That means that, despite how discouraging it is to realise that we are not living in a meritocracy where the strength of the idea is enough to sell it to those who matter, I need to find ways to shout louder, communicate what we do better, and get our message in front of the right people.

Because we are tantalisingly close to having all the data we need to understand the critical variables at play in the psychological wellbeing of children and young people in Care, and which placements and services can help to address them. We have an exciting partnership growing with a group of local authority commissioners that will couple our data with commissioning data, and we are applying for grants to help us to gather and analyse that data across much wider samples. We are also scaling up the previous project we did looking at whether BERRI can help to identify suitable candidates to “step down” from high tariff residential settings into family placements with individualised packages of support. These larger scale projects mean that we will be able to show that the model works, at both the human and financial levels. And with a little bit more momentum we can start making the difference I know we are capable of. The trick is hanging onto the vision of what is possible and celebrating what we have already achieved, whilst having the realism to put in the graft that will get us there. I need to keep pushing upwards for longer than I ever imagined, in the hope of reaching the fabled sunlight of easier progress – even if so many variables skew us away from the meritocracy that I imagined.

 

*I think that’s why I used the pronoun “we” and shared credit with my team, even when I was asked to describe myself as a speaker, rather than taking full credit on my own. This transpires to be a common female trait, and part of the double bind for women where being assertive is seen as aggressive whilst being collaborative is seen as lacking leadership. In fact, many words are used exclusively towards women and highlight how pervasive these biases about women in leadership roles are.

**albeit a second generation immigrant to the UK, with Jewish heritage

Can you make things better for children and young people in Care whilst saving money?

That seems to be the critical question in an age in which there is no money in the budget to try anything innovative just because it will create improvement. To be able to try anything new that involves spending any money we have to evidence that double win of also saving costs. A few years ago when I was in the NHS, I found that really frustrating – I had so many ideas about how we could do things better by creating new services or better collaborations with other agencies, or reaching out to do the proactive and preventative work that would save money down the line, but it was almost impossible to get them off the ground because the budgets were so tight. Since then I’ve tried various things to unlock the spend-to-save deadlock, but it was only once we started looking at the economic impacts of some projects using BERRI that we had clear evidence that we could save money whilst making services better, and on a fairly substantial scale. Our pilot in Bracknell Forest saved £474,000 in the first 12 months whilst making services better and improving the outcomes for the young people involved. And that was just a small scale pilot within a single local authority.

After so many years of being told that improving outcomes whilst saving costs would be impossible it sounds unlikely, but it is true. We made life better for the children involved – in some cases in ways that entirely changed the trajectory of their lives – whilst reducing costs for the local authority. The savings generated would be enough to fund services to address the mental health needs of all Looked After Children whilst still lowering the overall cost of Care. I’m not prone to hype, but that feels pretty extraordinary! Importantly we did it whilst also making life easier for the carers, professionals and placement providers involved. So it is no great surprise that we are now working with many Local Authorities to scope out and deliver wider scale projects.

So, what are we doing that is different? And where do the savings come from? Using BERRI we are identifying psychological needs effectively, and then addressing them early. For some young people that leads to significant change in their behaviour, risks or mental health, that then opens the door to different placement options, and for a small proportion of children the placement costs are substantially reduced. I’m not talking about forcing children in residential care to move to foster placements for financial reasons. I’m talking about better identifying the types of placements and services that young people need. For some, that will mean that they get to access residential care without having to break down a long series of foster placements to do so. For others it will mean that they get access to much increased mental health input, or specialist services. For many it will mean helping their carers to better understand their needs so they can make minor adjustments to the day to day care. But for some children it can open (or reopen) the doors to a family placement.

It may also have an impact on their longer-term trajectory, as it is well known that addressing mental health needs in childhood is easier and more cost effective than trying to address the difficulties they go on to develop in adulthood if these needs are not addressed. Using the BERRI helps carers to see behind the presenting behaviours and to recognise emotional, relational or attachment needs, or feel empowered to support these more empathically. Importantly, it can evidence the impact of the great work that many carers and organisations are doing already to support children by showing the changes they are making over time. It can help to set goals to work on, and to monitor what is and isn’t working effectively to create positive change. BERRI also helps to pick up learning difficulties, neurodevelopmental difficulties and disorders, so that children can then be more thoroughly assessed and care and education can be pitched appropriately.

We are also learning from our increasing data set what scores are typical in different settings, how individual children compare to the general population, and which variables are important in preventing negative outcomes in adulthood.

I sometimes use the metaphor of the cervical cancer screening programme. At a cost of around £500 per woman each 3-5 years, the screening programme prevents 2000 deaths per year. About 5% of women screened have abnormal cells, and 1-2% have the type of changes that are treated to reduce risk. As a result women who are screened are 70% less likely to get cervical cancer, which has an enormous human cost, but also costs £30,000+ to treat. Screening has saved the NHS £40 million. Most importantly it has led to the discovery that the human papillomavirus is significant in the development of cervical cancer. This has led to preventative treatment programmes with 10 million girls in the UK receiving the HPV vaccination. This has reduced the rates of cervical cancer (with 71% less women having pre-cancerous cervical disease), as well as preventing genital warts (by 91% in immunised age groups). It also has the potential to reduce other forms of cancer, as HPV is responsible for 63% of penile, 91% of anal, and 72% of oropharyngeal cancers, with this and the importance of herd immunity leading to the decision to immunise boys as well as girls in many countries.

I would argue that the case for psychological screening, particularly in population groups that have experience trauma, abuse or neglect, is even stronger. More than half of children in Care have a diagnosable mental health condition, and half of the remainder have significant mental health need that doesn’t reach diagnostic thresholds or doesn’t fit into a diagnostic category. They also go on to higher risks of a range of negative outcomes than the general population, including having a higher risk of heart disease, cancer, strokes, fractures and numerous other health conditions, as well as more than fifty times higher risk of homeless, addiction, imprisonment, requiring inpatient mental health care, or having their own children removed into Care. Like cancer, these have an enormous human cost on the individual and their network, and they also have a huge financial cost for the public purse (some estimates suggest £2-3 million per young person leaving Care, when including lower contributions to tax, increased benefits and the cost of services). If we can understand and address the issues that lead some young people down these more negative paths, and address those needs as early as possible in their lives, hopefully we can increase the proportion of young people who survive difficult early lives and go on to healthy happy adult lives.

If you want to learn more about BERRI and the impact it can have on your services feel free to get in touch. Or you can come and learn more about the pilot in Bracknell Forest and the larger scale projects we have started to expand on it, as I am presenting at the NCCTC next month with Matt Utley from the West London Alliance.

The elephant in the room: Mental health and children’s social care services

I heard a few months ago that the Housing, Communities and Local Government Select Committee were undertaking an inquiry to look at the funding of local authorities’ children’s services, and thought that sounded like an interesting topic that might relate to my areas of interest. I therefore met with a local MP about the topic, contributed to the BPS response to the inquiry, and (on the request of the committee) submitted my own response in relation to my innovative work with BERRI. I have subsequently been called to give evidence in person to the enquiry in a few weeks time.

Given I’ve been so immersed in this issue it seemed a good topic for a blog. I’m going to start with the evidence that this sector is in crisis, before thinking more about what a clinical psychologist like myself can contribute to addressing elements of this need. Hopefully I can then write another blog in a few weeks time to talk about my experience of giving evidence, and report back about whether the politicians grasp the issues and appear motivated to do something about it.

It didn’t surprise me that this was an issue that the government wished to give more scrutiny, given the steep increase in need in this area over the last decade, whilst funding for local authorities has been substantially reduced by the government’s austerity agenda. Human distress and unmet need rarely seems to gain political attention unless it is in such a crisis that the public are aware of the issues, or it has financial implications for the public purse, and children’s social care has suddenly hit both of those thresholds in the last year or so. 

A number of factors have combined to increase need in children’s services. This includes growing awareness of child abuse and its impact (particularly emotional abuse which has long lagged behind the more tangible forms of abuse), along with reduced stigma in disclosing having been abused (due, for example, to the publicity surrounding the Jimmy Saville scandal, the various institutional abuse enquiries, and the #metoo movement) and a reduced tolerance for forms of abuse that had been normalised or ignored in the past (due to cases like Baby P and the Rotherham child sexual exploitation trials, and subsequent prosecutions in many other areas). A lot of teenagers who had been allowed to remain in unsuitable living circumstances because of the belief that they would “vote with their feet” if removed are now appropriately protected and brought into Care, perhaps because of some precedent setting cases in which people have taken successful legal action against local authorities and have been compensated for failures to protect them in childhood. This includes an enormous legal settlement for two Care leavers from Jersey, who have received tens of millions of pounds compensation.

Children in Care are also entitled to stay in their foster placements up to the age of 21 where they want to and it would be beneficial for them, and to have support after leaving Care from a personal advisor until the age of 25. Another pressure is the reduced use of secure units on welfare grounds, and a reduced willingness to incarcerate children in institutions for recurrent minor offending. The increased stress, shame and social hardship of benefit changes and increases to cost of living has led to move children growing up in poverty, and more families developing the risk factors that can cause harm to children, such as drug or alcohol use, mental health problems, domestic violence and family breakdown. This has had a particularly negative impact in families in lower socioeconomic groups.

It is therefore unsurprising that over the same period of time the demands for social care services have risen steeply. Over the last decade there has been a 9% increase in referrals to social care and numbers of children considered in need, but there has been a 84% rise in child protection cases, and 26% more children are in Care. This creates a lot of additional workload for children’s services, with a 122% increase in demand for section 47 enquiries, and a 125% increase in Care Proceedings (as less children are now informally Accommodated with parental consent). Yet the budgets have shrunk, so there is no resource available to meet this need.

The financial picture is genuinely shocking, and yet it has hardly made the news (perhaps because looking at the numbers is considered too technical or boring for the lay public, and the political and news agenda has been hijacked by the continuing debacle of Brexit). But reviewing the figures makes sobering reading. The cuts to local authorities since 2010 are unprecedented. The National Audit Office highlighted the extent of the shortfall in their report on the financial sustainability of local authorities published last year. They point out that central government spending on social care has halved. This has been masked by changes in how funding is delivered, and some additional funds from council tax being made available to spend locally, but the cuts are still enormous and amount to a real terms reduction of nearly one third of the entire budget for local authorities, but the burden is again being disproportionately felt in more deprived areas.

Such cuts are unrealistic and unsustainable, as they make the total budget too small to cover anything other than statutory services, which are legally protected. This means that councils have no means to make ends meet without dipping into their savings. The report shows that two thirds of local authorities had drawn from their reserves by 2016-17, so there is an ever decreasing amount left in the pot for contingencies, and the audit office predicted that 11% of authorities will empty that pot by the end of this financial year. Councils are having to sell off properties and come up with increasingly radical plans to try to fulfil their minimum duties. Recently Northamptonshire County Council had to declare themselves bankrupt as they had no means to cover statutory services from the available budget.

This mismatch between demand and resourcing has led to enormous cuts to non-statutory services, with two thirds of the spend on preventative and community children’s services disappearing. This means that, as with mental health, there is a minimal set of brief services delivered for milder or less entrenched difficulties, but that there is then an abyss in which no services are available until they reach the threshold for the crisis-focused specialist services – which are expensive and time-consuming to deliver and can’t keep up with demand. The focus has moved from collaborative work to assessments and interventions that are perceived as the end of the line, despite the absence of the precursor interventions that might have enabled change.

To me, the elephant in the room when it comes to children’s social care is mental health need. I don’t just mean the clean single-condition, diagnosable treatable mental health need that gets through the doors to CAMHS. That’s the need up on the sterile concrete plains of mental health research that Prof Miranda Wolpert describes so well. I mean the real messy need down in what Miranda calls the swampy lowlands where real complex people live in varied circumstances, where numerous issues intersect to create barriers in their lives that are not straightforward to address, and do not fall into the simple diagnosis to treatment pathway that currently gets through the doors to CAMHS. That’s the need that determines the outcomes for these children, and the pathway on which they leave Care and try to negotiate adulthood. It is that need which determines whether they can go on to happiness, employment and family life or whether they become one of the Care leavers who end up facing prison, homelessness, mental health problems, addiction, conflict and/or their own children going into Care.

So what are these broader mental health needs? In my experience, a complex and interwoven picture of trauma, adversity, behaviour problems, attachment difficulties, developmental disorders or delay and mental health needs is typical of children in Care or receiving social care services. As well as the traditional “mental health” needs of anxiety and depression I see a much broader picture that is expressed in a variety of ways. Some children act out with their behaviour, others withdraw and show signs of emotional difficulties (including low mood, poor self-esteem, and a lack of positive identity or perception of belonging). They often struggle to form healthy relationships/attachments to others, and can present a risk to themselves and others. They have an increased prevalence of conditions like Learning Disability, Autism, ADHD, or psychosis that add an additional layer of challenge in standard services effectively meeting their needs. That is why my BERRI assessment system attempts to cover all of these areas.

Seen as a group, children who are Looked After have high levels of mental health difficulties (45% have a diagnosable condition, and over two thirds have significant mental health need), so it would be easy to blame the Care system. However, this extraordinary level of need is predominantly caused prior to them coming into Care. It is well established that Adverse Childhood Experiences lead to multiple layers of vulnerability, and these are very prevalent for Looked After Children (my own research suggests an average of 4 historic ACEs per child, along with 2 current vulnerability factors at the point they come into care, such as involvement in gangs, sexual exploitation, school exclusion or the criminal justice system). Looked After Children are in the vast majority traumatised children, who have experienced abuse and/or neglect. But these problems don’t occur in isolation. They are contextually embedded. Children in Care come disproportionately from families that experience the adversities of poverty, crime, family breakdown, and poor housing. They are more likely to be born to parents who have lower education, higher risks of unemployment, and a higher incidence of mental health problems, substance misuse, domestic violence and a history of abuse or neglect in their own childhoods. As a result, their parents are less able to provide safe and stable care. Patterns of difficulty often carry through many generations of the family, and the problems they face are a symptom of our increasing social inequality. 

However, CAMHS are not really set up to meet these complex and interwoven needs, and cut off at 18 years of age, whilst children can stay in care until they are 21 and receive leaving care services until the age of 25. They also have ongoing needs that will need to be revisited over time as they develop or different themes emerge as they enter different life stages or face different challenges. It might be that a dental care model, in which there is long-term oversight but with responsive services as and when they emerge works better than the time-limited episodic care that is currently on offer. Likewise services need to be embedded so that they collaborate with placements and other support services, rather than stand in isolation.

The wider context of the underlying contextual and vulnerability factors mean that treating symptoms or even specific conditions might be an ineffective model of intervention. We need to think back to Maslow’s hierarchy. These children first and foremost need their basic needs met, and to have reliable food, shelter and warmth. They need safety and security, medical care and an environment that doesn’t contain ongoing risks. They need opportunities for identity and belonging, such as education, employment, hobbies, peer relationships, and family. They need intimacy and trust in their friendships, sexual/romantic relationships and relationships with carers. When that is reliably in place they need opportunities for achievement and being valued, so that they can gain self-esteem, confidence, status, responsibility and individuality. The icing on the cake is then self-actualisation, the chance to explore creativity, set goals, reflect on morals and values, and feel purpose and fulfilment. Mental health needs only fit in mid-way up that pyramid. We cannot expect a child to have a positive outlook and good coping strategies and social skills if they are not in a safe environment, don’t have their basic needs met, or cannot trust those around them. To see the point of going along to a therapist takes enough self-esteem to believe you deserve to feel happier, and you then need the organisation and social skills to get there, and the trust to confide your story, or a carer who will advocate for you and help you to achieve these steps. There are many building blocks that need to be put in place by the caregiver and environment before therapeutic interventions are possible, and it may be that when we get these other elements right, the child is able to recover using their own resources and that of their caregivers, without ever seeing a therapist.

My perspective is that if we can help to identify needs of children as early as possible and skill up the caregivers and the systems around the child, we can make the most impact. That is why I have increasingly moved from working with individual children to working with their caregivers and the systems that surround them, and have developed the BERRI system to identify needs and help carers understand them, as well as developing and delivering training to help carers and professionals understand the needs of the children and young people better. It doesn’t have the depth of working psychologically with a single individual, but it has the scope to make impact on a much wider scale, and it fits better with my personal strengths and interests. As I’ve said before, I’m not the most patient therapist to walk a long journey of recovery or personal development with a client, but I do have strengths with assessment and evidence-based practice.

My aims have always been to address human needs. I believe that Clinical Psychology in its simplest form is an attempt to make people happier and more able to lead fulfilling lives, and that is what drew me to this profession. And within that broader mission, my focus is to work with the most vulnerable members of society at the earliest possible point in the lifecycle, which has brought me to working with Looked After Children and the broader population of children and families receiving (or in need of) social care services. Recognising the mismatch between the level of need and the resources available to meet that need has increasingly led me to focus on systemic and population level interventions. Rather than drowning in the burnout that comes with trying to solve an overwhelming problem, I’ve tried to find a niche where my skills can make an impact. Having looked at this population group from multiple perspectives, and tested out projects in various settings, I have become increasingly persuaded that there is scope to make positive changes through the use of better systems to identify need, and increased clinical governance over the choice of placements and interventions. 

I have tried to develop practical, cost-effective ways to make a difference, and to gather evidence of their efficacy. I have then tried to share my findings, and what is already known from research, with the widest and most influential possible audience. That is why I have given so much of my time over to writing best practice papers and contributing to policy. Through these experiences I have gradually learnt to shape the messages I share to make them relevant and understandable to various audiences. After all, whilst most of psychology seems common sense to those of us working in the profession, once you have learnt about the main findings and the methodologies for gathering knowledge, to lay people (and professionals, commissioners and politicians) it might seem very complex and unfamiliar. Over time I have learnt that being able to articulate the financial benefits of improving people’s lives helps to get decision makers on board. So my goal in responding to the enquiry was to explain both the human and financial case for greater psychological input for children receiving social care services. I don’t know how well I have achieved that, but I’d be interested in your thoughts and feedback.

Reaching the summit?

For a long time, I’ve had a metaphor in my mind about how it feels to run a small business aiming to change children’s social care. The image is of me rolling a massive boulder up a hill. Progress is slow, it is hard work and I often find it tiring. Even when I rest I have to do so holding the rock in place. At times I feel like I might be reaching the summit, only to see that there is another climb ahead. I sometimes wonder why I’ve taken on this mammoth task, or whether my goals are even possible, but I am stubbornly determined that now I’m so far up the hill I don’t want to give it up. Maybe that is about sunk cost. But I’ve chipped off the worst of the bumps from the rock and got my rolling technique worked out, so I keep telling myself that if anyone can get this thing to the top of the hill, I can. Over the years of my journey I’ve tried to encourage other people to help me to push, so I am not bearing all the weight, but whilst I’ve had good company at times and plenty of encouragement, it has always seemed like the task is mine alone. That has been reinforced by numerous people telling me how I’m uniquely skilled at rock-rolling, even though I know that I was no better than many other people at the start of my journey. In fact I’m pretty sure anyone with some pretty basic skills who rolled a rock for this long could be standing in my shoes.

Of course, that bypasses the fact that I had to be willing to spend a lot of time on this, be resilient in the face of obstacles, and give up other easier opportunities to stick with it. And the fact I had the intellectual, social and personal characteristics to work out how to do this, choose a viable route and make improvements along the way. And it also omits to mention that had I known the real scope of the task would take me over a decade I might not have taken it on at the beginning. On the other hand, perhaps the fact it was difficult enough for nobody else to take on was why I did it. I think those who know me might point out it isn’t the first time I’ve jumped in at the deep end, and that I don’t do things in half measures. I don’t like taking the easy route in life, and if I set myself a challenge I like doing the task properly. I’ve always thought about what I can do to make the most impact, rather than to have the easiest life or earn the most money. I prefer to cut my own path, than to take one that is already well-trodden, and to find a way to enjoy the challenges of the journey.

So here I am, pushing my boulder and feeling like I’ve come quite a long way over the years. I might be deluding myself, but the gradient appears less steep these days. In fact, it feels tantalisingly close to reaching level ground, and I am starting to imagine what it might be like to roll my boulder down the other side of the hill. I’m trying not to be complacent that I’ve reached a point at which the boulder is stable enough not to roll back the way we came up, but people are starting to talk about how this boulder is not just on the level, but given one more push might gain enough momentum to create a landslide that will divert the river to irrigate the lands the local population need to farm. That would be beyond my wildest dreams. I mean, the motivation behind all this is to improve the lives of people who are having a tough time, but to think that it could have impact on the scale some people are now anticipating is mind-blowing. That would mean my big gamble of investing so much time and effort into this project could pay off in terms of impact. In a way that’s the great thing about indirect interventions – that they can make change that ripples out on a much bigger scale. In my boulder metaphor I’m trying to make change not by trying to teach them new farming skills one by one, but by trying to address some of the systemic barriers that impair their life chances, so that they have the opportunity to find their own ways to thrive.

So this blog is a marker of me standing at what I hope might be the top of the hill, and crossing my fingers the gaining momentum part happens. The mixture of hope and uncertainty is stressful to balance. When it’s a bit more concrete I’ll write a bit more, and hopefully I’ll not need a metaphor to couch my cautious optimism in, and can tell you about the actual project and the steps I’ve taken to progress it.

Runway: A blog about whether being self-employed or starting a business is a viable option financially

If an aircraft runs out of runway before becoming airborne then it will have to stop or it will potentially crash horribly. For this reason, runway is used as a metaphor for the relationship between the money available in a business and its running costs. If the business does not generate enough income to keep the cashflow up to cover costs, then it will either come to a stop or come to a horrible end. But unlike an airport, where sufficient runway already exists for the purposes of launching planes, with a new business you have to find or create the money that will hopefully let the business become self-sustaining. And unlike an airport, at which planes get up into the air uneventfully every few minutes every day for many years, most businesses fail within the first three years, often because of not being able to generate enough income to sustain the business in the longer term.

I think a lot of people in employment have fantasies about being self-employed or starting their own business. For clinicians, the fantasy is often about offering therapy in private practise to insured or well-heeled clients with milder problems. Whilst the hourly rates for private practise might seem attractive compared to a salary divided down into an hourly rate, the figures represent something really different. Salary is paid on leave days, bank holidays and when you are sick. It covers maternity/paternity leave and redundancy if you are no longer needed. You get supervision, CPD, equipment to use and premises to work in. You also have a team of other professionals supporting you in the background from admin to HR, finance, operational management, procurement and maintenance. You don’t have to think beyond providing the clinical and associated psychological services. Salary packages, particularly from the NHS, also contribute to very favourable life insurance and pension schemes. When you are self-employed you need to think about premises, insurance, supervision, CPD costs, DBS checks, accountancy, advertising, tax and how you will generate income if you don’t or can’t work. You may also need equipment from computers and stationary to psychometric tests (which are enormously expensive both to purchase and for record forms).

Remember that the bills need to be paid immediately, but clients may not pay you as promptly – and some may not pay at all. This is particularly true for me when doing expert witness work where the timelines from accepting the work to receiving payment for it are amazingly extended. If I accepted an instruction in principle on 1st January, I would typically receive instructions for it 1-3 weeks later. My appointments would take place 4-8 weeks after that, and my report would be submitted a fortnight later, perhaps in late March. There might then be further instructions or clarifying questions, before the case is heard at the end of May. Any invoices will only be processed when the case closes in June, and then sent to the Legal Aid Authority for scrutiny in July. If there are no queries the LAA then send payment to the solicitors, who eventually send it on to the expert in the August or September, though some will drag their heels for several more months. So I have to wait six to twelve more months to receive payment. And about 8% of the work is never paid, because the solicitors closes after the Legal Aid claim is made, or because the LAA determined that some of the work wasn’t “reasonable” or because there was a problem somewhere in the line of communication and one of the parties doesn’t claim a share of your invoice. Meanwhile the work is taxable in the financial year in which it is completed, and the VAT is payable at the point the invoice is issued. I also have to pay any staff who contributed at the end of the month in which we did the work.

Even as a sole trader working from home in a service industry with relatively low set-up costs, most of us need to earn some money to cover our living expenses, and can’t go for months or years unpaid. That means that unless you have a massive inheritance or lottery win to draw on, it might not be possible to give up salaried work to take the gamble of trying something independent. My rule of thumb is to have a minimum of three months living expenses saved before you consider leaving salaried employment. You might get this from a redundancy or mutually agreed resignation scheme, or by putting money aside whilst you are planning. You should also compare your current and projected earnings. My way of calculating this to calculate your annual salary plus 25% (the approximate value of the pension and protections) divided by 210 (the actual number of days an average NHS employee turns up to work). You can then compare this to what you think you could earn in a day if you had private clients, a contract with a large company to deliver training or services, a calendar full of supervision or consultancy, or whatever you imagine doing. You really need a multiple of three between the first number and the second to make being self-employed pay equivalently after costs, though if you really hate your job or are prepared to take a reduction in income (at least in the short-term) you might consider a multiple of two. I don’t believe it is viable to go below this because in my experience people never properly account for the amount of expenses involved, or the for the amount of non-income generating time required. As well as the fact that not all of your available slots will be filled until you are well established, it is worth bearing in mind that most full-time clinicians spend about 15-18 hours per week on direct clinical work, and the rest on work tasks that would be non-income generating in the private sector, such as screening referrals, setting up appointments, phone calls, email, supervision, meetings/indirect work, writing letters/reports, other admin and CPD.

That said, money isn’t everything. I know some amazing selfless people who have earned less than minimum wage for many years, but followed their heart because they cared passionately about what they were doing, and the impact it could make in the world. I’m not quite that altruistic, perhaps because I am the main earner for our family unit and feel an obligation to sustain our quality of life, but I’ve had to learn to live on a much less regular income. I pay myself minimum wage then supplement this with lump sums when the business is profitable. To make this even more unpredictable, I have often had to loan money into the business in order to pay salaries when others have been slow to pay us for work we’ve done. Overall I’d say my income is lower than when I worked in the NHS and did some court expert witness work on top, but nowadays on balance it probably matches my consultant grade salary. The amount I earn feels sufficient for our needs – and probably stretches a little further as some expenses have been absorbed (eg my mobile phone bill is paid by the company, as is the cost of any CPD I want, the costs of my accountant, and some little things like a sandwich and soft drink when I’m away from the office on business).

There are also some things that money can’t buy. I’ve loved the freedom and flexibility of being self-employed, even though there have been times that have been quite tough financially. Whilst it initially increased my workaholic tendencies to quite alarming proportions (peaking at working 9.30am to 6.30pm in the office and then 10pm until 2am at home most weekdays, and fitting in 5-10 hours of work per weekend), more recently I’ve been able to achieve more of a work-life balance. I’ve stopped doing as much consultancy and training that involved staying away over night, and reduced the court work that created so many high-pressure deadlines. I’ve started to cluster meetings in London once a month, arranging other meetings over videoconferencing where possible. I’ve withdrawn from the committee and policy work that was taking up a big chunk of my time. I’ve also recognised the wise advice of a past supervisor that said I needed to fill up life outside work with commitments that would compete with work, rather than expecting to ever be the kind of person who can ring-fence free time. So I’ve started putting social appointments in my calendar, made a commitment to swimming regularly, I’m doing more adventurous things with the children, and I’ve even been able to sneak out for the afternoon with my husband from time to time. Running my own business has also given me a chance to relocate to an area that I love, where my qualify of life and working environment is much nicer.

When weighing up the options, bear in mind that working as a sole trader can be quite isolating. In the NHS or other organisations we usually work within teams, often with the benefit of colleagues to bounce ideas off, or who can contribute to formulations from other perspectives. Working with others also allows you to collaborate or to delegate work to people with complementary skills or interests. It shares the risk of complex cases, and means you don’t feel solely responsible for the waiting list or the stuck cases. It can allow you to prioritise work and manage your workload. When you are the only one doing the work this becomes much more difficult, and the pressures and sense of responsibility for clients can increase substantially. Even though the waiting list might be shorter, you might feel more guilty if there is a delay in starting work with a new referral, or more responsible for ensuring a good outcome for everyone. When your income literally depends on how much work you do it can be hard not to end up over-working to the detriment of everything else in your life. However, on the flip side you can feel pride in positive outcomes, and a waiting list becomes a marker of success (that people are willing to wait for you) rather than a mark of failure like it is construed in the NHS (where there is pressure to meet targets, and services don’t have enough resources to keep pace with need, and are the only available option for most people).

You also need to realistically appraise your business plan. Most people go into business in the belief that they have found a niche in which they can earn a profit, and hope that demand for their services or product will arrive as soon as potential customers know it is available. However, that can lead people to be overly optimistic about how fast they can gain traction in the market, or the level of profit they can make. Unless the plan is to seek external investment, most small business owners need for the business to become profitable fairly quickly, and few would be willing to pour their life savings into a new business in the hope of a return further down the line. When trying to start up a company or expand a sole trader enterprise into a business that employs others it can often feel like a Catch 22 situation, that you can’t afford the things you need to generate the income that will fund the things you need. But unlike on Dragon’s Den or in Silicon Valley, few people have access to capital investment and most professionals (in the health and social care field at least) are wary about taking on loans before the business has the means to repay them, even if they can access lending.

My point is that even if you have a great business idea and an established reputation getting enough money to start and sustain a business is tough. Cashflow is a make or break issue. Generating sufficient working capital is one of several elements that challenge new start-ups. In fact, of small businesses that fail (based on figures from the USA), 82% attribute this to cashflow issues and 29% say that they ran out of cash, whilst 42% said that the issue was a lack of market need for their products or services, 23% don’t have the right team to deliver the business, and 19% can’t match a competitor.

I guess that makes me a survivor. I launched my small business seven years ago this month, and it is gratifying that we’ve managed to weather the politics of adversity to still be trading. However, making money is still something I find quite challenging. I’ve come out of a career in the NHS in which the financial transactions involved were far removed from my daily life, and the idea of making a profit was quite aversive. But I’ve had to learn to make my business financially viable. Whilst there have been times that have tested me almost to my limits, the business is still functioning and financially we are still on the runway. I view that as a success. However, I feel like we have never quite reached the position of being airborne, where the business is self-sustaining without me personally doing income generating work as a substantial proportion of my time – and that would be an enormous issue if I ever needed time off sick.

My penultimate piece of advice is to speak to people who understand business and finance before you embark upon your journey, and regularly as you go along. I’ve had the benefit of great guidance as I’ve travelled outside of the NHS and into the world of business. As well as my fantastic ongoing mentoring from Impact Hub, which has included some work on the financial elements of the business plan, I recently won a place on a scheme sponsored by Barclays bank to help social purpose businesses to scale up. I’ve been attending Judge Business School at Cambridge University with several other small businesses, where we have had a series of days to explore our options and make a growth plan for the business. Having identified gaps, I’ve then taken actions to rectify them. For example, we’ve built a website for BERRI so that prospective subscribers can see what our tools have to offer, and that has brought in a flurry of new subscribers. I’ve also explored the options to help me scale up more rapidly and increase the impact of what we can deliver. Thankfully we have a strong business case, and I’ve been increasingly able to articulate that as a result of the work I’ve been doing. Over the last month I have spoken to two potential sources of investment. That would give me more runway to play with, but I need to work out whether we are fully aligned in terms of the destination and route to get there before I can be sure that is the right move to make compared to continued slow organic growth.

My final advice is to recognise your own limitations, and to find ways to delegate the tasks you are not good at or not enthused about, and spend time with people who share your passions or the skills you want to grow. For me that means having an administrator who makes up and chases up my invoices, accountants who can deal with payroll, tax, NI, pensions etc and advisors who guide me to apply for the right grants, tax rebates and training schemes. I also meet up regularly with other social entrepreneurs to share our progress and plan collaborative projects. I just appointed an experienced Business Development Lead for the company, who I hope will help me to weigh up the options for investment, and help us to grow quickly but in a way that feels right and prioritises making an positive impact on the lives of vulnerable children over maximising profit. I’m hoping we’ll reach sustainability by the end of the year, but there are still hurdles to overcome, and even when we get into the air I can’t imagine it will be a journey without occasional turbulence.

Communicating the value of evidence

I presented at a couple of conferences over the last few weeks about my BERRI system. And I was struck, once again, by how little weight is given to evidence when it comes to services that are commissioned in the social care sector. Various glossy marketing claims and slick consultants were successfully persuading commissioners and service managers that it was equivalent to use their systems and “metrics” (in which people gave entirely subjective ratings on various arbitrarily chosen variables) to using validated outcome measures. By validated outcome measures, I mean questionnaires or metrics that have been developed through a methodical process and validated with scientific rigour that explores whether they are measuring the right things, whether they are measuring them reliably, whether those measures are sensitive to change, and whether the results are meaningful. A pathway that then leads to an established scientific process of critical appraisal when those studies are presented at conferences, published and made subject to peer review.

But outside of the academic/scientific community it is very hard to prove that having a proper process is worth the time and investment it takes. It means that you are running a much longer race than those who work without evidence. At one event last week, I asked a question of a consultancy firm making hundreds of thousands of pounds out of “improving children’s social care outcomes”, about their basis for what they chose to measure, how they measure it, and how they had validated their claims. The answer was that they were confident that they were measuring the right things, and that having any kind of scientific process or validation would slow down their ability to make impact (aka profit). My answer was that without it there was no evidence they were making any impact.

They couldn’t see that their process of skipping to the doing bit was equivalent to thinking that architects, structural drawings, planning permission and buildings regulation control slow down building houses, and selling houses they’d built without all that burdensome process. Thinking anyone can build a house (or a psychometric measure to track outcomes) feels like an example of the Dunning-Kruger effect, the idea that those with the least knowledge overestimate their knowledge the most. But the worst thing was that those commissioning couldn’t see the difference either. They find the language of evidence to be in the domain of academics and clinicians, and don’t understand it, or its importance. We are in an age where expertise is dismissed in favour of messages that resonate with a populist agenda, and it seems that this even applies when commissioning services that affect the outcomes of vulnerable population groups. I don’t know how we change this, but we need to.

For those who don’t know, I’ve been working on BERRI for 12 years now, on and off, with the goal of being able to map the needs of complex children and young people, such as those living in public care, in a way that is meaningful, sensitive to change and helps those caring for them to meet those needs better. For as long as I’ve worked with Looked After children, there has been a recognition of the fact that this population does worse in life along a wide range of metrics, and a desire to improve outcomes for them for both altruistic and financial reasons. Since Every Child Matters in 2003, there have been attempts to improve outcomes, defined with aspirations in five areas of functioning:

  • stay safe
  • be healthy
  • enjoy and achieve
  • make a positive contribution
  • achieve economic well-being

A lot of services, the one that I led included, tried to rate children on each of these areas, and make care plans that aimed to help them increase their chances in each area. Each was supposed to be associated with a detailed framework of how various agencies can work together to achieve it. However, whilst the goals are worthy, they are also vague, and it is hard to give any objective score of how much progress a young person is making along each target area. And in my specific area of mental health and psychological wellbeing they had nothing specific to say.

As with so much legislation, Every Child Matters was not followed up by the following government, and with the move of children’s social care and child protection into the remit of the Department for Education, the focus shifted towards educational attainments as a metric of success. But looking primarily at educational attendance and attainments has several problems. Firstly it assumes that children in Care are in all other ways equivalent to the general population with which they are compared (when in fact in many ways they are not, having both disproportionate socioeconomic adversity and disproportionate exposure to trauma and risk factors, as well as much higher incidence of neurodevelopmental disorder and learning disability). Secondly it limits the scope of consideration to the ages in which education is happening (primarily 5-18, but in exceptional circumstances 3-21) rather than the whole life course. Thirdly it doesn’t look at the quality of care that is being received – which has important implications for how we recruit, select and support the workforce of foster carers and residential care staff, and what expectations we have of placement providers (something I think critical, given we are spending a billion pounds a year on residential care placements, and more on secure provision, fostering agencies and therapy services that at the moment don’t have to do very much at all to show they are effective, beyond providing food, accommodation, and ensuring educational attendance). Finally, it masks how important attachment relationships, and support to improve mental health are in this population. I can see that strategically it makes sense for politicians and commissioners not to measure this need – they don’t want to identify mental health needs that services are not resourced to meet – but that is significantly failing the children and young people involved.

In my role as a clinician lead for children in Care and adopted within a CAMH service, I kept finding that children were being referred with behaviour problems, but underlying that were significant difficulties with attachment, and complex trauma histories. I was acutely aware that my service was unable to meet demand, leading us to need some system to prioritise referrals, and that there was a lot of ambiguity about what was in the remit of CAMHS and what was in the remit of social care. I wasn’t alone in that dilemma. There were a lot of defensive boundaries going on in CAMHS around the country, rejecting referrals that did not indicate a treatable mental health condition, even if the child had significant behavioural or emotional difficulties. The justification was that many children were making a normal response to abnormal experiences, and that CAMHS clinicians didn’t want to pathologise this or locate it like an organic condition inside the child, so it should best be dealt with as a social care issue.

On the other hand, I was mindful of the fact that this population have enormous mental health needs, having disproportionately experienced the Adverse Childhood Experiences that are known to lead to adverse mental and physical health outcomes. Research done by many of my peers has shown that two thirds to three quarters of Looked After children and young people score over 17 on the SDQ (the Strengths and Difficulties Questionnaire – the government mandated and CORC recommended measure for screening mental health need in children) meaning they should be eligible for a CAMH service, and various research studies have shown that 45% of LAC have a diagnosable mental health condition, but the resources are not available to meet that need. As The Mental Health Foundation’s 2002 review entitled “Mental Health of Looked After Children” put it:

Research shows that looked-after children generally have greater mental health needs than other young people, including a significant proportion who have more than one condition and/or a serious psychiatric disorder (McCann et al, 1996). But their mental health problems are frequently unnoticed or ignored. There is a need for a system of early mental health assessment and intervention for looked-after children and young people, including those who go on to be adopted.

My initial goal was to develop a new questionnaire to cover the mental health and psychological wellbeing issues that this population were experiencing, as well as considering attachment/trauma history and the child’s ability to trust others and form healthy relationships, and the behaviours that these often expressed through. I was also interested in what issues determined the type of placement given to a child, and the risk of placement breakdown, as well as what opened doors to specialist services such as therapy, and whether those services and interventions really made any difference. I therefore ran two focus groups to explore what concerns carers and professionals had about Looked After children and young people, and asked them about what they saw that might indicate a mental health problem, or any related concerns that led people to want my input, or that caused placements to wobble or break down. One group contained foster carers and the professional networks around them (link workers, children’s social workers, the nurse who did the LAC medicals, service managers) and one contained residential care workers and the professional networks around them (home managers, children’s social workers, the nurse who did the LAC medicals, service managers). I wrote their responses down on flip-charts, and then I sorted them into themes.

I had initially thought that it might cluster as behavioural and emotional, or internalising and externalising, but my items seemed more complex than that. In the end there were five themes that emerged:

  • Behaviour
  • Emotional wellbeing
  • Risk (to self and others)
  • Relationships/attachments
  • Indicators (of psychiatric or neurodevelopmental conditions)

The first letters gave me the name for the scale: BERRI. I then piloted the scale with various carers, and then with a group of clinical psychologists involved with CPLAAC (the national network within the British Psychological Society that contained about 300 Clinical Psychologists working with Looked After and Adopted Children that I was chair of for about six years). I then added a life events checklist to set the issues we were identifying in context.

The working group I chaired in 2007 on the state of outcome measurement for Looked After and adopted children (on the invitation of CORC) came to the conclusion that no suitable metrics were available or widely used. We therefore agreed to further develop and validate the various tools that members of the group had home-brewed, including my BERRI. There was acknowledgement that it takes a lot of work to develop a new psychometric instrument in a valid way, but a consensus that this needed to be done. So I resolved to find a way to follow that proper process to validate and norm BERRI, despite the lack of any funding, ring-fenced time or logistical support to do so. The first challenge was to collect enough data to allow me to analyse the items on the measure, and the five themes I had sorted them into. But I didn’t have the resources to run a research trial and then enter all the data into a database.

My way around this barrier was to get my peers to use the measure and give me their data. To do this I took advantage of some of the technically skilled people in my personal network and developed a website into which people could type anonymous BERRI scores and receive back a report with the scores and some generic advice about how to manage each domain. I tested this out and found my peers were quite enthused about it. We then had a formal pilot phase, where 750 BERRIs were completed by Clinical Psychologists about children and young people they were working with. I then talked about it with some young people and care leavers to check that they felt the areas we were covering were relevant and helpful to know about. Then I started to use the system in a large pilot with residential care providers and developed tools to focus in on particular concerns as goals to work on, and track them day by day or week by week, as well as creating tools to give managers an overview of the progress of the children in their care. We’ve had a lot of feedback about how useful and game-changing the system is, and how it has the potential to revolutionise various aspects of commissioning and decision-making in children’s social care.

But I really wanted the process to be one in which we were truly scientific and based our claims on evidence. I’ve never marketed the BERRI or made claims about what it can do until very recently, when I finally reached a point where we had evidence to substantiate some modest claims*. But to me the process is critical and there is still a long way to go in making the data as useful as it can be. So from day one a process of iterative research was built in to the way we developed BERRI. As soon as it was being used by large numbers of services and we had collected a large data set we were able to look closely at how the items were used, the factor structure, internal consistency and which variables changed over time. We ran a series of validity and reliability analyses including correlations with the SDQ, Conners, and the child’s story – including ACEs, placement information and various vulnerability factors in the child’s current situation. But even then I worried about the bias, so a doctoral student is now running an independent study of inter-rater reliability and convergent/divergent validity across 42 children’s homes.

BERRI will always be developed hand in hand with research, so that there is an ongoing process of refining our outputs in light of the data. The first step in that is getting age and gender norms. But the data can also indicate what we need to do to improve the measure, and the usefulness of the output reports. For example, it seems that it might be meaningful to look at two aspects of “Relationships” being distinct from each other. If the evidence continues to show this, we will change the way we generate the reports from the data to talk about social skills deficits and attachment difficulties separately in our reports. We might also tweak which items fall into which of the five factors. We also want to check that the five factor model is not based on the a priori sorting of the items into the five headings, so we are planning a study in which the item order is randomised on each use to repeat our factor analysis. We also want to explore whether there are threshold scores in any factor or critical items within factors that indicate which types of placements are required or predict placement breakdown. We might also be able to model CSE risk.

The results to date have been really exciting. I have begun to present them at conferences and we are currently preparing some articles to submit for publication. For example, I am currently writing up a paper about the ADHD-like presentation so many traumatised children have, and how we have learnt from our BERRI research that this reflects early life ACEs priming readiness for fight-or-flight rather than proximal events or a randomly distributed organic condition. But the findings depend on all the groundwork of how BERRI was developed, our rigorous validation process and the data we have collected. It is the data that gives us the ability to interpret what is going on, and to give advice at the individual and organisational level.

So you’ll forgive me if I’m somewhat cynical about systems that request a subjective likert rating of five domains from Every Child Matters, or an equally subjective score out of 100 for twelve domains pulled from the personal experience of the consultant when working in children’s social care services, that then claim to be able to map needs and progress without any validation of their methodology, areas to rate, sensitivity to change or the meaning of their scores. Having gone through the process the long way might put me at a commercial disadvantage, rather than going straight to marketing, but I like my houses built on the foundations of good evidence. I can feel confident that the load bearing beams will keep the structure sound for a lifetime when they are placed with precision and underpinned by the calculations and expertise of architects, structural engineers, surveyors and buildings control, rather than cobbled together as quickly as possible, marketed with amorphous claims and sold on rapidly to anyone who will pay for them. After all, I’m not in it to make a quick buck. I know my work is a slow and cumulative thing, and BERRI still has a long way to go before it can create the greatest impact. But my goals are big: I want to improve outcomes for children and young people who have experienced adversity, and I want that impact to influence the whole culture of children’s social care provision in the UK and to continue to be felt through the generations. And to do that, I need to build the thing properly.

* that carers, therapists and managers find it useful and easy to use, that using the BERRI pathway demonstrated an improvement of 14% over 6 months for the first 125 children placed on the system, and that BERRI has a robust factor structure, good reliability between raters, and the basic statistical qualities that suggest sufficient validity for use. We also have some testimonials, including a commissioner who used BERRI to map the needs of 15 high tariff children and found four suitable to move to foster or family placements with support, saving nearly half a million pounds per year from his budget – a finding we would like to replicate with a much larger study, given the opportunity.

 

 

Sowing seeds

I was late to plant my vegetable seeds this year. Due to Defra restrictions to prevent avian flu, our chickens were living in our polytunnel until the end of March. It then needed digging over and the raised beds building for this year, as well as some plans for irrigation. We don’t have any staging in there yet, and I don’t have a greenhouse here in which to start my seedlings. And so because it seemed complicated and I didn’t have much energy due to ongoing health irritations, we reached the second weekend in April without any seeds planted. I could have conceded, as I did last year, and bought seedlings to plant out, but that seemed like a lazy option and I knew taking a shortcut makes me feel less proud of the results. Plus I have accumulated a stockpile of seeds that needs to be used, and the kids love planting, so that is what we spent the first weekend of the Easter holidays doing. Thankfully most of them have sprouted quickly and just reached the size where I have started planting them out (though some have not grown at all).

It struck me whilst I was planting out the seedlings and topping up the seed trays that sowing seeds is an act of faith that they will sprout and grow to produce plants, flowers, fruit or vegetables given time and nurture. Whilst generally the freshest largest seeds do the best, that isn’t always the case as weather conditions and wildlife can easily disrupt your plans in the garden. Sometimes the most promising looking seeds don’t lead to viable plants, or the most lush looking plants fail to produce fruit, whilst the least promising looking seeds or most straggly plants can sometimes surprise you with an abundant harvest down the line. Some of the outcome depends on skill, some on diligence and some on factors outside of our control. Each time you have to prepare the soil, sow the seed and water it regularly to see what comes out. It is an investment of resources and energy that will hopefully be repaid in the future. That idea was resonant for me for a number of reasons.

Firstly, I am trying to invest effort in improving my physical health. The motivation for that comes from looking forward into the prospective futures available to me, and how my health and fitness will affect me and my family. It has become much clearer that what I eat today, or the exercise I do or don’t do, has an impact on me that I’ll feel in the future. I’m making an effort to be more active, get enough sleep and to eat more vegetables and less processed food (I’m a big fan of spring greens at the moment – they are so cheap to buy, but are deliciously sweet and tasty, as well as being seasonal and grown in the UK). So far I have lost 10lbs but I have bigger goals, and want this to be the beginning of cumulative changes in my life. I want my kids to have an active, happy Mum who does lots of stuff with them, rather than a perpetually tired Mum who is preoccupied with work stress. There is a famous Reddit post that talks about non-zero days and effort being a gift from past you to future you that I would recommend reading if you haven’t stumbled upon it yet.

Investing energy for the future potential also connects to the wider theme of working in mental health – where we and the client invest time and energy in trying to make the future better for them – and also that of trying to make a career in psychology. As application season passes on the forum, we can see the hope and heartache that this involves. Many people become almost obsessional about checking the forum for news of when courses have short-listed, and when the offer letters come out – so much so that it completely changes the traffic pattern to the forum (which normally has an average visit time of over 10 minutes, in which the typical user views many pages, but has two months per year in which repeat checkers raise the number of visits, but bring the average visit time down to 2 minutes, often just viewing a single page over and over again).

The early years of most psychology’ careers are seen as an investment necessary to pass the career bottleneck of being selected for training. Prior to that, many applicants feel they are gambling their time on a potential future that may never happen. There is a sense of trying to tick boxes, but not knowing exactly what the boxes are, or why they are necessary which I think needs to be explored and challenged. For many people, it seems like those early stages feel pointless in and of themselves. They are not seen as a long term career plan, and are therefore easily dismissed as being worthless except to jump hoops to try to gain a clinical training place, but I think they have merit in their own right. Many people gain great satisfaction from doing these “low level” care jobs, and they are invaluable in the daily lives of many people in their times of greatest need. They are also a fantastic way in which you can gain and apply the basic psychological skills of listening, empathy and compassion to client’s lives, and to experience the ways that the system around them can help or hinder their wellbeing. Being a mindful and reflective frontline care worker (or researcher) is the time at which people engage the most in the lives of clients, and ensures that the advice we give later down the line is grounded in reality. It also lets us experience the hard work and competing pressures of the staff we may end up advising from the lofty perch of being a qualified health professional, so it is a shame to see so many people horizon gazing to the detriment of getting the most out of the moment they are in.

The same theme of investing time and energy to create something for the future is true in setting up a small business. All over the country people are ploughing in their own money and time to set up small ventures, despite the time involved being more than full-time hours and the initial return often being much less than minimum wage. I hadn’t realised when I set out that even when the business has been running for a while, you often end up having to repeat this process over and over again. As staff move on, or contracts change, or the balance of work stops being enjoyable, or you hit hurdles along the way you have to regroup and use the available resources to fulfil your commitments, or even to start over in a new direction. That process can be disheartening, but it can also be an opportunity for growth, and is a good reminder for those running a business to take a step back and look again at the short, middle and long-term goals of the business and the methods used to achieve them. It is hard when a business feels so personal to lose a member of staff, or to have to step away from a long-standing contract or area of work, but it can allow you to invest more energy in trying to plan the business you want to create.

The toughest part of running a business rather than being self-employed is wanting to do the right thing for your employees, whilst also achieving the aims of the business and creating an enjoyable role (and some profit) for yourself. It can be particularly hard to make good financial and business decisions as a caring, empathic, progressive person who wants to do the right thing by everybody else involved, so it is extra important to have good business and financial advice if you are not just responsible for yourself, and your own plans for the future. The owner of the business is always the last to get paid, and feels responsible for the well-being of every other member of staff – even though for them it feels more like a job, and less like a personal mission.

In a social business we are also the ones responsible for deciding how we provide our services, and what the focus will be. There is endless demand for my services as a court expert witness, as a trainer and consultant to the residential and foster care sector, but I know if I get too swept up into delivering services personally I don’t leave enough capacity to steer the business. So I have to pick and choose the activities that best align with my long-term goals. I have to plan the future of my company in a way that has the most impact on recipients and creates a financial reward for me and my employees in the future. That “triple bottom line” of caring about people (employees and service recipients) and the planet (systems and wider issues) as well as profit (earning enough to pay employees and yourself) is part of the joy and challenge of running a socially worthwhile business.

The sheer number of choices and possibilities can be quite overwhelming at times, and each decision feels like it needs knowledge that I don’t have to make it in an informed way. For example, I need to decide whether to formalise the social enterprise structure within which we deliver our outcome measurement tools. If we do it will open doors to sources of investment that might allow us to scale more rapidly and would be closed to a traditional company. However investment always comes with strings attached and can easily change the direction of the company, or reduce the autonomy with which it operates. It feels similar to decide on a new office base. Do I rent a serviced office, commit to a 3 year rental of a unit on a local farm, or get a business loan and purchase a small building? What if we need to grow or shrink so that this choice doesn’t fit the company structure in 12 months time?

It is hard to predict the future impact of seemingly small choices in the present. I can see why anxiety can sometimes make these choices overwhelming, as it is easy to end up with endless background research and tables of pros and cons that are immobilising. I’m sometimes tempted to make them with a coin toss* or a counting rhyme as we did on the playground at primary school. Like sowing seeds, we just have to research and plan the best we can within reasonable time constraints and then follow the instructions and see what grows!

 

*I was once told to toss a coin and then check if your reaction was relief or to want to make it “best of three” and to then follow your gut rather than the result. It seems as good a method of decision making as any other.

Starting over: Selecting offices and staffing

After the stress of my last blog about problems with the offices we were leaving in Milton Keynes*, I was keen to make sure that we set up a base I felt really comfortable with up in Derbyshire, and gather a great team up here. I viewed a lot of potential offices and tried to really get a good gut feeling about where we would belong. The plan is to rent an office or set of offices that has scope to expand if we secure the grant we have applied for, or other external funding that lets us expand more quickly.

The first place I viewed was a serviced office centre. The rooms were pleasant and good value (less than half the price per square foot that I had been paying further south) but the site was quite generic and a looked a bit warehouse-like. More importantly it was on the far side of a market town with quite a lot of traffic, and further from the motorway. I then viewed an office suite in a pretty restored station building on a quiet branch line. Despite this being my favourite option, it turned out only a single room was available there, and the tenants who had the rest of the building were spilling out into all the public areas, which were filled with their storage and materials. Plus the room didn’t have an individual lock – and I’ve learnt to be wary of that!

The next two places advertised were full, despite having road signage, listings on Rightmove and vacancies marked on their websites. The next place was a dilapidated shop with offices above, but transpired to be under offer, and to need a lot more work than would be possible in our timescales. The next a single room retail space, with no sink or loo unless you went into the next door building, that was quite a walk from the nearest parking. A small office building for sale, but cramped in a back street in a town slightly further from my preferred areas. Then a lovely large set of rooms in a very smart building with dedicated parking and reception facilities, that became less attractive as the already high rent then gained a service charge, and charges for the phone/broadband and was then ruled out by access only being permitted when members of staff from the main business were present, and the building being locked up at 3.30pm on a Friday!

Then a small set of offices that were a bit too far away and had a contract with an excessive notice period. Next was a bright but slightly run down set of rooms over a letting agent, at a good value inclusive price, but with slightly dingy rear access. Then we viewed another office building that was for sale, but was too big, over priced and came with only a single parking space. Then another serviced office building in a massive complex that contained function rooms and all sorts of entertainment facilities, but had limited parking and was rather dirty and dated looking. Again there were all sorts of extra charges for phone/internet, insurance and a per person charge per month for furniture. However, some of the rooms were nice, and they did come with two parking spaces right outside. Whilst viewing we also met a potential business advisor and heard about the exciting collaborations within the complex, but somehow it just didn’t feel right.

It is always very interesting when your head and your guts give you different messages. Logically the last place had the most to offer, yet it was the rooms above the letting agent that gave me the best feeling, and the owner talked the least and was the most straightforward. A bit of negotiation later, and he had agreed to redecorate the rooms, provide some furniture and jet-wash the rear access, as well as hanging a door so that we could still access the toilets and kitchen, but other staff and customers could not come up to our offices uninvited. Having learnt my lesson, this time the repairs will be specified on the contract as being completed before rent is due!

I also interviewed for a new assistant psychologist for our Liverpool contract. The project is going to be in collaboration with my peer supervisor, so that feels like an extra benefit to me, as I get to spend more time with him. We even had fun interviewing, in the lovely Quaker building in the town centre, and ate delicious food at Mowglis. When it came to the applicants we interviewed, we were really pleased to be spoilt for choice. We felt that three of the candidates would have been great for the job, and were able to select someone we are really comfortable to add to the team.

I have also put up an advert for a new administrator. Having had both brilliant and awful experience of non-clinical staff in the past, I wanted to make sure we recruit the former. This person will be the hub in the centre of the business, around which the rest of us rotate, and they need a mixture of administrative, financial and interpersonal skill, with the ability to keep me and the business organised! So I put a lot of effort into the job description and person specification. It is the first time I have used online recruitment advertising, so fingers crossed we find the right person. The applications seem to be numerous and impressive, so we are off to a good start.

Also during the summer I met an inspirational potential collaborator, so I am hopeful that I can negotiate a productive way we can work together, whether he joins us as a part time COO, or whether we make a service level agreement between our two organisations. I only hope that I can find a few more clinical psychologists to join the team, as we continue to have more requests for our input than we can fulfil.

Finally, keep your fingers crossed for me, as I will hopefully hear back soon about the DfE grant that I applied for to expand our pilot of outcome measurement and our psychologically informed care pathway!

*Thankfully I have now resolved the issues with Regus, so I have edited the previous blog to reflect this. I don’t normally edit things I have posted, because I prefer to write honestly and leave what I say on the record. However, it was a condition of the resolution that I did so. I thought long and hard about it and concluded that this blog and my social media is not the right place for making an angry noise, and that I could tell the story equally accurately in a slightly less detailed and more dispassionate way.

Spreading too thin

In general I’m a frugal person. I buy foods that are reduced because they have reached their best before date and most of my clothes and shoes in the sales. I collect coupons and shop around for good offers. I try to waste as little as possible, and to recycle as much as I can. So I can understand wanting to get good value for money.

On the other hand, I like doing things properly. For example, when it comes to a sandwich, I like a thick slice of granary bread, fresh from the oven, with generous amounts of toppings. As it happens I’m not a big fan of butter or margarine, perhaps a symptom of being overweight in the 1980s and 90s when fat was literally seen as a cause of fat, whilst the carbs underneath were seen as relatively healthy. But whether it is soft cheese and cucumber, avocado and salad, cheddar and chutney, hummus and roasted veg, or toasted cheese and banana, the topping needs to cover the bread, with sufficient depth to make the sandwich proportionate. If the cheese has nearly run out, I’ll have half a cheese sandwich that tastes good rather than a mean whole.

So when it comes to services, I can see the motivation to get value for money, and to ensure that resources are being used in the most cost-effective way. I’ve developed pathways, clinics and groups to meet needs more effectively, and I’m happy to delegate less complex work to less experienced or less qualified staff. I can’t see the justification for paying psychiatrist salaries to deliver therapy, when a member of staff with half the hourly rate can be an equally good (if not superior) therapist. I can see the importance of capping the cost of agency staff, so that this money can be invested in increasing the substantive workforce. And when it comes to staff who are not pulling their weight (my record being a member of staff who had spent a whole year with a caseload of four clients, whilst colleagues in the same job had five times that along with other responsibilities) I can see the need for performance management.

However, there comes a point that too much pressure for efficiency actually makes services less effective. I saw this happen gradually over the 16 years I worked in the NHS. If we cut out all the conversations between cases, all the informal supervision, all the CPD opportunities, the time to bond as a team and to reflect and process information between appointments, then clinicians are less able to be empathic and individualised with clients. If you also give people tougher and tougher cases to work on, expecting faster throughput than with the more mixed caseload that preceded it, and couple this with cuts in admin despite there being more and more paperwork to do, you increase burnout and time off sick. Add some pay freezes, lose a proportion of posts, put people in smaller premises and tell them to hot-desk or become mobile workers and they no longer feel valued. Make it a set of competing businesslike trusts rather than one amazing non-profit organisation, tender out services like cleaning and home visiting to allow them to be done on minimum wage without the terms and conditions of the NHS, allow private companies to win contracts, and keep people in a perpetual state of change, then morale falls. Nobody has any loyalty or job security and it no longer chimes with the ethics of the people who work there.

The sandwich has been eroded down to bread and butter, and then to crackers and margarine, and then to a value brand version of the same that is 30% smaller. It might look like costs have been driven down, but the price is a reduction in the quality of services, and in the wellbeing of staff. It reduces the willingness to go above and beyond that has been the backbone of the NHS, and increases presenteeism – the tendency to feel that you need to be at work longer, and look like you are working harder, without this making meaningful impact on the work you get done. The UK has lower productivity than most other developed nations, perhaps because we have longer working hours, and work expands to fit the time available.

All over the public sector at the moment I see services trying to spread their resources thinner and thinner, and I’m acutely aware that this means they can’t do the whole job. Social Services departments have barely the capacity to maintain their statutory role, so supporting families in need goes by the wayside. Some good staff find other jobs. A proportion of the remainder go off long-term sick, leaving an ever bigger burden on those that remain. Teachers are forced to teach to tests that assess primary school pupils on aspects of English grammar that graduates struggle with that have little relevance to daily life, and squash the rest of the curriculum into less time. Children’s centres, youth clubs and leisure facilities are disappearing at a time when it is clear that parenting support and exercise are critical in improving well-being and decreasing long-term health and social care costs. We’ve been feeling the cost of ideological austerity bite, even before the financial shock of the Brexit vote, so I am struggling to see how things can improve in the foreseeable future, let alone once any steps are made to implement the extraction of the UK from the EU.

It is hard in this climate not to feel overwhelmed by pessimism. Staff are not pieces of equipment that can be upgraded or replaced at the click of your fingers. I can make a plan for how to cover a remit that needs 12 staff with 7, but I can’t then tell you how to do it with 5. I can only tell you that if you want the job doing properly it needs 12, and if you go below 7 it won’t be fit for purpose. If I sticky plaster over the cracks, you can pretend that paying for 5 is enough, and that it is the clinicians who are failing, whilst we burn out trying to do twice the amount of work each. But no matter how hard I work, I can’t be in four parts of the country at once, or do recruitment, service development, supervision and provide a clinical service in a part-time job.

Maybe the problem is that I am stubborn. I won’t just toe the line whilst covering my eyes and ears and going lalalalalalala when it comes to everything that isn’t being done. Like my exit point from the NHS, there comes a time where I’d rather leave than do things badly. And where the only efficiency available for me to recommend that fits the prevailing rationale is to pay two cheaper staff instead of my time. I’m teetering on the edge of the plank they’ve made me walk, and I’m increasingly tempted to jump. Maybe in retrospect they’ll recognise how much was getting done with such limited resources.