Published: 17/04/2003, Volume II3, No. 5851 Page 24 25
The inquiry into the death of Victoria Climbié prompted calls for dedicated children's trusts, combining some or all of the services provided by education authorities, social services and health. But what shape would the new trusts take, asks Bob Hudson
Joining things up is the watchword of many, if not most, government initiatives these days, but services for children have remained stubbornly outside the frame. Ineffective joint working can - as Victoria Climbié's case reminds us - be a matter of life or death.
Health secretary Alan Milburn's main response to the fragmentation, confusion and poor practice revealed by Lord Laming's report into the Climbié case was to urge the creation of children's trusts. But the future of children's services, and the place of health services within them, remains shrouded in uncertainty.
1Few dispute that the current system is chaotic and characterised by a silo mentality. The initial impetus for children's trusts came from last year's inter-departmental childcare review project managed by the strategy unit, which condemned the unco-ordinated programmes relating to childcare, each with its own funding streams, planning processes and targets.
2This in turn fed into the 2002 spending review, which recognised that services needed to be child-focused and co-ordinated across social services, health, education, housing and other agencies at local level. Children's trusts were accordingly proposed as a way of securing the sort of joined-up approach that has been a feature of many adult services.
Though still embryonic, the notion of children's trusts has broadened out beyond 'early years' issues and has the potential to cover many combinations of services and professionals involved with children and young people. The inter-departmental guidance for prospective applicants identifies a number of common features aimed at ensuring co-ordination around the needs of service users:
3someone to ensure co-ordination of services;
clear short and long-term vision and objectives;
co-ordinated assessment of need;
pooled budgets across some or all services;
workforce planning across agencies;
effective information-sharing systems;
streamlined assessments and case management systems;
new forms of integrated provision.
It is said that, as a minimum, this should involve some or all services provided by local education authorities, social services and health, but that others - including the private and voluntary sectors - should also be encouraged.
The current legal framework does not allow police, probation services, Connexions partnerships or Sure Start local programmes either to delegate functions or pool budgets formally, but the government is said to be looking for radical models based on broader partnerships that could point the way to legislative change.
Children's trusts will be led by local authorities - a reversal of the position on care trusts. But just as care trusts were regarded with suspicion by local government because they were 'NHS bodies', so children's trusts might be viewed nervously within the NHS as a 'local government takeover'.
One possibility, for example, is to reunite social workers, health visitors, child health clinics and school health services within a children's trust, thereby returning to the situation that existed before the NHS reorganisation of 1974.
Generally, the view from the centre seems to be that everything is 'up for grabs'within the children's trust framework. This ranges from a 'whole systems' children's trust for all children aged 0-19 in a local authority, to a more specific focus on things like child protection, early years services, child and adolescent mental health, and children with special needs or disabilities.
Some children's trusts will be strategic and commissioning bodies only, others will combine commissioning and provision. Expressions of interest should be made by the end of March, and an anticipated 14 'pilots'will go live some time between July and the end of the year. Interest is said to be high, with£1m put aside to assist successful applicants release staff for planning purposes, establishing structures and joint training.
These are certainly developments that the NHS cannot afford to ignore. Back in the 1990s, the health select committee undertook a number of studies on health services for children and formed a poor opinion of the co-ordination between different sections of the NHS, and between health, education, social services and the voluntary sector.
4,5 And there is no reason to think there has been a huge change in the intervening years. There is a wide range of areas where good joint co-ordination is needed, including children with chronic health disorders, equipment for use in the community, child protection services, respite services, transition plans for adolescents moving into young adulthood, healthcare for 'looked after' children and services to facilitate the continuing education of sick children.
Moreover, hospitals need to be seen as part of their community and their services integrated with community services for children.
However, children's trusts are not the only show in town, and there is a degree of planning blight as people wait for the green paper on children at risk, due out soon. Debate surrounds the future position of child protection services, and whether this will be within the children's trust remit or removed entirely or partially from local government.
The 'nationalisation'model on child protection has been put forward by the Institute for Public Policy Research, which argues for a dedicated service run by a separate national agency outside of local government - an idea which is thought to be favoured by the prime minister.
6A less centralising model, but one that is nevertheless very concerned with upward accountability, is that suggested in the Laming report itself. Despite arguing that structures are not at the heart of the problem, Lord Laming proposes a complex system in which the current area child protection committees are replaced by local management boards for services to children and families, along with the creation of a new central children and families board chaired by a Cabinet minister.
This board would be serviced by a new strategic national agency for children and families headed by a chief executive whose role would equate to a children's commissioner for England.This would - through a regional structure - oversee the work of local children and families committees, with membership from relevant committees of the local authority, NHS and police.
Different again is the local co-ordination model supported by the Local Government Association, NHS Confederation and Association of Directors of Social Services.This queries the need for new organisations and structures where there is already a co-ordinated approach and argues for a 'service hub' of local health, social services and education agencies that would deliver or commission all children's services and be accountable to the local strategic partnership.
This is a model that is more truly local and one that would fit well with the children's trust approach.
It is built on the assumption that it is only at local level that the complexity of children's services can be made coherent and accountable, and by linking into the local strategic partnership it also recognises the role of local government in providing democratic accountability and representation.
All eyes are now on the green paper and how this will shape children's services. Since it was first announced in October, the focus has been on early intervention and prevention, rather than solely crisis-led child protection.This means the net will be cast more widely, covering educational underachievement, offending, anti-social behaviour, teenage pregnancy and ill health. It is being drawn up by a Cabinet sub-committee chaired by chief secretary to the Treasury Paul Boateng, who is known to dislike social services departments.
And if health minister Jacqui Smith follows Mr Milburn's line to end the 'old monolithic single social-services department structures', some radical change seems inescapable.
Given the health secretary's conversion to the idea of locally controlled services, opting for a more centralised system looks unlikely.Moreover, a fixation with new structures is not the right way to deal with complex issues that straddle a multiplicity of organisational and professional boundaries.
Even in the area of child protection, where legislation, guidance and protocol are most deeply embedded, achievements will be limited unless greater attention is paid to the ways local networks of providers behave.
Partnership working has no qualities of spontaneous growth or self-perpetuation; it is achieved through a series of negotiations around particular courses of action.Unfortunately it cannot always be accomplished as simply and quickly as politicians would like, and they are often tempted to shake up structures instead.
The message for the pending shift in children's services is to stick with partnering rather than re-structuring, and to build on what is already there, underpinned by more sophisticated and joined-up performance measures from the centre.Children's trusts could certainly fit in with this approach, but if localities are given the opportunity to shape their own destiny they need to grasp it firmly and show that the new localism can deliver.
1The Victoria Climbié Inquiry. Lord Laming's report, 2002.
2The interdepartmental childcare review. Delivering for children and families.
3Children's trusts guidance.
Department of Health, 2002.
4Health services for children and young people in the community: home and school.Health select committee, third report 1996-97. Stationery Office.
5Hospital services for children and young people.
Health select committee, fifth report 1996-97.
6From welfare to wellbeing: the future of social care.
The proposal to establish children's trusts follows years of poor coordination of services.
The establishment of these trusts will involve structural integration with other organisations and may not appeal to everyone in the NHS.
The government seems prepared to consider almost any form for these trusts.
Partnerships, not restructuring, would seem to be the way forward.
Bob Hudson is principal research fellow, Nuffield Institute for Health, Leeds University.