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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Gaining Influence

Quite a long time ago, I identified that it gives me most satisfaction when work gives me the opportunity to have 5 I’s: Intellectual challenge, Independence, Innovation, Income and Influence. This month I have really been working on the last of those, and trying to connect with the right people to make change within the Looked After Children sector as a whole, rather than individual by individual or company by company.

It transpires that over time I have accidentally built up a wide professional network, and a credible platform from which to connect with higher level influencers. It seems that all the time I’ve invested into unpaid stuff helps when it comes to connecting with new people and looking like I know what I’m talking about. This is helpful for me to hold in mind as committee work can all too often feeling like a drain on my time that is almost invisible to anyone else and may have little that is tangible as an outcome for what can be quite an onerous process. Logically I know that this type of activity is rewarded by the innate satisfaction of contributing to important work that needs doing, but this is something I find easier to recognise at the start of the process when I first put up my hand to volunteer and after the end of all the graft than whilst in the middle of it.

Being chair of CPLAAC, on the national CYPF committee for the BPS, part of the NICE guidance development group and the BPS/FJC standards group have let me contribute to various publications that will hopefully reach wider audiences and influence practice. Whether that is in terms of the support and interventions offered for children with attachment problems or the standards that should be expected of psychologists who act as experts to the family courts or the chapter on best practise for psychological services for children and families with high social care needs in What good looks like in psychological services for children, young people and their families, the paper I wrote about Social Enterprises as a vehicle for delivering psychological services or the CFCPR issue I edited on good clinical practise around attachment difficulties, I feel like I have been part of some good work that establishes professional standards and reference points.

And with those things on my CV and a network of allies who share my goals about improving outcomes for Looked After Children, I have been able to meet with various decision makers and influencers about my ideas. The first important contact I made was with Jonathan Stanley, the chair of the Independent Children’s Homes Association. He has been fantastic at promoting my work to residential care providers and helping me to gain a seat at the table. I then met Almudena Lara at the DfE, although she was very new to the role of being LAC lead, and moved on before she was able to pick up our discussion again. I have also met with Social Finance. More recently I was able to meet with Sir Martin Narey, the government advisor (and ex-chair of Barnardos) conducting a review of children’s homes in the UK, and a representative of the DfE. And latterly I had the opportunity to meet Lord Listowel at a recent conference and hope to speak with him further soon.

In all of these meetings, I have been promoting the value of clinical governance in the social care sector. That is, the importance of being able to evidence clinical outcomes and substantiate that you are doing what you claim to do – in this case, that placement providers are improving outcomes for children and young people in their care. My wider goal is to allow commissioners, social workers and Ofsted to be able to see what kind of placement a child needs, whether a placement is making positive change for a child and who can provide the most suitable and effective placement. I’m also keen that the idea of “therapeutic care” is better defined, and that therapists working within care organisations need to be qualified, supervised, regulated by a professional body and practice within their areas of competence. But my main goal is to stop the situation in which placements are paid to provide care for the most complex and vulnerable young people in society, and do so by providing accommodation, food and transport to education but do nothing to address their emotional, behavioural, mental health, developmental/learning needs, risk to self and others, or ability to form healthy relationships with others. I think the tools I have been developing, like http://www.BERRI.org.uk, and the training I provide for staff/carers can help with that, but my goal is nothing less than to change the culture of care in the UK.

Evidence has shown that money invested in the most complex children during their childhood is repaid tenfold in savings to the public purse in reductions in use of mental health, social care and criminal justice services over their lifetime. So why is it that the placements for the most complex children and young people are primarily provided by carers with very low levels of qualification and training? The first steps to improving standards are to ensure that all carers in the foster and residential sector get training about managing the impact of trauma and disrupted attachments, and that all children in public care are regularly monitored on outcome measurements. But these need to be meaningful, and linked into practice, rather than done as hoops to jump that are disconnected from daily care.

I can think of nothing more worthwhile to do with my professional life than to improve care for Looked After Children in the UK, and I hope that I can achieve enough reach and influence to make a genuine difference.