Commissioning Support Programme

Commissioning for the Most Vulnerable ‘Highly Resistant’

Families

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?

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..

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

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.

A vicious cycle?

Increasing numbers of vulnerable

children Tight narrow

definitionsand fiercerationing

Separateassessments

for differentresources

Intensiveintegrated support for

very few

Huge resources into post-

breakdown care

Inter-generational failing families

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 p

oin

t in

the lif

e

cycl

e

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

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

A Systematic Process Focussed on Need

Patient/ public

Petitions

Published prospectus

Review service provision

Assessing needs

Seeking public and patient views

Managing performance

(quality, performance,

outcomes) Referrals, individual needs assessment; advice on choices; treatment/ activity

Managing demand

Shaping the structure of supply

Designing services

Deciding priorities

National targets

Patient/ public

Petitions

Published prospectus

Review service provision

Assessing needs

Seeking public and patient views

Managing performance

(quality, performance,

outcomes) Referrals, individual needs assessment; advice on choices; treatment/ activity

Managing demand

Shaping the structure of supply

Designing services

Deciding priorities

National targets

Phase 1: Needs assessment and Strategic Planning Phase 2: Shaping and Managing the Market Phase 3: Improving performance, monitoring and evaluating Phase 1: Needs assessment and Strategic Planning Phase 2: Shaping and Managing the Market Phase 3: Improving performance, monitoring and evaluating

Look at outcomes for children and young people Look at particular

groups of children and young people

Commission –including use of

pooled resources

Identify resources and set priorities

Decide how to commission

services efficiently

Monitor and review services and

process

Develop needs assessment with

user and staff views

Plan pattern of services and focus

on prevention

Plan for workforce and market

development Process for joint planning &

commissioning

Look at outcomes for children and young people Look at particular

groups of children and young people

Commission –including use of

pooled resources

Identify resources and set priorities

Decide how to commission

services efficiently

Monitor and review services and

process

Develop needs assessment with

user and staff views

Plan pattern of services and focus

on prevention

Plan for workforce and market

development Process for joint planning &

commissioning

Look at outcomes for children and young people Look at particular

groups of children and young people

Commission –including use of

pooled resources

Identify resources and set priorities

Decide how to commission

services efficiently

Monitor and review services and

process

Develop needs assessment with

user and staff views

Plan pattern of services and focus

on prevention

Plan for workforce and market

development Process for joint planning &

commissioning

10

Commissioners deliver the CTB Agenda

Local Strategic

Partnership

Children’s Trust

Children’s Trust Board

Joint Commissionin

g Unit Operational Groups

Operational Groups

Operational and Advisory

Groups

LSCB

Operational Groups

Operational Groups

Localities

Note – governance arrangements are

different in all local areas

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

May and June 20091313

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.

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 higherlevels of intervention

Resources drawn out of post-breakdown

care into earlier support

Holistic assessment and integrated

support targeted at these families

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

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)

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..

Information and contacts

• www.commissioningsupport.org.uk • www.ssiacymru.org.uk

• keith.moultrie@commissioningsupport.org.uk

• katy.burch@commissioningsupport.org.uk