1. Commissioning Support Programme Commissioning for the Most Vulnerable ‘Highly Resistant’ Families

2. Workshop Outline What’s the commissioning challenge for most vulnerable, resistant families? Why is (joint) commissioning so significant here? What are some of the most effective approaches to commissioning in this area?

3. The Population ‘Children and families experiencing severe stresses and at risk of significant harm, family breakdown or compulsory entry into the care system’. (P Hardiker, K Exton & M Barker (1996) The prevention of child abuse: a framework for analysing services, National Commission of Inquiry into the Prevention of Child Abuse, HMSO) Of those families, sub-population who are ambivalent, deny/avoid, unresponsive, hostile..

4. What’s the Commissioning Issue? Huge emphasis on prevention and early intervention in recent years. Great for vulnerable families with less complex needs Little impact on these most complex families

5. The problem? Level 1 and universal services are getting better at identifying CYP and their families with emerging problems but don’t expect to work with the more vulnerable families in the community. Level 2 services do not do enough to help universal services cope with more difficult CYP. Level 2 services are not well enough targeted to address the needs of the most vulnerable families. Level 3 and 4 services deal with too many inappropriate children and the most vulnerable families who are helped too late.

6. A vicious cycle? Increasing numbers of vulnerable children Tight narrow definitions and fierce rationing Separate assessments for different resources Intensive integrated support for very few Huge resources into post-breakdown care Inter-generational failing families

7. What is the commissioning issue? 5 Other children Vulnerable children Children with complex needs Tertiary (treatment or remedial) Secondary (intervention for at-risk populations) Primary (universal interventions) At any point in the life cycle

8. Why Commissioning? ‘The process for deciding how to use the total resource available for children, young people and parents in order to improve outcomes in the most efficient, effective, equitable and sustainable way.’ Achieving Better Outcomes, Commissioning Support Programme, 2009

9. Why Joint Commissioning for this Population? MULTIPLE and HIGH LEVEL needs Integrated support is likely to be required to: –Stay safe –Do better in school –Cope better with physical and mental health challenges –Help their parents to parent better Services cant be developed or delivered in isolation Effective assessment and co-ordination is vital

10. A Systematic Process Focussed on Need 10

11. Commissioners deliver the CTB Agenda Local Strategic Partnership Children’s Trust Children’s Trust Board Joint Commissioning Unit Operational Groups Operational and Advisory Groups LSCB Operational Groups Localities Note – governance arrangements are different in all local areas

12. Evidence – Informed Change Agents Attention to consensus building and change management –Commissioning agencies –Providers –Service users and carers –Professionals –Politicians 12 Evidence-informed analysis –National priorities, emerging practice, and research evidence base –Needs analysis –Market / service mapping –Cost and quality analysis

13. May and June 2009 13 A realistic balance of evidence sources National and international research as well as government guidance and legislation. Population data and prevalence rates. Referral, assessment and service activity data. Illustrative care pathway/case studies. Engagement activities with patients/service users and carers, providers, professionals and other stakeholders.

14. The Goal – A Virtuous Cycle? Positive engagement with these families Recognition and early identification of families who’ll become most vulnerable Help to build up resilience and avoidance of higher levels of intervention Resources drawn out of post-breakdown care into earlier support Holistic assessment and integrated support targeted at these families

15. Ways Forward – Get a Clear Brief from the CTB Most vulnerable families as a CYPP priority, signed up to by all agencies with resources.. Strong engagement from the LSCB Commissioning function with clear separation from service management An evidence base which speaks to all agencies – based on costs as well as need A clear remit to look at resources, AND at internal and external services, AND at identification referral and assessment, AND probably at locality arrangements

16. Ways Forward – Promising Commissioning Practice Systematic, planned project to develop and deliver and review a commissioning strategy over a year period drawing on the joint planning and commissioning triangle Evidence reviews which look at the characteristics of effective interventions with most vulnerable and resistant families (as opposed to non-resistant) Needs - Audit of 50 families most vulnerable / taking up highest level of resource across agencies in one area (to determine need in detail)

17. Ways Forward – Promising Commissioning Practice Needs – Detailed case reviews involving triangulation of workers, carer and child experience of interventions – to convince professionals.. Redesign – focus both on pathways, decision- making and how to target support on these families as on services and intervention Quality assurance arrangements for localities..

18. Information and contacts www.commissioningsupport.org.uk www.ssiacymru.org.uk keith.moultrie@commissioningsupport.org.uk katy.burch@commissioningsupport.org.uk