Creating a therapeutic ecology in commissioning

Reports have noted the challenges that local authorities face in planning to meet demand – sufficiency approaches are patchy at best and this brings with it a range of consequences, such as increased use of unregulated provision and inappropriate use of non-specialist residential provision, often leading to placement breakdown.

By not specifying the “types” of children’s homes and the range of practice models that are required to meet different needs and a more regional approach to planning these, we leave the “market” unmanaged. There is little control over the type and location of new homes, whether by councils or private sector entrants, and we see an increase in new homes having serious regulatory breaches early in their existence. There is a degree of naivety on what is needed to establish and sustain these services, and how to use them to best effect rather than seeing them as “beds” or “places”.

If the commissioning system is wrong, it is hardly surprising to see this reflected in provision that fails our young people. We need to address this through a structured and targeted approach to commissioning of provision and begin to embed a more ecological and sustaining overarching model.

Expanding practice

The Consortium of Therapeutic Communities (TCTC) promotes the use of psychosocial and relational practice. These are value-based, theoretically-informed models of practice, frameworks for therapeutic governance, workforce development, networking and policy support. More local authorities are engaging in our work to either help develop the quality and breadth in the provider landscape or directly engaging to strengthen their approaches to commissioning.

The UK already has a robust set of technical, quality assurance service standards for both Therapeutic Communities and Therapeutic Child Care (TCC). A key advantage of these standards is that to demonstrate compliance, organisations working with different clients can utilise different forms of evidence, which allows for diversity and adaptation in the sector. Following this approach allows authorities to compare “apples with pears”, but also creates a more engaged dialogue with providers.

We have developed practitioner competencies that align with the service standards and can be used within provision for staff recruitment, induction and appraisal. As the standards guide and regulate provision so the competences guide and regulate staff. Over time, a genuinely self-regulating and psychosocial ecology is established.

Managing the market

A challenge for council commissioners is to be able to make sense of and compare the wide variety of “therapeutic” models providers offer. While there has been little consensus on the application of the term, and what it looks like in practice, the model supported by TCTC is a one that is accredited by the Royal College of Psychiatrists, that is regularly reviewed and developed by professional with sector-expertise. Whether the model is, for example, trauma-informed, it must meet the standards and undergo regular peer-review to be accredited as therapeutic. This is how we move from the procurement of numbers of beds into commissioning therapeutic and responsive provision for children in the UK.

In one project, the Commissioning Alliance has been using the TCTC-developed “technical governance checklist”, designed to be used alongside the TCC standards. This has allowed the building of a consensus between the local authorities and potential providers for the intended therapeutic element on the framework. This covers what the authority is looking for in terms of governance, therapeutic practice, workforce structures, model of care and outcomes.

In another project across north east London, we are supporting commissioners at an earlier stage using an adapted version of the checklist to “audit” the shape and diversity of existing provision in their region. Using the findings, it becomes possible to plan in at the strategic level, the support structures needed for regional quality enhancement and encouraging the “shape” of the provider landscape, including council-run provision. Providers become more open and reflective about their practice models, what their workforce requires in terms of training and support, and how to ensure effective clinical input.

Key takeaways

We need to close the gap between high-level commissioning and the realities of service provision. The mechanism to create a set of shared aims and language, and to embed systems for quality enhancement in the sector, is through a combination of service standards, practitioner competencies and a psychosocial model of practice – which we have termed a therapeutic ecology.

This is a model for sustainable commissioning and is relevant whether it’s an in-house local authority home being created, a formal partnership arrangement, a regional purchasing framework or even helping with individual placement considerations. The process described here delivers better outcomes, better value for money, more stable placements where and when needed, a better workforce experience and, importantly, much more ecologically stable homes, certainly “built on love”, but also on solid ground.

• Kevin Gallagher and Chris Nicholson are from The Consortium of Therapeutic Communities