Growing crisis for children’s social care

As the cabinet leads for children’s services in the north-west of England we are urging the chancellor to allocate the additional funds we need to address the growing crisis in children’s social care. The demand and complexity of cases is increasing, creating overspends in our children’s services budgets, at the same time that our council budgets are being reduced. This is an unsustainable financial demand for each of our councils.

In the north-west there are now more than 13,000 looked-after children. This represents a 20-year high and is the greatest number of children in care of any region in England. This has been driven by growth of 12% since 2013 alone, double the 6% increase in the rest of the country. Analysis from the Placements Northwest census identifies sharp escalation in costs, for example a £45m increase in expenditure on residential care placements this year. We have recorded 90,930 referrals in 2016-17, which is an increase of 2% on the previous year. Our data suggests that this is being driven by the increase in domestic abuse and mental ill health.

We know that the sustainable solution to reducing children’s social care is early intervention. But the increasing cost of children’s social care is driving our limited resources away from funding early help. This is consistent with the national picture that is illustrated in the Turning the Tide report produced by Action for Children, National Children’s Bureau and the Children’s Society. As the finance bill makes its way through parliament, we are asking the government to respond to the crisis of children’s social care, and provide adequate funding to meet these needs.

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Patient safety getting worse, say two-thirds of NHS doctors

The Royal College of Physicians (RCP), which carried out the study, said the results exposed a health system “pushed to its limit” in which doctors felt they could not deliver what was asked of them.

One told researchers: “We are not robots, we are human beings with limits.” Another said: “I cried on my drive home because I am so frustrated and distraught at the substandard care we are delivering.”

According to the study, 80% of those asked said they were worried about the ability of their service to deliver safe patient care in the next 12 months and 84% believed the workforce was demoralised by the increasing pressures on the NHS.

By all but one measure, doctors said conditions were worse than last year. In positive news, there was a reduction in the number of doctors experiencing delays in patients being transferred from their care.

“It is extremely worrying and depressing that our doctors have experienced an even worse winter than last year, particularly when so much effort was put into forward planning and cancelling elective procedures to enable us to cope better,” said the RCP’s president, Prof Jane Dacre.

“We simply cannot go through this again. It is not as if the situation was either new or unexpected. As the NHS reaches 70, our patients deserve better. Somehow, we need to move faster towards a better resourced, adequately staffed NHS during 2018 or it will happen again.”

The RCP proposed relaxing visa restrictions for health workers, making more money available to match growing patient need, including in social care, and more investment in public health initiatives that reduce demand.

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How to look after mental health in later life

Councils still without extra powers to crack down on empty homes

On Monday, as the prime minister unveiled a package of measures to boost housebuilding, the housing secretary, Sajid Javid, said ministers had already taken steps to tackle the problem of homes being left uninhabited.

He claimed local authorities had been handed the ability to charge more council tax for vacant properties, adding: “So we’re taking action on that.”

But the Guardian can reveal that the policy outlined in the Autumn budget, to allow councils to double the amount of tax levied on homes if they are left empty, has yet to be enacted.

The campaigner Guy Shrubsole, who runs the Who Owns England group, obtained an email from a government official saying the proposal “is not yet in place since it needs an amendment to primary legislation”.

He uncovered the minutes of a Westminster council meeting that said government officials had “highlighted a potential risk in relation to the government meeting the legislative timetable necessary for a 1 April 2018 implementation”, which could delay action until 2019.

Pointing to the huge number of people sleeping rough on London’s streets, Shrubsole said: “It’s a national scandal that we still have thousands of homes lying empty, many owned by billionaires and offshore firms.

“The government’s unforgivable delay in introducing its promised new empty homes tax means councils will lose out on millions of pounds of revenue that could be spent on affordable housing. And the wealthy owners of empty properties will keep laughing all the way to the bank.”

The Ministry of Housing, Communities and Local Government confirmed there had as yet been no action taken on the policy, saying it would be brought in “as soon as we can”. Meanwhile, a source close to Javid said the cabinet minister’s comments were simply about the proposals that had been announced, adding: “We will bring forward the legislation.”

Among the commitments were: allowing former shops to be turned into homes; basing future planning permissions on developers’ build-out rates; and pressurising councils that fail to produce adequate proposals about the properties they plan to build.

Tackling the problem of empty homes is also seen as critical, which is why the government decided to ramp up the premium that can be charged on council tax from 50% to 100%.

Labour’s shadow housing secretary, John Healey, criticised the delay. “Just like pledges to ban letting agency fees or build new starter homes, ministers have done nothing to legislate for double-rate council tax for empty properties. Their failure to follow speeches with action shows the government is simply not serious about tackling the housing crisis,” he said.

The Liberal Democrat leader, Sir Vince Cable, said Javid had been “boasting about a measure that is apparently unenforceable at the moment”, saying his party would “charge empty homes at 300% as a tougher disincentive”. A freedom of information request by the Lib Dems revealed more than 11,000 homes across the country had been empty for more than a decade.

Nursing associates: will they become a cheap substitute for nurses?

Hilda Alexis has always wanted to be a nurse. But lack of educational opportunity and raising a family meant that being a healthcare assistant was the closest she thought she would ever get. Now, mid-career, she has a chance to realise her dream.

Alexis is one of the first 2,000 trainee nursing associates (NAs) who are part way through preparation for a new role in the NHS in England. The job is seen as a bridge between healthcare assistant and registered nurse (RN), taking on some tasks usually performed by the latter. But it will also offer a route for some NAs to qualify as nurses.

For Alexis, 49, who has worked for Barts health NHS trust in London for more than 15 years, this is the incentive she has been waiting for. “I’ve wanted to be a nurse all my life,” she says. “This is a wonderful opportunity for people like me. And I think it’s wonderful for the NHS.”

Not everyone agrees. Some critics see NAs as a threat to nursing’s graduate-entry status, implemented five years ago, and a reinvention of the state-enrolled nurse (SEN), training for which was phased out from the 1980s.

Others are wary of the speed with which NAs are being introduced, seeing the initiative as a knee-jerk response to nurse shortages that need more considered workforce planning. The number of unfilled advertised nursing and midwifery posts in England is at a record of more than 34,000.

The idea of NAs emerged from a 2015 review of education and training for nursing and midwifery, which recommended widening the entry gate for healthcare assistants wishing to enter the professions. Creation of the role was announced the same year, with the first trainees starting in late 2016. In addition to the first 2,000, a further 5,000 are due to start in April.

Such has been the speed of implementation that the necessary legislative changes have yet to be made to enable NAs to be regulated by the Nursing and Midwifery Council. That means there are not yet any agreed standards of education, training, conduct and performance, although the council has just closed a consultation on its proposal that NAs will have to pay the same – £120 a year – to be on its books as nurses and midwives.

With the first 1,000 NAs due to complete their training at the end of this year, the timetable for finalising arrangements is extremely tight if they are to move seamlessly into new jobs.

Because of the lack of a national template, other than an advisory framework, training of the first NAs is being conducted in a variety of ways across the 35 pilot sites involved so far. While this has obvious pitfalls, it has enabled the new role to be tailored to local needs.

Prof Debbie Dzik-Jurasz, deputy director of the Barts Health academy and coordinator of the NA pilot across north-east London, which involves 127 trainees, says: “Our real focus has been on trying to develop a practitioner who understands the complexity of the health needs of our local population. We have much higher incidences of mental illness, particularly depression and anxiety, for example, and of diabetes in young people.”

Training is principally on-the-job: trainees typically spend a day a week at a participating university, but the bulk of the course involves working under supervision in a variety of care settings. This ensures that those from hospital backgrounds get experience of community healthcare and vice versa.

Undoubtedly the most controversial aspect of the NA programme’s development has been the intention that NAs administer drugs: while national guidelines are awaited, universities are reportedly taking a range of approaches to teaching on this, depending on local practice and often on the backgrounds and experience of individual trainees.

Almost all the first 2,000 trainees are, like Alexis, experienced healthcare assistants. Those used to working in hospitals are likely to have less experience of helping with drugs administration. According to a breakdown by Health Education England (HEE), the healthcare education and training body, 84% of the 2,000 are women and the most common age range is 24-35 – although the youngest began at 18 and the oldest at 65.

Prof Warren Turner, dean of the school of health and social care at South Bank University, London, which is working with the north-east London pilot, says many of the trainees have never set foot in a university nor undertaken any non-vocational study since leaving school.

He recalls seeing one trainee hovering outside South Bank’s front door on her first day. Another arrived and they linked arms and marched in together. “I thought that said a lot,” Turner says. “If I’m honest, I was expecting a relatively high drop-out rate. But I could count on the fingers of one hand how many we have lost.”

“It’s intense, and the standard is high, but pretty straightforward,” she says.

Up to half of all qualified NAs are expected to elect to undergo a further two years’ workplace-based training to become registered nurses. Projections indicate that this could add 2,400 nurses a year to the workforce from 2021 (pdf) – a significant number, but small by comparison with the 22,000 a year from undergraduate nurse training.

Health employers are more interested in the NA role itself. They see it as a key part of a more flexible healthcare workforce, responding to changes in the way – and where – care is delivered, and freeing up nurses to take on more complex tasks. However, the NA role will always remain nurse-led.

Critics will be watching carefully to check that NAs, who will be paid at NHS band 4 (£19,406-£22,683) on qualification, do not simply become a cheap substitute for nurses, and that the job does not ossify in the way that the SEN route became a dead end for too many.

The Royal College of Nursing, which says it is already getting reports of trusts planning to cut registered nurse posts and replace them with NAs, warns: “Substitution of registered nurses with NAs by financially challenged employers, particularly in the context of significant shortfalls in the registered nurse workforce, could have unintended consequences on the ability to provide safe and effective care.”

There are also many issues yet to be resolved, not least professional standards for NAs and the cost of their training to employers. Although the HEE says it is meeting all costs of the pilot trainees, who are paid at band 3 (£16,968-£19,852), NHS trusts fear they will have to bear the cost in the long term, including paying for cover for trainees while they gain experience of different healthcare settings.

Dzik-Jurasz says: “We will have to think hard about how we model that. It’s really important that associates get this wider experience, and it’s great to see how excited they are for the learning opportunities, but it’s a significant issue for the employer when they are spending six to eight weeks at a time working in other areas.”

‘Plunged into poverty’: are kinship carers getting the support they need?

“I have wondered how this would have ended if I had been a less vocal, expressive or determined person,” a grandmother told a Gloucestershire family court last autumn, after applying to be appointed special guardian to her infant grandchild.

She was successful, but was keen to air her criticisms of the “extraordinary experience”. She alleges there was poor communication from children’s services, she was wrongly told she was ineligible for financial support, and unexplained delays meant her grandchild was in foster care for longer than necessary.

“It has left me feeling shattered by the lack of kindness and understanding I experienced in such a painful context,” she told the judge.

Responding to her statement, Gloucestershire’s interim improvement and operations director, Neelam Bhardwaja, said: “We know that taking responsibility for a young child is a huge decision and can be very stressful. We acted with integrity and kindness towards everyone involved in this case, as well as providing financial support including paying for some independent legal advice.

“We feel confident this child has the loving and committed family they need and we support the special guardianship arrangements.”

The grandmother in this case is not alone in struggling with a local authority’s attitude to kinship care. Around 180,000 children live with relatives or friends, and nine in 10 kinship carers say they do not feel supported in bringing up children who might otherwise be adopted or go into long-term foster care.

Kinship care is more stable than foster care and, by objective measures, has significantly better outcomes for children. So how do local authorities view it, and how much are they willing – or able – to resource this type of placement?

With large numbers in informal arrangements, the root problem for many kinship care families is being invisible to policymakers and local authorities. According to charity Grandparents Plus, support for kinship care is a postcode lottery. Chief executive Lucy Peake says many are “plunged into poverty” after volunteering to care for a child they had never expected to bring up.

The charity wants children in kinship care to be supported according to their needs rather than their legal status. But Charlotte Ramsden, director of children’s services for Salford, says that with budgets slashed and the child population increasing, local authorities’ capacity to respond “is massively less” than it should be.

Failures by councils to identify and properly assess and prepare kinship carers pose a genuine problem for children, says Mike Stein of York University, who researches the corporate parenting of young people.

“It gets my blood boiling. It’s so unjust that your life chances should be affected by inadequacies in this area,” he says.

Ramsden says that kinship carers are valued by local authorities, but paying them the same as foster carers is simply not achievable. “In an ideal world, if resources weren’t an issue, we might be saying something very different,” she says.

Sandra started looking after her nine-month-old grandson seven years ago after social workers took emergency measures to remove him from her son. She was given five minutes to decide whether he would go home with her or into foster care. She received five months of nursery fees from her local authority so she could keep hold of her job. Since then, Sandra has not had any financial support – despite it being the local authority’s decision to take action.

“I feel hard done by by the local authority,” she says. “I think a lot of kinship carers do because the council just thinks: ‘We don’t have to pay for a foster carer.’ Some get £400 a week per child, so we’re saving them that.”

While the lack of money may pull councils in one direction, a trend for children to stay with their birth families pulls in the other.

Special guardianship numbers are soaring and the way relatives and friends are viewed in terms of their capacity to care for a child at risk has changed considerably, says Joan Hunt, an expert in family law.

Ten years ago, a grandparent whose own child was an unsafe parent might have been regarded with suspicion by a local authority. Now, case law firmly encourages the assessment of relatives and means that families are much more likely to be carefully considered. Ramsden says children’s services try to be flexible if a family member offers to look after a child.

What financial, practical and emotional support is available for the increasing number of kinship families?

Statutory guidance from 2011 says children in kinship care and their carers should receive the support they need regardless of their legal status.

“If local authorities implemented that it would make a huge difference, but they are terrified of opening the floodgates, and that if they make services and money available, they will have thousands of carers knocking at their door,” says Hunt.

Given that the guidance on support is often not followed, Hunt believes that only primary legislation is likely to lead to genuine improvements.

But despite budgetary constraints, some new thinking is being introduced. In an initiative pioneered and delivered by Tact, which delivers Peterborough council’s fostering and adoption services, the same practical and emotional support and training will be available to all kinship carers where the council has been involved in creating the child’s placement.

Part of the problem local authorities face in developing sustained support for kinship carers is systemic, says Andy Elvin, chief executive of Tact.

“Because funding is always year-on-year, it’s hard for managers to make decisions on the next 10 years,” he says. “If you could look at a child growing up for the next 12 years and you want a good outcome and value for money over that time, then you might make different decisions than if you’re looking at next March.

Hunt is clear that using kinship carers more and better supporting them would save taxpayers money in the long term – not least because it would lead to improved outcomes for more children.

With the right resourcing from central government to allow councils to offer sustained help over a child’s lifetime, “you’d have more people coming forward as kinship carers, and if they had more support, more would last”, says Elvin.

“Long-term stability is good for children, so you end up with [fewer] children who would go on to need adult services, or intensive support services through adolescence,” he says.

Ofsted criticises council where social workers report ‘unmanageable’ caseloads

The toxic trio: what social workers need to know

There is concern that terms such as the ‘toxic trio’ are problematic because they can lead to the parents – most often the mother who is frequently the victim of abuse herself – being deemed toxic or seen as the main source of risk, and therefore they don’t hold the perpetrator of domestic abuse to account for their behaviour.

What is the ‘toxic trio’?

The use of the term ‘multiple and complex needs’ is not necessarily any less stigmatising – it is yet another label applied to a person or family and one that is used to exclude some from services. Furthermore, any combination of needs may be complex, not just substance use and mental health problems. As such, supporting families affected by these three issues involves exactly that – talking explicitly about domestic abuse, substance use and mental ill-health and helping them to address the impact that these issues are having on them and their family.

Living with mental health problems, using alcohol or drugs, or experiencing domestic abuse does not automatically mean a parent/carer is unable to safeguard their child(ren) from serious harm. Furthermore, adequate support can reduce (although not necessarily eradicate) the risk of children experiencing long-term negative effects of growing up with such problems. This means children can outgrow their troubled childhood. This is particularly true where only one issue affects the family.

Major concerns arise when more than one of these problems is present, as is often the case. It is the ‘multiplicative’ impact of combinations of factors that have been found to increase the risk of harm to children, with family disharmony and domestic violence posing the greatest risk to children’s immediate safety and long-term wellbeing (Brandon et al, 2010).

So, identifying all three issues and how they impact on the adults and children present in any family is vital. Furthermore, professionals need an in-depth understanding of how the issues interlink – particularly in terms of what domestic abuse is and how victims may end up using substances as a way of coping with their experiences – to ensure the interventions that are put in place are as effective as possible in promoting the safety and wellbeing of all members of a household.

Gathering and analysing information

A key message that has emerged from serious case reviews is that practitioners need to gather and analyse more information; they “must be encouraged to be curious, and to think critically and systematically” to understand how the difficulties affecting families interact (Brandon et al, 2008, p98). Unless professionals are sufficiently curious, questions will go unasked and important information will not be gathered.

Each family member should be spoken to individually about what is happening in the household. This is particularly important given the tendency to focus on mothers in families where a child or children are at risk of harm. It has been noted that fathers can be more difficult to engage with, either because they refuse to talk to social workers, are absent from the home when professionals visit, or do not live in the home with the child (Farmer, 2006 cited in Cleaver et al, 2011). However, every effort must be made to engage with fathers, even more so in cases of domestic abuse where usually the father/male carer is the perpetrator and poses a high level of risk to the family.

Children should be spoken to away from their parents wherever possible as they may not feel able to talk about what is happening in the family in front of them. This is particularly true if they fear negative consequences for their parents/carers or themselves, eg if they disclose that one parent/carer is abusive towards the other or towards the children. Very often, children and young people don’t want to get their parents into trouble, and also fear the family being separated as a result of disclosing.

In a similar vein, in cases that involve domestic abuse, both parents/carers should be spoken to, and spoken to separately. It is unlikely that a victim of domestic abuse will feel able to speak freely in front of the perpetrator, and perpetrators will often use such ‘forums’ to further manipulate and control the victim.

Hundreds of lung cancer patients may be dying early each year

The team behind the study say more than 800 patients a year could have their lives extended if the rates of treatment in the top 20% of areas were applied across the country.

“We are not talking about a few lives here, we are talking about something that matters,” said Prof Henrik Møller, head of cancer epidemiology and population health at King’s College London and first author of the research.

It is not the first time disparities in healthcare across the UK have been linked to cancer patients dying early, with previous research suggesting diagnosis and treatment is a “postcode lottery”.

The latest study, published in the journal Thorax, is based on statistics for more than 175,000 lung cancer patients in England diagnosed between 2010 and 2014.

The team looked at treatment rates across areas covered by former administrative bodies known as primary care trusts, and split them into five groups ranging from lowest to highest rates. Radiotherapy data, however, was not available for 2014.

For the lowest ranking of the five groups, the median rate was just 9.3% of patients receiving surgery, 4.0% receiving radical radiotherapy and 21.6% receiving chemotherapy, while the group with the highest rates had medians of 17.2% for surgery, 12.9% for radical radiotherapy and 34.5% for chemotherapy.

The team found the impact of such treatments on survival were strongest for particular stages of the disease, depending on treatment.

The results suggest that if all areas of the nation had the same level of surgery as those in the highest-ranking 20%, about 190 deaths could be avoided each year among those who had been diagnosed with early stage lung cancer within the previous two years.

Radical radiotherapy showed the strongest link to survival among those showing some local spread of the disease or for whom the stage was unknown, with the results suggesting that variation in treatment rates across England corresponds to a difference of about 370 people alive per year at two years after diagnosis. The variation in chemotherapy treatment rates was also linked to avoidable deaths.

The team say the figures were not affected by factors such as age, socioeconomic status or the presence of other illness.

Further analysis found that the point at which greater treatment leads to no further survival benefits has not yet been reached even for the highest treatment rates in England.

“The message is we treat our lung cancer patients too little and too passively, and existing therapies should be used more actively,” said Møller.

The study did not look at quality of life or longer-term outcomes, but the team say that as prognosis is poor for lung cancer patients it is appropriate to consider the short term.

While the analysis paints a picture of significant variation across England, the authors note that there is good news, pointing out that across the nation, survival of lung cancer patients was continuing to rise, with one-year survival increasing from 26% in 2005 to 36% in 2014, according to data analysed by the team. That, they note, is “remarkable progress”.

But they add that rates of treatment including surgical restriction are lower in England than in some other countries, such as Denmark, where one-year survival is 46%.

Professor Charles Swanton, Cancer Research UK’s chief clinician, said the analysis showed there was work to be done in bringing lung cancer care up to the highest standards around the nation, adding that the UK lags behind other European countries.

“Earlier diagnosis of lung cancer will play a major role in improving outcomes, as will ensuring optimal access to life-saving treatments including surgery, radiotherapy and medical therapies,” he said. “The NHS in England should continue to strive to overcome this devastating disease and provide patients with access to the best evidence-based treatments regardless of where they live.”

Criminal offences for social workers who fail to act on abuse rejected by government

The government will not introduce new rules that would make social workers who don’t report child abuse punishable with criminal offences, a consultation response has said.

The document, published this week, outlined the responses to a consultation on the introduction of mandatory reporting and a ‘duty to act’ for professionals working with children.

Both proposed duties would have made professionals working with children liable for criminal charges if they did not report child abuse when it was suspected.

The then Prime Minister David Cameron suggested the move in 2015. At the time he proposed expanding the crime of wilful neglect, which currently applies to care workers and health workers providing care for adults and children, to professionals who fail to act on child abuse.

This was dismissed before the consultation as it would have meant stretching the offence “beyond its original purpose”. It did however inform the duty to act option proposed in the consultation.

Case ‘not been made’

Sanctions under mandatory reporting would have been incurred if a person failed to report abuse for any reason other than genuine errors or mistakes. Under a duty to act sanctions would focus on cases where there were “reckless reasons for failure to act”. It would have included practitioners consciously taking no action, or an action that was insufficient or inappropriate.

Potential punishment for social workers who breached either duty could have included existing practitioner sanctions (such as through the regulator), additional processes involving the Disclosure and Barring Service, or criminal sanctions at individual and organisational levels.

Following a consultation, the government said: “The case for a mandatory reporting duty or duty to act has not currently been made”.

“Therefore, we do not intend to introduce a mandatory reporting duty or duty to act at this time,” the government response said.

More than half (51%) of those who responded to the consultation said a duty to act would have an “adverse” impact on the child protection system, such as “impacting recruitment and retention of staff, and negatively impacting the serious case review process”.

Further criticism of the proposal also said a duty to act would not recognise the complicated judgements required by practitioners working with abuse, and that it would increase pressure on resources.

More than two-thirds of respondents felt a mandatory reporting duty would negatively impact the child protection system.

A majority also said sanctions should not be too severe, and should be less to professional bodies.

Most were in favour of allowing existing government reforms to child protection, which included investment into innovation fund projects and the accreditation of social workers, to take effect before considering the need for additional statutory measures.

‘Listened to the views’

Following the feedback, the government said it would provide coordination between agencies to implement stronger safeguarding arrangements locally and consider the current legal framework to assess whether it is sufficiently robust in terms of criminal offences for concealing child abuse neglect.

Isabelle Trowler, the chief social worker for children and families, said the government had “listened to the views of social work leaders” in heeding the warning of the impact mandatory reporting could have.

“Our focus should be to continue building public confidence in our first-class child protection system which holds a door wide open for vulnerable children and also provides support for families.”

Richard Watts, chair of the Local Government Association welcomed the news, and added the organisation did not think mandatory reporting would have addressed current child protection challenges.

“Mandatory reporting systems demand an overwhelming focus on the investigation of families rather than the provision of support and the promotion of wellbeing. With children’s services facing a £2 billion funding gap by 2020 and demand for child protection services continuing to increase at a staggering rate, we strongly believe that the government needs to focus its efforts on providing the resources that councils need to provide early support for children and families before problems become serious.”