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.

Holding the buck: Some thoughts about accountability in the modern marketplace

A couple of weeks ago, I gave a talk to the Institute for Recovery from Childhood Trauma at the House of Lords. I decided it would be too stressful to travel down that morning, so about three weeks in advance I booked an apartment through booking.com. I’ve stayed in apartments and rooms through online sites quite a few times before without incident. Normally they send a code for the door by text or email, or instructions to open a key safe. However, this booking was confirmed with instructions to collect the key from a nearby address by 9pm (I was told if I arrived later there would be a £20 late collection fee). So I caught an earlier train and got a taxi to the pick-up address, which transpired to be an office building, locked up for the night. The security guard on site who came out to see why I was loitering had never heard of this being a collection point for apartment keys. So I spent 45 minutes waiting at the pick-up address and checking the apartment address just down the road, with no ability to check my email or find the phone number of the owner due to the o2 outage. I then found a restaurant which let me use its wifi to contact the apartment owner. He answers the phone as Booking.com and says the pickup address sent to me by email was never given (despite me having it in writing on my screen as I spoke to him) and that I had not confirmed the time. He says he will send a man to meet me with a key. But he isn’t willing to send the man to the restaurant in which I am sitting, I have to go wait across the road outside Patisserie Valerie (which is also closed) for a man in a red jacket.

In about 15 minutes that man arrives. He greets me by name, but does not offer me any apologies or identification. I can’t tell if he is the man I spoke to on the phone or not. He does not provide a key to the apartment, but tells me to follow him and walks off in the opposite direction to the apartment. I ask him where we are going, he says “to the apartment”. I say that it isn’t the right way, and I don’t feel comfortable following a strange man to an unknown address. He is short with me and tells me that he is taking me to an alternative apartment, because a cleaner snapped the key in the apartment door 20 minutes previously. I find this suspicious as a) I’ve been waiting at the apartment and just up the road for 90 minutes and nobody has come or gone from it in this time, and b) why would a cleaner be in an apartment at 10pm that is supposed to have check-in from 3pm to 9pm, and c) why did the man on the phone not notify me of a change of address or email me with a change of booking through the site on which I had booked?

He leads me down less busy streets and alleys across Soho. I start to get anxious that I’m in a part of London that is unfamiliar to me, and have no idea where I am going. I will not be at the address I have booked and nobody will know where I am, its past 11pm and dark, and I’m being led by a total stranger who has shown me no ID. So I call my husband, explain the situation and start reading out street names so he knows where I am. He says that I sound nervous, and that if my gut doesn’t feel like this is safe I should trust it and go somewhere that does.

My mind goes into overdrive. I start worrying I’m being taken to an unknown address, where I might be robbed or attacked or anything. I’m thinking perhaps they gave the fake address as a means to be harder to trace, or perhaps they use the photos of one apartment in a good location to put people in cheaper accommodation in less favourable locations. Perhaps he is nothing to do with Booking.com and is just a confidence trickster. Did he definitely use my name? Was he the man on the phone? I have no way of knowing. I can’t just follow a stranger to an unknown address in the middle of the night with no explanation. I find an open wine bar to run into and hide.

Suddenly, all those feelings are right at the surface and I’m sobbing with fear and hiding behind the counter of the wine bar until the man has gone. Then the man who claims to be from Booking.com (I still can’t tell if he is also the man in the red jacket, or someone different) calls me and asks where I am, and I say “I don’t feel safe dealing with you and being taken to an unknown address, I’m going to find somewhere that feels safe to sleep”. It seems like something I should be able to take for granted, that now seems out of reach.

The staff at the bar are super-nice and patch me up, give me some water and use of their wifi. They offer me wine and fancy olives. I take the latter (and they are the best olives ever, as well as thoroughly nice people, so do check out Antidote if you are ever in Soho). When I calm down a bit, I start searching all the usual websites to find a hotel room. I then find out there is nowhere else to stay. And I mean that literally. Even when I increase my parameters to travel up to an hour from my location, nothing is coming up on any hotel booking site that isn’t fully booked. So I’m sat there in a random wine bar in Soho, 200 miles from home, and there are no longer trains to get back there even if I didn’t have to be in London by 9am the next morning to speak at the House of Lords.

At nearly 11pm I find one, very expensive, hotel with a single room available through LastMinute.com. I book it, pay and then pay £20 to get a taxi there only to find it is overbooked and they’ve already turned away 4 other customers. It is a converted Georgian townhouse with a small number of rooms, so I’m sat in the only chair in a tiny lobby. I’m repeatedly calling LastMinute, and it has gone past midnight so there is no longer even a means to find another hotel (as you can’t search for availability for the previous night), and they tell me they don’t have a room. It takes me four calls and 47 minutes on the line to speak to Last Minute’s customer services, who conclude they can’t find an alternative room for me, and don’t see that as their responsibility. At 1.25am they suggest a room is available at the Taj St James Court hotel and they have reserved it for me. I call them, they have no rooms and have never heard of me. It is now 1.30am, and I am making plans to sleep in the bucket chair I am sitting in, in the hotel lobby, as I have nowhere else to go* and it is raining heavily. Eventually at 2am the hotel say that one guest has not checked in yet, and agree to take the gamble and let me use the room. I get less than four hours sleep for twice-the-price-I’d-normally-set-as-my-upper-limit-for-a-room, before having to head out to speak at the House of Lords.

Having given the talk** I decided to complain to both Booking.com and LastMinute.com. The response from the former was “You got a refund for the apartment, so it’s all settled” and the latter offered “€20 as a goodwill gesture due to the 2 hour delay checking in”. No recognition of the fact the experience was traumatic, wasted 5 hours of my evening, cost me 3 extra taxis, and left me 200 miles from home without somewhere safe to sleep. I am faced with the realisation that trauma is subjective, and to many men hearing the tale I might have taken fright for no reason and brought the events that followed upon myself. I am forced to say “imagine if your Mum were in this situation” when explaining it to try to trigger sympathy. But nobody really cares. The apartment owner feels he has done his bit by refunding (and the website has conveniently blocked me from leaving a review). The men in the call centres were in another country, abstracted away from the problem. The customer service teams are seeing the facts in retrospect, not the feelings the experience generated, and are motivated to protect their brand rather than genuinely caring about me as a customer. The night manager of the hotel cared, because he met me in person, and saw I was upset. As a result he tried his best, but he wasn’t in a position that could resolve the problem.

And that’s where I finally reach the point. In a system where you book with a middleman who doesn’t actually provide the product you are paying for, nobody really feels accountable for the service you receive. And, to bring this round to being relevant to a wider point for health and social care, this model is being increasingly replicated in public services, where the NHS or local authority commission the service from another provider, who is assumed to be responsible. That split between online broker and real life provider, or the public sector split between purchaser and provider seems like a good model for each of those parties, as the purchaser delegates responsibility whilst fulfilling their obligations (or making a profit, in the case of online brokerage sites) with much reduced staffing and without having to invest in any tangible assets. The provider gains access to a wider market, rather than becoming obsolete. But somehow inevitably, as in my experience, the recipient of the service misses out in the middle, and finds out there is minimal quality control and an absence of clear lines of accountability when things go wrong or aren’t delivered as planned.

For example, there is a level of risk aversion that has made local authorities anxious about providing residential care placements, because of the prevalence of historic institutional abuse and the increasing awareness of child sexual exploitation and involvement in county lines (and the accompanying risk of compensation lawsuits). The result is a marketplace where private providers (many of them owned by international venture capital groups who pay minimal UK taxes) use unqualified, low-paid staff to care for some of the most complex and vulnerable young people in the UK, and it is hard for recipients or commissioners to distinguish them from provision that has different financial or delivery models. Likewise in health (and public transport) private providers cherry pick off the profitable services, whilst the public purse is left holding the can when they don’t deliver. There is a move to entrench this even further with the push towards Integrated Care Providers, where private organisations can manage the entire health and social care services for a particular region of the UK, in a way that is potentially unaccountable for its decisions and not subject to the rules for public sector organisations (like Freedom of Information requests, public consultation, or being subject to Judicial Enquiries if things go wrong, or even their statutory obligations). I think that might be a recipe for disaster, but then, I’m not a fan of corporations and the super-rich profiting from the suffering of the rest of us.

Update: Booking.com have agreed to reimburse my costs in relation to the apartment (but have not yet done so), whilst LastMinute.com have not yet replied, telling me they take 28 working days to respond to customer complaints that don’t accept the initial boilerplate response. I suspect that just like in health and social care, the (explicit or implicit) policy is to respond to those who kick up a fuss and have the potential to create negative publicity if things are not resolved, meaning that those who are devalued most by society have the least redress when things go wrong.

*call me a wuss, but I declined the option of having one bed in a bunk room in a hostel shared with 8-12 strangers
** which I will give again and video as soon as I shake the cold that’s currently making me croak

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 them 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.

*I’m still intending to act on the advice to also have a strengths scale to recognise resilience and positive factors, so that it doesn’t feel like we see the children purely as a list of problems. However, I didn’t want to duplicate the work of others, so I am following up a potentially exciting lead in terms of a collaboration with the Mulberry Bush School, who have explored the positive factors they have seen as markers of progress in their environment.
** 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 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.

 

 

Solve for happiness: Some thoughts on big data/AI and mental health

We are hearing a lot about the use of big data at the moment, mostly that it has been an underhand way to manipulate people politically, that has been used by those with no ethical compunctions to get people to vote against their own best interests*, and in favour of Brexit and Trump. Cambridge Analytica and AIQ seem to have commercially exploited academic research and breached data protection rules to try to nudge political behaviour with targeted messaging. Whether or not that was successful is up for debate, but to the public the narrative is about big data being bad – something technocrats are exploiting for nefarious reasons. I can understand that, because of the associations between gathering data on people and totalitarian political regimes, and because of concerns about privacy, data protection and consent. There is increasing awareness of what had previously been an unspoken deal – that websites harvest your data and show you targeted advertising, rather than charge you directly for services, and the new GDPR means that we will be asked to explicitly consent to these types of data collection and usage.

But what about the potential for big data to do good? I know that DeepMind are doing some data crunching to look at whether AI algorithms can help identify indicators that determine outcomes in certain health conditions and point doctors towards more effective treatments. Their work to identify warning signs of acute kidney injury was criticised because of breaches to data protection when they were given access to 1.6 million medical records without individual patient consent, but whilst the data issues do need to be sorted out, the potential for projects like this to improve health and save lives is undeniable. Computers can look through huge amounts of detailed data much more quickly and cost-effectively than humans. They can also do so consistently, without fatigue or bias, and without a priori assumptions that skew their observations.

Research often highlights findings that seem counterintuitive to clinicians or human researchers, and that means that using the data to generate the patterns can find things that we overlook. One example I read about today was the fact that admitting offending behaviour does not reduce the risk of recidivism in sexual or violent offenders (in fact those who show most denial offend less, whilst those who demonstrate more disclosures and shame are more likely to reoffend). But this is also true about telling people they are being given a placebo (which will still produce positive placebo effects), using positive mantras to enhance self-esteem (which seem to trigger more negative thoughts and have a net negative impact on mood and self-esteem) or about expressing anger (rather than this being cathartic and leading to a reduction in anger, it actually increases it). Various fascinating examples are listed here. There is also the well-known Dunning Kruger effect, whereby ignorance also includes a lack of insight into our own ignorance. As a population, we consistently overestimate our own ability, with people in the bottom percentiles often ranking themselves well above average.

I often refer to the importance of knowing the boundaries of your own competence, and identifying your own “growing edges” when it comes to personal and professional development. We talk about the stages of insight and knowledge developing from unconscious incompetence to conscious competence, and finally to unconscious competence where we can use the skill without conscious focus. Confucius said “Real knowledge is to know the extent of one’s ignorance.” And it may well be that when it comes to solving some of the big problems we are limited by our own frame of reference, what we think of as relevant data, our preconceptions and our ability to build complex models. Using giant data sets and setting technology to sift through and make sense of them using various paradigms of AI might help open up new possibilities to researchers, or find patterns that are outside of human observation. For example, certain medications, foods or lifestyle traits might have significant impact on certain specific health conditions. I am reminded of a recent article about how a third of antidepressants are prescribed for things other than their primary function (for example, one can seemingly help with inflammatory bowel disease that has very limited treatment options). A computer sifting through all the data can pick up both these unintended positive effects and also rare or complex harmful side-effects or interactions that we may not be aware of.

What difference could this make in mental health? Well, I think quite a lot. Of course many predictors of mental health are sociopolitical and outside of the control of the individual, but we also know that some small lifestyle changes can have very positive impacts on mental health – exercising more, for example, or having a healthy diet, or getting more sleep, or using mindfulness, even just getting outdoors more, learning something new, doing something for others, or spending more time with other people (and less time on social media) can have a positive impact. There are also many therapy and therapist variables that may make an impact on mental health, for people who engage in some form of talking therapy, although variance in outcomes seems to actually boil down to feeling heard and believed by a therapist who respects the individuality and cultural context of the client. And of course there are many medical treatments available.

So is there a way of using big data to look at what really works to help people feel happier in their lives? I think the potential for apps to collect mass data and test out what makes impact is enormous, and there are a proliferation of apps in the happiness niche and more that claim to help wellbeing in a broader way. They seem to have found a market niche, and to offer something positive to help people make incremental life changes that are associated with happiness. What I’m not sure of is whether they reach the people that need them most, or if they are evaluating their impact, but presumably this is only a matter of time, as real life services get stripped back and technology tries to fill that gap.

I think there is huge need to look at what can make positive change to people’s wellbeing at a population scale, and I think we need to be tackling that at multiple levels. First and foremost, we need to make the sociopolitical changes that will stop harming the most vulnerable in society, and encourage greater social interconnectedness to prevent loneliness and isolation. We need to increase population knowledge and tweak the financial incentives for healthy lifestyle choices (eg with much wider use of free or subsidised gym memberships, and tax on unhealthy food options). And we need to invest in preventative and early intervention services, as well as much more support during pregnancy and parenting, and in mental health and social care. But I can also see a role for technology. Imagine an app that asked lots of questions and then gave tailored lifestyle recommendations, and monitored changes if the person tried them. Imagine an app that helped people identify appropriate local sources of support to tackle issues with their health and wellbeing, and monitored their impact when people used them. As well as having a positive immediate impact for users, I’m sure we’d learn a lot from that data that could be applied at the population level.

*I think the evidence is strong enough that the demographics who voted for these people/policies in the greatest numbers are the very people who have come out the worst from them, so I am just going to state it as a fact and not divert into my personal politics in this blog, given I have covered them in previous topics about Brexitmy politics, “alternative facts”, Trump, why and what next, the women’s march, and Grenfell and the Manchester bomb.

Pushing upwards

When I was an undergraduate psychology student, I found parts of the course curriculum kind of boring. I was interested in human behaviour and experiences, because I wanted to understand how to alleviate distress and increase wellbeing. Unfortunately I was not so interested in the neurochemistry or neuroanatomy that is the underlying mechanics for those emotions and behaviours. I was interested in behavioural ecology, like the evolutionary/survival value of altruism to vampire bats, and its parallels in human behaviour (eg why we have developed a system of rules and punishments to enforce the social contract). But I wasn’t so interested in animal perception and cognition. I found some of the early psychological experiments on both animals and humans to be really cruel and distressing, though I was aware that they helped to progress our understanding of brain and behaviour, and helped us to recognise the need for the ethical considerations we apply to experiments now.

Because I didn’t love the whole course, during the second year of the course I began to wonder whether I had selected the subject on autopilot, because my Mum is also a clinical psychologist (now retired).  A few other life events compounded this lost feeling by lowering my mood generally* and I developed an increasing existential doubt about whether I was making the right choices in my life.  I also wanted to test out my values and the options available to me, so my focus drifted to my social relationships and activities outside of psychology. I became less motivated and didn’t attend all of my lectures, and (despite having previously been quite successful in educational assessments) I got a 2:2 for one module that I hadn’t enjoyed. It was a mark that fairly reflected my effort/interest level, and in any other context it wouldn’t have been a big deal. However, I was gutted because I felt like the whole course would be pointless if I didn’t excel academically, as I was aware of how competitive the path into clinical psychology was. I considered changing course or dropping out, but I couldn’t think of anything I would rather do.

One of the images that helped pull me through that time, was from the I Ching – an ancient Chinese book of wisdom, also known as the book of changes. The basic gist is that you throw coins to point you to one of 64 readings, which can be generated with various variations and additional comments, and (like a horoscope or cold reading or fortune cookie, but perhaps with a bit more zen wisdom) the resulting text is ambiguous and non-specific enough for you to draw relevance to your life situation. The page that I was sent to was called “pushing upwards” and the hexagram was of wood below the earth. The image it described was of a seed below the surface, using all of its stores of energy to push a shoot upwards in the hope that it would reach the light and conditions in which it could grow and thrive. The text explained that to do this is an effortful process, in which you are gambling that this investment of energy will be worthwhile in reaching a goal that might still be out of sight. It describes the heaping up of small efforts to create the conditions in which future success is possible. The seed takes time to unfold into the tree: Although the results are not immediately visible and gratifying, “that which pushes upwards does not come back”. The reading tells you to put in a sustained effort if you want to achieve great things. It reassures you that if you are driven by a deeper sense of purpose (rather than wealth or glory) and willing to learn from wise people around you, you should not fear the path ahead. It implies that in time favourable conditions will help you along. In this way, it says, a person can rise from obscurity and lowliness to power and influence, provided that you make your efforts in a humble, flexible and authentic way.

This was a good metaphor for needing to put in more effort to achieve my goals, and it also reminded me of my core values and my drive to in some way make the world a better place, by improving the experience of other humans who had been dealt a tougher hand in life. Thankfully, as I entered my third year I got together with my husband (who has continued to be a supportive and stabilising influence for more than two decades since) and entered a much happier phase in my life. I also found the modules in the final year of undergraduate much more relevant to my interests, because they were much more closely tied in to the theory and practice of clinical psychology. As a result I started to put in more effort and get higher marks. I also started to gather work experience, and to seek out advice from qualified CPs. Gradually, those efforts paid dividends – I secured an AP post on a research project straight after graduating** and then worked incredibly hard to do that job, write up papers for publication and complete a masters degree by research at the same time, before gaining wider experience in a more clinical role with a different client group and then securing my place on clinical training.

From the moment I entered that third year with that mindset, I enjoyed the rest of my journey into clinical psychology. No matter what the client group or type of work, I felt like I was doing something worthwhile and I was also constantly learning and being challenged. I had some inspiring supervisors, both as an AP and as a trainee. I didn’t love every placement (they were all good learning experiences, but my enjoyment varied depending on my interest in the client group, the style and context of the work, and the amount of travel involved to get there). Likewise I didn’t click with every supervisor equally, but I did learn a lot from each of them. In my first AP role my supervisor was a role model of the true scientist practitioner, who secured grant funding to push forward the evidence base of the clinical work, and constantly published papers and disseminated findings. She pushed me to participate in that world, and with her support I co-wrote six peer reviewed journal articles during those two years! She is still my role model of embodying the link between research and practice in psychology, and I would love to emulate Esme’s energy and influence in my own field of work. I then worked in a project that trained student social workers, and assisted with expert reports on parenting – something I continue to have an interest in to this day. It gave me a much more practical grounding, and an awareness of social care systems that I have subsequently built on.

As a trainee I gained a basic grounding in brief CBT-based interventions in an adult service, and learnt more about the structure of mental health services and working as part of a multidisciplinary team. I also worked in services for people with intellectual disability, where I learnt about the value of indirect work, and gave more explicit consideration to issues of capacity and consent. I loved my core child and family placement, and the warmth, pragmatism and commitment of my supervisor, Patricia, set the tone for the kind of psychologist I wanted to become. I returned to her for a specialist placement to pick up the cases that were more complex, transgenerational or involved child protection issues that I had avoided the first time around. I was lucky enough during that second specialist placement to also have the opportunity to work one session a week into an NCH Action for Children project for child and young adult survivors of sexual abuse. There I was reminded of the value of human connections over any academic knowledge, as well as having the opportunity to use Cognitive Analytic Therapy for the first time. I also did a specialist placement in a child development service, with some work into a sexual abuse team – including working with children who had survived abuse and co-facilitating a group for mothers whose partners had sexually abused their children. I learnt more about complexity and systems, and some healthy cynicism about organisational change. I still remember the chart for the new tiered model of services pinned up on my supervisor’s wall, with ovals that widened at lower tiers, entitled “the shape of future services” to which he had added a handwritten subtitle “is pear-shaped”.

When I qualified I was torn between a post with the favourite supervisor I had spent two placements with and one that several people warned me was “burnout waiting to happen” working in child protection. After a long discussion with a good friend I concluded I wanted to continue to challenge myself, and also to put myself where I was most needed. I therefore took the latter post, and worked in a split post across CAMHS and child protection. I learnt from a fantastic supervisor how to work in complex systems and services. David also taught me how to be an expert witness for the family court. The balance between being down-to-earth, approachable and yet grounded in knowledge and theory, as well as the clear communication under pressure gave me another role model of the type of psychologist I wanted to become. He taught me to ask the uncomfortable questions, and to balance holding empathy for parents with speaking up for the best interests of the child. Then in my longest standing post, I learnt from another fantastic head of service to think about process in supervision, how to bring fun and creativity into my work, and also to pick my battles! I also did a lot more collaborative work, and got involved in service development and audit, as well as gradually stepping up to greater supervisory and management responsibility. In that post I had the benefit of working with an inspiring social work team manager who had been doing really innovative work to increase access to permanent placements for older and more complex children. I also went out to America for a couple of weeks to train with Dan Hughes, where I learnt about the power of being present in the intersubjective space, and became more willing to show my own vulnerability and emotional reactions.

I have also learnt from less positive experiences – the times where I got it completely wrong, or unintentionally triggered negative responses in others. For example, I remember an AP I supervised feeding back disliking that I had introduced her to colleagues as “my AP”, intending that to be as supportive as I had perceived it being when I had been an AP myself, rather than as indicative of any claim of ownership. I remember crying when criticised in a multi-agency meeting about the autism pathway, and realising too late that it had been a bad decision to come into work that day whilst my house was flooded and I didn’t have enough emotional resources for work. I still cringe looking back on one time I tried to be supportive to a junior colleague who had to give evidence in court, but ended up making myself look stupid and inhibiting her ability to impart her observations in a useful way. I recall the challenges of having to raise concerns about how a colleague’s homophobia might have a negative impact on service users, and how they justified this being part of their cultural and religious identity. I remember the camaraderie, but also the pressure of working within a big system, feeling responsible for protecting more junior colleagues from organisational changes, worrying about waiting lists, and defensively managing referrals.

Most of all, when I think about negative experiences, I remember how gutted I was when my wonderful employing organisation lost the competitive tender for our service, and how horrible the initial meeting with the new service directors and managers at our new employing trust was. It started with a gloating talk from the new clinical director, and him taking digs at our senior staff about how some people in the room might think they know how to run CAMH services, but clearly he new better as they had won the tender. The jokes about how nobody need worry about their job security, except the consultant grade psychologists, as “you are quite expensive and we haven’t figured out what to do with you yet”. And the patronising response of the service director to my questions about whether the plan for my service section in their tender specification was fixed: “If you think you can do better, cheaper, love, knock yourself out”. I remember the pressure to rewrite the service specification and job plans for my team whilst my kids were in neonatal intensive care, and to take on various tasks to compensate for the fact they hadn’t appointed a locum to cover my absence. I remember my team being left out of the accommodation plan entirely whilst I was on maternity leave, and after protesting, returning to an undecorated, unfurnished office without internet or telephone points (or mobile reception) that could only be accessed by swiping out the fire exit across two flights of stairs, then swiping into another wing of the building and going down to the furthest end of the corridor. I remember being told to income generate or face temporary staff on my team being made redundant, and then being told that I was allowed to neither quote nor invoice as I wasn’t a budget holder. I remember being promised time off in lieu for all that I did during my maternity leave, but then being denied this on my return as “we can’t pay you full-time pay for part time work, no matter what you did in the previous financial year”.

I remember the day I walked out of a meeting with an operational manager, out of the building, out of the car park and down the road, and felt like I could keep walking forever and never go back. In the end I walked across town to my previous base and talked to the directorate manager there, who made it feel less personal. Over the following weeks I sought out some personal therapy through Occupational Health, and picked apart what was me and what was the toxic system around me. Then I decided to take a career break and spoke to HR to confirm that I would be able to continue my self-employed activities during a career break without this being considered “taking up alternative employment” and blocking my right to return. I also wanted confirmation that I would return on the same grade to the same client group. I always joke that the HR lady I spoke to should never play poker, because as I told her my reasons for leaving her face gave away too much. I watched her non-verbally say something along the lines of “oh shit, we’re in trouble here, pretend we’re not, pretend we’re not” before casually raising the option of redundancy and a gagging contract***.

So I had to uproot and push upwards into new an unfamiliar soil. Initially I applied for other NHS jobs, but ended up withdrawing before interview for one and declining a job offer for another, because I wasn’t prepared to work in another toxic culture. In the end I used my expert witness work as my parachute, and figured I would work it out as I went along. I changed from being a sole trader to a limited company so that I could employ an AP. I felt like I had been gradually dehydrated by the conditions I had worked in until I was just a husk of myself, and as I started doing my own thing I found some rain I started to find my own shape again. At first I used my own business to try to achieve what I had hoped to in my NHS career independently. As I have said in previous blogs, I helped set up a parenting charity, but felt the political agenda of the founder wasn’t consistent with the clinical goals. I secured funding for, designed, managed and evaluated a service to support people with diabetes, but ultimately it wasn’t commissioned. I set up a psychology service within a social care provider, and trained staff all across the country, but whilst I enjoyed the work I didn’t enjoy spending so much time away from my home and kids.

The challenges have continued, as I have had to foster my entrepreneurial side and learn the skills to run a business, hold a budget and manage staff. I’ve found new ways to disseminate knowledge – through being on committees, doing policy work, and writing for different audiences in my book, practice journals and on social media and this blog. I’ve developed ways to use technology to improve services, and I’ve returned to doing research. I’ve had to be flexible enough to try new things until I’ve been able to find a way to work that feels authentic. This blog documents much of that journey.

Through it all I have never been bored or complacent about my work. I’ve always enjoyed finding new challenges, and new ways to apply psychological knowledge. I have always found that my work provides moments of flow – that sense of deep and satisfying immersion in the present moment to the exclusion of everything else, that you get when you have sufficient agency and skills to meet a challenge, and feel a sense of reward from doing something well or contributing to something worthwhile. By comparison with so many people who do repetitive, boring or physically challenging work, I feel a great deal of gratitude that I earn my living doing something that is so varied, with so much autonomy and opportunity for enjoyment. Thankfully I have always been able to find sufficient challenge and novelty in how I work, along with sufficient freedom to satisfy me. And there have always been new human puzzles that intrigue me, and the varied settings and ways of working that I have experienced each involve looking at what I have to offer afresh and customising what I do for the new context.

 

So here I am, running my small business and trying to establish the use of structured needs assessments and outcome measurements in children’s social care. Once again, those themes of pushing upwards are back, as I have been putting in a big investment of time and effort to nurture this project over many years in the hope that it grows into something productive. Now that I am more established and have a mortgage to pay, plus rent on my office and employee salaries it feels like a bigger gamble than early on in my career where I had little to lose. But I have that same feeling of clarity about where I want to make my impact in the world that I did when I decided clinical psychology was for me after wavering as an undergraduate. I also have the same faith that my cumulative efforts will eventually be repaid with positive outcomes and a move into easier progress. If I go back to the image of the seed growing underground, I’d like to think that the journey through the earth has been completed and the new shoots are now reaching up into the sunlight where they can be replenished by energy from the external elements. I know as a gardener that with good planning and regular nurture the slow growth of seeds sown over winter can quickly turn into the rapid growth of spring and summer. I can only hope that I’ve done enough to establish my new plants and all this effort comes to fruition soon!

*My landlady decided to sell the house I was renting (despite having agreed I could stay on there in my third year), so I had to find an alternative place to live. My Dad was tested for prostate cancer. And I experienced the second incident in this past blog about rape culture in which I felt at risk of rape.
** Before you say “it must have been easier back then” I would note that I got that post against 110 other applicants. So even in 1995 things were pretty competitive, and probably more effortful as we had to find job adverts in the BPS appointments memorandum booklet that was posted out with the Psychologist magazine, phone up for an application pack, and then post in a hand written application, as NHS jobs didn’t exist and internet based application systems had not been invented yet. Which makes me feel very old.
*** A legal “compromise agreement” that included terms saying I would not tell people why I was leaving or speak negatively about the trust from which I departed, and could not take legal action against them – terms I understand are pretty common in that situation, but the government has subsequently outlawed after bad publicity, as they can be seen as an attempt to silence whistle-blowers.

I am not a therapist

I’ve always been someone that likes to keep busy, and has a lot of ideas about places where psychological thinking can make a positive impact. The aspect of my character that I now identify as entrepreneurial and put to good use in my business has always led me to want to try new things and create innovative solutions to problems. I like a lot of things about being a clinical psychologist, and particularly our ability to turn our hand to multiple types and levels of work. However, unlike many other clinical psychologists, I don’t really see myself as a therapist. In fact, I haven’t seen more than a handful of clients for individual therapy over the last decade, and even before that it was a pretty small proportion of my qualified jobs. I’ve always had more of a focus on the other facets of being a clinical psychologist. I think the picture of a clinical psychologist as a therapist is so strong that a lot of people will now be wondering how I fill my time!

So I will answer that question: I have done loads of highly specialist assessments (of neurodevelopmental concerns, attachment, parenting capacity, mental health, life skills, self-esteem, wellbeing etc) and lots of formulating and report-writing – some in collaboration with psychiatric or medical colleagues or within a wider MDT, but more as an external expert or second opinion. I have advised the family courts as an expert in care proceedings and complex custody disputes, and completed numerous pre-court assessments for local authorities to help inform their care planning. I’ve managed teams and services, and supervised from 2-20 other staff at a time, along with sitting in various organisational/management structures. I have designed and delivered training to parents, carers and professionals, and I have done lots of consultancy to various organisations and professionals (mainly those providing health and social care services, or involved in the family courts), and help placement providers to improve their services. I design and deliver group programs (eg Managing behaviour with attachment in mind), but then rapidly cascade train other staff to continue to deliver them. I wrote a book about attachment/developmental trauma, and lots of papers and policy documents about Looked After children, and acting as an expert witness to the family court. I sat on a BPS committee and I contributed to NICE and SCIE guidelines. I’ve designed, managed and evaluated therapy services (but employed others at lower bands to deliver the therapy). I’ve been an expert advisor to the HCPC in a fitness to practice case and to the team investigating a death in public care. I’ve done loads of practice-led research about each client group I’ve worked with, from looking at the psychological and health economic impacts of offering brief therapy to hospital users with diabetes, to commissioned evaluations of other services. So I have plenty to fill my days despite not having a therapy caseload!

I have reflected on why it is that I don’t feel drawn to therapy, and reached the conclusion that, whilst I see it as a very worthwhile endeavour, I don’t really have the patience for resolving difficulties one person at a time over sessions spanning many months. I’m always more interested in grappling with the bigger questions of why people are in distress, and what we can do to most effectively prevent or ameliorate those difficulties. When I’ve solved the riddle (or at least, reached a plan that improves upon existing solutions) I like to evaluate its efficacy, modify it if necessary and then disseminate the learning and/or train others to replicate the solution. I try to step outwards from the individual issue to the broader themes and ways that we can intervene on a wider scale. To use a visual metaphor, if dealing with mental health problems is like bailing out a ship, then rather than scooping out water one cup at a time, I am trying to work out how to plug the leaks, and to design boats that won’t have the same vulnerabilities to leakage in the future. It also helps me to avoid feeling hopeless about factors outside my control and demand exceeding supply, or burned out by an accumulation of traumatic stories.

Jenny Taylor, a past chair of the Division of Clinical Psychology, once described our profession as the structural engineers of the therapy world. Unlike a therapist trained in a single modality of therapy, we can survey the landscape and assess the need, then design the intervention that best meets that need – even if we are not always best placed to deliver it. We can base that recommendation on our knowledge of the current evidence base, which can change as new information comes to light.  If we consider the challenges people face as a river they need to cross, a therapist trained in a single model of therapy might be a bridge-maker. A psychodynamic therapist might be a mason who can build traditional stone bridges and claims that this design best stands the test of time. A CBT therapist might be a carpenter with a set of designs for wooden arched bridges that he claims are cheaper and quicker to erect. Each sees their own skill as either suitable to solve the challenge or not, but also has some incentive to sustain their own livelihood by continuing their tradition. A clinical psychologist can survey the land either side of the river, the span length required to cross it, and the materials available in the locality. They can then advise on the various options, including the relative costs and the evidence of how they fare in different conditions. They may or may not feel that bridge required is within their own skill-set to erect, but have a reasonable overview of other bridgebuilders in the area to recommend. If new designs of metal suspension bridges are developed, this is not threatening to the structural engineer, who can adjust their recommendations to incorporate the emerging evidence base.

I really like this metaphor and strongly identify with the role of structural engineer rather than bridgebuilder. I had always thought that this was instilled in me by my first graduate job, where I was an assistant psychologist on a research project about improving quality of life in residential care homes for older people, and I could see how the research and clinical work were closely tied together and built on each other reciprocally. But now I think my love of data and the scientific method runs deeper than that and I can see it infused throughout my whole approach to life since childhood. When it comes to my work I am a scientist practitioner down to my bones, as I always collect data as I go along. Where I don’t feel like I understand the situation well enough, I first look to the literature and then to gathering data and doing my own analysis to try to gain insight. When I develop something new to try, wherever possible I try to evaluate what we are doing, and refine it through an iterative process until we can prove maximum efficacy. I see that process as being part of the USP of a clinical psychologist – that we think like scientists and gather data to inform our interventions.

But I’m not sure that we communicate this mindset well enough, or that it is universal amongst the profession. It certainly isn’t what draws people into the profession in my experience. Too many clinical course application forms I review could be paraphrased as “I want to learn to be a good therapist” with an afterthought of “and do/use research” because they think that is what selectors want to hear – but in my view therapy can be done by lots of cheaper professionals, who might do an equally if not better job of it. I believe that clinical psychologists should be more than well paid therapists. We should know the evidence base and be able to take on the most complex assessments and formulations (even if others then deliver part or all of the treatment) but also to be able to develop, refine and evaluate novel therapeutic interventions, supervise other staff, improve services, consult, train and manage – things that extend beyond the skillset of most therapists. I’m sure it is clear by now that this is where my own interests lie. And I think it shows through in everything I do.

For example, when I was asked to lead the CAMHS service providing neurodevelopmental assessments I started with a literature review and current policy and best practice guidance. I then conducted an audit of the existing pathways, then tried to make things better. We set up a new clinic system with more rapid throughput and more thorough assessments, and then re-audited showing a reduction from an average of 18 months of input to five, with increased clinician confidence in the service and higher client satisfaction. I also wrote a booklet to help provide the information to parents whose child received a diagnosis of an Autistic Spectrum Condition. Although it required dedicated clinician time for the multi-disciplinary clinic and for the psychometric assessments generated, overall the new pathway freed up capacity because less cases were being held open by other clinicians whilst waiting for assessment, or kept open for prolonged periods afterwards to help the family understand the diagnosis and connect up to local sources of support.  I also sat on a multiagency strategy group to look at establishing best practice standards for the county.

I had the same approach when I was asked to support the adoption and permanence service. I initially set up a consultancy clinic, where social workers could bring cases to discuss or book in families to see jointly. I found that I was explaining similar information about attachment, trauma and neuroscience to multiple professionals, parents and carers in the consultations. So I designed a group to share this content. I called it “Managing Behaviour with Attachment in Mind”, and developed some “doodles” I would draw on flipchart paper to explain the concepts more accessibly. I evaluated the impact and showed it to be an effective format for supporting parents in this situation. The groups were popular and over-subscribed, so I trained others to deliver the group to keep up with demand, first in my service and then more widely. Many people in the groups liked to photograph the doodles to remind them of the topic, so I decided to write a book to share them and Attachment: In Common Sense and Doodles was born.

But I also wanted to know about how we could achieve permanence for more children. I started by looking at the literature about what makes effective adoptive matches. Very little information was available, so I systematically audited the paperwork from 116 adoptive matches and followed them up over 7 years to see what factors influenced the placement outcomes. I was able to look at whether the innovative adoption project to place children with more complex needs had better or worse outcomes, and was able to explore the impact of different motivations for adopting. Whilst to me this was just a natural process of answering the question as an evidence based practitioner, it transpired that these studies of adoption risk and resilience factors were amongst the largest ever done, and I have discovered unique findings that I really should publish*.

You could argue that I was using a sledgehammer to crack a nut by doing all this research and trying to change process when organisations are notoriously slow to change, and that I could have spent my time more productively working with more individual adoptive families. But that’s not how I’d see it. The research I did helped me to understand what the key variables are when considering whether a child can achieve permanence, what kind of family we need to look for to place them successfully, and what kinds of support might ensure that the placement succeeds. I hope that I have fed that knowledge back through my court work, and into various organisational and policy work over the last decade. I have also disseminated it at conferences. However, I would still like to spread it further, because it is my belief that such knowledge can have positive impact at multiple levels – it can help to inform individual placement decisions, service-wide strategies for helping optimal numbers of children to access permanence, and national policy about adoption.

That work led naturally on to developing our services for Looked After Children when I left the NHS and set up my own company, LifePsychol Ltd. We provide training and consulting to foster carers and residential care staff, the social care organisations that support them, and the wider professional networks surrounding them, including education and health staff, police, lawyers, magistrates and judges. As I started to get more immersed in working with children in and on the edge of Care, it led me to recognise that there was a lack of validated and reliable tools to identify the needs in these populations, no outcome measurement tools that could reliably measure change over time in a way that was sensitive to the context and type of life events these young people experience, and a dearth of clinical governance in terms of the efficacy of both placements and interventions for this group of children. That seemed shocking to me, given their highly complex needs, and massively elevated incidence of mental health problems, challenging behaviour, risk to self and others, and prevalence of intellectual or neurodevelopmental difficulties.

As well as the human cost of not being able to identify the best choices for people, it seemed unacceptable that huge amounts of money were being spent on placements and specialist services for this group without any evidence of them changing their wellbeing or life course for the better. Placements seemed to struggle to identify what to work on and how, and there was little objective indication of what defined a successful placement, beyond annual visits from Ofsted (who were predominantly focused on process and procedure). The high level of need and the lack of clinical governance in the sector has allowed various specialist therapists and services to spring up that are virtually unregulated, and many placements have adopted terms like “therapeutic” without these having a consistent definition or meaning. So I wanted to see whether I could make any headway in changing that.

Meanwhile there is pressure from the government to improve outcomes for children in public Care, because they are seen to fare badly compared to the general population of children the same age. The difficulty is that this isn’t comparing like for like – children in care have many more adversities to face, both organic and in terms of their life experiences, that mean they often deviate from the norm. For example, I found that there was a 20 point skew downwards in IQ distribution in children in residential care compared to population norms, meaning that 20-25% of children in this setting had a learning disability, compared to 2% in the general population. Likewise the incidence of Autistic Spectrum Conditions and other neurodevelopmental difficulties amongst children in Care is more than triple that in the wider population. The same is true of young offenders. If we don’t acknowledge that, then the sector is being asked to seek impossible goals and will inevitably be seen as failing, even if placements and services are performing optimally and adding a lot of value to the lives of the children they work with.

To state the obvious, children in care are not just randomly drawn from the population – by definition their needs have not been met, and this can mean both the presence of additional challenges and exposure to harm or deficits in care. I believe that to look at the needs of this population and the degree to which these are met by placements or interventions, we need to either compare them to carefully matched controls or ensure that outcomes are always considered relative to baseline. The latter seems more pragmatic. Scores for young people also need to be considered in the context of what is going on in their lives – as changes in placement, daily routine, contact arrangements, or the arrival or departure of other children from the home can make big impacts on the child’s functioning.

So I’ve been beavering away exploring these issues and developing systems to measure needs and make the data meaningful for those providing care and services. The impact might not be as obvious as delivering psychological therapy directly, but I’d like to think that over time it can improve services for thousands (or even tens of thousands) of children, and make a greater net change in the world.

 

*Maybe I’ll write more about this in a future blog. But the short version is that I have been trying to secure some funding to complete the statistical analysis and disseminate this information, and would still like to do so, so if you have any ideas or useful connections to assist with this please let me know. Failing that I hope I’ll find enough time to write a book on making better adoptive matches at some point in the future.