The cost of turning around the lives of 120,000 troubled families

Suffer five or more of these and you are officially a "troubled" family. Ministers estimate that £9bn of public money is spent on these households every year, or £75,000 per family.

The Prime Minister’s offer of £448m for the next three years will cover 40 per cent of the cost of dealing with the families once results have been achieved, and councils will have to foot the remaining 60 per cent.

But the sum shows the scale of the challenge facing local areas: £448m divided by 120,000 equates to £3,733 per family. If that is 40 per cent of the cost of dealing with these families, and councils must meet the other 60 per cent, then the total spend per family stands at £9,332.50. But what can councils really do for a troubled family with just under £10,000 spread over three years?

Price of intervention

Turning around a troubled family is costly. Intensive support schemes such as family intervention projects (FIPs) cost up to £20,000 a year for each family. Family nurse partnership (FNP), a programme proven to transform the lives of young mothers and their children, costs £3,000 a year for each participant, and multi-systemic therapy (MST), an evidence-based programme targeting young people at risk of being taken into care or custody, will cost about £10,000 a family over three to five months.

These three examples illustrate the investment required if local areas are to meet the Prime Minister’s challenge, using evidence-based programmes that will achieve the best outcomes and long-term value for money.

The Institute for Public Policy Research has already warned that a lack of government funding could mean that intensive work with families is diluted. So the onus is on local authorities to find cost-effective and intensive ways of working with families, without cutting corners on results.

Charles Wells, clinical supervisor at The Brandon Centre, which provides advice, counselling and psychotherapy services to young people, manages three teams providing MST to vulnerable young people and their families in north London.

"There is a risk of programmes eventually being watered down for financial reasons," he says. "So an initiative that might be effective one-to-one may be turned into a group programme because it means you can treat 12 people a time and only pay two staff."

He argues that local commis­sioners of children’s services need to understand why intensive support programmes are successful. "You have to look at the evidence of why it works – is it just because there is a professional going into the home three times a week or is it the fact that that professional is doing cognitive behavioural therapy with a parent who is depressed?" he asks.

Multi-systemic therapy (MST) practitioners are all clinicians qualified to master’s level – primarily clinical psychologists, but in some cases social workers. The programme is licensed, which means therapists have to adhere to the template of the original programme developed in the US. Families involved complete monthly questionnaires, designed to check that professionals are following the correct processes.

"It’s an expensive service," says Wells. "MST will probably be in the region of a quarter of a million pounds a year for a local authority. So there is a temptation to get some people with a background in working with youth into the family home three times a week. They could say they’re doing the same as MST, but they’d be doing it on the cheap. If a young person is refusing to go to school, coming home late and dealing drugs out of their bedroom window and the parent is sent to a parenting class for two hours once-a-week, that intervention does not match the scale of the problem. To keep a young person out of custody, £10,000 per family isn’t bad."

David Derbyshire is head of performance and improvement at Action for Children, and a member of the National Family Intervention Strategy Group, which advises the Department for Education on intensive family support.

He believes there is a need for lower-cost, higher volume early interventions. "We run FIPs and other support services that are dealing with that heavy end of need," he says. "We know those work in terms of outcomes for children and families and long-term cost-effectiveness. We’re exploring whether an intensive period of support can be applied to families with lower level needs, to turn on its head the supposition that you only apply intensive services to families in crisis."

He adds that the charity is in the process of setting up multi-systemic therapy, among several other evidence-based initiatives, but believes the adoption of such schemes is being slowed by confusion over how funding for troubled families will work in practice. "The potential of these programmes is that they have an evidence base of successful outcomes, which exceeds and dwarfs any other kind of evidence base in the sector," he says.

"Local authorities are unable to plan on the basis of long-term budgets. Councils know what their financial settlement is up until 2014, but they have to stay within those limits. What you really want is a 10-year plan by which you can spend more in the first four years, because you know you’re going to be running programmes that reduce demand in years five to 10.
"If you look at the £448m announced by government, the detail of how the 60/40 payment-by-results split is going to work is still being worked out. Until local areas feel confident about that, we’re not going to see lots of new intensive family support services to work with troubled families."

Evidence-based programmes

George Hosking, chief executive of the Wave Trust, the charity that brought family nurse partnership to the UK, believes that evidence-based programmes could be scaled up to meet greater need. For example, the government has agreed funding for a trial of a "group family nurse partnership" in Leeds, Nottingham, Sheffield and Southampton.

It will work with young women who would benefit from additional support, but are not eligible for one-to-one support. Midwives, family nurses and children’s centre workers will co-ordinate groups for young women from pregnancy until their child is one. The idea is that all midwifery care will be carried out within the groups, with the young women encouraged to self-care, for example by testing their own urine or measuring their blood pressure.

"There’s nothing wrong with a controlled experiment, where you’re trying to find better ways of working to see if you can reach a larger number of people effectively – provided it’s monitored and we know what the results of it are," Hosking says.

But he cautions against taking evidence-based programmes and changing the way they are implemented without careful research. "To take a proven programme and alter it from what we know works is usually not a good idea, because history shows the fundamental things which produced quality are lost."
A Department of Health spokeswoman says that schemes such as the group family nurse partnership have the potential to extend the benefits of intensive support to a wider group of families, but admits it is still "too early to know if the model works".

Whether programmes such as FNPs can be scaled up to meet the needs of larger numbers of families could make or break Cameron’s 2015 target. Without new ways of delivering intensive interventions, the challenge of widening support to 120,000 families with current levels of funding could be insurmountable.

INTENSIVE SUPPORT SCHEMES

Family Nurse Partnership
Average annual cost £3,000

Family nurse partnership (FNP) offers young first-time mothers intensive home visiting during early pregnancy until their child is two, focusing on attachment, relationships and psychological preparation for parenthood.

FNP is a licensed programme developed in the US at the University of Colorado. The UK version has to follow the model of the original scheme.

Research spanning 30 years in the US shows cost savings ranging from $17,000 to $34,000 per child by the time they reach 15, with a $3 to $5 return for every $1 invested.

The British government has committed to increase the number of places on the FNP programme to 13,000 at any one time by 2015.

Multi-systemic Therapy
Average cost over three to five months £10,000

Multi-systemic therapy (MST) is an intensive intervention aimed at young people at risk of entering care or custody, lasting between three and five months for each family.

It works with 11- to 17-year-olds and their families to improve parenting, engagement with education, reduce offending behaviour and tackle underlying health problems, including substance misuse.

Therapists work in the home and are on call 24 hours a day. MST was developed by the Family Services Research Center at the Medical University of South Carolina and is licensed, which means the UK version of the initiative follows strict guidelines. Research from Washington State Institute for Public Policy suggests £5 is saved for every £1 invested in the programme.

Family Intervention Project
Average annual cost Up to £20,000
 
Family intervention projects (FIPs) provide intensive support to families that have multiple social, health and behaviour problems. A dedicated key worker develops a detailed plan for the whole family, underpinned by a contract outlining the support offered and the changes required by the family. Sanctions are used to encourage families to change behaviour.

FIPs were developed after charity Action for Children’s pioneering Dundee Families Project in 1995. It is not licensed and has evolved to work with a range of families as a drive to reduce antisocial behaviour.

FIPs now work with families whose children are at risk of being taken into care. Research into FIPs in 27 local authorities found that almost £2 was saved for every £1 invested. The estimated saving to the public purse for each family is £50,000 a year.

Sources: Department of Health, Department for Education, The Brandon Centre