The case for integrated children’s services
Over the last eighteen months I have been asked by the Government to look at two groups of disabled children. For the Department of Health (DoH), I reviewed the system of care and treatment of disabled children with a complex mix of needs involving challenging behaviour, learning disabilities and often autism. For the Department for Education (DfE), I’m currently looking at the experiences and outcomes of children in residential special schools and colleges.
The questions that the DfE review poses are:
- the characteristics of the children and young people in residential special schools and colleges, and how they came to be placed there
- the pattern of provision across the country and how it is commissioned and procured
- what good quality support looks like for these children and young people
- the experiences and outcomes of these children and young people and their families, and how these can be improved
- how schools and colleges are supported by all agencies to meet children and young people’s needs
- how effectively the workforce in residential special schools and colleges meets these needs
- destinations for children and young people leaving settings.
The two groups of children have two significant issues in common. The first is that they are children placed away from home, the second is that they are placed because they are seen as “too complex” for local authorities and their partners to support locally.
They are also children who, once placed away from home, can be out of sight and out of mind. Many are placed as a last resort and the children will have experienced multiple failures of the system before this placement. A school said to me recently: “these children have been failed so often, they see themselves as failures and so our first job is to teach them they can succeed.”
This impacts not only on the children and their families themselves but on local services. These services get less and less confident of their ability to meet the needs of children and so, if we are not careful, a spiral of placements occur, at huge cost, and not always for the best outcomes for children.
Within the review of residential special schools we have looked at the issue of looked-after children. It’s not necessarily straightforward; there are some children, particularly those in placements lasting 44 weeks or more who should be classed as looked-after and aren’t. There is a confusing variation of practice in terms of defining looked-after status, which can benefit the child because it seems to increase local authority engagement at reviews; worryingly, some reviews take place without important stakeholders in the child’s care around the table. We have also seen many looked-after children in schools for children with social, emotional and mental health needs. These children have often come from failed fostering and adoption placements, and it’s key that we build effective support at all levels of the system to ensure the mental health needs of these children are met.
Children with this range of complexity are the very children in need of a multi-agency response to meet their needs. The basis for such an approach is there already: these children will be known to education teams, because they should all be in school; they will be known to social care staff because of the high level of family support they often require. Some of them will be looked-after children, so the local authority’s duties as a corporate parent will also apply. And yet, we still get things wrong, we still don’t join up support effectively. So what do they need?
First, they need better human rights. The United Nations Convention on the Rights of the Child confers on all children the right to a childhood. This must be upheld for children with complex needs and behaviour that challenges, with these rights recognised by the NHS Constitution, DfE, DoE and local commissioners. So when we place children a long way from home, how do we protect their rights to family life, or to the very best education, so we place the same standards on specialist out-of-authority provision as we do for the best of our in-authority schools? Do we ask the same demanding questions on progress and outcomes as we do for our own children?
Second, we need a model of care. The numbers of children with complex needs is rising – it’s a challenge that isn’t going to go away – so what’s the most effective provision and support? It’s often about bringing education, child and adolescent mental health services (CAMHS) and care together. It’s about understanding the best, well evidenced interventions to support children. It’s about the standards of all services including the most specialist and about the role of alternative provision. It’s about looking at models of schooling, resourced units and specialist support.
Third, we need a real understanding of skill sets in this area. When children challenge the system, who supports the children and who supports the staff working with them? The silos that we create for education, social care and health, and the professional boundaries within these, do little service to the children who cross boundaries and need a multi-agency response for their needs to be met. As part of the DoH review I have asked the Royal College of Psychiatrists, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners and other royal colleges to clarify the responsibility of medical and other professionals for these children, and jointly develop guidance to ensure respective roles are widely and consistently understood. For the wider reviews, the whole issue of an integrated workforce and core skills set for those working with children must be considered.
Fourth, we need smarter commissioning of services. Commissioning by local authorities, including both social care and SEN teams, and clinical commissioning groups should consider the value of early intervention in services which are based on the needs and concerns of families, and that can respond to emergencies whenever they occur.
Finally, we really need to look at the definitions and management of challenging behaviour. For many of the children and young people my reviews cover, the trigger for out-of-authority placements is school exclusion, and the reason for that exclusion is defined as challenging behaviour. Are we getting less tolerant of behaviour? Is it becoming significantly more challenging? And is that coming from within the child, or as part of the system pressures around the child? The reviews are showing that lots of factors make up behaviour: the need for security and certainty for some autistic young people, the complexity of family situations for some children with SEMH, and the ability of professionals across the piece to understand, or not, the fact that behaviour is about communication.
Bringing services together
It’s remarkable then that when talking to commissioners and managers across all services, I was often told that it was impossible to create local services for these children because of the small numbers involved. The case for better alignment of services and smarter commissioning is clear. I think professionals can do better for these children too. But only if we tackle the lack of ownership or accountability across a fragmented system.
Dame Christine Lenehan is Director of the Council for Disabled Children and author of the Lenehan Review: These Are Our Children:
Dame Christine is currently leading a review for the DfE, due to be published later this year, into the experiences and outcomes of children and young people in residential special schools and colleges.