Evaluating recurrent care and edge of care services

The Norfolk Parent Infant Mental Health Attachment Project (PIMHAP) was a joint venture between Norfolk and Suffolk NHS Foundation Trust and Norfolk County Council. It was created in 2015 to intervene with cases that were “edge of care”, with a focus on those that combined safeguarding concerns with parental mental health problems, and attachment problems between parents and infants.

In this project we evaluated PIMHAP based on 55 families who were referred during its first year. Families referred had a range of complex histories including mental illness, drug or alcohol abuse, domestic violence, and a previous child taken into care.

Some results suggested that clients under-reported emotional and psychological problems when given a chance to self-report, and this was something that needed to be considered for similar studies.

However, other reports were more positive and overall, we found that 85.4% of families were able to remain with or reunite with their child and there was also a wider trend of lowering the safeguarding risk status. Although it is hard to quantify this in financial terms, we estimated that this has saved approximately £350,000. This did not consider the wider benefits across the lifespan for both parents and children.

We also found that the service helped professionals involved by bringing a range of perspectives together, but also highlighted the differences in professional standards and expectations that were held by those in different roles. Professionals commented on how they appreciated space for reflective work which helped with enhancing practice and gave staff an opportunity to discuss things in a safe space.

There were some aspects of disagreement among professionals. Differing expectations created challenges, for example limited resources meant that there was an expectation that certain services could be extended, but others knew that logistically it wasn’t feasible with the resources available. Some professionals identified the risk to the child was a core part of their work, while to other professionals parental wellbeing was a greater concern.

Publications

McPherson, S., Andrews, L., Taggart, D., Cox, P., Pratt, R., Smith, V. and Thandi, J. (2018) Evaluating integrative services in edge-of-care work. Journal of Social Welfare and Family Law. 40 (3), 299-320

The Rise Project was established by the Marigold Children’s Centre in Southend-on-Sea in 2017. It worked with women who have had at least one child removed following care proceedings. The aim was to prevent them from experiencing further ‘repeat rapid’ removals.

Rise was unusual in this field of emerging services because they were part-delivered by practitioners who also play an active role in child protection proceedings and were located in physical premises associated by clients with such proceedings.

Our evaluation covered 6 mothers who engaged with the service, the majority of whom were previously known to Rise staff. Engagement was tailored according to client needs and was co-designed by mothers and their support workers.

The Rise project team were clearly meeting their service brief. The staff were dedicated and enthusiastic in making a difference to the lives of the women with whom they worked.

A significant finding was that the women clients and practitioners saw advantages for both pre- and post-proceedings services being delivered by the same team in the same premises. This arrangement was not typical across similar services with the same goals offered elsewhere.

In 2017, the Venus Charity in Sefton, Merseyside secured Big Lottery (Women and Girls Initiative) funding to establish a new service to reduce recurrent care proceedings. The ‘Step Together’ Service works with birth mothers who have already had at least one child removed from their care in order to try to prevent them from experiencing further ‘repeat rapid’ removals.

Our evaluation found that the service had impacted positively on clients’ lives, and had identified unmet and ongoing complex psychological needs of engaging clients. Over the five year evaluation period a total of 160 women were referred to Step Together, of whom 75 engaged with the service. Of these 75 clients, 9 were pregnant at referral and 1 had become pregnant by the six months review point. No clients who were still engaged at 12 months became pregnant during the period of support.

All babies born to women in the service remained in their mother’s care under a Child in Need or Child Protection plan (other than two where the status was still undecided at the end of the evaluation period). This should be seen as a clear achievement on the part of both the service and their clients.

All of the women who gave birth went through care proceedings for children to be removed from their care but engagement with the Step Together Service was cited as a protective factor during pre-birth assessments. Cost savings can be inferred, with some caution, but are estimated at over £0.6m per year for the local authority for preventing children going into care plus one-off savings from avoided pregnancies and consequent ‘avoided’ care proceedings of £177,200.

Many clients who engaged well with the service had a range of positive outcomes which included:

• engaging with counselling or mental health support;
• starting employment, volunteering, education or training;
• having children returned to their care or keeping their baby;
• receiving positive feedback from social workers;
• more stable housing and/or finances;
• improved relationships with family;
• having contact with her child.

Professionals we interviewed had a good relationship with Step Together staff, seeing them as professional, supportive, approachable, friendly and easy to work with. Several mentioned there was good communication and sharing of information between themselves and Step Together workers. All those interviewed felt that the Step Together intervention was successful for their clients.

Three interviewees, including both social workers, felt they had a better relationship with their clients, and that their clients were engaging better with them. This was seen in large part as due to the work of Step Together staff to build trusted and friendly relationships with the women, something that was described as “invaluable”.

Strengths highlighted were that Step Together being a consistent presence in a client’s life was very important to develop and maintain long-term changes in women’s lives. The adaptability of the service, where Step Together was able to quickly co-ordinate and/or provide different strands of support, was seen as a positive as were the group work and course and peer support.

Other important aspects of the service included work to support women to make positive changes in their lives, build up confidence and self-belief, plus practical support to clients and time spent with them.

The Comma Service was established in 2015 and offers parents at risk of recurrence a bespoke package of support. The service was developed, co-designed and co-produced with women who had experienced removal of a child into care.

The project engaged with 26 women during the 18 month evaluation period. Without intervention we would have expected 3 women to have experienced a pregnancy likely to lead to care proceedings.

However, none of the clients who engaged with the service for at least six months became pregnant, generating one-off savings of around £96,789 plus additional savings of up to £158,028 per year arising from children not becoming looked after. In addition, the Comma Service played a role in securing the return of 2 looked after children to their mother, generating further savings of £105,352 per year.

Comma clients had high levels of psychological need on a par with people who receive mental health services. In the case of quality of life, Comma clients reported much worse scores than even clinical populations.

A third of the sample improved on self-esteem and psychological distress measures overall, and half of the sample improved on psychological problems and trauma. These improvements were reliable statistically even if few of them moved the clients below the levels seen in clinical populations. Psychological need therefore remained high after 6 months.

The Strengthening Families Service was set up in 2014 as a direct response by Salford City Council to the growing number of women repeatedly losing their children to the care system due to a range of issues such as domestic abuse, poor parenting, crime, drug and alcohol abuse.

We analysed data from the Strengthening Families Service which had engaged with 209 families over five years, of whom 65 clients from 37 families were tracked in detail by our evaluation. Our evaluation found that the service had delivered a service that directly contributed to the avoidance of 118 children becoming looked after, representing annual savings on looking after these children of £3.8 million.

Interviews highlighted the development of good joint working between Strengthening Families workers and social workers and professionals from other services. Both parents and professionals felt that the different role played by Strengthening Families staff, compared with that of social workers, assisted in the engagement of families.

Important differences identified were that Strengthening Families practitioners could visit parents more frequently, stay involved for longer and assist with practical issues, alongside supporting parents to improve their parenting capacity and understanding of professional concerns.

The service delivered positive impact and improved outcomes for children and families, including significant reductions in levels of partner abuse and substance misuse amongst parents. Outcomes included families being able to keep their children at home safely, improved parenting, ability to manage finances better and improved family functioning.

Although caution must be taken due to a small number of children, it appeared as though the children of parents supported by the service performed better than looked after children in their level of development by age 5.

Strengthening Families also developed contacts, and shared learning with, other agencies providing similar services around the country, including contributing to the spread and scale work on recurrent care services in Greater Manchester.

The Edge of Care Service was established by Family Action in Croydon in 2018 to work with families where a child was on the edge of care and child care proceedings were likely/imminent, or where a child had recently been taken into care and support could enable them to return safely to their family home.

Our evaluation found that the service was perceived by other professionals to be effective and successful in producing positive outcomes for young people and their families. Most risky behaviours in young people were reduced after intervention from the service (this included gang affiliations, cannabis usage, unprotected sexual activities and missing episodes).

Other positive outcomes for young people included improved emotional wellbeing, the building of stronger relationships with parents and siblings, improved educational outcomes and attendance, introduction of coping strategies and improved behaviours. A range of positive support and outcomes for parents were also identified.

Without intervention, all of the 11 young people who engaged fully with the Edge of Care Service would have almost certainly become Looked After Children according to the referral criteria. However, just 1 was in care following the intervention. Significant cost savings can be extrapolated including one-off savings of around £322,630 in avoided care proceedings during the 12 month evaluation period and an annual cost to the local authority of between £526,760 and £1.6m per year in avoiding care placements.

Building relationships with and within families was seen as central to the delivery and success of the Edge of Care Service. Practitioners reported feeling hindered from providing therapeutic support as their clients’ immediate practical problems needed to be addressed in the first instance.

The MDT pilot in Tendring, Essex, was set up in February 2021 and works with families where there are complex issues who struggle to maintain positive change and families that have a distinct pattern of reinvolvement with social care or who demonstrate similar ongoing issues that trigger re-referrals.

It received referrals for 152 children and young people from 63 families in its first year.

Our evaluation of the pilot is due to be completed by the end of 2022.

Our evaluation of the Supporting Parents Community of Practice indicated that it generated outcomes delivering specific benefits:

• Increased practitioner confidence to engage recurrent care experienced parents through peer-led learning, enabling more self-supported networking on specialist practice with this vulnerable population.
• Improved practice understanding of wider determinants of behaviours that increase the likelihood of unplanned/untimely pregnancy and the risk of HIV/STI, thereby promoting improved sexual health.
• New open access resources for practitioners working in this area.
• Enhanced understanding across health, midwifery, family law and social care sectors of the experiences of this population.

Overall, the Community of Practice succeeded in its broad aims to enable participants to co-curate an effective exploratory space to enhance practice in its target fields. It has built a critical mass of cross-cutting expertise and experience that can contribute to long term change goals which respond to pressing needs across family justice, public health and children’s social care.

The Flourish service at Lambeth offers an 18-month intervention for women who have experienced a court-ordered removal of one or more children.

Flourish was developed in February 2021 to address the needs identified in a scoping review for a London Borough Council which found that women within the area faced complex psychosocial adversities contributing to high rates of Recurrent Care Proceedings (RCP). (Rickman et al., 2017).

The service consists of a team manager and two practitioners each working a small case load. The service emphasises the importance of supportive relationships for improving mental health and wellbeing. It includes the use of therapeutic interventions, whilst teaching skills to build self-worth, resilience and stability. The final stage of the intervention involves building women’s independence and connecting them to community networks and resources.

This evaluation assessed the effects of the recurrent care service in a variety of ways using qualitative and quantitative methodologies. We developed a number of recommendations, including maintaining simple referral routes for professionals so services are accessible, developing "fast-track" pathways for vulnerable parents to access therapy after court proceedings, and carrying out a second review in 2 to 3 years when more clients have accessed the service.