Published: 05/02/2004, Volume II4, No. 5891 Page 18 19
The case for integrating children's services is strong, but the barriers are high.
Rather than imposing structural change, the government must manipulate the individual components of children's services With the government proposing to reshape children's services, there are many questions - and much anxiety - in the air.What will children's trusts mean for child health services? How can professional roles be protected if different sectors are merged into amorphous new teams? Are we really being asked to reorganise again, so soon after the creation of primary care trusts?
Some of these concerns are valid, others may be instinctive reactions to the threat of change.
But what should services for children look like in the years ahead?
First, where did the concept of integrating children's services come from? Is it yet another scheme dreamed up by a Westminster think tank?
The plain answer to this is, no.
Integration is an idea which comes most starkly from the experiences of children and families themselves. Examples abound of families that have found the links between health and other statutory services at best disjointed, at worst chaotic.
Ask parents of disabled children, who tell of multiple assessments, of appointments made to suit professionals, not families, of 30odd people from different agencies trooping through their doors. Think of the health of children looked after by local authorities, characterised by lower immunisation rates, fewer regular check-ups and low takeup of essential services.
The idea comes, too, from the failures of our child protection systems - in health, social services and elsewhere - and the tendency of each agency to scapegoat the other. The Laming inquiry into the death of Victoria Climbié brought few plaudits for any professional group, but its most damning conclusion was the lack of communication between agencies.
And the idea of integrated services comes from acknowledging that the lives of children are integrated. Good health, for example, helps children to succeed in education, while if they are denied access to school they also miss out on health education. The same applies to child protection:
children at risk of abuse will also be at risk of poor health outcomes. The cycles of success and failure in each part of a child's life are inextricably linked.
So the proposition that services for children should be better integrated has a sound pedigree.
Ifit were simple to achieve, though, it would have been done years ago.
The fact is that whenever local services have sought to reshape themselves, they have concluded, like a lost motorist, 'I wouldn't start from here'. The same applies today.
While some have suggested that all services can be swept into one structure in the name of accountability, this approach encounters some real barriers.
Most obviously, the geographic boundaries of the different agencies do not always fit. Even where the local authority is unitary, it does not always correspond to the boundaries of the PCT, while two-tier authorities may have to develop relationships with as many as a dozen PCTs. Similarly, admissions policies allow many children to attend schools outside their local authority, and the catchment areas for GP surgeries do not overlap with school catchment areas. This means that the desire for unified chains of accountability can seldom be realised.
What is more, different services come from different worlds, with their own histories. Targets, which determine the behaviours and priorities of us all, do not overlap, and sometimes directly conflict. Funding streams come with different timescales and reporting requirements.
Differences in training, work culture, language and in assumptions about children all act against joint working.
Most powerfully, there is evidence to show that structural change itself brings little gain. In many areas, well-publicised attempts at joint management of health and social care have foundered. Structural change could, it has been argued, put children's lives at risk in the short term for unproven gains in the future.
So the case for integrating our approaches to children is strong, yet the barriers to integration remain high. This leaves the government with a choice: to impose structural change, or to become deft at manoeuvring the levers that encourage integration.
Assuming that the government has seen the wisdom of the second approach, what might be the levers that could helpfully be pulled?
We can - and should - move towards common planning and commissioning of services for children. Some children and young people's partnerships have brought together key stakeholders at a senior level and produced genuine joint plans which have influenced practice.
And some local authorities - particularly unitary authorities - have forged good relationships with the children's lead on the PCT, used section 31 flexibilities to delegate budgets to each other, and established joint services.
In several areas there are joint posts - for child and adolescent mental health services, for looked-after children, for disabled children.
Building on these experiences, we should move towards effective partnerships in every area, backed up by a duty on PCTs, local authorities, the voluntary sector and others to co-operate in their implementation. The key to success is to secure buy-in to the process at the highest level.
We can work to common standards. The children's national service framework is due for publication this spring - ministers willing - and it is designed to cut across the traditional organisational demarcations. Indeed, delivering the NSF will require joined-up planning and delivery.
The three main inspection bodies will check progress against these standards jointly, and there is nothing like a forthcoming inspection to encourage change in working practice.
Although the new approach in the Department of Health means that this NSF will not be garnished with specific targets, we should not imagine that it is any less powerful.We should relish a reduction in government-set targets and balance this with the acceptance of inspection-led standards that can more flexibly reflect local needs and aspirations.
Locally, we can co-locate health and social services for children.
The green paper Every Child Matters proposes more children's services based in schools, and there is much to be said for this.
Some of the governance issues are complex, given the independence of school governing bodies from their local authority, but nothing encourages better joint working than sharing an office.
We can unify assessment processes. Of course different professionals will retain their own detailed inspections, but the first stages, and the information recorded as a result, should be in common across all professions.
This in turn will require improvements in information sharing, which, despite popular opinion, will not require changes in data protection law.
We can strengthen multiagency training: setting up more development courses which train groups of practitioners alongside each other, ensuring each group learns about the distinctive role and duties of their colleagues, and helping to construct a climbing frame of qualifications that will make it easier for staff in one branch of child health to transfer roles during their career.
Some of our current professional demarcations may be based on client need, but many are based on old-style protectionism.
And we can change structures, where we want to. Children's trust pilots across the country are experimenting with different models of shared planning and management, under children's trust boards.
Where they work, and produce better outcomes for children and families we should not be afraid of change. It seems, though, the government recognises the need to learn from the first pilots and allow local solutions to develop rather than to impose one model on all.
Children's services are indeed set to alter, and structural change may be a part of this. But the real changes we can anticipate are that the needs of children will be placed at the heart of planning;
that the different strands of public services will work more effectively together; that local practitioners will see each other as colleagues, not competitors; and that children and young people's voices will be heard in the meetings where future services are designed.
Paul Ennals is chief executive of the National Children's Bureau.He is also a member of the children's task force at the Department of Health, and of the children's national service framework strategy group.He cochaired the external working group developing draft standards for The Healthy Child.